INTERVENTIONAL NEURORADIOLOGY

Dr Abhinav Gupta
Stroke team
Neurologist
Casualty doctor on duty
ICU doctor on duty
Neurosurgeon/ Interventional surgeon
Anesthetist on call
Stroke nurse
Cath lab Technician and Nurse
Imp questions to initiate thrombolysis protocol
1.Exact time when 1st symptom was noticed. IF TIME OF ONSET UPTO 4.5 HRS
THEN TPA GROUP IF TIME >4.5 HRS THEN THROMBECTOMY GROUP
2. Any maj surgery in 2 weeks
3. Recent maj stroke
4.SEND BLD INVESTIGATIONS
CBC, bld sugar, KFT, PT INR, Bld group, ECG

ACESS THE PATIENT AND SEND FOR CT SCAN

CT HEAD PLAIN
CT BRAIN AND NECK VESSELS

THREE COMPARTMENT OPERATIONAL MODEL OF ISCHEMIC BRAIN TISSUE

The ischemic “core” is described as region with CBF values less than
10ml/100g/min.
A surrounding “pneumbral” region showed CBF values less than 20ml/g/min, but
more than 10ml/g/min –this region is still salvaged if blood flow is restored.
Oligemic –zone has preserved function and morphology 25-80ml/g/min.
Apps to use
Google- IV Thrombolysis
-NIHSS score
Identify a stroke and its onset
WITHIN 5 MIN
FAST, Last well seen
Diagnosis clinically difficult: Inform the neurologist and the Medicine SR

IF STROKE ONSET < 6 HRS OR WAKE UP STROKE, CONSENT

WITHIN 10 MIN

Identify the primary decision authority and council IRRESPECTIVE OF RBS

It is a possible acute stroke due to lack of blood supply to brain and the deficit can
be reversed depending on the damage found
We have all facilities for its treatment 24X7
We need to rush to confirm the diagnosis and treat after your approval
We have informed the financial counsellor who will detail you soon and guide you
for admission

Family not willing for admission or expensive treatment or other financial issues
which prompt delay: Confirm with the counsellor and Continue for diagnosis
confirmation.

Inform radiologist, radiology technician, neurologist and neurointerventionist -

ABOUT SHIFT TO RADIOLOGY ROOM
WITHIN 25 MIN
Shift for NCCT head plus CT angio brain and neck vessels
Check the following to be accompanied, before shifting the patient:
(a) Intracath in situ
(b) BP apparatus
(c) ECG sheet
(d) RBS values
(e) Infusion pump with tubing
(f) 2 rTPA vials
(g) 10cc syringe

While shifting, check with blood work up and for ECHO

Intervention after CT
CT normal or Early CT signs of ischemia Large infarct core ICH

Rule out rTPA contraindications Conservative

Neurosurgeron

Onset <4.5 hrs, Onset >4.5 hrs,

Start rTPA Thrombectomy / Intervention team informed

while CTA is being done

CTA reveals large vessel occlusion No major vessel block

(Proximal ICA or M1), Block
Inform neurosurgeon/Intervention

rtPA is continued and the patient is taken up Continue rTPA, ECHO

within in 60 min for thrombectomy,
if the onset is < 6hrs for anterior and up to 24 hr
for post circulation

Dosing of rTPA
TO BE STARTED AFTER ONLY THROMBOLYSIS SPECIAL CONSENT FORM TO BE
MADE
0.9 mg/kg IV; not to exceed 90 mg total dose; administer 10% of the total dose as
an initial IV bolus over 1 minute and the remainder infused over 60 minutes
Monitor and control blood pressure during and following administration
In patients without recent use of oral anticoagulants or heparin, treatment can be
initiated prior to the availability of coagulation study results
Discontinue if the pretreatment INR is >1.7 or the aPTT is elevated

ECASS-III
Placebo controlled trial of alteplase (rt-PA) in acute ischemic hemispheric stroke
where thrombolysis is initiated between 3 and 4 hours after stroke onset
Randomized 1:1 to receive intravenous rt-PA (alteplase 0.9mg/kg bodyweight,
maximally 90mg; 10% bolus plus one hour infusion) or placebo started between 3
and 4 hours from the onset of stroke.
Results:
A recent metaanalysis (Lancet 2004; 363 (9411): 768–
774) showed that thrombolysis with rt-PA may be
beneficial up to 270 minutes.

