9/8/2009

National Stroke Association

presents
Acute Stroke Treatment:
Evidence and
Opportunities
September 10, 2009

This program is supported by educational

grants from Genentech, Inc. and Penumbra,
Inc.

Accreditation
This activity has been planned and
implemented in accordance with the
Essential Areas and policies of the
Accreditation Council of Continuing Medical
g the jjoint sponsorship
p
p of
Education through
Medical Education Resources and National
Stroke Association.
Medical Education Resources is accredited
by the ACCME to provide continuing
medical education for physicians.

9/8/2009

Accreditation
Medical Education Resources is an approved
provider of continuing nursing education by
Colorado Nurses Association,
Association an accredited
approver by the American Nurses Credentialing
Centers Commission on Accreditation.

Credit Designation
MER designates this educational activity for a
maximum of 1.5 AMA PRA Category 1 CreditTM.
Physicians should only claim credit commensurate
with
ith the e
extent
tent of their participation in the
activity.
This CE activity provides 1.5 contact hours.
Provider approval expires July 31, 2010.

Disclaimer
The content and views presented in this
educational program are those of the authors and
faculty and do not necessarily reflect those of
Medical Education Resources or National Stroke
Association. Before prescribing any medicine, primary
References and full prescribing information should be
consulted. All faculty members participating in continuing
medical education programs sponsored by MER are
expected to disclose any real or perceived conflict of
interest related to the content of their presentations. Faculty
disclosures are included in your program materials.

9/8/2009

Learning Objectives
At the conclusion of this activity, participants should be able
to:
Describe the incidence of ischemic stroke and the
opportunity to maximize patient outcomes.
Describe guidelines-based acute ischemic stroke treatment
strategies.
Identify clinically important recent advances in stroke
management and apply the latest guidelines into clinical
practice.
Access enduring resources to assist clinicians to educate
themselves and make modifications to current practice
and/or process.

The Critical First Hours

in Acute Stroke:
The Emergency Department
Edward C. Jauch, MD MS
Associate Professor
Department of Emergency Medicine
Associate Professor
Department of Neurosciences
Medical University of South Carolina
Charleston, SC

Disclosures
Consulting
Genentech (2008)
Research support
Novo Nordisk
National Institutes of Health support
IMS-III, SPOTRIAS, ALIAS2, FAST-MAG

9/8/2009

Lecture Goals
Briefly review the pathophysiology of
brain ischemia
Review treatment options for ischemic
stroke
Highlight critical steps in the Emergency
Department
Brief look at the future

Pathophysiology of Ischemic Stroke

Cerebral Blood Flow Thresholds
100

CBF ml / 100 gm / min

90
80

Normal

70
60
50
40
30
20

Hypoperfusion

10

Oligemia

Abnormal neuronal
function documented by
a correlation with acute
clinical deficit

Ischemia

Penumbra
Infarct

(Muir, Lancet Neurology, 2005)

Goals of Early ED Management

Penumbra
Abnormal neuronal function documented by a
correlation with acute clinical deficit
Physiological and/or biochemical characteristics
consistent with cellular dysfunction but not death
Uncertain fate but salvage is correlated with better
clinical recovery

Limit penumbral progression

Physiologic optimization
Targeted neuroprotection
Global (pluripotential) neuroprotection

Optimize blood flow

Restore flow and improve collateral flow

9/8/2009

Other Time Dependent

Neurologic Emergencies
Altered Mental Status

Coma /
Cardiac
A
Arrest
t

Stroke
/ TIA

Weak &
Dizzy

Trauma

System Development:
Learn from Trauma & Heart Attacks

Protocol & center development

Increase public awareness
Rapid access to EMS
Prehospital notification
notification, triage
Prehospital diagnosis, interventions
Confirmatory tests
Strong collaboration with specialists
Team and protocols in place in ED
Door to Drug/Groin
or Golden hour of trauma

61 year old male, acute aphasia, right facial

droop, and right sided weakness
12:30

Sudden onset while

working in yard

12:45

Family calls 911

13:05
13 05

Ad
Advanced
d squad
d
evaluates, rapidly
triages and transports

13:15

Squad notifies
receiving hospital of
possible stroke patient;
hospital notifies team

