LẤY HUYẾT KHỐI LÕI RỘNG

PGS.TS TRẦN ANH TUẤN

TRUNG TÂM ĐIỆN QUANG BỆNH VIỆN BẠCH MAI
Tại sao lại mở rộng lấy huyết khối?
• Tiến bộ về kỹ thuật, vật liệu, quan điểm điều trị.
• Hiệu quả đầu ra của can thiệp LOV
• Đầu ra tồi của điều trị nội khoa đơn thuần với LOV
Tối ưu hóa kỹ thuật kéo huyết khối
Chiều dài và loại stent?
 React
Aspiration
Stent Aspiration
retriever
X
Solumbra technique

Stent Retriever Aspiration

Tối ưu hóa kỹ thuật → để việc lấy huyết khối không
vô ích
 Mở rộng cửa sổ lấy huyết khối cơ học

ECASS
R-TPA NINDS III EXTEND

0 3 4,5 6 9 16 24

(Hours)

MR CLEAN DEFUSE III

ESCAPE
REVACAST
MT
SWIFT PRIME
EXTEND-IA DAWN
Stroke. 2019;50:e344–e418
QUAY TRỞ LẠI VỚI NCCT?

Có chẩn đoán được thời gian nhồi máu não?

Có chẩn đoán được độ rộng của nhồi máu
não?
Có chẩn đoán được vị trí mạch tắc?
Có cần thiết xác định ngưỡng điểm Aspect?
• “Emergency imaging of the brain is
recommended before any specific treatment for
AIS. Non-enhanced CT will provide the
necessary information for initial treatment of IV
r-tPA (Class I; level of Evidence A)*”

• Rule out the hemorrhage

• Identify ischemic lesion

*AHA/ASA-stroke guide line 2015

RCTs: Inclusion criteria (ASPECTs)

Inclusion criteria Inclusion (Median - IQR)

Mr Clean - 9 (7-10)
SWIFT Prime >1/3 MCA 9 (7-10)
Escape 6-10 9 (8-10)
Extend-IA (Mismatch) -
Revascat ≥7 (CT) ≥6 (MR) 7 (6-9)
THRACE - 0-4: 11%
5-7: 41%
8-10: 48%
Chỉ can thiệp ở ASPECT ≥6 ?
TIME IS BRAIN AND IMAGING
IS BRAIN
• RESCUE-LIMIT

Yoshimura S, Sakai N, Yamagami H, et al. Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med. 2022;386(14):1303-1313. doi:10.1056/NEJMoa2118191
• Methods
• Study Design: multicenter (n = 45,
Japan), open-label, RCT, blinded
endpoint assessment.
• Patients:
• LVOs in ICA or M1 of MCA by CTA or
MRA.
• ASPECT 3-5 by CT or DW-MRI.
• NIHSS ≥ 6.
• mRS 0 or 1 before onset.
• < 6 hrs last known well or < 24 hours
if no early change on FLAIR.
• Yoshimura S, Sakai N, Yamagami H, et al. Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med. 2022;386(14):1303-1313. doi:10.1056/NEJMoa2118191
RESCUE-LIMIT
• Treatment:
• 1:1 EVT + Medical Care vs Medical Care
Alone.
• Enrolled & randomized: 203.
• EVT at HCP discretion including stent retriever,
aspiration, balloon angioplasty.
• Alteplase can be used in both groups at
HCP discretion.
• ~27% received alteplase per group.
• Outcomes
• Primary: mRS 0-3 at 90 d.
• Secondary: Improvement ≥ 8 points in
NIHSS at 48 hrs.
CAN NV JC - Large AIS Core Trials (RESCUE-LIMIT, ANGEL-
ASPECT, SELECT2 | 2023-MAY-04 | Confidential, for Internal 25
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• Patient Demographics
RESCUE-LIMIT

• Yoshimura S, Sakai N, Yamagami H, et al. Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med. 2022;386(14):1303-1313. doi:10.1056/NEJMoa2118191

CAN NV JC - Large AIS Core Trials (RESCUE-LIMIT, ANGEL-

ASPECT, SELECT2 | 2023-MAY-04 | Confidential, for Internal 26
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• Results RESCUE-LIMIT

• Yoshimura S, Sakai N, Yamagami H, et al. Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med. 2022;386(14):1303-1313. doi:10.1056/NEJMoa2118191

CAN NV JC - Large AIS Core Trials (RESCUE-LIMIT, ANGEL-

ASPECT, SELECT2 | 2023-MAY-04 | Confidential, for Internal 27
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• Results RESCUE-LIMIT
• Ordinal shift across the range of mRS scores favouring EVT with common
odds ratio of 2.42.

