Day 1. Monday, 7 September
Coming together for Stroke Management
The first edition of very international the Stroke Live Course (SLICE) began today in the beautiful city of Nice, France. As announced in the opening ceremony, the aim of SLICE is to be an international multidisciplinary brainstorming session around acute phase management of ischemic stroke patients, covering the neurological, anesthesiological and neuroradiological aspects of disease management.
SLICE is based on:
- the presentation of prospective case videos, recorded throughout the world
- advanced discussions in ischemic stroke management with experts from experienced international teams (Bern, Switzerland; Barcelona, Spain; Montpellier, France; and from the United States, centers in Charleston, SC, New York, NY, Pittsburgh, PA and Stanford, CA)
- a critical synthesis of the literature presented by experts in the field
- open discussions and enhanced live interactivity with the audience facilitated by the official application of SLICE for smartphones.
A morning variety of challenging cases
We began with a challenging case of a vertebrobasilar territory ischemic stroke managed by the Montpellier, France neuroradiology team. Considering the absence of access through the classical vertebral approach and despite the increased risk of thromboembolic complications, an original approach by retrograde catheterization of the basilar artery was successfully performed. This allowed the team to reach the basilar artery thrombus and administer IA rt-PA with a good clinical recovery at the follow-up.
The second case from the Charleston neuroradiology team was an excellent illustration of the efficacy and rapidity of the thromboaspiration technique, even in very tortuous anatomy. In addition, the difficulty of recognizing an intracranial plaque responsible for the ischemic stroke was also emphasized. Indeed, a moderate neurological deficit associated with a complete right middle cerebral artery (MCA) M1 segment occlusion should orientate us toward this particular etiology that requires specific management. Successful intracranial stenting was performed. However, despite a transient clinical recovery, the patient presented a reocclusion of the stented vessel that led to a worsening of the neurological deficit.
The morning session ended with a critical synthesis of the existing literature on the IV thrombolytic indications for ischemic strokes in 2015 provided by the Dr. C. Arquizan from the Montpellier, France neurology stroke team. This complete update covered all aspects of the IV thrombolytic administration with regard to epidemiological, clinical and imaging considerations in association with or without mechanical thrombectomy.
A silicone flow model workshop
For the first time, the “real-time” progression and retrieval of an actual thrombus through the arterial tree was demonstrated on a realistic silicone flow model. Despite the limits of the silicone model, this allows the physicians to understand the mechanical behavior of the thrombus and its consequences on endovascular management.
An afternoon of international cases
The afternoon sessions followed with an ischemic stroke case from New York’s Mont Sinai Hospital team. It reminded us that stroke management could also be subject to some practical issues – such as iodinated contrast media leakage during the CT acquisition – that could have a severe impact on the management of the case. Despite the successful recanalization of the left MCA occlusion using aspiration by an intermediate catheter, the patient presented an extended malignant infarct and an hemorrhagic transformation that needed a decompressive craniectomy. This informative case gave rise to important questions regarding the non-enhanced CT-based decision making for endovascular treatment, as well as the challenges of blood pressure management when facing an hemorrhagic transformation (systolic blood pressure has to be lower than 120 mmHg).
The fourth case of ischemic stroke was from the Vall d'Hebron, Barcelona, Spain neuroradiology team. It consisted of a left carotid ‘T’ occlusion. Several aspiration assisted stent retrievals allowed the complete recanalization of the occluded vessels. An original approach using at the same time two stent retrievers for M1 and internal carotid artery (ICA) termination for the retrieval of an important thrombus burden was showed. Furthermore, antiemetic drugs were also administered to the patient in order to prevent vomiting during the procedure under local anesthesia. Unfortunately, the successful endovascular procedure did not result in clinical recovery.
Three interesting lectures on imaging modalities for patient selection were presented by Drs G. Albers (Stanford, CA, USA), M. Goyal (Calgary, Canada) and T. Jovin (Pittsburgh, PA, USA). Since the endovascular treatment for ischemic stroke has proven to be efficient, the question of advanced imaging by MRI or perfusion CT has become a hot topic among specialists. The proponents of advanced imaging argue that despite the time required to do them, these imaging techniques allow the extension of the treatment window for patients with salvageable tissue and avoid the administration of futile or harmful reperfusion therapies. On the other side, proponents of minimal brain and vessel imaging argue that ischemic stroke decision-making is dichotomous (for the most part), and that the thresholds values for the perfusion parameters in use today vary with time, not to mention the fact that perfection in imaging takes time and resources. To date, no one has the definitive answer.
A final stroke case
The last case of the day was from the Bern neuroradiology team and consisted of an occlusion of the superior and anterior M2 branch of the left MCA. It was responsible for a small cerebral infarct presented as a speech disturbance with a low NIHSS (=5) at the initial onset. A spontaneous clinical recovery was followed by the patient worsening with an NIHSS increasing to 5. After discussion with the neurologist, the indication for performing thrombectomy was retained. One pass with a stent retriever allowed the complete recanalization of the occluded M2 branch (TICI 3) and a good clinical outcome at follow-up. This controversial case illustrated the limits of the NIHSS score for patient assessment, especially for speech deficits which could be very disabling despite a low NIHSS. The “key” question in such cases is to know how to balance the importance of the risk in terms of possible harm for the patient.
Time was also dedicated so that our industry partners could present their latest devices and innovations. Stryker gave an interesting and complete presentation of its stent retrievers range. Neuravi spoke of their experience in thrombus characterization and reproduction.
After this rich day, all the SLICE online team and SLICE organization wish you a good evening,
Enjoy Nice and see you tomorrow!
Omer Eker, MD & Cyril Dargazanli, MD
The social media and report team