9/8/2009

61 year old male with possible stroke

Arrives at Our Lady of Faint Hope
13:30
ED triage and
physician evaluation
13:45

Stroke Team responds

p

14:00

CT scan performed

14:15
Discuss with family
and PMD
14:20
Critical data back
FSBS gluc 97
BP remains 150/70s

Detection
Dispatch
Deliveryy
Door
Data
Decision
selection
Drug
Disposition

Early recognition
Early EMS activation
Transport & management
g
ED triage
ED evaluation & management
Neurology input, therapy
Thrombolytic & future agents
Admission or transfer

Dispatch: 911
Delivery: Transport & Management
Public education
EMS education

ABCs
Stroke recognition
Time of onset
Neurologic evaluation
Glucose
Early hospital notification
Rapid transport (Air?)
Transport family

Triage to stroke centers

(Silliman Stroke. 2003;34:729 733)

9/8/2009

Door: Emergent Triage

Data: ED Evaluation

61 yo male with possible stroke

14:20

CT reading: No
hemorrhage or
early ischemia

14:25

Checklist done:
No exclusion
criteria met

14:30

Decision time

61 yo male with acute stroke

The decision to treat
14:35

IV rt-PA given
Patient weight 90 kg
0.9 mg/kg total (90 mg max dose
10% (8 mg) bolus
Remaining 90% (73 mg) over 1 hr

15:45

Patient goes to ICU

Report personally given to ICU staff

15:50

Pathway actions begin

(HOB, BP, aspiration
precautions, carotid ultrasound)

9/8/2009

Decision: Team Approach

Drug:
IV, IA, Mechanical, Other

Goal Directed Therapy for

Cerebral Resuscitation
Like sepsis, early goal directed therapy will
improve stroke outcome
Look to other forms of brain injury for
guidance (post-cardiac arrest syndrome)
Limit ongoing injury
Organ support
(Nolan Resuscitation 2008; 79:350379)

Goal Directed Therapy for

Cerebral Resuscitation - Stroke
Glucose control
Current goal 140-185 mg/dl
GRASP (GIK for glucose > 110 mg/dl)
Control by stroke subtype

Temperature control
Hyperthermia prevention
Induced hypothermia
Mild (35oC)
Moderate (33oC) CHILI, COAST-II
(Bruno Stroke. 200;39:384-389)

9/8/2009

Goal Directed Therapy for

Cerebral Resuscitation - Stroke
Optimal oxygenation
Hypoxia is bad
Normobaric oxygen (45l/min)

Optimal BP management
Extremes associated with worse
outcomes
ICH studies will come first
(Leonardi-Bee Stroke 2002;33:1315-1320)
(Singhal Stroke. 2005;36:797-802)

Current Recanalization Options

No recanalization

Recanalization strategies
Intravenous rt-PA
0-3 hrs (I A)
3-4.5 (I B) with specific patient selection

Other investigational treatments

Intra-arterial thrombolysis (I B)
Embolectomy (IIb B)
Acute intracranial stenting (III C)

(Stroke. 2007;XX)

Limitations of IV tPA
Generalizability
4% utilization of tPA
~25% present within 3 hours; 29% eligible
12323 screened for 180 in PROACT II

Big strokes are difficult

Baseline NIHSS >10 and a dense MCA sign
predicted poor clinical outcome
TTATS recanalization rate of no more than 30%
for large vessel occlusion

Sustained recanalization in only 10-20%

Increased risk of sICH with larger strokes
(Kleindorfer Stroke 2004; 35:27-29)
(Tomsick. AJNR 1996; 17:79-85)
(Genentech, Summary basis for Activase approval. NDA. PLA96-0350)
(Alexandrov. NEJM 2004;10:1379-83)

9/8/2009

Extending the Therapeutic

Window
The optimal temporal window remains
elusive
Two strategies to increase eligibility
Identifying a optimal subset using clinical
variables
Utilize advanced imaging to identify
salvageable tissue

CT and MRI: Core / Penumbra

A CBV MTT with recanalization small

stroke
(Majda Thurnher,
University
of Vienna)
E CBV
MTTMedical
big
stroke
(Parsons Neurology 2007;68:730736)

61 year old male s/p t-PA

Hospital Course
Carotid U/S shows 60 -80%
stenosis left ICA
Speech recommends
swallowing II diet and daily
checks
Physical therapy ongoing
CEA performed day 4
Patient discharged day 7
back to baseline except
slight increase in golf
handicap

10

9/8/2009

The Future of Stroke Treatment

Prevention! Prevention! Prevention!

