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Introduction- Stroke | Neuro-Interventions
Introduction- Stroke | Neuro-Interventions
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Background on Patient Selection for Ischemic Stroke | Neuro-Interventions
Background on Patient Selection for Ischemic Stroke | Neuro-Interventions
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Keys to Good Outcomes in Ischemic Stroke | Neuro-Interventions
Keys to Good Outcomes in Ischemic Stroke | Neuro-Interventions
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Techniques for Treating Stroke | Neuro-Interventions
Techniques for Treating Stroke | Neuro-Interventions
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Case- Stroke - 64 year old male | Neuro-Interventions
Case- Stroke - 64 year old male | Neuro-Interventions
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Importance of Endovascular Thrombectomy | Neuro-Interventions
Importance of Endovascular Thrombectomy | Neuro-Interventions
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Case- Stroke, hyper dense sign, acute clot | Neuro-Interventions
Case- Stroke, hyper dense sign, acute clot | Neuro-Interventions
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Transcript

I'm Sabine and I know a lot of you through online social media through Twitter thanks for inviting me and you know the topic is neuro intervention and it was a little bit of a big topic so I decided to focus a little bit more on to stroke and so out of the people in the

audience now who is participating in stroke thrombectomy so we got a lot good good and that's it's it's something that's really cool and you know I was at Northwestern and actually we didn't do any of that for a body trained person so

I'm gonna kind of go into how we do stroke and why it became such a big deal in 2015 so that just changed the topic to stroke care and you know it'll kind of go into that so sorry this thing's a little bit slow I think the other person

really hard there we go so no disclosures and I have a lot of pretty videos here so it should kind of help you with your post food coma post afternoon lunch so these guys I have to hand it to these five gentlemen a lot of

them are here at the conference the first two I work with and they you know literally hand held me through my first like hundred cases so because I had no I've never even put a catheter above the neck when I came to this job and they

basically taught us in fellowship to be pretty scared of the brain so I have to hand it to these guys who are who are really just shapeshifters and the whole on the whole field and today we're gonna you know I won't bore you with like the

trials and all this I just want to you know especially for those who don't do stroke maybe get you excited and maybe we'll try to do some of that in your lab and like I said I had a ton of unk experience at Northwestern that's what

they're known for why 90 Wow 90 why 90 my cerebral experience was zero my PA D experience was zero - so of course the job I ended up going to that's all they do is all cerebral in PA D so it was kind of funny

and the reason I'm kind of putting this here is that for those that don't do it's it's it's totally you can learn and it's not something to be scared about even some of the tips and tricks I'll show you here how we do our setup

and everything it shouldn't you shouldn't be worried about it if you're you know if you're IRS are worried about doing it it's it's all doable PIH it's in Whittier not many people know where the hell Whittier is so I put it on a

map that's where we are next to LA and I grew up near Whittier I didn't even know it existed but it's a nice little niche place so you know what has really

changed in stroke imaging and I'm gonna go over that now acute stroke is a big

time deal I mean you get about eight hundred thousand strokes per year just in the US and over 90% of them are ischemic there's two types of strokes ischemic and hemorrhagic and you know it can kil

and the brain is a pretty tough organ and it basically it's there's not much room for error but the one thing it does have is it has collaterals and that's what makes stroke thrombectomy work

because the collaterals are supplying just enough blood to that area that has the clot to keep it alive for a little bit of time and so those collaterals come from the pia peel and the circle of willis so that's kind of the background

of why stroke thrombectomy works and everyone will talk about how time is brain so time is brain two million brain cells per minute are dying I mean I don't know how they measured this number but we always say

it now - two million brain cells every minute so this is out of you know I don't do trauma my Center but this is the only thing I will I will jump out of bed and rush to work overnight for call because every second counts and you know

what really changed now strokes been around for a while but I never really heard about it until 2015 and so then I kind of looked at why what happened so intervening on stroke it has been around for a while

