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MINISTRY OF EDUCATION AND TRANING MINISTRY OF NATIONAL DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES NGUYEN VAN PHUONG STUDY ON CLINICAL CHARACTERISTICS, COMPUTED TOMOGRAPHY IMAGING AND EFFICIENCY OF MECHANICAL THROMBECTOMY IN PATIENTS WITH ACUTE ISCHEMIC STROKE SPECIALIZED : ANESTHETICS AND RESUSCITATION CODE : 62.72.01.22 THE SUMMARY OF MEDICAL PHILOSOPHIC THESIS Ha Noi - 2019 THIS STUDY HAD BEEN IMPLEMENTED IN THE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES The supervisors: Associate Professor Ph.D TRAN DUY ANH Associate Professor Ph.D LE VAN TRUONG Reviewer No.1: Associate Professor Ph.D Cong Quyet Thang Reviewer No.2: Associate Professor Ph.D Nguyen Hoang Ngoc Reviewer No 3: Associate Professor Ph.D Pham Dinh Dai The thesis was defended in Institute Committee Council at The 108 Institute of Clinical Medical and Pharmaceutical Sciences at … .m, ……… , 2019 Can find full text document of this thesis in: National Library 108 Institute of Clinical Medical and Pharmaceutical Sciences Library INTRODUCTION Stroke is the third leading cause of death and the leading cause of serious, long-term disability In which, the ischemic stroke were accounts for 80% of stroke Large vessel occlusion stroke had severe clinical events and causes high disability rates Mechanical thrombectomy has been approved by American Heart Association/American Stroke Association with level IA in 2015 as standard treatment for acute anterior circulation stroke due to occlusions of the internal carotid artery (ICA) or the M1 segment of the middle cerebral artery (MCA) and improvement of functional independence compared with standard medical care However, the selection of patients with acute ischemic stroke (AIS) are appropriate, whoes are still difficult, especially in many stroke centers in Viet Nam So that the study on clinical characteristics and computerized tomography imaging of AIS patients due to large cerebral vessels occlusion were necessary and meaningful in clinical practice The effectiveness of mechanical revascularization, which were reported on many international studies, but there are not many in Vietnam From that fact, we performed " Study on clinical characteristics, computed tomography imaging and efficiency of mechanical thrombectomy in patients with acute ischemic stroke", the thesis had two main purposes: Clinical characteristics, computed tomography imaging of acute ischemic stroke due to large vessel of the anterior cerebral artery system occlusion have been had endovascular mechanical revascularization Evaluated the effectiveness and safety of the endovascular mechanical revascularization method to treated acute ischemic strokes due to large vessel of the anterior cerebral artery system occlusion THE NEW POINTS OF THESIS - The research results provide data on clinical characteristics and computed tomography imaging of acute ischemic stroke due to large vessel of the anterior cerebral artery system occlusion - The effectiveness of the endovascular mechanical revascularization method to treated acute ischemic strokes due to large vessel in Vietnam - Understand the influence factors on good outcome and mortality after mechanical thrombectomy in patients with acute large vessel occlusion stroke THE STRUCTURE OF THESIS The thesis consists of 116 pages, including the questions (2 pages), the overview (36 pages), the subjects and methods (19 pages), the research results (25 pages), the discussions (31 pages), the conclusions (2 pages) and the recommendations (1 page) There are 31 tables, 16 charts, graph and 13 figures The reference has 19 Vietnamese and 131 foreign references Five articles related to the subject have been published ABBREVIATIONS AIS: Acute ischemic stroke CT: computed tomography ASPECTS: Alberta Stroke Program Early Computed Tomography Score CTA: computed tomography angiography ICA: internal carotid artery LVO: large vessel occlusion MCA: middle cerebral artery MT: Mechanical thrombectomy mRS: modified Rankin scale n: Number of patients NIHSS: The National Institutes of Health Stroke Scale TICI: The thrombolysis in cerebral infarction CHAPTER – OVERVIEW 1.1 Diagnosis of ischemic stroke 1.1.1 Clinical diagnosis of ischemic stroke The clinical symptoms of AIS were very diverse, they depend on the location of the infaction, but there were the following common clinical symptoms: Paralysis, facial paralysis, language disorders, visual disturbances, double