Increased public and medical education
Stroke systems
Primary, comprehensive, enabled
New diagnostic tools
Neuroimaging, markers
Thrombolytics
TNK, rPA, Ancrod
pp
IA,, specialty
p
y catheters,, stents
Intra-arterial approaches
Combination agents
Antiplatelets, LMWH, GPIIbIIIa
Collateral augmentation Invasive, noninvasive
Cerebral protection
Hypothermia, neuroprotection,
traditional Chinese medicine
Surgical
Hemicraniectomy, cell transplant
Rehabilitation
Constraint therapy

61 year old male s/p rt-PA

24 hour follow-up
Initial NIHSS = 10
24 hr NIHSS = 3
Mild facial palsy
Right arm drift
Mild dysarthria

Repeat CT shows infarct

Selected Ongoing Clinical

Reperfusion Trials
Recanalization studies
New lytics (TNK stopped)
Multidrug approach
CLEARER,, ROSIE,, Argatroban
g

Combined IV IA
IMS-III

Combined IV IA device
IMS-III, MR Rescue, registry

Patient selection IA
MR Rescue, PICS, EXTEND
RETRIEVE, PISTE, DAWN (p)

Intracranial stenting
Ultrasound enhanced thrombolysis

11

9/8/2009

Collateral Enhancement and

Flow Augmentation
Attempts to increase perfusion
via stenoses and collateral
circulation
Willisian and leptomeningeal
collaterals

Medical approaches
Rheologic (albumin, hemodilution)
Induced hypertension (CHIPPS)

Device approaches
Intra-aortic obstruction (SENTIS)
Counter pulsation (CUFFS)
SPGS (ImpACT 24)

Ongoing Neuroprotective Studies

Targeted
Prehospital magnesium (FAST-MAG)
1298 pts; 2o from onset

Minocycline
y
to Improve
p
Neurologic
g Outcome
High dose albumin (ALIAS)
Citicoline (ICTUS)

Global
Hypothermia
Surface and intravenous
With and without tPA
With caffeinol

PhotoThera The laser

Conclusions
The burden of stroke will increase
In acute brain injury, time will remain brain
p systems
y
and teams to optimally
p
y
Goal to develop
treat
Multiple approaches will likely be involved
Reperfusion
Physiology optimization
Aggressive rehabilitation

Ongoing trials will provide important

guidance

12

9/8/2009

Acute Stroke Treatment

The Therapeutic Window for Intravenous
Thrombolysis: An Update
Steven R. Levine, M.D., FAHA, FAAN
Professor of Neurology
The Mount Sinai Stroke Center
The Mount Sinai School of Medicine
New York, New York

Disclosure Statement
Research funded by NIH & Gaisman
Foundation
MEDLINK Associate Editor
NSA Acute Advisory Board
SAMMPRIS Executive Committee
External/Independent Monitor: IMS III,
CLEAR-ER, FASTMAG, INSTINCT
Off-label application
Intravenous rt-PA between 3-4.5 hours from
stroke onset

ECJ1

Mrs. Smith
She is 76 with a history of hypertension, cigarette
smoking and hyperlipidemia. She has no prior
stroke history. She is taking anti-hypertensive and
statin therapy.
At 10:15 a.m. she notices a funny feeling in her
left arm and doesnt
doesn t seem to be moving as well as
the right one. She doesnt think much of this and
continued to cook.
Her husband comes home at 1:00 p.m. from a
round of golf and notices her face seems
somewhat crooked and she is slurring her words.
He asks her how she feels and she says her left
arm feels funny.

