Pre-hospital management – before and beyond
The day’s first topic was presented by M. Piotin (Paris, France) who questioned “drip and ship” versus “mothership” transfers. Noting that today only a few, limited, retrospective studies exist concerning this question, no clear cut answer could be given. Each transporting program has its own advantages and disadvantages – a direct transportation to the CSC does decrease the imaging to puncture time, but it might postpone IVT administration leading to increase of loading work at the CSCs. We shouldn’t forget that one of the key factor in the successful transport of patients between hospitals is the quality of the cooperation between them.
The second lecture of the day was given by J. Gralla (Bern, Switzerland) who tried to find out what is the main factor in delaying MTs once the patient has arrived at the hospital. It was emphasized that a high work load plays a central role in this delay, which further validates the claim that good pre-hospital evaluation is necessary.
Challenging clinical cases
Clinical cases were presented coming from Barcelona, Spain, Montpellier and Paris in France as well as Pittsburgh in the USA.
The first and second cases were led by M. Ribo (Barcelona, Spain) who opened the discussion with the question of whether or not to treat M2-M3 occlusions. In the interactive voting that followed, most of the participants voted that it “depends on the occulted branch”, with some voicing their concerns about treating such small vessels. The second most popular answer was to perform MT. Concerning which technique to use – aspiration versus stent retriever – there was no clear winner. The option of IAT was also suggested.
The third and fourth cases of the day, presented by V. Costalat (Montpellier, France), were complex and raised a series of provocative questions:
- Whether a patient with a high RACE score should be transferred to a nearby hospital or to a more distant CSC? The majority of the audience chose to transfer the patient to the closer hospital first where stroke mimickers could be ruled out and IVT given as a bridging therapy.
- Should we treat a rapidly improving patient? Here the audience voted equally – half choosing to go directly to the angiosuite and the other half suggesting that we perform vascular imaging first.
- Regarding the question about MT in a patient with a clinical/radiological mismatch, most of the audience members voted “NO”, supporting the conservative treatment arm.
- A majority of the participants also said that they would choose to treat an older patient with a large core before treating a younger patient with a rapidly improving stroke.
- Which sedation would you use in a distal occlusion: GA or conscious sedation? Our audience voted in favor of CS.
The fifth case of the day on post-circulation LVO was presented by J-P. Desilles (Paris, France) and raised several significant points:
- The RACE score was not designed to evaluate posterior circulation but, since in the case of these strokes the patient’s neurological state is usually bad they will receive high scores for each side of their body.
- Most of the audience supported IVT administration.
- Microbleeds in MRI does not rule out MT.
- No scale exists today assessing 3-months outcomes based on the post-fossa infarct core.
Recorded Thrombus Lab In Silicon Demonstrations
Gascou (Montpellier, France) gave us a nice demonstration concerning the benefits of silicon model, pointing out how closely they now resemble real anatomy. He presented several techniques that are commonly used in our institution for treating obstructions in different locations. These include:
- Carotid T occlusions – using a manual aspiration accomplished through a 9 Fr balloon guide catheter located at the ICA.
- Distal M2 occlusions – using a stent retriever (3 or 4 mm) combined with proximal aspiration.
In the first of these, E. Juttler (Germany) discussed the differences between IVT and MT patient selection. While the use of IVT implies extensive exclusion criteria, these same parameters should not be taken into account when dealing with MT. He concluded that all patients with LVO should be treated with MT – even if they are not candidates for IVT – and regardless of the severity of the stroke or the patient’s age. Patients with pre-stroke disabilities should not be ruled out automatically; each case needs to be examined individually.
Nogueira (Atlanta, GA, USA), challenged the six-hour time window for MT based on an individual’s collateral system. Rigid time windows do not respect individual physiological variation and, therefore, time should not be the main consideration for MT, but rather physiology instead.
During our lunch break, three active training stations allowed participants the opportunity of experiencing the silicon model, the RACE score and the anesthesiology field.
Working towards a “faster future”….
Arquizan (Montpellier, France) suggested one criteria for choosing where to transport your patient, “if the patient cannot move an entire side, then take them to a CSC”. This general approach is based on the assumption that patients with entire side paresis/plegia most probably have LVO, a fact which would save the need for further skilled evaluation. Additionally, if the patient has known contraindications for IVT, or is outside the therapeutic time window for IVT, wake-up stroke or the transport time to CSC, and the time to the referral center is more or less the same, then that patient should be transferred directly to a CSC.
All in order to gain precious time by bypassing the primary local hospital.
And now on to Day 2!
Shani AVNERY KALMANOVICH
Department of Interventional Neuroradiology
Gui de Chauliac University Hospital
|Read the report of Day 2|
|Read the report of Day 3|