ASPECT
ASPECTS: The Alberta Stroke Program Early CT score 2001.
10 point topographic imaging score

MCA territory divided into 10 regions each of which is given1 point.

For each area involved 1 point is deducted from that score.
Baseline ASPECTS – correlated inversely with NIHSS and as ASPECTS decreases the
probability of dependence death and hemorrhage increases.
Better then ECASS

ASPECT score
The Alberta Stroke Program Early CT Score (ASPECTS) is a systematic approach to
detect early CT signs like the insular ribbon sign or obscuration of the lentiform
nucleus.
Although the ASPECTS score was previously shown to be a strong predictor of
functional outcome after IVT, it has now been shown prospectively and
successfully to predict also the outcome after EVT.
An independent meta-analysis showed that EVT improves outcomes both in
patients with CT-based ASPECTS of 8 to 10 (ie, minimal ischemic damage) as well
as of 5 to 7 (ie, moderate ischemic damage).
On the contrary, patients with a low ASPECTS of 0 to 4 showed no treatment
benefit by EVT, suggesting that EVT has little or no efficacy in patients with large
ischemic core.
Practical clinical utility of the alberta stroke programe early CT score
Less than-3 hour patient
ASPECT is used as prognostic tool for less than 3 hours from stroke onset . If
ASPECT values are low, there is lack of major clinical recovery or response from
thrombolysis , even with successful recanalization.
They do not exclude patient from intravenous rt-PA therapy based on the extent
of EIC, unless it involves the entire MCA territory (ASPECT<3).
A low ASPECT may protend subsequent clinical deterioration in the form of
malignant MCA infarction.

Currently if EIC changes is extensive (ASPECT<5) the intra-arterial rescue is not

advocated.

Patients with good ASPECT are typically excellent candidates to include combined
I.V and I.A approach

Additonal TCD or CTA in such patients , especially if of a young age , to confirm a

proximal vascular occlusion, esp if of a young age, to confirm a proximal vascular
occlusion, unless a clear hyperdense MCA sign .
3 to 6 hour patient
The ASPECT is likely more valuable semi quantitative score beyond the first 3 hour
after symptoms onset.
Treatment with intravenous rt-PA normally has a limited but statistically significant
benefit in the 180-270 minute time window
Based on PROACT-II ASPECT evaluation,a high ASPECTS in the setting of an MCA
occlusion seem to be the ideal candidate for intervention.

Intravenous rt-PA in the 180-270 minute time window

Intra arterial lysis in the 270 to 360 minute time window.

More than 6 hour
The ASPECT might also be useful in the more than 6 hour time window.
A subgroup of such patient is likely to have a salvageable pneumbra ,which can be
achieved , as demonstrated in DIAS trial.

