The day begins
The second day began rhythmed by the nice duet of Drs. J. Gralla and R. Weber as they looked at “redefining the synergistic approach of lithics and mechanics” sharing their personal experience regarding the different treatment approaches. One of their key observations being that IV lithics and MT should be complementary and not competitive – but which one should be prioritized and when?
Concerning IV lithics, it seems an appropriate and highly effective choice in patients with small, distal occlusions or in case of drip and ship, while MT is more commonly suggested for proximal large occlusions in patients who are transported directly to a Comprehensive Stroke Center (CSC). Despite an attempt to simplify what remains a complicated decision, it is clear that we are obliged to take into account the whole set of parameters, learning to take a cautious balance between them both. During their presentation, Drs J. Gralla and R. Weber presented interesting studies supporting their varying approaches.
We then heard a lecture on “predictors of post-alteplase recanalization in stroke referral for thrombectomy; and recanalization with tenecteplase versus alteplase” by Dr P. Seners who discussed the influence of IV lithics prior to MT. He presented studies which examined the different parameters that might influence lithic activity; i.e., types of transportation (mothership vs. drip and ship), thrombus size and thrombus location. The combination of “drip and ship” with short and distally located thrombi seemed an “ideal” setting for IV lithics. Dr Seners went on to present a recent study comparing tenecteplase with alteplase in which similar recanalization rates were seen before thrombectomy in patients intended for MT as in “the drip and ship” paradigm.
Cases… from you, for all of us!
We then began our “Stroke recorded case” session, beginning with one presented by Dr. Gralla of a young patient with an occlusion of the vertebral artery, followed four days later with an occlusion of the basilar artery. After gentle aspiration of the thrombi, Dr. Gralla, faced with a proximal stenosis of the vertebral artery, needed to decide whether to stent or not. The audience expressed different opinions concerning which approach to take and we learned, after the discussion, that Dr. Gralla finally chose to insert a stent, achieving good clinical and imaging results.
The second case dealt with a patient having a low NIHSS score and an occlusion of the ICA. Prof. Costalat’s presentation aroused an enthusiastic and animated discussion during which no consensus was achieved regarding the necessity of MT in this situation. Furthermore, many questions were asked concerning the safety and the benefits of recanalizing a distal occlusion that was only demonstrated after recanalization of the proximal ICA – especially when IV lithics were on board. The same was seen to be true concerning stenting of a carotid stenosis, especially in the acute setting.
Dr. B. Lapergue shared his experience in the third case, presenting various studies concerning off-label administration of IV thrombolysis. He discussed extreme cases such as wake-up strokes and strokes with low NIHSS scores.
The fourth case, by Dr. R. Chapot, involved a young patient with a high NHISS score and the presence of shower emboli who didn’t receive IV lysis since she was using irreversible NOAC. Uniquely, he performed gentle and repeated thrombi collection from both the distal ACA and distal MCA, inserting a stent into the common carotid artery due to the presence of a fresh thrombus at the arterial orifice. The expert panel members expressed their objections to this procedure, mainly due to the lack of evidence, suggesting local aspiration as an alternative to the carotid stenting.
Recorded thrombus lab
Using a silicon model, Dr. G. Gascou provided us with a series of remarkably detailed, step-by-step demonstrations of two different techniques commonly used in M1 occlusions: the ARTS and Solumbra techniques. Dr. Gascou further refined their use with the important points for our consideration; discussing the advantages and disadvantages of each approach.
- In the “Drip-ship and ship back” session, J. Thornton shared his experience with this interesting model and approach.
- In another sponsored session, M. Mohlenbruch presented intermediate results from the SESAME study examining the safety and efficacy of direct aspiration as a first line treatment using the Sophia/Sophia plus catheter. He also presented initial clinical experiences with the WEDGE catheter.
Lectures and more interactive discussions!
The afternoon lectures began with Dr. T. Jovin speaking about the different types of total occlusions of the ICA. Despite commonly facing acute and subacute occlusions, it is not always easy to decide which patient should be treated and when.
Dr. Jovin shared his personal experience by presenting interesting cases of patients with chronic occlusions of the ICA who were recanalized. He then offered us a brief historical review along with a description of his recommended technical approach to achieve recanalization.
Prof. Costalat presented an interesting case of a patient with an older known occlusion of the ICA who presented with ipsilateral M1 occlusion. An intracranial MT was initially performed followed by carotid stenting. This new approach toward chronic occlusions of the ICA needs to be further discussed.
The next lecture concerned an important cause of ischemic stroke which is now attracting a great deal of attention and has recently been recognized as a major cause of ischemic stroke in young patients – the carotid web. Dr. N. Gaillard presented an interesting historical review along with studies regarding the carotid web and its significance in stroke pathophysiology. Dr. Gaillard showed imaging examples and spoke about current treatment options which include medical treatment with anticoagulants and mechanical treatment using carotid stenting.
We still have a lot to learn about this mysterious entity.
Dr. Ribo presented the next lecture on carotid stenting in the acute setting in which he illustrated cases and studies concerning carotid stenting in this acute phase. Followed by a lively discussion involving the expert panel and audience, all of whom tried to answer the question of whether it was necessary and how safe it really is to perform carotid stenting in an acute setting.
Once again, a unanimous decision was not reached.
The final lecture of the day was an attempt to understand cervical lesions.
Prof. Costalat presented different types of tandem occlusions including dissections, atheromas, carotid web and emboli. With the goal of aiming to prevent stroke recurrence, he introduced the approach to carotid stenting his service is using, carefully reminding us that, “this is the Montpellier approach- our choice not the truth”.
He underlined that each case should be evaluated individually, taking into account the type of lesion, vessel wall integrity, the ASPECT score, the age of the patient and whether or not the patient received IV thrombolysis.
Prof. Costalat also shared with the audience a suggested pharmacologic protocol.
And so Day 2 ends. So much to discuss and all happening so fast, what else could we do but continue our discussions while taking in the Mediterranean sunset….and looking forward to what we will all share on Day 3!
Shani AVNERY KALMANOVICH
Department of Interventional Neuroradiology
Gui de Chauliac University Hospital