13

Slide 39
ECJ1

This is a lot of text. Several slides have >9 lines of text which may be hard to read depending on the
viewing circumstances
Edward Jauch, 8/7/2009

9/8/2009

Mrs. Smith - 2
He is concerned and calls 911 and EMS brings her
to the local ED where the stroke team is called
stat after the EP finds at 1:20 p.m. dysarthria &
left-sided weakness and orders a stat head CT
scan & blood work. He establishes time of stroke
onset at 10:15 a.m. BP = 164/94. EKG shows NSR.
The
Th neurologist,
l i t iin th
the h
hospital,
it l responds
d and
d fifinds
d
an NIHSS of 8:
2 points for LUE motor
1 point for LLE motor
1 point for facial asymmetry
1 point for partial visual field impairment
1 point for dysarthria
1 point for partial sensory loss
1 point for extinction/neglect

Mrs. Smith - 3
Mrs. Smith is back from head CT at 1:50
p.m. & the CT is read as normal except for
possibly subtle EIC in the right parietal
lobe; labs are normal.
The
Th neurologist
l i t has
h recently
tl h
heard
d & read
d
about treatment with IV t-PA up until 4.5
hours with some benefit but knows it is not
currently FDA-approved. She discusses
with Mrs. Smith & her husband the
potential risks and benefits for off-label
use.

Mrs. Smith - 4
Given the couples tremendous fear of a
disabling stroke and being dependent, they
readily request treatment, even though it is now
2:05 p.m.
g documents her discussion with
The neurologist
the patient and her husband in the chart, and
has a witness sign, time, & date the note.
t-PA is ordered & mixed, per the NINDS t-PA
protocol* and the IV bolus is started at
2:25 p.m.
*NINDS rt-PA Stroke Study Group: Tissue
plasminogen activator for acute ischemic stroke.
New Engl J Med 1995;333:1581-1587.

14

9/8/2009

Mrs. Smith - 5
2 hours after the t-PA bolus, Mrs. Smith NIHSS is
6:
1 point for LUE motor
1 point for LLE motor
1 point for facial asymmetry
1
1 point for dysarthria
1 point for partial sensory loss
1 point for extinction/neglect

24 hours after t-PA, her NIHSS is 4:

1 point for LUE motor
1 point for facial asymmetry
1 point for dysarthria
1 point for partial sensory loss

Mrs. Smith - 6
24 hours after t-PA, Mrs. Smith was placed on
325 mg/d of enteric coated aspirin, her dose of
statin was raised as her LDL-cholesterol was
160. She was provided with smoking
cessation counseling, information &
medication, & a physiatry consult.
Mrs. Smith was evaluated for the etiology of
her stroke and was found to have a 2 cm right
parietal infarct on DWI MRI and a high-grade
right extracranial ICA stenosis for which she
underwent CEA 2 weeks later.
LDL = low density lipoprotein; DWI MRI = diffusion-weighted imaging
magnetic resonance imaging; CEA = carotid endarterectomy

Favorable Outcome (mRS 0-1, BI 95-100,

NIHSS 0-1) at Day 90
Adjusted odds ratio with 95% confidence interval by stroke
onset to treatment time (OTT) ITT population (N=2,776)

ECASS, ATLANTIS, and NINDS rt-PA

Stroke Trial Investigators: Combined
A l i Lancet
Analysis,
L
t 2004;363:768-74
2004 363 768 74
Basis for ECASS 3

mRS = modified Rankin Scale;

BI = Barthel Index; ITT = intention-to-treat

15

9/8/2009

ECASS 3:Thrombolysis with Alteplase 3 to 4.5 Hours

after Acute Ischemic Stroke
Hacke W, et al NEJM 2008;359:1317-1329

A phase III RCT to test the efficacy of IV rt-PA in AIS

patients treated between 3 - 4.5 hrs after stroke
onset
NINDS rt-PA p
protocol ((but DVT tx)) but excluding:
g
Age > 80 years
On oral anticoagulation (independent of INR)
Baseline NIH Stroke Scale score > 25
A history of stroke & diabetes

Primary endpoint: 0-1 mRS at 3 mos.