• BP measurement every 15 minutes for 1 hour, then every 30 min for 6

hours then hourly for 24 hours.
• GCS assessment every 10 minutes for 1 hour, then every 20 minute for 6
hours then every 30 minutes for 24 hours.
• No IV heparin, warfarin, or antiplatelet drugs during the infusion or for 24
hours post infusion.
• Avoid nasogastric tubes, blood draws, or invasive lines/procedures for 24
hours post infusion, if possible.
• No intramuscular injections.
• Head MRI at 24 hours post infusion.
• Maintain IV’s already in place (restart only if necessary).
• Watch for gingival oozing, ecchymosis, petechiae, abdominal and/or flank
pain, hemoptysis, hematemesis, shortness of breath, rales, rhonchi,
arrhythmias.
• Assess IV/arterial puncture sites, urine, gums, skin, stool, emesis, etc, for
bleeding. Report to neurologist if this occurs.
• If clinical suspicion of intracerebral haemorrhage, discontinue t-PA infusion
and
 Obtain Urgent CT scan.
 INR, PTT, platelet count, fibrinogen, Blood type & cross
matching.
 Prepare for administration of 6-8 units cryoprecipitated fibrinogen
& factor VIII.
 Prepare for administration of 6-8 units platelets.
 Maintain blood glucose between 14-180 mg/dl
rTPA contraindications
CT scan findings of intracranial hemorrhage or major acute infarct (>1/3 cerebral
hemisphere)
Suspicion of subarachnoid hemorrhage (even if head CT is negative for
hemorrhage)
Significant head trauma or prior stroke in previous 3 month
Recent intracranial or intra-spinal surgery
History of previous intracranial hemorrhage or brain aneurysm,
vascular malformation or brain tumor
Arterial puncture at non-compressible site in previous 7 days
Known bleeding diathesis OR
1)Current use of oral anticoagulants with INR > 1.7 or PT >15
2)Use of heparin within 48 hours preceding onset of stroke & prolonged aPTT at
time of presentation. Low molecular weight heparin use in the past 24 hours.
3)Platelets < 100,000
4)Active internal hemorrhage
5)Novel oral anticoagulant use in the past 48 hours (if last dose> 48 hours, confirm
normal renal function [creatinine clearance > 50 mL/min] and normal
coagulation [aPTT, INR, platelet count, thrombin time or appropriate factor
Xa activity assays] before tPA administration
Persistent systolic BP >185 mm Hg or diastolic BP > 110 mm Hg despite treatment
Blood glucose concentration < 50 mg/dl

Patients treated within 3-4.5 hour window warnings/contraindications

Age > 80
Any anticoagulant use INR if greater than 1.5
NIHSSS > 25
History of Stroke AND Diabetes
rTPA contraindications
Warnings (risks must be weighted against anticipated benefits)
MI within last 3 months (with normal TTE)
Current use of oral anticoagulants with INR >  1.5 or PT  > 15
seconds
Major surgery or serious trauma within previous 2 weeks
Minor neurological deficit or rapidly improving symptoms
High likelihood of left heart thrombus
Aortic dissection
Severe neurological deficit (NIH stroke scale score > 22)
Seizure at symptom onset
History of IVDU and/or suspicion for endocarditis
Tox-screen positive for ETOH, cocaine, opiates, or amphetamines (if
available, but should not delay tPA protocol)
Subacute bacterial endocarditis
Acute pericarditis
History of hemorrhagic diabetic retinopathy
Significant hepatic dysfunction with abnormal INR
Pregnancy
Sickle cell disease
Internal hemorrhage (e.g., GI or urinary tract) < 3 weeks
Blood glucose < 50 mg/dL

Not a contraindication
Current aspirin, NSAID or antiplatelet drugs (dipyridamole, ticlopidine,
clopidogrel)
History of PUD (not currently active [>3 months])
Intraarterial thrombolysis ( PROACT )
IA thrombolysis ( dose 0.1mg/kg) given over 2 hours was significantly associated
with substantial increases in recanalization rates and good and excellent outcomes
in AIS. Intra-arterial thrombolytic treatment is gaining traction at some
comprehensive stroke facilities at tertiary hospitals. It is often administered as an
off-label therapy within 6 h of onset of stroke in patients with anterior circulation
and up to 12–24 h after onset in the posterior circulation
Indications for Mechanical Thrombectomy
Although IVT is a treatment option ≤4.5 hours after stroke onset, additional or
primary EVT can be performed within a more extended time window of 6 hrs in
anterior circulation and upto 24 hrs in posterior circulation .
Patients with significant deficits manifesting National Institutes of Health Stroke
Scale scores between 8 and 20 are more likely to benefit from reperfusion with
EVT.
EVT in patients presenting with minor to mild stroke severity and proximal large
vessel occlusion seems to be favorable and safe.
The Stent-Assisted Recanalization in Acute Ischemic Stroke (SARIS)

