Advanced Treatment Options for Stroke Patients

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Advanced Treatment Options for
Stroke Patients
Vickie Gordon PhD, ACNP-BC, CNRN
Stroke
• Stroke is the rapidly developing loss of brain
function(s) due to interruption in the blood supply to
the brain and can result in permanent neurological
damage.
• Two Types
– Ischemic Stroke
– Hemorrhagic Stroke
Ischemic Stroke
• Occlusion (50%)
– Large vessel (ICA)
– Branch (MCA)
– Perforator (lacunar)
• Embolization (25%)
– Intra/Extracranial
– Cardiac
• Cryptogenic (25%)
Limitations of IV rtPA
• Generalizability
– 4% utilization of rtPA
– 25% present within 3 hours: 29% eligible
• Major strokes are difficult
– Baseline NIHSS >10 or dense MCA sign predicted poor
clinical outcome
– Large vessel recanalization rate low.
• Increased risk of sICH with larger strokes
Recanalization Acute Ischemic Stroke:
Endovascular Treatment
• Contra indication to IV rtPA
• No change in NIHSS score one hour following
administration of IV rtPA
• 3 hour treatment window has expired but less than
10 hours
• Severe neurological deficits (NIHSS>16)
– Evidence of major cervical or intracranial vessel
occlusion
Recanalization Acute Ischemic Stroke: Endovascular
Treatment
• Treatment within 8 hours; longer in some cases
(posterior circulation).
• IV/IA rtPA
• Merci Retrieval Device (FDA approved)
• Penumbra Aspiration Device (FDA approved)
Endovascular Treatment
• Femoral or radial access
• Series of catheters
– Sheath
– Guide Catheter
– Micro catheter
• Wire navigation
Biplane and 3D reconstruction
Intra-Arterial rtPA Treatment
• rtPA into the thrombus
Mechanical Embolectomy
Merci Device
Mechanical Embolectomy
Penumbra
Extracranial Stenting
• Extracranial Carotid Artery
Stenosis
• Distal Protection
Intracranial Stenting
• ICAD accounts for 10-29%
of brain ischemic events
• Symptomatic ICAD 25% of
patients with 70-99%
stenosis had a stroke
within 2 years
• Balloon angioplasty alone
not effective
Intracranial Stenting
• Gateway Balloon and
Wingspan Intracranial
Stent
• Balloon Angioplasty
• Stent Placement
New Strategies
• Thrombolytic
– rtPA alternatives
– IIb/IIIa inhibitors
– TCD enhanced thrombolysis
• Neuroprotective
– Mild Hypothermia
– Albumin
– Drug Therapy
• Endovascular
– EKOS (ultrasound enhanced thrombolysis
– Neuroflo (perfusion augmentation)
– Stent Retriever
Reperfusion: Neuroflo Device
EKOS Neurowave
Etiology of Hemorrhagic Stroke
Intracranial Aneurysm Rupture
• Treatment options
– Surgical clipping
– Endovascular embolization (coiling)
• Goal is to exclude the aneurysm from the cerebral circulation and
prevent rupture or re rupture while not producing adverse
neurological outcomes.
Aneurysm Treatment
• Coil Embolization
– Platinum coils
– Platinum alloy
– Microfilaments
• Stent Placement
– Adjunctive to coil placement
• Balloon Assist
• Polymer Embolization
Coil Devices
•
•
•
•
Diameter
Length
Shape
Tensile strength
Types of Coils
Coil Embolization
• Balloon-assisted
– Temporary inflation of the balloon in the parent artery
during coil positioning.
• Advantage no permanent device left in artery.
• Disadvantage: temporary occlusion with each coil.
• Stent-assisted
– Deployment in the parent artery acts as a scaffold for the
coils.
• Advantage: no temporary occlusion.
• Disadvantage: requires anti platelet therapy.
Aneurysm Treatment/Balloon Assist
Aneurysm Treatment/Stent-Coil
Aneurysm Treatment/Polymer Embolization
AVM treatment
Intraparenchymal Hemorrhage Treatment
Clinical Management: Preprocedure
• Peripheral Pulse check
• Baseline neurological
check
• Baseline vital signs
• Baseline Lab results
• Baseline ACT
• Anti-platelet therapy
(plavix, aspirin, aggrenox)
• Contrast allergy pretreatment (Benadryl,
Prednisone,
hydrocortisone)
• 2 IV lines (all interventional
patients)
• Maintaining immobility
• Rapid recovery after
anesthesia
– Neuro-protection
• Management of
anticoagulation
• Manipulating systolic blood
pressure
– Avoid nitrates
Clinical management: Postprocedure
•Neurological check
•Vital signs
•Monitor Lab results
•Anti-platelet therapy
(plavix, aspirin, aggrenox)
•Peripheral Pulse check
Complications of Endovascular Treatment
• Morbidity and Mortality of
endovascular treatment- 510%.
• Cerebral Infarction
• Cerebral Hemorrhage
• Cerebral Edema
Cerebral Infarction
• Thrombus formation
– Intra procedure
– Post procedure
• Parent artery dissection
• Parent artery occlusion
– Coil migration
– Stent migration
• Cerebral vasospasm
• Vessel Re-stenosis
Cerebral Hemorrhage
• Aneurysm rupture
• AVM rupture
• Ischemic reperfusion injury
– Hemorrhage
– Contrast extravasations
• Parent artery perforation
Cerebral Edema
• Peaks 3 to 5 days following
injury
• Increased risk with large
hemorrhage or hemispheric
infarcts
• Increased risk of brain
herniation.
Impact of Cerebral Infarction, Edema and
Hemorrhage
Thank you
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