821 patients: 418 rt-PA & 403 placebo
Median time to tx: 3 hrs 59 min

IV rt-PA now shown to be beneficial if given

within 3-4.5 hours of stroke onset
Increases t-PA treatment window by 50%
Endpoint

tPA

Placebo

Favorable
52.4
Outcome
(mRS 0 or 1)
at 90 Days (%)
Endpoint
Any ICH

45.2

1.34 (1.02 - 1.76)

.04

Global favorable outcome OR 1.28

(1.00-1.65) vs. 1.9 (1.2-2.9) in
NINDS t-PA Trial

tPA

Placebo

27.0

17.6

.001

0.2/3.5

.008

Symptomatic ICH 2.4/7.9

Mortality

Odds Ratio (95% CI)

7.7

8.4

.68

Hacke W, et al NEJM 2008;359:1317-1329

ECASS 3 Results

Hacke W, et al NEJM 2008;359:1317-29

16

9/8/2009

Recommendations: An Advisory Statement from the Stroke

Council, American Heart Association & American Stroke
Association - del Zoppo et al: Stroke 2009;40:2945-8
rt-PA should be administered to eligible pts within 3.0-4.5 hrs
after stroke (Class I Recommendation, LOE B)
Eligibility criteria in this time period similar to those for persons
treated at earlier time periods with the following additional
exclusion criteria:
Age > 80 years; Oral anticoagulant use with INR 1.7*;
1 7*; baseline NIHSSS > 25;
a history of stroke and diabetes
(*For the 3.0 4.5 hr window all pts receiving oral anticoagulant are excluded
whatever their INR).

The efficacy of IV rt-PA within 3.0 4.5 hrs after stroke in pts
with these exclusion criteria is not well-established & requires
further study. (Class IIb Recommendation, LOE C)
Delays in evaluation & initiation of rt-PA should be
avoided because the opportunity for improvement
is greater with earlier treatment

Safe Implementation of Thrombolysis in StrokeInternational Stroke Treatment Registry 3-4.5 hour Study
(SITS-ISTR 3-to-4.5 hour)
Post hoc sampling of limited data from Dec 2002 Nov 2007
from the ongoing International Registry
11,865 patients treated with t-PA within 3 hrs compared with
664 patients treated with t-PA within 3-4.5 hours (Walgren et al
L
Lancet
t 2008;372:1303-9)
2008 372 1303 9)
72% treated after 3 hours were between 3-3.5 hours
While there were several weaknesses in this study, no
differences were found between the 2 groups for:
Symptomatic ICH
Mortality
mRS 0-2 at 3 months

Number needed to treat to benefit and to harm for IV t-PA in the

3-4.5 hours window - Saver et al Stroke 2009;40:2433-37
Number of Patients Benefited and Harmed Per 100 Patients Treated With
Intravenous t-PA in Different Time Windows
NNTB = 6.1
NNTH = 37.5

13 Hours
NINDS t-PA Trials

34.5 Hours
ECASS 3 Trial

For transitions across all 7 levels of the mRS

Benefit per 100

Harm per 100

32.3

16.4

3.3

2.7

For individual dichotomizations of the mRS

Net BPH 0 vs 16
Net BPH 01 vs 26

7.7

5.7

16.1

7.3

Net BPH 02 vs 36
11.9
Mean mRS difference in NINDS tPA trials was 0.53 and in
ECASS 3 trial it was 0.21. BPH indicates benefit per 100.

5.0

17

9/8/2009

Why do we need a Bridging Protocol?

Recanalization & Reocclusion post IV rt-PA:
63 Patients with MCAO
UT-Houston TCD Data, Courtesy of James Grotta

No recanalization = 27%
Partial recanalization = 33%
Complete recanalization = 18%
Reocclusion = 22%
Sustained recanalization rates:
12% at 60 & 120 min w/o
ultrasound

Beyond IV or IA rt-PA Treatment Alone

More effective acute recanalization
strategies are needed
IA seems to help more severe strokes
and larger clot burdens better than IV
How to get the best of both worlds IV
and IA rt-PA?
Bridge with IV during preparation for IA
What dose?