1995 I'm sure all of you have done thrombolysis this is basically they started doing it in the brain they would drip some TPA hope to break up the clot and these trials proact 1 and to show that there was a benefit there was a lot

of bleeding as you can imagine and blood in the brain is no bueno so then 2001 came along and you you had this mercy device and mercy was invented at UCLA and it was the first clot retriever

before penumbra before any of this and I'll show you a picture of what the mercy device was but that was back in 2001 so these folks at UCLA were doing it in 2009 and 2012 more devices came out and so this is looking great

everything's looking like stroke is here to stay but then in 2013 basically three trials came out that said intervening on stroke sucks don't do it it showed that there was a higher mortality in those patients who you intervene on so

basically in 2013 all these companies got sad a bunch of neuro IRS was like okay we're not doing this anymore but luckily per imaging really changed so radiology really changed how to select patients and so now we could

finally see which of these patients who are suffering from an ischemic stroke has brained it safe they didn't have that before so we use all these color maps all these pretty color maps that actually they're very easy to read and

their perfusion imaging so then they redid the trials selecting the right patients and it was pretty crazy six trials at the same time came out of 2015 you've probably heard of these someone talked about mr. clean escapes Swift

Prime all these came out and amazingly they came out all around the world at the same time so this was the highest level of data and all of it showed that stroke thrombectomy was a game-changer it showed that if you select the right

patients you're gonna get really really good results so in 2015 that's when it really really ramped up so it's pretty new in the game even though it's been around for a while is is doing stroke now even now you've maybe heard of

diffuse and dawn people have talked about how you can you can intervene on patients up to 24 hours since their stroke started and you get we've even done longer than that everyone's brain is different and you

just have to you know use that higher imaging standard called perfusion to see what's available so what are keys to

good outcomes now the stroke care is a total team approach I mean everyone's working together different Doc's ER

neurology whoever's doing the intervention you know the EMTs are involved I mean they're the ones who first assess the stroke and they call the hospital and say I think we have a large vessel

occlusion and so things are already getting ramped up in radiology ICU texts and nurses all that stuff we're working together to get these patients on the table and intervened and then all the post stroke management too so it's

always been shown to I mean everyone is looking at times it's almost like a STEMI where everything is recorded and especially for neuro and Stroke lumpectomy hospitals in order to maintain their certification need to

record everything so as long as you're involved early in the workflow things are helping and we're still trying to make make our times better even just a couple minutes shaved off here and there it can help now

there's guidelines out there this thing is 255 pages and who wants to read 255 pages and it's pretty long but their guidelines and just to kind of review some things that no one really even follows the guidelines now I mean there

has been strokes in pediatric patients that people will intervene on all these different words NIH SS that's a stroke scale assessment aspects is there's different things that I'm going to show you all of these things are guidelines

so now no one even really follows these numbers I mean they're a good way to start but you can really change your management again on that perfusion so probably perfusion is one of the most important aspects and you know a lot of

things can mimic stroke he actually had a whole stroke activation for a patient one time at my hospital and we did the whole CT and everything everything looked fine and then it was found that the blood glucose was 34 I mean so

there's these things a patient looked like he was having a stroke but he was just hypoglycemic so a lot of times you have have things like that now even your INR are your platelets being below you can still

intervene and and pretty much nothing stops they have renal failure it doesn't matter you just it's then they start talking about neurons over nephrons and so they just put a really high priority on getting the thrombectomy because it

is life changing and imaging is so important so they you know I'll stress again and again this is what perfusion has really changed you know your selection for a stroke candidate and we use CT most centers use CT you can do

MRI - but MRI you know slower and not always available and so most people will just do what they call it triple scan which is a non-contrast CT head and that's to see if you have any blood that's one of the things that will

probably be a contraindication to stroke thrombectomy and then the CT a head and perfusion so you always see the docs like looking at these color maps they look nice but they're really important so these are

the color maps I mean I think anyone can see that there's all this red on that side of the brain and that's the red that's what we call penumbra and so what we are always looking at so CBF is cerebral blood flow MTTs mean transit

time just means how much time does it take for blood to get there so the longer it is the red and that's that's why that value is abnormal and then cerebral blood volume so when the volume is in tact that means your collaterals

are giving enough flow to that area so that's showing that this the CVV map is normal and MTT is abnormal so all that brain is at risk so potentially if you can take out that clot you'll save that entire side of the brain and that's

where this perfusion imaging comes about and you know we use all these numbers aspects mr-s Stroke Scale and you don't have to know them per se but just to know that the higher the number is usually worst except for aspect so

always ask you what's the abscess score and that just tells you on a very you know primitive way on a non-contrast CT what brain is at risk and now you know whenever I get called about a stroke these are the the questions that

go through my head you know when did this when did the symptoms start what's the stroke scale you know but even though all these questions that are in my head all I'm really caring about is a profusion map and it's not that's