• Yoshimura S, Sakai N, Yamagami H, et al. Endovascular Therapy for Acute Stroke with a Large Ischemic Region. N Engl J Med. 2022;386(14):1303-1313. doi:10.1056/NEJMoa2118191

CAN NV JC - Large AIS Core Trials (RESCUE-LIMIT, ANGEL-

ASPECT, SELECT2 | 2023-MAY-04 | Confidential, for Internal 28
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• ANGEL-ASPECT

Huo X, Ma G, Tong X, et al. Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct [published online ahead of print, 2023 Feb 10]. N Engl J Med. 2023;10.1056/NEJMoa2213379.
doi:10.1056/NEJMoa2213379
 ANGEL-ASPECT
• Methods

• Study Design: multicenter (n = 46, China), • Treatment:

prospective, open-label, RCT, blinded endpoint
assessment
• 1:1 EVT + Medical Management vs
Medical Management Alone.
• Enrolled & randomized: 456.
• Patients: • ~28% received intravenous thrombolysis
per group.
• LVOs in anterior circulation (initial segment of • EVT at HCP discretion including stent
MCA, intracranial segment of distal ICA) by CTA retriever, aspiration, balloon angioplasty.
or MRA.
• ASPECT 3-5 by CT; infarct volume 70-100ml
(ASPECT 0-2, < 24 hrs, by CT; or ASPECT > 5, 6-
24 hrs, by CT) • Outcomes
• NIHSS 6-30. • Primary efficacy: mRS score at 90 d.
• mRS 0 or 1 before onset. • Primary safety: sICH 48 hrs.
• < 24 hrs last known well.
• Huo X, Ma G, Tong X, et al. Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct [published online ahead of print, 2023 Feb 10]. N Engl J Med. 2023;10.1056/NEJMoa2213379. doi:10.1056/NEJMoa2213379

CAN NV JC - Large AIS Core Trials (RESCUE-LIMIT, ANGEL-

ASPECT, SELECT2 | 2023-MAY-04 | Confidential, for Internal 30
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 ANGEL-ASPECT
• Patient Demographics

• Huo X, Ma G, Tong X, et al. Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct [published online ahead of print, 2023 Feb 10]. N Engl J Med. 2023;10.1056/NEJMoa2213379. doi:10.1056/NEJMoa2213379

CAN NV JC - Large AIS Core Trials (RESCUE-LIMIT, ANGEL-

ASPECT, SELECT2 | 2023-MAY-04 | Confidential, for Internal 31
Use Only
• Results
ANGEL-ASPECT

• Huo X, Ma G, Tong X, et al. Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct [published online ahead of print, 2023 Feb 10]. N Engl J Med. 2023;10.1056/NEJMoa2213379. doi:10.1056/NEJMoa2213379

CAN NV JC - Large AIS Core Trials (RESCUE-LIMIT, ANGEL-

ASPECT, SELECT2 | 2023-MAY-04 | Confidential, for Internal 32
Use Only
• Results
ANGEL-ASPECT
• A shift in mRS scores at 90 days toward better outcomes in favor of EVT
over medical management alone (generalized odds ratio 1.37; P = 0.004).

• Huo X, Ma G, Tong X, et al. Trial of Endovascular Therapy for Acute Ischemic Stroke with Large Infarct [published online ahead of print, 2023 Feb 10]. N Engl J Med. 2023;10.1056/NEJMoa2213379. doi:10.1056/NEJMoa2213379

CAN NV JC - Large AIS Core Trials (RESCUE-LIMIT, ANGEL-

ASPECT, SELECT2 | 2023-MAY-04 | Confidential, for Internal 33
Use Only
• SELECT2

Sarraj A, Hassan AE, Abraham MG, et al. Trial of Endovascular Thrombectomy for Large Ischemic Strokes [published online ahead of print, 2023 Feb 10]. N Engl J Med. 2023;10.1056/NEJMoa2214403.
doi:10.1056/NEJMoa2214403
• Methods
SELECT2
• Study Design: multicenter (n = 31, • Treatment:
US, CAN, EU, ANZ), prospective, • 1:1 EVT + Medical Care vs Medical
open-label, RCT, blinded endpoint Care Alone.
assessment • Enrolled & randomized: 352.
• 17.3~20.8% received intravenous
• Patients: thrombolysis per group.
• EVT at HCP discretion including stent
• LVOs in M1 segment of MCA or ICA. retriever, aspiration, or both.
• ASPECT 3-5 by non-contrast CT or
DW-MRI or core volume ≥ 50 ml by
CT perfusion. • Outcomes
• mRS 0 or 1 at randomization. • Primary efficacy: mRS score at 90 d.
• < 24 hrs last known well.
• Sarraj A, Hassan AE, Abraham MG, et al. Trial of Endovascular Thrombectomy for Large Ischemic Strokes [published online ahead of print, 2023 Feb 10]. N Engl J Med. 2023;10.1056/NEJMoa2214403. doi:10.1056/NEJMoa2214403

CAN NV JC - Large AIS Core Trials (RESCUE-LIMIT, ANGEL-

ASPECT, SELECT2 | 2023-MAY-04 | Confidential, for Internal 35
Use Only
 SELECT2
• Patient Demographics

