After an introduction by Vincent Costalat and Raul Nogueira the first presentation of the day was by Jerome Berge on the geographical and baseline population in the Aquitaine region of France. Dr Berge spoke about stroke care transportation in France when a comprehensive stroke center is distant.
Organizing stroke care
As the southern part of the Aquitaine is far from Bordeaux, French authority provided for the creation of new stroke centers to improve the overall stroke care organization. A new center opened in Bayonne with one regional fellow with about 2 years training and 2 radiologists experienced in INR. The specific training for the fellow is shared between Bayonne and Bordeaux.
Dr Berge went on to describe which type of centers and doctors should be qualified for thrombectomies. A minimum number of DSAs should be 100, with at least 20 MTs as second operator and 30 MTs as first operator.
Two new centers opened on the 4th March 2019 with the obvious goal of treating more patients. With the success of this endeavor, Dr Berge concluded that the “goal will be to open 12 new stroke centers in France”.
Dr Laurent Lagoarde spoke as well about the importance of increasing the number of stroke centers in France. The Mothership (MS) model has been reported to decrease the delay between symptoms onset to groin puncture, theoretically with better results. In Bayonne, the MS model was associated with 84 minutes reduction of the delay compared to drip and ship model (DS).
Dr Lagorde said that this model can be improved.
Dr Louis Veunac described in detail the Bayonne experience with the MS strategy in Bayonne being associated with around a 60% increase of the number of MTs thanks to the enlargement of the possibility of giving IVTs and to perform MT within the acceptable time window. Most patients presented M1-M2 occlusions, followed by T carotid occlusions and were treated with conscious sedation, with stent retrievers (SR) and aspiration based on the ARTS or ADAPT techniques. About 76% of patients were TICI 2b-3 at the final angiograms.
Mean operating time was about 46 minutes in Bordeaux compared to 1 hour in Bayonne.
In conclusion, the experience reported by Dr Veunac was interesting and successful.
Dr Frederic Bourdain spoke about the advantages and disadvantages of the local stroke care organizations. The advantages being seen to be the reduced time and higher number of patients potentially treated; disadvantages were related to the lower experience of the operators.
The mean number of MT/months in Bayonne was 13. The mean age was 79 years, with a mean NIHSS 18, and mean ASPECTS score 8.
Data in the literature is contradictory about the association of MT results and operator experience. However, Dr Bourdain illustrated that while certain articles reported better results with higher operator experience, the complication rate between Bordeaux and Bayonne was quite comparable: catheterization failure was about 7%, perforation 4%, embolic complication slightly higher in Bayonne (7% vs 3%), and a slightly higher rate of hematoma in Bayonne (50% vs 40%).
He concluded with the fact that the results were quite good.
Prof. Raul Nogueira congratulated his French colleagues for their reported experience in improving stroke care management and urged them to continue to improve it.
Dr Marc Ribo continued the morning’s topic concerning various possibilities for improving the organization of stroke care. He described his experience in Barcelona, and how they started to change their organization by opening other affiliated centers. Interestingly, he discussed how a very higher volume (for example in cardiology) can be associated with a decrease in the quality by time and an increase of the rate of complications, likely related to the higher number of patients being treated along with the higher volume of work.
A possible solution would be to send an INR to the PSC every day, with the aim of teaching operators and developing the necessary skills for MT. This solution could be associated with a “dilution” of the operator experience but with an increase of the number of treated patients and a decrease in time.
The discussion is ongoing, and we continue to evaluate other possibilities, such as driving the PSC for MT.
Prof. Jan Gralla presented a case of a patient with an NIHSS 2 score (but fluctuating between 10 and 2), a left V3-V4 and basilar thrombus with a left PICA territory infarct. The discussion concerned the possibility of whether to give IVT as there is no agreement as whether giving IVT increases the risk of distal embolization.
Finally, the patient did not receive IVT. MT started after 4 hours of symptom’s onset. Access was difficult: the discussion is whether femoral access would be better in this case. Aspiration was accomplished through a Penumbra catheter, recanalization of the vertebro-basilar segment was obtained. Left PICA appeared occluded: the question was posed as to whether to perform or not MT of the PICA. There is no evidence in the literature, so the discussion was based on personal suggestions and experience.
During recurrent aspiration a dissection of the VA, perhaps iatrogenic was discovered with a question about the etiology of the dissection and the possibility of treating or not with a stent. Prof. Costalat asked about antiplatelet therapy in case of acute stenting. Based on Prof. Gralla’s opinion, ASA 250 mg iv might be enough and can be a balance between the risk of hemorrhagic transformation and stent occlusion. Finally, an Enterprise stent was delivered to protect the dissection.
