Question 4

Last updated 19/06/2020 - 02:20
 Topic: Neurology and Neurosurgery
Pass rate
32%
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Briefly describe the indications, post-procedure management and procedural complications of endovascular clot retrieval (ECR) for acute stroke.

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College answer

Indications:                                                                                                                            2 Marks

  • Ischaemic stroke with proven large-vessel occlusion on CT Angiogram (naming vessels not necessary) (1 mark)
  • Onset of symptoms up to 24 hours if CT imaging is supportive. (0.5 marks)
  • Functionally independent prior to stroke (0.5 marks)

Post-procedure management:                                                                                           4 Marks

  • Admission to monitored environment (e.g. stroke unit / HDU), usually intubated for procedure, so may describe extubation plan
  • Observe vascular access site for complications
  • Neurological monitoring for haemorrhagic transformation or further ischaemic complications
  • Blood Pressure Target: control as per agreed targets
  • Aspirin, 24-hours after thrombolysis and exclusion of haemorrhagic complications
  • Other neuroprotective measures (BSL, Na, position, temperature, CO2 etc.)
  • Oral intake after speech pathology assessment in patients with clinical neurological deficit
  • Mechanical DVT prophylaxis/stress ulcer prophylaxis.
  • Longer term management dependent on extent of deficit

Complications:                                                                                                                      4 Marks

    1. Direct device-related vascular injury:
      • vessel perforation
      • symptomatic intracranial haemorrhage
      • subarachnoid haemorrhage
 
      • arterial dissection
      • emboli to new territories
      • vasospasm
    • Vascular access site complications:
      • dissection
      • pseudoaneurysm
      • retro-peritoneal Haematoma
      • infection
    • Contrast-related:
      • Allergy
      • Renal Injury
    • Any complications related to anaesthesia

Examiners Comments:

Many candidates provided only generic responses without specific detail.

Discussion

Briefly, they said.

  • Indications:
    • Ischaemic stroke with large vessel occlusion
    • Substantial neurological deficit, NIHSS ≥ 5
    • Timeframe criteria:
      • Less than six hours: "broad clinical and imaging criteria"
      • 6-24 hour window: "significant volume of salvageable tissue"
    • Good level of premorbid independence
  • Complications:
    • Bleeding (though the risk of symptomatic ICH is no higher)
    • Cerebral oedema
    • Vascular access site complications
  • Evidence:
    • ​​​​​​​DAWN trial: 206 patients, 49% had good functional outcome vs 13%
    • DEFUSE-3 trial: 186 patients, 47% had good functional outcome vs 17%
    • Other trials: EXTEND1A, ESCAPE, SWIFT-PRIME, REVASCAT 
  • Post-procedure management:
  1. E​​​​​​xtubate early, if able.
  2.  Mechanical ventilation focuses on maintenance of normoxia and normocapnia
  3. Blood pressure control:
    1. Aim for SBP <140-160 for fully revascularised patients
    2. Aim for MAP 10-20% over normal baseline and SBP <185 for partially revascularised patients
  4. Minimise sedation and maximise the opportunity for regular reassessment
    Also, scan their head after the first 24 hrs.
  5. Control of electrolytes to prevent AF
  6. Maintenance of neutral fluid balance
  7. Glucose control: hyperglycaemia is harmful
  8. Antiplatelets after 24 hrs (earlier if they had an endovascular stent)
  9. Fever is harmful: paracetamol is recommended

References

Nogueira, R. G., et al. "Endovascular approaches to acute stroke, part 2: a comprehensive review of studies and trials." American Journal of Neuroradiology30.5 (2009): 859-875.

Silva, Gisele S., and Raul G. Nogueira. "Endovascular Treatment of Acute Ischemic Stroke." CONTINUUM: Lifelong Learning in Neurology 26.2 (2020): 310-331.

Brinjikji, Waleed, et al. "Patient outcomes with endovascular embolectomy therapy for acute ischemic stroke a study of the national inpatient sample: 2006 to 2008." Stroke 42.6 (2011): 1648-1652.

Kidwell, Chelsea S., et al. "Design and rationale of the mechanical retrieval and recanalization of stroke clots using embolectomy (mr rescue) trial."International Journal of Stroke 9.1 (2014): 110-116.

Jansen, Olav, et al. "Neurothrombectomy for the treatment of acute ischemic stroke: results from the TREVO study." Cerebrovascular Diseases 36.3 (2013): 218-225.

Furlan, Anthony, et al. "Intra-arterial prourokinase for acute ischemic stroke: the PROACT II study: a randomized controlled trial." Jama 282.21 (1999): 2003-2011.

Ma, Alice, Gerard Moynihan, and Lachlan H. Donaldson. "Intensive Care Management Following Endovascular Clot Retrieval for Acute Stroke: A Systematic Review of the Literature." Journal of Clinical Interventional Radiology ISVIR (2019).

Rodrigues, Filipe Brogueira, et al. "Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis." bmj 353 (2016): i1754.

Hao, Yonggang, et al. "Risk of intracranial hemorrhage after endovascular treatment for acute ischemic stroke: systematic review and meta-analysis." Interventional neurology 6.1-2 (2017): 57-64.

Nogueira, Raul G., et al. "Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct." New England Journal of Medicine 378.1 (2018): 11-21.

Albers, Gregory W., et al. "Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging." New England Journal of Medicine 378.8 (2018): 708-718.

Powers, William J., et al. "Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association." Stroke 50.12 (2019): e344-e418.

Leslie-Mazwi, Thabele, et al. "Post-thrombectomy management of the ELVO patient: Guidelines from the Society of NeuroInterventional Surgery." Journal of neurointerventional surgery 9.12 (2017): 1258-1266.

van de Graaf, Rob A., et al. "Periprocedural antithrombotic treatment during acute mechanical thrombectomy for ischemic stroke: a systematic review." Frontiers in neurology 9 (2018): 238.

Torbey, Michel T., et al. "Evidence-based guidelines for the management of large hemispheric infarction." Neurocritical care 22.1 (2015): 146-164.

Ananthasubramaniam, Karthik, et al. "How safely and for how long can warfarin therapy be withheld in prosthetic heart valve patients hospitalized with a major hemorrhage?." Chest 119.2 (2001): 478-484.

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