• Sarraj A, Hassan AE, Abraham MG, et al. Trial of Endovascular Thrombectomy for Large Ischemic Strokes [published online ahead of print, 2023 Feb 10]. N Engl J Med. 2023;10.1056/NEJMoa2214403. doi:10.1056/NEJMoa2214403

CAN NV JC - Large AIS Core Trials (RESCUE-LIMIT, ANGEL-

ASPECT, SELECT2 | 2023-MAY-04 | Confidential, for Internal 36
Use Only
• Results
SELECT2

• Sarraj A, Hassan AE, Abraham MG, et al. Trial of Endovascular Thrombectomy for Large Ischemic Strokes [published online ahead of print, 2023 Feb 10]. N Engl J Med. 2023;10.1056/NEJMoa2214403. doi:10.1056/NEJMoa2214403

CAN NV JC - Large AIS Core Trials (RESCUE-LIMIT, ANGEL-

ASPECT, SELECT2 | 2023-MAY-04 | Confidential, for Internal 37
Use Only
• Results
SELECT2
• A shift in mRS scores at 90 days toward better outcomes in favor of EVT
over medical care alone (generalized odds ratio 1.51; P < 0.001).

• Sarraj A, Hassan AE, Abraham MG, et al. Trial of Endovascular Thrombectomy for Large Ischemic Strokes [published online ahead of print, 2023 Feb 10]. N Engl J Med. 2023;10.1056/NEJMoa2214403. doi:10.1056/NEJMoa2214403

CAN NV JC - Large AIS Core Trials (RESCUE-LIMIT, ANGEL-

ASPECT, SELECT2 | 2023-MAY-04 | Confidential, for Internal 38
Use Only
• Results
SELECT2

• Sarraj A, Hassan AE, Abraham MG, et al. Trial of Endovascular Thrombectomy for Large Ischemic Strokes [published online ahead of print, 2023 Feb 10]. N Engl J Med. 2023;10.1056/NEJMoa2214403. doi:10.1056/NEJMoa2214403

CAN NV JC - Large AIS Core Trials (RESCUE-LIMIT, ANGEL-

ASPECT, SELECT2 | 2023-MAY-04 | Confidential, for Internal 39
Use Only
• Summary
Large Ischemic Strokes
Three recent RCTs have observed the efficacy and safety of EVT + medical management,
compared to medical management alone, is beneficial in patients with LVOs with large ischemic
regions.

Study GEO Location Ischemic Region Size State Last known well
RESCUE-LIMIT JPN LVOs ICA, MCA (M1, M2) ASPECT 3 - 5 NIHSS ≥ 6 < 6 hrs
mRS 0 -1 < 24 hrs if no
change on FLAIR
ANGEL-ASPECT CHN LVOs ICA, MCA (M1, M2) ASPECT 3 - 5 NIHSS 6 -30 < 24 hrs
Core 70 -100 ml mRS 0 -1
- ASPECT 0 - 2 < 24 hrs
- ASPECT >5, 6 - 24 hrs)
SELECT2 NA, EU, ANZ LVOs ICA, MCA (M1, M2) ASPECT 3 - 5 mRS 0 – 1 < 24 hrs
Core ≥ 50 ml

CAN NV JC - Large AIS Core Trials (RESCUE-LIMIT, ANGEL-

ASPECT, SELECT2 | 2023-MAY-04 | Confidential, for Internal 40
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Kết Luận:
• Việc lấy huyết khối cơ học ngày càng muộn (6-24h) hoặc Aspect thấp
(<6 đ) ngày càng được khuyến cáo ở các NC lớn gần đây làm suy giảm
giá trị của các con số lõi trên CT perfusion trong khi đó CT không tiêm
với ưu điểm tiếp cận nhanh chóng thuận tiện đã có thể chấm được
Aspect với giá trị ngang bằng đặt ra câu hỏi liệu có cần chụp CTP
không?
• Lâm sàng và CT sọ không tiêm hoàn toàn có thể được sử dụng để
thay thế các phượng tiện CĐHA nâng cao?
• Việc mở rộng cửa số lấy huyết khối từ 6 -24h đã được chứng minh.
• Nên lấy huyết khối kể cả với những bệnh nhân có lõi nhồi máu rộng.
Case 2: Nguyễn Thị D
• Khởi phát lúc 17h45, vào viện lúc 20h35.
• Vào viện vì liệt ½ người phải, cơ lực 3/5, thất ngôn.
• NIHSS: 10 đ/ Glasgow: 13đ
Trên hình ảnh MRI:
Hình ảnh tắc M2 trên trái Aspect 7đ
• Phim chụp ngay sau can thiệp 24h bệnh nhân có chuyển
dạng chảy máu.
• Bệnh nhân được rút ống, cơ lực cải thiện 4/5.
CẢM ƠN SỰ QUAN TÂM THEO DÕI

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