all our cases with TCAR I'm going to show you the last case here which is a 75 year old who had a previous left carotid endarterectomy for an asymptomatic stenosis with a patch. He had a laryngeal nerve palsy which is one of the things
that clearly stent buys you advantage with with no laryngeal palsies. And 18 months later came back with a high-grade asymptomatic recurrence that you see here. But a nice looking flat type 1 arch which was then done in the GORE scaffold
trial. And I just show you this because remember i told you this is a membrane covered stent and people were worried about preserving flow to the external. But it really actually looks very nice when it's done. So here's my answer.
Thank you very much Michael for giving me this opportunity and thank you everybody for having me it's a great honor to be here. So again I'd like to thank you for your patience and attention and restructuring the schedule today so thank you.
So I want to talk about some of the key things that we do in the neuro world. Neuro world is about two broad concepts. If there's a blood clot you want to get rid of it. If there's a blood vessel abnormality that is either at risk or has caused
hemorrhage you want to trying and take care of it. So the talk is going to exemplify many different cases that fall in one of these two categories. And when this happens...either the blood clot or hemorrhage... you really have a stroke. And the sooner
you can treat it the less disability the brain suffers. Because time is brain and stroke is a neurologic emergency. ...It's not on....can you hear me now... Okay well let me say stroke is a neurological emergency and the two categories of
strokes that fall into that are ischemic and hemorrhagic. So I'll be presenting different examples of cases that we deal with and these run the gamut and I've tried to highlight by picking cases that exemplify what we do. So both
ischemic and hemorrhagic strokes are brain emergencies. And recent studies have shown that an ischemic stroke you can actually revolutionize patient's outcome by selecting patients and using modern technology to treat
them. Intracerebral hemorrhage is no different and Dr. Gaughen actually set the stage for aneurysms as being an example of that. I'll show you some cases there. It's important to recognize that you don't
stop the subarachnoid hemorrhage when it comes to hemorrhagic disease you also have been intracerebral hemorrhage. And there are multiple underlying vascular abnormalities that actually cause our intracerebral hemorrhage and it's
important to be vigilant and pay attention and pick up these entities that you can treat. So stroke is a
treated. 77-year old guy comes in with slurred
speech. Left side of the face left side of the arm they're both weak. Patient was last known well sometime at night and has hypertension cholesterol. Has had a history of heart attack and heart failure takes Plavix.
There is a standardized way of assessing these patients symptom severity and that's called the NIH Storke Scale. It goes from 0 to 42 points and this patient's number of points is 12. And it's an under-representation of the severity of
the patient's symptoms because the way you measure this is weighted for right sided symptoms rather than left sided symptoms. Anyway the patient gets IV tPA to thrombolyze because if the patient came in
within a three to four and a half hour window. He was eligible and he got tPA. The tPA reduces the disability score from 12 to 9. It did not decrease any further. Why is that. Well it's like saying that the kitchen fire extinguisher should be
able to be as equally effective as a fire truck that comes to put out a very massive fire. Small fire in your kitchen can be handled by the kitchen fire extinguisher. But if you have a building on fire that kitchen fire extinguisher isn't
going to do anything. So in this case the way to think about this is the clot is big for what tPA can be expected to handle. So the pointer is not working and I don't think you can see the arrow. But the circle on the picture that shows
the CT scan of that patient's brain is dusky within the circle compared to other areas. Dusky brain is brain that is ischemic. It is on its way to die unless you do something. The scan on the other side with the arrow
pointing to is the blockage of a blood vessel that supplies that area of the brain. So if you can open up the blockage in a timely fashion you can prevent that dusky brain turning into completely dark brain which means it's dead brain.
Ok so people have looked at this and said okay tPA is a good medicine its FDA approved for patients who come in with stroke symptoms of who don't have bleeding in the head who could be having ischemic strokes. It works. But just like
the example that I used it can't be expected to be effective for every clot size. And that's that that's what the figure shows. ICA MCA Stem MCA division and MCA branch are all different distances from where the carotid bifurcates. Ok.
The farther out you go in the blood vessels branch the smaller it gets. Which means a small clot will cause a small branch to be occluded but not a large branch to be occluded. So therefore if you have a small clot in a small branch
tPA has a better chance of breaking that clot up than a large clot which is stuck in a more proximal branch. And that's intuitive. But somebody actually looked at those numbers and they said well you know what what we thought
turns out to be true. If you give tPA to all comers with ischemic stroke it has a less than one in three chance of being effective and opening that blood vessels. And if you look at the location of the blood clot to where
the branches as you go farther out into smaller branches and block that blood vessel and then give tPA the more effective tPA is for the smaller clot than it is for the larger clot. So that's intuitive and that's what this study shows. So this
explains why maybe the gentleman who came to our ED...77-year old man...didn't fully respond to tPA. So if this were about 12 years ago we would have used the device that's on the left called MERCI device. It's like a cork screw on a
catheter end of a wire end which is fed through the catheter to the area the blockage and you engage the clot and you pull it out. As you move along the timeline more and more devices started to become available for thrombectomies.
