Intervention in Stroke- Intra-arterial
thrombolyis and Mechanical thrombectomy
Dr Sanjeev Nayak
Consultant Neuroradiologist
Introduction




Stroke is the major cause of disability in the developed world
In the UK it accounts for 11% of deaths, it results in
significant morbidity of people who survive and represents a
substantial health and resource problem (NICE 2009)
Its early diagnosis is important as its treatment is dependent on
the time elapsed since the onset of the symptoms. Delay in
diagnosis and treatment translates into increase neuronal loss
and thereby increased morbidity.
Reperfusion remains the mainstay of acute ischemic stroke
treatment [4]

IV rtPA therapy for acute ischemic stoke improves 3-month
outcome if given within 3 hours of onset.

However > 50% do not demonstrate a favourable outcome

In several series mechanical clot disruption with IAT has been
shown to achieve higher recanalization rates.
Stroke in STOKE
Period : Jan 2010 to August 2010 (8 Months)
Total Number of Acute Strokes: 758 patients
Patients treated with IV rtPA : 39 patients
Patients treated with IA rtPA ± Mechanical thrombectomy : 18
Subjects and Methods:
A review of 18 patients presenting to our institution over a period of 8 months
with acute stroke where CTA confirmed the presence of a thrombus
These patients were resistant to IV rtPA and underwent partial to complete
clot removal either with IA thrombolysis or in conjunction with mechanical
thrombectomy.
13 of the 18 patients underwent mechanical thrombectomy
Solitaire AB device was used in 12 of the 13 patients
Thrombus-aspiration and guide wire thrombus dislodgement was attempted in 1.
Clinical Protocol:
Neurological examination was performed on all acute stroke patients
either by a neurologist or a stroke physician.
Main Inclusion Criteria:
Anterior Circulation Strokes:
•Age < 80 yrs
•NIHSS ≥ 8
•Onset of symptoms within 8 hours of treatment
•No large hypodensity on plain CT Head
•Occlusion of a major cerebral artery on CT Angiogram
Posterior Circulation Strokes:
•Time window extended up to 12 hours
•No haemorrhage on presenting CT Head.
An admission and post-interventional NIHSS score calculated on
all patients.
A 30-day MRS was then recorded on all these patients.
Clinical follow-up and rehabilitative care was then undertaken
through a multi-disciplinary approach
Imaging Protocol:

All patients underwent plain CT Head and CTA arch to COW

Patients with intracranial major vessel/cervical carotid occlusion
secondary to a thrombus were included for the intervention

Occlusion were either present at proximal M1 segment of MCA,
M1/M2 junction, terminal ICA or basilar occlusion

TIMI scores were recorded post procedure

Post procedural CT was performed at 24 hours and repeated at
necessary intervals depending on the clinical status of the patient.
Anti-thrombotic protocol






0.9 mg/Kg rtPA is the total dose per patient
Of which 0.6 mg/kg is adminsterted IV upon clinical and
imaging diagnosis of acute stroke (Bridging dose)
10% of the IV dose is given as a bolus.
0.3 mg/Kg is given intra-arterially in the neurointerventional
angio suite.
A maximum of 30 mg rtPA is administered intra-arterially
3 of our patients did not receive rTPA and only mechanical
thrombectomy was performed in them.
*One fell off the CT table and there was concern about any
bleed
*In other 2 the time of onset of symptoms was not known
Thrombectomy Protocol using a
Solitaire AB device