IMS Bridging Studies: Results

3-month mortality in IMS patients was
lower, but not statistically different from
historical controls (placebo & IV arms of
NINDS trial)
Sx
S ICH iin IMS similar
i il tto IV arm off
NINDS trial & higher than placebo arm
(p = 0.018)
IMS patients: better outcomes at 3 mo.
than placebo arm of NINDS trial
(all measures) IMS I: Stroke 2004;35: 904911
IMS II: Stroke 2007;38:2127-2135

18

9/8/2009

Comparison of Studies
Shaltoni et al Stroke 2007: UT-Houston experience

Median age, yrs

Median baseline
NIHSSS
Median time from
onset IV tx,min
Median time from
onset IA tx,min
% SxICH 36hrs
% ASxICH 36hrs
% PH-2
% TICI 2 or 3

Shaltoni
n=69

IMS-I
n=80

IMS-II
n=73

NINDS rtPA n=182

60
18

65
18

66
19

68
17

120

140

141

90

285

215

241

N/A

5.8
28.9
7.2
72.5

6.3
49
7.5
56

11
28.8
8.8
61

6.6
6.0
3.4
N/A

NA indicates not applicable.

IA = intra-arterial; SxICH = symptomatic intracerebral hemorrhage; ASxICH = asymptomatic ICH; PH-2 =
parenchymal hemorrhage type 2; TICI = thrombolysis in cerebral ischemia recanalization grading scheme

Acute Stroke Treatment

Endovascular Interventions
Philip M. Meyers, MD, FAHA
Associate Professor, Radiology and Neurological
Surgery
Columbia University, College of Physicians & Surgeons

19

9/8/2009

Disclosure Statement
No Financial Disclosure
External Monitor: IMS-III Trial
Off-label applications
Intra-arterial application of fibrinolytic agents
to treat acute ischemic stroke
Wingspan cerebral stent applied to treat
acute ischemic stroke

Topics

Limitations of intravenous fibrinolysis

Intra-arterial fibrinolysis
Mechanical thrombectomy
Other experimental revascularization
Balloon angioplasty
Stent revascularization

Intravenous Fibrinolysis
FDA Approved
Treatment window 0-3 hours from
symptom onset
NINDS showed
h
d 30% iincrease iin ffavorable
bl
outcomes at 90 days versus placebo
Limited efficacy:
IV t-PA opens 30 50% of major occluded
intracranial vessels within 1 2 hours

20

9/8/2009

Recanalization Rates: IV tPA 8 hrs

40
35
Percentt

M3,
M3 4

26

M2
M1
8

ICA

delZoppoAnnNeurol 32:78,1992

Anterior Cerebral Circulation

M4
M3

M2

M1

Small Distal Blockage

40%probability
40%
probability
ofrevascularization
AreaatRisk

21

9/8/2009

Large Proximal Blockage

8%probability
8%
probability
ofrevascularization
AreaatRisk

Intra-arterial Thrombolysis
PROACT II Study Design
Treatment group:
9 mg dose of Pro-urokinase + 3000 units
Heparin IV

Control group:
g p
Placebo + Heparin

Patients presenting with MCA M1 or M2

occlusion
Treatment window: 6 hours from symptom
onset
FurlanJAMA282:2003,1999

Intra-arterial Thrombolysis
PROACT II - Results
IA pro-UK
(n = 121)

Placebo
(n = 59)

Modified Rankin 0-2 at 3 months

40%

25%

TIMI 2 3

67%

2%

Intracerebral Hemorrhage

10%

2%

Mean time to treat: 5.3 hours

Furlan JAMA 282:2003,1999

22

9/8/2009

PROACT II Summary
Provides proof of principle in a worst-case
scenario:
Late time to treatment (5.3 hours)
Limited manipulation
manipulation, no mechanical
maceration of clot
Patient selection, NIHSS=17

Bridging Protocols: Outcome Rankin 0-2

% vs Time
80
70
60
Percent

50

62
IMS

66
EMS

40

40
30

PROA

20

25
Contr

10
0
3.3

4.2
5.3
Timeinhours

>6

Thrombectomy for Acute Stroke

CourtesyofConcentricMedical,Inc.