really gonna guide me to what what goes where and so you know what part of the

techniques so you know this is where our whole team is getting involved it's you're scrubbing in I'm scrubbing in and and prepping I'm doing the lines

everyone's just again shaving minutes off at that time and I try to look at the imaging to to guide how I'm gonna go up into the neck yeah that was one thing that was hard for me when I started a few years ago to be to get stable access

in the neck and so I learnt have to learn all these new catheters and techniques and so I learned about arch anatomy so the first thing is is you can have different types of aortic arches and it looks easy that image looks like

oh yeah it's easy for me to get my catheter and one of those vessels but actually it's it's really really hard your catheter just want to push out in order to get something stable it's really hard so that was a whole

technique part of learning that I was I thought was probably the hardest thing is stroke but you can see what my guys kind of taught me is the coaxial technique so there's no wider exchanges there's nothing like that everything and

this saves some time you basically you have an 8 French long sheath and you have a guide catheter and a wire and literally everything just rails up so you can get up and you can see in this video it's a little hard to see but

there's a little there's a catheter going there then I'm pushing that up and then there's another bigger catheter down below that's a balloon guide catheter and so that's gonna go up that there's no there's no exchanging there's

no like working with exchange length wires and things like that you can just get everything up there really quick you can see these angles look kind of tough I mean that's where things get pushed out and everything and but once you kind

of learn the catheters and everything it gets it gets a lot easier now I'm a Ford okay so and then everything we have these stroke packs I mean everything the last thing you want to do is be thinking about what do I

need to open up what do I so we have everything kind of just laid out this is how we're gonna do it now there's different sizes and things like that but really most of the things are all there and here's the coaxial technique I

mentioned you know this is something that in the body sphere we don't really do that much you're using two E's and stuff like that appropriately but in cardiac and in neuro it's very important to have like no bubble-free lines closed

systems and this this having this coaxial technique really speeds things up so that's the catheter 2e and the balloon guide catheter and you know it work this is kind of our lab where we do our neuro cases and it can be it's

pretty stressful during a narrow case because everyone's just kind of on there going as fast as they can but you know this is how our setup usually is we try to have two Doc's in there if we can during the day it kind of helps and then

our techs also really enjoy we have fun and stuff like that so that's during one of the neuro cases and ideally we'll have two Doc's and two texts scrubbed in so it's a lot but it does help with workflow so now once you get into the

neck then the other part of the procedure is the brain obviously you want to get the clot out now I knew some Anatomy when I started but it it it's really hard to think about the brain anatomy and because you're using biplane

you're using everything and everything overlaps I found these two pictures which is nice because this shows you you know the difference whenever you inject the carotid artery or you're gonna pacify the ACA and the MCA and those

vessels all overlap in both planes but this shows you a nice clot that's in the ACA so you can see the MCA and then a clot in the MCA so you can see the ACA so you it took me a little bit of time to like look at these pictures and

really you know define what vessel is what but once that one it just took cases to do now this is a balloon guide catheter we don't really use in the peripheral place either accept some people are

using it now in like Bertos and and car tows and things like that but on its a really nice catheter a lot of the data supports using a balloon guide catheter to be your base catheter and what it does is that balloon

inflates right there is the balloon and it stops the blood flow in your neck so you actually want to stop the blood flow when you're pulling the clot because that will be that will give you more chances of recovering the clot and then

also not letting the clock go distal more further into the brain so that's why this works this catheter is a little bit more bulkier I use it most of the time there's another one I use called neuron max and I kind of like the neuron

max more but this this both works pretty well now whenever this this little article here was actually it's a really good representation of why can we retrieve these clots and really all it is it sounds all fancy but you're

dropping the pressure before the clot and when you drop the pressure then they can suck in so all these devices you see that's all they're doing they're trying to increase the pressure gradient and and decrease the pressure behind the

clot so you can suck it in and you have these catheters distal axis catheters they're super expensive but they're really really necessary they let you go up the up the neck and this is what gets right on top of the clot and then you

have these thrombectomy devices now I mentioned this in 2001 UCLA created this kind of corkscrew looking thing you don't see this anymore because even though this video shows that it can retrieve clots it just would unravel so

you would pull it and the whole thing would unravel and you wouldn't really get your clot so it doesn't work like that in the video but it was the first of its kind then they basically changed the whole design to these stent