SARIS conducted to investigate the safety of intracranial stent deployment within

8 h of stroke onset, demonstrated expeditious recanalization, and favorable
outcomes at 30 and 180 days clinical follow-up .
Stent deployment averts arterial reocclusion and thrombus reformation in cases
with partial embolectomy or arterial stenosis. The utility of self-expanding stents
(SES) has been explored. The SES yields dramatically high recanalization rate of up
to 90% by a combination of balloon angioplasty and stent implantation .
Undoubtedly, the bridge endovascular therapy using MT, intracranial stent
deployment, and IV thrombolysis allows an extended time window, and therefore
a higher proportion of revascularisations and improved clinical outcomes in AIS
patients with large artery occlusion of anterior circulation.
an endovascular MMRT approach using pharmacological thrombolytic (IA lytic
drugs), in conjunction with MT using mechanical devices such as clot retrievers,
angioplasty with stenting, aspiration devices, and stent retrievers is being
increasingly adopted as the treatment of choice for stroke due to large vessel
occlusion. Endovascular MMRT or bridge therapy offers a safe alternative for AIS
patients, with large intracranial vessel occlusion, who fail to reperfuse with
systemic thrombolytic drugs.
b

A 76 year-old woman with an NIHSSS of 24 with left ICA “T” occlusion.

Intravenous tPA 36 mg was administered at 1:42 hours following onset. Left
CCA angiogram demonstrates left ICA occlusion above the ophthalmic
artery. Right CCA angiogram confirms no cross-filling, and some late
collateral filling from corticocortical anastomoses into M2 segments

at 2:22 hours postonset with a microcatheter in the supraclinoid ICA in

thrombus and the AP view at 2:33 hours postonset

. Following 8 mg IA tPA, reconstitution of flow was achieved at 3:35 hours

postonset, and the patient improved dramatically on the table

A 50-year-old man who collapsed and hit his head. His NIHSSS was 14.
Preliminary CT demonstrated no ischemic changes. Because of a frontal
scalp contusion systemic rtPA was eschewed in favor of direct IA injection

Lateral left CCA angiogram demonstrated no flow in the cervical ICA, but
minimal reconstitution of the cavernous ICA by meningeal collaterals.
Microcatheter injection explained the appearance: a bifid origin of the M1
segment, with a stump of M1 resembling an aneurysm, while the
microcatheter has entered a minor branch
The microcatheter was placed beyond the clot
1 mg of rtPA was injected; as the microcatheter was retracted into the
proximal clot, an additional 1 mg rtPA was injected. Then the microcatheter
was placed into the proximal clot and infusion of rtPA at 10 mg/hr was
begun. The 0.010-inch microguidewire was advanced approximately 10
inches and the microcatheter 20 inches after control injection

Recanalization of the cervical ICA occurred simultaneously with MCA

recanalization. Left CCA injection with AP view demonstrated antegrade
flow in the petrous ICA, reconstitution of the cavernous segment, and
hemodiluted patency of the M1 segment
Microcatheter injection confirmed rapid washout in the MCA
CT at 24 hours confirmed only a small deep infarct and likely sulcal
effacement

Techniques of Endovascular Thrombectomy

Stent retrievers-  stent-like devices eg.
Merci retriever: is a corkscrew-shaped device consisting of a flexiblenitinol wire in
5 helical loops. Designed for placement distal to the thrombus, its retrieval allows
en bloc thrombus removal.
The aspiration Tech : The penumbra device , by contrast, works proximally to
disrupt and aspirate the thrombus.
Both devices are designed for thrombectomy in carefully selected acute stroke
patients with large-vessel intracranial occlusions.
MERCI
Mechanical Embolus Removal in Cerebral Ischaemia