vision, forced gaze deviation In addition, there were also sensory disorders, and unconscious The National Institutes of Health Stroke Scale (NIHSS) is a tool used by healthcare providers to objectively quantify the impairment caused by a stroke The NIHSS is composed of 11 items, each of which scores a specific ability between a and For each item, a score of typically indicates normal function in that specific ability, while a higher score is indicative of some level of impairment The individual scores from each item are summed in order to calculate a patient's total NIHSS score The maximum possible score is 42, with the minimum score being 1.1.2 Clinical diagnosis of the location of acute ischemic stroke due to large vessel of the anterior cerebral artery system The cortical signs such as aphasia and neglect are sensitive indicators for large vessel occlusion (LVO) stroke Middle cerebral artery (MCA) occlusion stroke had signs: aphasia, neglect, motor deficits, loss of sensation in any part of the body and Conjugate Eye Deviation (CED -prévost's sign) Internal carotid artery (ICA) occlusion stroke, there are manifestations of MCA occlusion stroke signs and anterior cerebral artery (ACA) occlusion stroke signs 1.1.3 Computerized tomography diagnosis of acute ischemic stroke Non-contrast computed tomography (NCCT) remains a widely used imaging technique and plays an important role in the evaluation of patients with acute ischaemic stroke NCCT had helped identify early ischemic changes signs include changes in brain parenchyma that reflect either decreased attenuation (eg, loss of definition of the lentiform nucleus) or tissue swelling (eg, hemispheric sulcal effacement, effacement of the lateral ventricle) Systematic approaches to recognition of early ischemic changes such as the Alberta Stroke Program Early CT Score (ASPECTS) system improve the detection of early ischemic changes Computed tomography angiography (CTA) uses an injection of contrast material into your blood vessels and CT scanning to help diagnose and evaluate blood vessel disease or related conditions, such as aneurysms or blockages In Thesis, CTA helped determining the occlusive of cerebral location, collateral flow 1.2 Endovascular mechanical revascularization method to treated acute ischemic strokes due to large vessel occlusion 1.2.1 Mechanical thrombectomy systems - The first generation with Merci (Merci Retrieval System) device of Concentric Medical and Penumbra system (Penumbra system) of Penumbra Inc - The second generation has stent Solitaire (Solitaire FR stentriever) of Covidien, stent Trevo (Trevo ProVue stentriever) of the Stryker company and A Direct Aspiration First Pass Technique (ADAPT) of Penumbra Inc 1.2.2 Complications of endovascular mechanical revascularization - Complications related to contrast drugs: Hypersensitivity reactions, acute kidney injury - Complications related to the intervention process: Intracranial haemorrhage, cerebral arterial dissection, embolization to new or target vessel territory, access-site problems, reocclusion after thrombectomy - Complications related to the process of care and treatment 1.2.3 Studies on endovascular mechanical revascularization to treated acute ischemic strokes due to large vessel occlusion - In the world, typical and famous are studies using DCCH of 2nd generation, showing high revascularization rate (up to 88%), patients with good neurological outcomes from 45 to 72%, windows treatment is extended 6-8 hours That is research MR CLEAN, ESCAPE, SWIFT PRIME, EXTEND-IA, REVASCAT - In Vietnam, studies at Bach Mai Hospital, Ho Chi Minh City University of Medicine and Pharmacy, People's Hospital 115, Hospital 108 reported results of revusculation from 71 to 89% and results good neurological recovery from 42 to 63% CHAPTER SUBJECTS AND METHODS 2.1 Subjects - Patients with acute ischemic stroke were examined and treated at the 108 Military Central Hospital - Study time: from June 2016 to March 2018 2.1.1 Criteria for selecting patients - Criteria for diagnosis of acute ischemic stroke due to large vessel occlusion: + Clinically (based on WHO): Sudden facial drooping, sudden arm weakness, sudden speech difficulties + Used noncontrast CT scan was taken to exclude presence of intracranial hermorrhage, determine ASPECTS score + Used CTA to identify located artery occlusion The large vessel include: Internal carotid artery, Middle cerebral artery (segment M1, M2) - Criteria for selecting