Day 2. Tuesday, 4 October
Local versus general anesthesia
The second morning the Stroke Live Course began with a very interesting discussion and debate between advocates of conscious sedation (CS) or general anesthesia (GA).
CS advocates reviewed the literature and clinical data, whose main messages were the fact that mechanical thrombectomy (MT) is an effective treatment, but general anesthesia (GA) decreases the chances for good outcomes, increases morbidity and mortality and decreases the rate of recanalization. However, all studies these were retrospective.
The key point here appeared to be blood pressure (BP), which was not optimized in these retrospective studies. Optimized BP could improve results, perhaps by using certain drugs during GA and it was on this subject that Dr Bösel, from Heidelberg University Hopsital, Germany, presented the primary SIESTA results. SIESTA is a randomized prospective study comparing GA and CS with optimal BP management and at this point, no difference has been observed between GA and CS concerning NIHSS at 24 hours. Further results are awaited, which will be presented soon.
Conclusion? Both approaches can be used, still, if possible, do it under CS, however, if GA is necessary, this can too be used as well without compromising patient outcomes.
The Dawn trial
Tudor Jovin, from the University of Pittsburgh Medical Center presented the DAWN trial. The aim of this ongoing study is to evaluate the hypothesis that MT performed with the TREVO device plus medical management leads to superior clinical outcomes at three-months as compared to medical management alone in appropriately selected patient when treatment is initiated within 6 to 24 hours after these patients were last seen well. For now, 151 patients have been enrolled and the results of the interim analysis will be coming out soon.
Balloon or not to balloon?
In this very interesting topic, Matthew Gounis, from the New England Center for Stroke Research in the US, explain that, by in vitro assessment and depending on clot characteristics, the use of balloon guide catheters (BGC) as compared with standard 6 Fr access reduces the number of distal emboli.
Several clinical studies (Nguyen stroke 2014, Velasco Radiology 2016, Menon 2016) have also confirmed the efficacy of BGC (showing an improvement in procedural time, an increased rate of first-pass success and better rates of good outcomes).
Stroke tracker experience
Raul G. Nogueira from Grady Memorial Hospital (Atlanta, GA, USA) and Demetrius Lopes from Rush Hospital (Chicago, ILL, USA) presented two innovative smartphone applications for the management of stroke patients. These apps are designed to help medical workers in evaluating the condition of stroke patient during emergencies and ensure that the patient is directed to the optimal medical center.
This symposium focused on a retrospective study comparing the Eric device versus others stent retrievers. There was no observed difference in terms of recanalization, but the ERIC device did show a tendency to less intracranial hemorrhage, less passes and allowed for faster recanalizations of the target vessel.
Here we saw a video case comparing the classic pure unseat manoeuver versus the push and fluff technique. Interestingly, the push and fluff technique showed an improvement in clot trapping. Raul Nogueira (Grady Memorial Hospital, Atlanta, GA, USA) performed a “live in silicon” demonstration of the technique and explained how to do it. After his explanation, participants were able to test this maneuver themselves in the realistic silicon models.
Alain Bonafe (Montpellier, France) and Jean Marc Olivot (Toulouse, France) debated different concepts of acute phase brain imaging.
In the SWIFT PRIME study, subgroup analysis reported that there was no differences in patient outcomes whether the rapid software was used or not and, even in cases of large infarcts, MT was beneficial for patients. Furthermore, time from symptom onset to randomization was increased when MRI was used as compared to CT.
The role of advanced imaging should be used to rule out hemorrhage, an absence of occlusions, a large core and an absence or small amount of “at risk” tissue. The minimal imaging requested should be CT (CTP) or MRI (DWI) with core volume evaluation within six hours.
Reviewing the trials
Dr W. Van Zwam (Maastricht, Netherlands) presented a complete, highly informative and objective analysis comparing the results of the main trials on the endovascular treatment for ischemic stroke (MR CLEAN, ESCAPE, EXTEND IA, SWIFT PRIME, REVASCAT, THRACE, THERAPY, PISTE) as well as results from the HERMES trial.
This was an excellent opportunity to refresh our memories on these different trials and their results that have become the basis of our treatment strategies today.
What we know today is that IAT is very effective < 6h (or < 8h reperfusion) for all ages, with or without IV tPA, for all NIHSS levels (if there is a large vessel occlusion) and for all infarct size categories (ASPECTS). Still, some questions remain unanswered, for example: bridging IV TPA; the wake-up stroke and stroke after 6h; the minor stroke; the posterior circulation stroke; the aspiration technique versus stent retriever, etc… We still do not have enough evidence to answer these points and, while some trials are ongoing, newer trials are now clearly required.
It was in this spirit that Charles Majoie (AMC Amsterdam, The Netherlands) introduced the MR CLEAN NO-IV whose aim is to assess the effect of MT alone compared with IVT-MT on functional outcome in patients with AIS.
We have seen very interesting cases from Grady Hospital and Karolinska which triggered discussions on three main points:
- The difficulties of catheterization of supra aortic trunks in elderly patients and the use of direct carotid puncture with a 6 french access
- The management of hemodynamic stroke and intracranial stent placement in the acute phase.
- The management of atheromatous tandem occlusion: put a stent or not? Before or after intracranial recanalization? In the acute phase or delayed?
Cocktail above the sea
So the second day ended with a dinner and seafront cocktail at sunset… a great time.
For all the SLICE team, we wish you our best, and look forward to seeing you tomorrow for the last day of this fascinating congress.
Gregory Gascou, MD