1. To review the current imaging techniques and the individualised patient imaging assessment for acute ischaemic stroke.
2. To overview the current endovascular indications and techniques for acute ischaemic stroke.
3. To discuss the current endovascular treatment challenges, such as tandem lesions, distal occlusions and treatment beyond the six-hour time window.
During the last years acute ischemic stroke (AIS) treatment has been revolutionised with the introduction of endovascular treatment - thrombectomy (ET). Several randomised controlled trials have clearly shown the clinical benefits of this treatment and, recent studies have broadening the inclusion criteria, specially concerning the therapeutic time window. Imaging has a central role in the acute ischemic stroke management. Diagnostic neuroradiology is essential to make the correct diagnosis of AIS and to select the appropriate candidates for ET. Imaging provides all the information needed for patient selection, excluding stroke mimics, depicting the vessel occlusion and defining the potential salvage brain tissue: evaluating the collateral arterial circulation status, the extent of irreversible lesion (core) and/or the extension of potentially reversible ischemia (penumbra). Interventional neuroradiology has achieved tremendous clinical results with the fast and high recanalization rates, but further improvements are expected. There are still some technical aspects to be improved, such as the tandem lesions, distal occlusions and anaesthesiology protocol, which will be discussed in this session. In parallel, several organisational processes, from local department/hospital to regional/national organisation, must be optimised, in order to fasten the patient access to the correct stroke center and increase the number of patients treated. The radiology/neuroradiology departments’ organisation and professionals are critical for the implementation of AIS national health strategies.
1. To review the current indications for endovascular treatment in acute ischaemic stroke.
2. To overview the endovascular treatment techniques for acute ischaemic stroke: stent retriever and aspiration.
3. To discuss the different options of anaesthesia type, blood pressure control, and post-thrombectomy medical treatment.
Endovascular thrombectomy has clearly demonstrated its benefit for primary treatment of patients with acute ischaemic stroke from large vessel occlusion. During the past years, mechanical thrombectomy was mostly done by the use of stent retrievers. But, due to ongoing technical developments and experiences on the job, other techniques, such as thrombus aspiration and mixed techniques, has emerged as effective treatment tools as well. Although today very fast procedure times with impressive recanalization rates can be achieved using these techniques, it is still of utmost importance to select the correct patients for endovascular treatment to avoid futile recanalization and to prevent additional harm to ischaemic stroke patients. Besides the proper indication setting, optimal clinical circumstances during and after the procedure should be pursued as well. In this lecture, current insights into the indication setting, different endovascular techniques, choices in supportive care during an endovascular procedure and post-thrombectomy medical care will be discussed and illustrated.
1. To review the literature data regarding the incidence, natural history and treatment of tandem lesions.
2. To overview the endovascular treatment techniques for the treatment of acute ischaemic stroke: stent retriever vs aspiration, and current indications for endovascular treatment in acute ischaemic stroke.
3. To discuss the potential indications for stenting in the setting of acute ischaemic stroke and tandem lesions.
In 20 - 30% of patients with acute ischemic stroke due to a large vessel occlusion of the anterior circulation, who are eligible for endovascular treatment, a concomitant ipsilateral cervical internal carotid artery stenosis or (pseud)occlusion is present. These so-called tandem lesions are known to be relatively refractory to intravenous rtPA administration and clinical outcome is therefore poor if not treated endovascularly.
Recent studies have shown a large treatment benefit of endovascular treatment in these patients, comparable with the treatment effect in patients who have an intracranial occlusion without cervical carotid pathology. In current guidelines thrombectomy of the intracranial occlusion is therefore recommended for patients with these tandem lesions. However, no clear guidelines for the management of the extracranial carotid pathology exist, because no evidence for the optimal management is yet present. Several options like carotid stenting in the acute phase, before or after thrombectomy, PTA only followed by delayed stenting or delayed carotid endarteriectomy are available. Furthermore, different carotid pathologies like dissections and atherosclerotic lesions obviate a uniform treatment recommendation.
Various extracranial carotid artery pathologies, different treatment options and available evidence from published studies will be presented and discussed in this presentation.
1. To review the literature data regarding the incidence, natural history and treatment of distal arterial occlusions.
2. To review the literature data regarding the incidence, natural history and treatment of wake-up strokes and arterial ischaemic strokes beyond the six-hour time window.
3. To discuss the potential indications for endovascular treatment beyond the proximal arterial occlusion and beyond the six-hour time window.
Most of the guidelines recommend endovascular recanalization in patients with acute ischaemic stroke due to large vessel occlusions up until 6 hours after symptom onset. Metaanalysis of pooled individual patient data from 1287 patients in MRCLEAN, ESCAPE, REVASCAT, EXTEND and SWIFTPRIME trials suggests that the benefit of thrombectomy rapidly decays over time and may no longer exist beyond 7.3 hours from stroke onset. The just published DAWN Trial has evaluated late and unwitnessed stroke patients. Eligible patients, with clinical and imaging mismatch (defined by age, core, and NIHSS), who receive mechanical thrombectomy have better outcomes, compared to standard medical therapy. This treatment effect is the highest out of any stroke trials to date and suggests that the presence of clinical-core mismatch is a critical predictor of treatment effect independent of time to presentation. Metaanalysis of randomized trials favoured endovascular treatment across all sites of occlussions with better endovascular treatment effect in patients with thrombi in ICA and proximal M1 MCA segments than in those with thrombi in distal M1 MCA or M2 segments because proximal thrombi are larger in volume , less likely to recanalize with intravenous alteplase and more easily reached by endovascular thrombectomy. The question of benefit with more distally located occlusions in the M2 middle cerebral artery segment is only partially addressed, because randomized trials had very few patients with more distally located occlusions in the M2 middle cerebral artery segment and do not have enough power to fully confirm benefit or harm in these patients .