So the next device is Penumbra. You've heard that device in the previous talk. And it has that little separator wire that's got a little bulb which distrupts the clot mechanically as the other catheter goes up and down which is
connected to a suction device. They were effective but by the time they actually open the blood vessel that didn't seem to make a whole lot of difference. Not as effective. Patients didn't do all that well despite having spent the time. So the
field continue to work towards something that was more effective in opening up blood vessels. Then came 2011 there abouts when 2012 two devices came out that are both called stent retriever both Solitaire and Trevo and the picture is
what you see. It's a collapsible stent that you cannot leave. It's not a detachable stent that you advance against the clot beyond the clot and unsheath. And engage the clot so that you can retrieve the whole stent back.
And when you retrieve it back you find that the clot has also been retrieved. Ok so there are two devices they're both FDA approved. And there is now overwhelming data that mechanical thrombectomy is very successful and
effective in opening up these large vessel occlusions. There's one more device that has since undergone a iteration in development and that's the Penumbra 5MAX ACE and there are few additional devices. They're nothing
more than if you think about it like a Dyson vacuum cleaners. it's a large-bore aspiration catheter that you go ahead and park in the face of the clot turn on the suction canister which is connected to this
aspiration catheter and you engage the clot with this vacuum and the aspiration catheter. Wait a few minutes and then retrieve the clot back. So with these new technologies we have actually seen great improvement in how
we can benefit our patient. So what we did in the 77-year old gentleman is you can see there is that arrow showing on this side of the screen where there is blockage. You see that the central blood vessels fill but the ones going
towards the side of the screen the MCA branches don't. On the other side where there's the circle that's the lateral view showing that the branch is going to the top of the head fill but the ones going towards the side of the head
right over here they don't fill. So in this case we went ahead and deploy a stent retriever. I can't remember whether it was Solitaire or Trevo it was one of the two. And the red line on that image outlines where the stent is spanning
between from the distal end to the proximal end where the clot is. After five minutes we removed the stent retriever and what you see is fragments of clot that are brought back. And now that blood vessel that was included is
fully open as you can see where the arrow shows. And the circle outlines what was missing its now fully filled in. So this gentleman comes back to see me in clinics a month later. Walking in no deficits. How representative is this
of the results that we saw in the trials. There were five major trials. Now there are more that have all shown that somebody who comes in has a large blood vessel occlusion like this gentleman did if you treat them in this fashion
there is a roughly sixty to seventy percent chance that they will be independent after such treatment. Previously the independent score was at best high thirties. So this is a big revolution in the way we treat the
ischemic stroke patients. Now there are other this is not just a one-off there may be such examples that we see daily. You have a blood vessel here that's the carotid artery and it stops at the skull base.
Beyond that there is no blood flow. So we use not just a stent retriever but a combination of stent retriever and aspiration catheters and after using these devices in multiple passes were completely able to open up that blood
vessel. Ok. What this patient was left with was that area that's demarcated in a circle that's all the stroke that he has. And he actually walked out of the hospital. And what we pulled out is laid out on
the bottom and those are the different clot fragments each time we did this procedure we recovered. And it measures several centimeters actually. So again this patient also went some from very high disabling numbers to actually no
deficit at the time of discharge. Here is
up with. So this is a 75 year old man with sudden vision loss in his left eye. The usual risk factors. Had a have a PVL and outside institution which was deemed normal. And then there was a CTA done to look at the culprit lesion.
And I'm going to show you just some still pictures because I want you to look at a couple of things. So calcium in the arch. Again 75 year old man remember. Bovine arch. So all of a sudden now we got two complicating factors and a
calcified lesions here symptomatic. And here's what it looks like. Obviously we did this with TCAR so there's a little carotid cut down here. You can see our retractor in place. And a very tight lesion which doesn't look perfect but
a little different to the cardiologist who say...yeah it's a little bit hazy here and it's not perfect...we would accept that. Because if you remember if you go from a 90% lesion to a 30-percent lesion in the carotid you never
treat a primary 30-percent carotid lesion. And again the proof is in the pudding. So the hemodynamics the next day by duplex... this is an internal crowded waveform in the stent and they're normal. So leave that alone.
Don't get crazy about trying to make it look perfect.