patients to apply mechanical thrombectomy based on 2018 guidelines for management of acute ischemic stroke of American Heart Association/American Stroke Association: (1) prestroke mRS score of to 1; (2) causative occlusion of the internal carotid artery or MCA segment (M1); (3) age ≥18 years; (4) NIHSS score of ≥6; (5) treatment can be initiated (groin puncture) within hours of symptom onset and (6) relatives of patients agree to apply the technique and participate in study 2.1.2 Criteria for exclusion of patients Relative contraindications follow the 2018 guidelines for management of acute ischemic stroke of American Heart Association/American Stroke Association: - Patients with severe systemic diseases such as liver failure, severe renal failure, coagulopathy, late stage cancer - There is a history of allergy contrast drug - History of severe head trauma, myocardial infarction or cranial surgery in the last months - Risk of high bleeding: Platelet count times normal 2.2 Material and ethods 2.2.1 Type of study A prospective, descriptive and comparative before-after study 2.2.2 Sample size Sample size: This is before-after study, so we calculate the sample size for the study using the following formula: n= Including: n: sample size Z: coefficient of confidence, α = 0.05 and Z (1- α/2) = 1.96 p: The ratio of patients with good neurological recovery results after 90 days p = (p1 + p2)/2 p1 = 0.36: the rate of patients with good neurological recovery (mRS: 0-2) after 90 days when apply mechanical thrombectomy with MERCI, in the Multi-MERCI study was 36%; p2 = 0.59: The proportion of patients with good neurological recovery results after 90 days, in ADAPT study was 59% in the study of Vargas J in 2017 So the result of p = (0.36 + 0.59) / = 0.47 D: The difference between the two ratios: D = p2 - p1 = 0.59 - 0.36 = 0.23 F = 7.85: Sample force of 80% corresponds to a level of p meaning 0.05 In conclusion: n= The minimum study object was 72 patients 2.3 Evaluation criteria 2.3.1 Purpose 2.3.1.1 Clinical evaluation = 72 - Clinical manifestations confirmed by neurological and stroke examination - Glasgow score based assessments by Graham Teasdale and Bryan J Jennett (1974) - Assessment of muscle strength according to the British Medical Research Council in 1994 (Medical research coucil - MRC grade) - Evaluation of NIHSS scores: Stroke scale of the National Institutes of Health Stroke Scale (NIHSS) was introduced in 1989 point …………… No stroke symptoms 1-4 points ………… Minor stroke 5-15 points ………… Moderate stroke 16-20 points ……… Moderate to severe stroke 21-42 points …………Severe stroke 2.3.1.2 Evaluate the results of computed tomography images - Early signs of ischemic stroke on nonconstrast CT scan + The hyperdense artery sign: Caused by new blood clots in the vessels, often observed in the middle cerebral artery + Hypo attennuating brain tisue including: Cortical sulcal effacement, loss of the insular ribbon, obscuration of the lentiform nucleus, loss of gray-white matter differentiation in the basal ganglia - Evaluating ASPECTS score on noncontrast CT Alberta Stroke Program Early CT score (ASPECTS) is a 10-point quantitative score used to assess early ischemic changes on non-contrast CT head ASPECTS is intended to provide a reliable and reproducible grading system on non-contrast CT examinations of the head for detection of early ischemic changes in patients suspected of having acute large vessel anterior circulation occlusion - Determine the location of occlusion vessel on CTA: where the contrast drug does not pass or pass less than the opposite side, which is the obstruction or narrowing of the artery - Collaterals and clot burden were determined on baseline CTA The collateral score grades distal arteries filling with a 4-point scale with (+) constituting absent collaterals (0% filling of the occluded territory), (+) 1for poor collaterals (>0% and ≤50% filling of the occluded territory), (+) for moderate collaterals (>50% and 0.05 1.1 With AIS due to LVO of anterior system, CT images normal was 29.1% The rate of patients with ischemic after hours (81.7%) was higher than before hours (55.8%), the difference was statistically significant with p hour p OR 40.0 0.05 Conjugate Eye Deviation Glasgow score < NIHSS score >15 ASPECTS score 0.05 0.01 >0.05 >0.05 Poor collateral flow on CTA 2,4 1,6 - 3,1 < 0.05 There were factors: Glasgow score < (OR= 2.9; 95% CI: 1.43.9; p=0.01) and poor collateral flow on CTA (OR=4.2; 95% CI: 1.63.1; p