retrievers and stent retrievers is a stent that's attached to a wire it doesn't it doesn't detach so you literally step stent the clot and then you've pulled it then the clock gets incorporated into the stent and you pull

it and so that's what the technique is now using stent retrievers are just aspirating the clock and so here's how they deploy that's dent in there and after a little the time you can pull the stent again these videos are ideal

and that the whole clot comes down so that's a stroke thrombectomy and there's all these little intermediate catheters or whatnot in between to help you retrieve these clots these are the two ones that are mainly used there's more

on the market coming out but you got solitaire at rivo and again you get into the brain and then you know these neuro surgeons and neuralyzed IRS decided to create all these names for different techniques so you can see there there's

eight different techniques there's probably even more about how you can recover these clots seems kind of crazy but literally a lot of them are just doing the same thing and and I would say most operators now do adapt or do trap

and that's basically trapping or sandwich in the clock or just aspirating it which I'll show you both of those and got to know other things how to do carotid stenting things like that medical management these are things that

I'm still learning about one in my in my field in my experience

well I'll kind of show you a case just to kind of show you what what it looks like and so when are you doing it an angiogram you can see that there's a

clot that that little vessel there's no pointer up here is there okay so the vessel that's going going to the right of the image that's the MCA and so there's a big clot there you should see all these other vessels that you kind of

see start filling in later those are the collaterals so that's what you see on the first image when you see those collaterals you know that okay that brain is probably still alive so let me get this clock so this is what happens

you basically get that little micro catheter up there and this is deploying the stent so in the middle that's deploying the stent and you just is basically pin pulls is pretty amazing a little tiny device so that's the stent

across the clot into the middle cerebral artery and then what you do and I labeled it here so you can see so you have that solitaire stent Retriever and then you have a base catheter intermediate catheter and then you have

that balloon guide so you can see all that work near there and this technique is when you pull the stunt retriever into the catheter so you literally pull it in now more people don't pull the whole thing

in they take it out as a unit called the trap or sandwich but this just shows you something like that and then you you do another image and there you go so that now you have the blood flow into the middle cerebral artery and it's pretty

it's a good feeling when you sit like okay you know obviously you're not how the woods get you're pretty much banking that that patient's brain is gonna be okay but usually it is and so say for this patient this was the perfusion map

so you see everything that's at risk there at the end of the case this was an MRI done the next day the the white area is what infarcted and that's okay that's your basal ganglia the patient will be asymptomatic because you just need one

so the whole other part of the brain which controls speech controls movements everything that is back so you know that's a good feeling this patient you know went home in two days and was fine versus before they were gonna you know

probably not be able to maintain independent lifestyle so here here this video is a little bit long when it shows you the ADAP technique which is just getting that catheter to the clot and we don't have to show it this one's like a

minute long but you just get the catheter to the clot and aspirate people are now trying to look at the data what's better using a stent Retriever or not and surprisingly it shows that the adaptor the aspiration technique is

working as well then you save a lot of money cuz those stent retrievers are really expensive technically it's kind of hard to get that clot the catheter up there at times but we're always mentioning Tiki scores

once we do a clot retrieval and the Tiki score just means perfusion we want three we're happy with A to C which is a new one or a two B anything below to be not that great and we consider it a failure even though all of these start off at

zero so we really want a to B or higher and grade three just means you have completely normal perfusion um so you'll see these people kind of all the docs I was like screaming like a tiki to to III that's what that

stuff means and just for a little

perspective is why stroke is so you know hot right now I mean here's the number needed to treat means the number of patients you need to do to get an immeasurable outcome and so for lung

cancer screening programs where people are getting C T's of the chest to see if they have lung cancer you need to scan 217 patients okay mammograms right how you need to scan 84 you need to do 84 mammograms to find a

cancer all right what about PCI for STEMI so you need to treat 50 patients in order to save a life doing a STEMI then what about everyone knows what a defibrillator is I mean someone goes on the cardiac shock you need it treat

three people to save a life their stroke is two so you need to treat two people to save a life and making measurable outcome so that's why this is such an important procedure why everyone wants to do it because it's one of the most

effective therapies again if you pick the right patient and here are just different clots that we've taken out you know I used to take pictures a lot but it says that they come out you know sometimes they come out one piece

sometimes they come on multiple different pieces but that one that that case I just showed you is that middle square and it is really satisfying so for those of you who already do it I'm sure you guys are pretty familiar with