Interventions performed via femoral approach
6F guiding catheter placed in ICA/Vertebral artery
DSA performed to visualise the location of thrombus
Clot passed with a microwire and a 18 microcatheter
Super selective contrast injection performed via the
microcatheter to define the distal end of the clot.
Solitaire AB device was then placed within the clot for 3-5 m
Entire system withdrawn back into the guiding catheter with
50mls of negative suction applied at the level of guiding
catheter
Up to 3 attempts performed
46 yr. old male with presenting NIHSS score of 15
Micro catheter Run
Solitaire-AB in position
NIHSS improved from 15 to 3
PRE
AND
POST
THROMBUS
•6-8 hours since
onset of AC
symptoms
•< 80 year-old
•<12 hours since
onset of PC
symptoms
•<80 year-old
CT:
no established
infarction
CT:
no bleed
No contraindication*
CTA
Thrombus on CTA:
•bridging IV thrombolysis with 0.6mg/kg
• + remaining 0.3 mg/kg IA on table
•+/-thrombectomy
Age
Sex
Symptoms to
presentation
interval(mins)
Clinical presentation
CTA findings
1.
68
m
300
Headache 7/7, collapse, GCS 6,intubated
Distal basilar and P1 seg of PCA thrombosis
2.
67
f
310
Right facial , UL and LL weakness, dysarthria
Thrombosis of left M1 and M2
3.
65
m
540
R facial LMN palsy, L 6th N palsy, diplopia,
profound ataxia and confusion
Basilar artery thrombosis
4.
53
m
95
Right facial weakness (LMN), dysarthria,
Right vertebral art thrombosis (intra dural seg)
5.
47
m
180
Facial and limp weakness, dysarthria
M2 segment thrombosis
6.
65
m
650
Profound ataxia, left facial, arm and leg
weakness plus left nystagmus
Left vertebral and basilar thrombus
7.
70
m
55
Right LMN facial weakness, nystagmus
Small basilar thrombus
8.
76
m
85
Left dense hemiplegia
Complete occlusion of M2
9.
71
m
40
Right sided weakness and aphasia
M3/4 and A2 thrombosis
10.
46
m
60
Left sided weakness
M1 thrombosis
11.
81
m
210
Left dense hemiplegia, left conjugate gaze and
aphasia – Right TACS
Complete occlusion of M1
12.
72
m
120
Right dense hemiplegia, hemi anopia and
aphasia – Left TACS
Occlusion of M1
13.
65
f
60
Dysphasia, right facial, right UL 0/5, right LL
2/5
Occlusion of M1
14.
71
m
150
Right dense hemiplegia, aphasia and right
neglect – Left TACS
Occlusion of paraclinoid ICA involving M1
and A1 segments
15.
65
f
180
Left sided weakness
Occlusion of M1 and part of M2
16.
61
m
NK
Found collapse with GCS 4
Basilar thrombus and left PCA
17.
22
f
210
Right sided UMN signs, left conjugate gaze,
reduced GCS
Thrombosis of M1 segment of MCA
18
43
M
120
Left Sided weakness
Right MCA thrombotic occlusion
NIHHS
On
admission
Time
To Tx
( hrs)
Duration
Of Tx
IA
MT
No of Solitaire
passes
Post Rx
TIMI
Score
Post Rx
NIHHS
score
MRS on discharge
1.
BS
60
65
N
N
-
3
BS
2
2.
16
80
180
Y
N
-
2
11
4
3.
BS
60
240
Y
Y*
-
2
BS
4
4.
BS
120
90
Y
Y
NA
3
BS
1
5.
23
60
85
Y
N
-
2
11
3
6.
BS
60
105
Y
N
-
3
BS
1
7.
BS
125
105
Y
N
-
3
BS
1
8.
17
140
160
Y
Y
2
3
8
2
9.
8
280
90
Y
Y
-
2
15
4
10.
15
120
90
Y
Y
1
3
3
2
11.
31
200
180
N
Y
4
3
27
4
12.
22
150
60
N
Y
2
3
6
2
13.
10
130
85
Y
Y
2
3
5
2
14.
25
150
180
N
Y
4
0
26
4
15.
27
90
105
Y
Y
3
3
14
2
16.
BS
60
170
Y
Y
NA
3
NA
5
17.
14
70
80
N
Y
NA
3
1
1
18
15
75
70
Y
Y
1
3
0
0
Results
•Time of onset to A&E presentation
Anterior Circulation (12 patients) : 40 min to 310 min (Median value 150 mins)
Posterior Circulation (6 patients) : 55 min to 650 min (Median value 300 min)
1 patient with no known time onset.
•Common Presenting Symptoms:
Anterior Circulation: Dense hemiparesis, neglect, dysphasia
Posterior Circulation: Headache, profound ataxia, cranial nerve palsies, collapse
•CT Head : No established infarction or intracranial bleed.
•CTA : Major intracranial vessel occlusion
Time to Treatment (A&E to angio suite): 60 min to 280 min (median 105 min)
Duration of Interventional Procedure: 60 min to 240 min (median 102 min)
Mechanical Thrombectomy: 13 of 18 patients (Solitaire 12 patients)
Number of passes with Solitaire: 1 to 4 passes (median 2 pass)
12 Anterior Circulation Strokes:
Admission NIHHS: Between 8 and 31 (median 16)
AOL recanalization and TIMI reperfusion scoring system from IMS I review
Score
AOL Recanalization
Score
TIMI Reperfusion
0
No recanalization of the primary occlusive lesion
0
No perfusion
I
Incomplete or partial recanalization of the primary
occlusive lesion with no distal flow
1
Perfusion past the initial occlusion, but
no distal branch filling
II
Incomplete or partial recanalization of the primary
occlusive lesion with any distal flow
2
Perfusion with incomplete or slow
distal branch filling
III
Complete recanalization of the primary occlusion
with any distal flow
3
Full perfusion with filling of all distal
branches, including M 3, 4
AOL indicates arterial occlusive lesion; TIMI, Thrombolysis in Myocardial Infarction
Anterior Circulation Strokes (12 patients):
Pre-TX
NIHHS
Post-TX
NIHHS
Improvement
Discharge
MRS score
16
11
5
4
23
11
12
3
17
8
9
2
8
15
Worse
4*
15
3
12
2
31
27
4
4
22
6
16
2
10
5
5
2
25
26
Worse
4*
27
14
13
2
14
1
13
1
15
0
15
0
Anterior Circulation Strokes (12 patients)
MT performed in 10 patients (Solitaire)
TIMI 3 recanalization: 8 (80%)
* MT aborted in 1 patient due to anaesthetic concerns
* MT unsuccessful in 1 patient
Anterior Circulation Strokes (12 patients)
•Improvement in NIHHS score of ≥ 4 : 10 patients (83.33%)
•Discharge MRS of ≤ 2 : 7 patients (58.33%)
•Discharge MRS of 3: 1 patient (8.33%)
•Discharge MRS of 4 : 4 patients (33.33%)
*MT not performed in 1 patient (only IA given)
*MT aborted in 1 as the anaesthetist raised concerns of bleeding
*MT performed in 1 but no revascularisation acheived.
*MT successful in 1 but developed patchy infarction.
Posterior Circulation Strokes (6 patients) :
TIMI SCORE
Discharge MRS
3
2
1
4
3
1
3
1
3
1
3
5 (locked in)
Posterior Circulation strokes (6 patients)
3 patients underwent MT (50%)
3 treated with IA (50%)
Complete Recanalization (TIMI 3) : 5 patients (83.33%)
Discharge MRS of ≤ 2 : 4 patients (66.66%)
MRS of 4 : 1 patient
MRS of 5 (Locked in) : 1 patient
REVIEW OF 18 CASES
OUR RESULTS:
Recanalization Rates : (TIMI III 72%)
Recanalization achieved with Solitaire Device : 91% TIMI III
Discharge mRS of ≤ 2 : 11 patients (61%)

