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VIETNAM NATIONAL CONGRESS OF CARDIOLOGY 15th Meeting, Ninh Binh Updated in Treatment of Acute Ischemic Stroke: Intravenous r-tPA or Endovascular Therapy Nguyen Quang Anh, MD Introduction • Ischemic: 80% of stroke • Third leading cause of dead in developed country • Cardiovascular disease, diabetes,… • 2025: prediction of 1.2 millions patients/year • In Viet Nam, stroke is top cause of Death (account for 18% - 2008) “Time is brain”! Protocol in BM Hospital from 2012-15 Administered to the Emergency Department (10 mins) First aid with clinical examination and test (35 mins) CT/MRI (non contrast, angio, multiphase/ perfusion) (15-25mins) Hemorrhage Rule out Ischemic with evidence of big arteries occlusion IR room (60 mins) Treatment • IV r-tPA (NINDS) -> approved by FDA 1995 • Time window: • 3h (NINDS)/ 1/9 (180’) -> 1/14 (4.5h) • > 4.5h: more harmful than benefit • New: Demoteplase (DIAS III), Tenecteplase (*) Group, NINDS rt-PA Stroke Study, (1995) N Engl J Med 333(24): p 1581-7 (**) Hacke, Werner, et al., (2008) New England Journal of Medicine 359(13): p 1317-1329 – IV only should be done in first 4.5 hours (the shorter time, the better result) • NOT GOOD with proximal part of main arteries (10% ICA, 30% M1 in revascularization) * (*) Group, NINDS rt-PA Stroke Study, (1995) N Engl J Med 333(24): p 1581-7 Indication – Age ≥ 18 – Clinical diagnosis of ischemic stroke causing neurological deficit – Time of onset symptoms ≤ 4.5 hours – Non-contrast CT scan showing no hemorrhage or well-establish new infarct Contraindication – – – – – – – – – – Large infarction in CT Scanner History of intracranial hemorrhage or brain aneurysm or vascular malformation or brain tumor Suspicion of SAH SBP ≥ 185mmHg or DBP ≤ 110mmHg Seizure at onset Recent surgery/trauma (less than 15 days) Recent intracranial or spinal surgery, head trauma, or stroke (less than months) Active internal bleeding (less than 22 days) Platelets ≤ 100.000 or INR > 1.5 Recommendation from AHA/ASA guidelines 2015 – Patients eligible for intravenous r-tPA should receive r-tPA even if endovascular treatments are being consider (Class 1; Level of Evidence A) – In careful selected patients with anterior circulation occlusion who have contraindications to intravenous r-tPA, endovascular therapy with stent retrievers completed within hours of stroke onset is reasonable (Class 2a, Level of Evidence C) Endovascular Therapy • «Bridging Therapy»: Intravenous r-tPA + Mechanical Thrombectomy – waiting for 45mins – hour • Intra-arterial r-tPA: – Not effective compared to mechanical thrombectomy – Increase hemorrhage rate post-treatment • Mechanical Thrombectomy Results • Technique – 37.8% (164/434) IA rt-PA – 34.3% (149/434) MT with old devices (Merci or Penumbra) – Only 1.2% (5/434) MT with new devices (stent retrievers) -> Stent Retriever used in this study!!! Recently Evidences • IMS III, SYNTHESIS, MR RESCUE, EXTEND-IA • SWIFT PRIME, REVASCAT • MR CLEAN • ESCAPE MR CLEAN Design and results • Methods – IV >< IV + MT in the first 4.5 hours – Treatment up to hours with anterior circulation occlusion • Results – 267 >< 233 (190/233-81.5% treated with stent retriever) – 445/500-89% treated with IV-tPA – mRS 0-2: 19.1% >< 32.6% -> Thrombectomy is better – Symptomatic hemorrhage: no significant difference ESCAPE Design and results • Methods – – – – IV >< IV + MT in the first 4.5 hours 238/316 received rt-PA with 118 control >< 120 intervention Treatment up to 12 hours with anterior circulation occlusion NO large infarct core (ASPECTs < 6), NO poor collateral (< 53% -> Thrombectomy is better – Mortality: 19% >< 10.4% – Symptomatic hemorrhage: 2.7% >< 3.6% Conclusion from guidelines 2015 – Based on randomized clinical trials 2013-2015 – “Certain endovascular procedures have been demonstrated to provide clinical benefit in selected patients with acute ischemic stroke” Protocol changes • 1) Treatment: – IV + MT in the first 4.5 hours – After 4.5 hours, mechanical thrombectomy only – No later than hours • 2) Good patients selection: – NIHSS: from (to 25) – Age ≥ 18 (to 80) – ASPECTS ≥ • 3) Big arterial Occlusion (M1, ICA)/ Good collateral Good combination + IV r-tpA (For < 4.5hrs but don’t wait, the Mechanical Thrombectomy right after transfusion) Solitaire (Priority) Conclusion • Acute ischemic stroke is still the challenge, always keep up to date • Treatment: not wait, try the combination IVtPA with Mechanical Thrombectomy in the first 4.5 hours window if possible Case • Male patient, 53 years old • Normal history • Suddenly right hemiplegia • Administered to hospital within 2nd hours • NIHSS = 16 MRI TICI = Before After mRS = THANK YOU FOR YOUR ATTENTION