Final intracranial angiograms showed patency of the artery and the stent, without intraprocedural complications. The CT control at 15 hours showed no hemorrhagic transformation. MRI at 36 hours showed no increase of the ischemic area, and the absence of compressive symptoms in the posterior cranial fossa.
An interesting and rare case of pregnant woman with a right M1 occlusion was presented by Prof. Francisco Mont’alverne. The discussion that followed concerned several points including whether IVT is recommended? The 2018 guidelines said that IVT could be possibly employed based on the clinical scenario and the general risk of bleeding. What would be the benefit of IVT in large vessel occlusions such as an M1 occlusion in a pregnant woman?
In addition, an important point is the radioprotection for the fetus. During MT, they performed two passages using the stent-retriever technique, failing to achieve recanalization. A 3rd type of stent was then used, gaining M1 vessel recanalization, with M2 segments still occluded. A Y stenting technique was then performed opening the stents in the M1 and A1 segments and retrieving both at the same time. TICI 3 was obtained.
The final ASPECTS score was 7 with basal ganglia infarct based on the perforator’s infarct and the patient recovered well. It was concluded that evidence from the literature, although limited, showed no increase of teratogenic effects for the fetus, and no higher risk of miscarriage.
Pr Vincent Costalat demonstrated a pre-recorded silicon case of an M1 occlusion treated with a robot performing MT. Pr Costalat was outside the angiosuite, controlling the machine and performing microcatheterization, stent delivering, and stent retriever. Within the angiosuite a technician was present to perform basic activities such as preparing the materials, inflating the balloon guiding catheter, loading the microwires.
MT was successful in one passage. However, it is important to underline that there are important limitations. Installation of the robot is not fast; cervical access should be done by operators or technicians.
The idea of using a robot is an interesting technology for the future of the MT, as it is already employed in other specialties such as surgery or cardiology.
Prof. Marc Ribo spoke again about stroke care organization, precisely how to improve it based on his experience in Spain. Stroke care organization is focusing nowadays on the increase of the number of patients directly transferred to the CSC, minimizing the time delay from symptoms onset to recanalization, and improving the patient outcome that is generally associated with time. There are also economic implications that strongly impact the economy: better organization, less time, better outcome and less dependency of patients offer the opportunity of cost reductions of about 27 million euros over the next 10 years.
Prof. Ribo described how they screen patients with a high suspicion of LVO using the RACE score: patients with RACE ≥4 are directly transferred in the angiosuite, and just before treatment a fast NIHSS evaluation is performed.
An important conclusion was that “you can only improve what you can measure”. Accordingly, we need to measure if we want to improve our stroke care organization.
More stroke recorded cases
Dr Gregory Gascou described a case involving an 89-year-old female with NIHSS 19. Non-enhanced CT scan showed an ischemic area, likely related to LVO. The patient had been transferred to the CSC and received an MRI with the RAPID protocol showing distal hypoperfusion, plus a CTA demonstrated a distal right M3 occlusion. The patient did not receive IVT. The discussion following concerned why the patient received an MRI perfusion, and was not sent directly to the angiosuite.
The faculty spoke about whether GA or LA was the best option during MT in this case with contradictory opinions and a literature which was not homogeneous. Prof. Jovin doesn’t agree with GA because he thinks that the brain is less protected during GA. On the other side, Dr Machi performs almost all of their MTs under GA because clinical results are not different between GA and LA, and from the technical point of view GA can help the procedure.
For this case, Dr Gascou asked for a GA. MT has been performed with a Tiger 13 through a Headway Duo 167cm, inside a Neuro 3 Max. Treatment was successful and a TICI 3 was obtained. The patient was NIHSS 12 after 3 weeks.
Dr Benjamin Gory reported on the experience of the CHRU of Nancy about the direct-to-angio approach with 3D CT HD. They are planning to do a randomized trial comparing the classic approach vs the direct-to-angio approach with 3DCT HD. Probably this approach will save time for the patient, but Prof. Cognard underlined that it can be associated with an excessive use of the angiosuite because of the not negligible rate of stroke-mimics.
Dr Pasquale Mordasini presented a case of an 82-year-old patient with NIHSS 20, a T carotid occlusion and ASPECTS 4 who was admitted to the CSC in Berne. MRI and advanced imaging were performed. No IVT was given.
Patient was sent to the angiosuite. MT was performed using the triaxial approach with a 9F Merci, SOFIA 6F, and stent-retriever. Access was hard because of the anatomy. Partial recanalization was obtained and a second SR strategy with a CATCH mini has been performed for an M2 occlusion.