this this is more for those like me who never even saw a stroke case and saw what could what could you do now again time is brain and there's a big need now not all operators and there's a lot of drama in the whole field of who

should treat stroke neurosurgeons and neuro IR or something like where we should be the only ones doing it there's IRS like me said no we can do it there's cardiologists who want to do it so it's a lot of drama right now but there's a

need not by just based on numbers even if all neuro IRS and neurosurgeons did it they can't manage to do all the strokes so there's a need and we're in the process of trying to figure out some guidelines

and stuff like that with SAR that paper is going to be released in the next we next month or two but we we are showing that even a body you know trained person can learn it but just defining by doing it appropriately

you know again the need is there because all these centers when you drip in shit meaning you give TPA and then you ship them out to another Center you lose a lot of time time is brain you lose two hours that's a lot think about two

million brain cells per minute so you know EMTs are in charge of where you're taking them and it's getting so much attention that even Wall Street Journal brought out this article last year in in 2018 it said you know the stroke care is

amazing but you might not get it if you go to the wrong hospital so it's something that's you're gonna see a lot more in the next couple of years and you know we're working on on the drama side of it - we finally were able to change

Jake owes mind and now Jake o is on board of having da di ours to it so that was like a big win but you know I I know plenty of people who feel very strongly against you know people like me doing it but I think it's just you had a show

that you can do it safely so and you know this was I took this these slides from David sacks and who runs loose sar stroke course which is actually gonna be in a couple of days and he just runs the numbers and when you look at the numbers

you know that there you need like ano strokes so we need people and you know I think I bought e i RZ you do have enough training you just need to be taught and

mentored now there's a plenty of articles to that show that it's effective and safe so I'm just showing these because a lot of times I RS are scared like to do it and especially they're not trained but they can and

again the guidelines will be out very very soon so this was this is the this is the old statement this was in 2009 so that 2019 which I became part of - is and these are all the authors of it so again

that's gonna really change some of the landscape - and help people get trained we're sending up training and everything as well now our our techs and nurses also had to learn how to how to manage stroke patients and everything they all

loved it now - so I'm just gonna end

with a kind of a cool case that this is this is a non-contrast CT of the head and if you look in the center this is one we call a hyper dense sign so this is that basilar artery the vertebral

it's brighter than the rest of the brain that's a cute clot so that's when we say hyper dense sign I've never seen one this big in and in the basilar artery so this was a case he was a 35 year old guy he just had a knee replacement surgery

he was doing his PT on post-op day - and he just fell he just became comatose with either the CT and so we immediately took them you know now to talk about these maps again cerebral blood volume is normal but you can see the MTT is all

increased in the cerebellum and cerebellum whatever not that big of a deal but your brainstem your brainstem carries everything so you can become locked in locked-in syndrome or pretty much died with the basilar stroke so he

ended up taking him and oops sorry let's see if this will play you can see sorry can you play in the back both yeah there if you just go forward one it should play yeah so you can see there's no blood flow going to the back of the

brain that's an injection of the left vertebral artery and there's no flow going up there and so you get your catheter past the clot so that's that caught that catheter is in the posterior cerebral artery PCA and in this one we

dropped a stent retriever and did the trap technique which is removing it as a unit you can see it kind of being removed and he goes into the catheter on the back and then you do this so this is

what the clock looks like so that clock came out in one big piece like a femoral vein right there and he had it out happening was he had a patent foramen ovale at a PF Oh and he developed a blood clot post arthroplasty and this

went straight to his brain and but he was fine and we ended up opening his his basilar artery he literally woke up like 20 minutes later and he was fine so again that's when you you see there was a little bit

of a stroke in his cerebellum but that was totally asymptomatic and so you know that's why I find these cases really satisfying you know not all of them go like that and I quote about 30% of cases doing well and then the other 70% not

going so well but it's still pretty good and so I mentioned Twitter I am on it and pretty active on it a lot of people I learned so many things and and these are some good accounts for neuro but I've really learned so much and now I

met the process where I I'm like teaching techniques to my guys who taught me and I'm like learning these off of Twitter so it's kind of interesting I always hated on Twitter when I when I feels like who who signs

up for that like it's all about Instagram but it's it's pretty it's it's an amazing platform and you can learn a lot so I definitely recommend to sign up for it and that's it and you can email me or contact me any questions Thanks

[Applause] [Music]

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