Multi Merci Trial
Recanalization Rates (TIMI II/III) : 68% (TIMI III not reported)
mRS scores ≤ 2: 36%

Penumbra Trial
Recanalization Rates (TIMI II/III: 82% ) (TIMI III: 27%)
mRS scores ≤ 2: 25%

72 year old male, NIHSS improved from 22 to 6 in 24hrs
43 yr. old male, Mr L, Presented at 21:45 hrs. Friday night
1st Pass with Solitaire Device
Intra-Arterial with 23mg rtPA
2nd Pass with Solitaire
Complete revascularization, NIHSS improved from 15 to 0
Patient Discharged on Sunday afternoon!!
61 yr old male found collapsed GCS 4
2 passes with Solitaire
IA rtPA
Complete Revascularization
Modified Rankin Scale
2
1
No
Mild
Independent
3
Moderate
4
Moderately
Severe
Dependent
5
Severe
Conclusion



Early interventions in acute stroke reduces patient
morbidity and mortality and is extremely costeffective.
Always aim to achieve complete revascularisation in
suitable patients
The relationship between reperfusion and clinical
outcomes, is not linear and depends on other factors
including intensity and duration of the ischemia,
baseline stroke severity, collateral circulation, cerebral
perfusion pressure, lesion location and lesion volume