23

9/8/2009

Case #1

75 year old woman

New onset atrial fibrillation
Evaluation for elective cardioversion
During echocardiogram, she develops
acute neurological changes
Aphasia
Right hemiplegia
Gaze deviation

Concentric Merci Trial

Mechanical Thrombectomy

Concentric Merci Trial

Mechanical Thrombectomy

24

9/8/2009

Multi MERCI (Part I) Revascularization by Vessel

Merci WITHOUT Adjunctive Therapy

rt-PA alone

100%
90%
80%
70%
60%
50%
40%
30%
20%

67%

52%

54%

60%

54%

Carotid

MCA

Vert/Bas

Overall

10%
0%

PROACT
N=121

Multi MERCI (Part I) Revascularization by Vessel

Merci WITH Adjunctive Therapy

rt-PA alone
Addtl. Revasc with Adjunctive Tx

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

15%

15%

52%

54%

20%

60%

15%
54%

67%

Carotid MCA Vert/BasOverallPROACT

N=33

N=68

N=10

N=111

N=121

Multi MERCI Clinical Outcomes

Recanalized

Not Recanalized

70

60

50
51.9

49.1

Percent

40

30
24.8

20

10
9.6
0
Good Outcome

Mortality (90 day)

SmithISC2007

25

9/8/2009

Recanalization and Outcome - IA

CaseswithReperfusion(p=0.02)
95%PredictionBands

CaseswithoutReperfusion

Timefromstrokeonsettoreperfusionminutes
CourtesyofEdJauch,MD

KhatriP,ISC2008,NewOrleans,LA

Penumbra

CourtesyofPenumbra,Inc.

Case #2
72 year old man
Intermittent dizziness for several weeks
Rapid onset of nausea, vomiting,
somnolence,
l
and
d lleft-sided
ft id d weakness
k

26

9/8/2009

27

9/8/2009

Comparison of Stroke Techniques

Thrombolytics

Addtl. Revasc with Adjunctive Tx

0.9

Penumbra Device

Recanalization,%

0.8
0.7

15%

06
0.6
0.5
0.4

66%

0.3
0.2

40%

80%
54%

0.1
0

IV TPA

IA TPA

MERCI

PENUMBRA

Intracranial Revascularization
with Stent-Angioplasty

CourtesyofBostonScientific,Inc.

28

9/8/2009

Case #3
67 year old man
Sudden onset aphasia and confusion,
followed by onset of dense right hemiparesis.
ED evaluation shows NIHSS=23.
Patient receives 0.9 mg/kg rtPA at 2 hours
from stroke onset.
For presumed large artery occlusion, patient
was taken to angiography for possible
endovascular treatment.

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Future of Stroke Intervention

Treatment
Intravenous fibrinolysis

Class and Level of Evidence

Class I
LOE A

Intra-arterial fibrinolysis

Class I

LOE B

Mechanical embolectomy

Class IIb

LOE B

Stenting

Class III

LOE C

MeyersCirculation119(16):223549,2009

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Conclusion
Stroke is an important public health problem
Ongoing efforts by the medical community to
meet this growing need
Intravenous fibrinolysis remains the FDA
approved treatment for acute ischemic stroke
within 3 (possibly up to4.5) hours onset
Endovascular stroke treatment is an area of
active, ongoing research but remains
experimental.

To receive CME and CE, please complete

the program evaluation.

Upcoming CME Event

Register Today for Preventing Recurrent
Stroke: Targets for Managing Risk, a live
webcast presented by Philip Gorelick, MD
and Fernando Testai, MD
September 23, 2009; 12:00 PM Eastern
Visit www.stroke.org for more information on
this and other educational offerings.

31

9/8/2009

For more information regarding National

Stroke Associations Acute Stroke
Resource Center and other professional
programs
p
g
g
go to www.stroke.org.
g

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