The Merci procedure is performed after femoral  artery acess is obtained with the
Merci balloon guide, which comes in both 8- and 9-F outer diameters.
Once the balloon guide is in the conduit vessel of interest, a medium-sized
catheter (4.2- and 5.3-F outer diameters), the distal access catheter (used for
triaxial support), and microcatheter of choice are advanced over the microwire to
the clot under direct fluoroscopic guidance.
The microwire is then exchanged for the Merci retriever system with placement
distal to the clot .
The balloon guide is then inflated. Using a slow, steady pulling motion, the
retriever engages the clot while the distal access catheter position is maintained.
Then, as the clot moves more proximally, the distal access catheter, microcatheter,
and retriever are moved toward the guide while aggressive aspiration is
performed from the guide.
The retriever can be resheathed and the steps repeated.
Stent Retriever Technique

Retrievable stents are self-expandable stent-like devices that are fully retrievable.
Therefore, these devices combine the advantages of prompt flow restoration and
mechanical thrombectomy. Excellent recanalization results can be achieved with
this technique with rates of Thrombolysis in Cerebral Infarction (TICI) grade 2a/b
or 3 flow as high as 90%. low rates of symptomatic ICH and low mortality rates.
Cont
At the stent retriever technique, the target vessel is entered with a 0.014-inch
guidewire and a suitable microcatheter between 0.018 and 0.027 inch.
The thrombus is crossed with the guidewire, and the microcatheter is placed distal
to the thrombus. The stent retriever is advanced to the distal end of the
microcatheter.
Then, the microcatheter is removed to deploy the device under fluoroscopy. A
control angiogram is performed after successful unfolding of the device.
The sizes of stent retriever devices range from 3.0×15 mm to 6.0×30 mm;
however, typically a 6.0-mm device is used. After a short period of time, the
device is pulled back with continuous aspiration.
The procedure is repeated until a TICI grade of 2b or 3 is reached
Th Thrombectomy
Penumbra
The Penumbra system has 3 main components:
A reperfusion catheter, separator, and a thrombus removal ring.
The Penumbra procedure is performed after arterial access is obtained and usually
after systemic heparinization. All components of the Penumbra system are
deliverable through a 6-F standard guide catheter, but an 070 Neuron catheter
(Penumbra, Inc.) is the guide designed for the system. The reperfusion catheter is
then advanced past the guide catheter over a guidewire and placed proximal to
the clot. The catheters and separators are available in different sizes for various
arterial diameters. The guidewire is then removed from the reperfusion catheter,
and the penumbra separator is advanced through the reperfusion catheter. The
aspiration pump is then started and a continuous aspiration, clot disruption-
debulking process is performed with the separator. In general, the Penumbra
device works better in straight arterial segments than around curves or at branch
points because the separator may cause arterial . In addition, the largest catheter
possible should be used to allow for the greatest amount of aspiration because
suction decreases dramatically with decreasing vessel diameter
Penumbra
Penumbra Thrombus Perturbation and Aspiration System

Aspiration Technique

situations that are resistant to stent retriever recanalization attempts. These

situations include occlusions located in terminal internal carotid artery (ICA) and
middle cerebral artery bifurcation and trifurcation thrombi, as well as hard
thrombi configuration. For these cases, direct aspiration of the thrombus can be
used as an alternative technique.
When the aspiration technique is used, the thrombus is passed with the
microwire and microcatheter, and the aspiration catheter is placed directly in the
proximal part of the thrombus. The microwire and the microcatheter are
removed. Entrapment of the thrombus is indicated by the absence of backflow.
The catheter is then retrieved with constant negative pressure to avoid loss of
thrombus. After each retrieval of clot fragments, the procedure is repeated until a
TICI grade of ≥2 or 3 was reached.
The main advantages of aspiration technique are the fast procedure time and the
high rate of favorable clinical outcome.
Aspiration Method

Endovascular thrombectomy with the aspiration technique in acute ischemic

stroke. A, Acute occlusion of the distal middle cerebral artery (arrow), (B)
placement of an aspiration catheter on the occlusion site (arrow). C and D,
Thrombus material within the aspiration tube (arrows). E, Successful
recanalization after primary aspiration technique with Penumbra ACE catheter
(Penumbra Inc).
Merci retriever