NIHSS after 24 was 14, exhibiting reduction of the hemiplegia and hemianopsia.
The ensuing discussion concerned the possibility of direct carotid puncture given the very difficult access. A second point of discussion was whether advanced imaging was needed or not when there is a clear clinical-radiological mismatch.
Dr Michael Tymiasnki spoke about neuroprotection in AIS patients. Stroke is responsible for about 60% of disabilities and it is interesting that only 10% of treated patients regain independence. In this scenario neuroprotection can be useful. Neuroprotection is mainly based on a molecule peptide called NA1. NA1 is a small protein designed to protect brain cells from the effects of stroke: it works by reducing the damage induced by the lack of blood or damage caused in the process of restoring the blood flow. Associating neuroprotection with standard treatments of AIS (MT) can be more effective. Neuroprotection is more effective in ischemia-reperfusion than in permanent ischemia. Possibilities of neuroprotection include:
- Treatment as a prophylactic approach in cases of high risk of stroke
- Treatment in an ultra-early time delay, while there is still brain left to save
- In select responders who have brain left to save at time of treatment (need for imaging is delayed)
ESCAPE NA-1 is a multicenter, randomized, double-blinded, placebo-controlled, parallel group, single-dose design to determine the efficacy and safety of intravenous NA-1 in subjects with AIS undergoing endovascular thrombectomy (www.escapena1.ca).
We are waiting for ongoing clinical trial results.
Stroke recorded cases
Prof. Vincent Costalat showed us a case of a 42-year-old patient from Lunel who was transferred to Montpellier. NIHSS was 11. MRI showed left basal ganglia infarction at DWI imaging, while PWI images showed left hypoperfusion in the M1 territory. PWI-ADC mismatch and clinical-radiological mismatch were in favor of treatment. MRI imaging showed a tandem occlusion.
No IVT therapy had been performed because of the low rate of recanalization among tandem occlusions, as well as the possible need to perform acute carotid stenting.
A first angiogram showed a left ICA dissection. The first clinical decision was whether to perform a retrograde approach (first intracranial occlusion after ICA dissection) or an anterograde approach (first ICA stenting and after intracranial occlusion). The choice was made to perform an aspiration of all the carotid with a SOFIA 6F, aspirating a large amount of clot. ICA was recanalized, but there was still an M1 occlusion treated with an SR technique. After the first passage, recanalization of the MCA was obtained, with some small embolus in the frontal region.
However, after 5 minutes, a second angiogram showed a sub-occlusion of the MCA. Intra-arterial 20 mg lytics has been employed, but there was still a deterioration and slow flow. Prof. Jovin said that it this was likely related to platelet activation, while Prof. Nogueira argued that it is instead related to vasospasm. However, both nimodipine and IA lytic did not work very fast and by the time circulation improved TICI 2b was obtained. The decision was made not to stent.
At the CTA and CTP intracranial vessels were patent, while the carotid was occluded with hypoperfusion related to the ICA occlusion.
From Italy, Dr Francesco Asteggiano showed us a case of an M1 occlusion with severe cervical ICA stenosis with active bleeding of the basal ganglia perforators. MT was performed achieving recanalization, while the carotid was stented, adding 120mg ASA.
Unfortunately, the patient died from large basal ganglia hematoma. The question of whether it is reasonable to recanalize a patient with a so called “angiographic spot-sign” was debated.
Prof. Robert Mikulik spoke about ESO initiatives for stroke pathway monitoring describing the heterogeneity of the organization of stroke care in Europe, with countries from the Eastern Europe having fewer good results. The initiative is called ESO-Est and works with the stroke organization in each of these countries. The most important point, as reported by Prof. Mikulik, was to measure treatment quality. For this reason, a registry has been created in the Czech Republic to collect the data and to perform statistics about the organization of stroke care.
What are the next steps?
- Improve organization
Prof. Mouhammad Jumaa presented the 5 keys points for workflow improvement.
The principles of workflow improvement are the following:
- Analyze and refine
- Develop new concepts
One of the most important points remains prehospital patient organization. Thez RACE score can be a reliable strategy to filter and select patients potentially candidate for MT.
Take home messages from day 1
The main messages of the day were mostly about the organization of stroke care, underlining the importance of saving time, increasing the number of peripheral centers performing MT, simplifying the evaluation of AIS patients at the prehospital phase.
One key lesson: If we want to improve the system it is mandatory that we “measure” our performance with registries and statistics about our stroke care management!