ct angio in stroke

[97t]

are you guys getting ct angios on stroke patients that are not tpa candidates if mri not immediately available?

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[xaelia]

Occasionally. We never get MRI prior to TPA, but also don't always need CTA. It depends on individual patient factors - whether there's uncertainty over new stroke symptoms in the setting of previous deficit, obvious ischemic signs on the non-contrast, etc. But, this is an academic center with an in-house stroke fellow who accompanies these patients to the scanner to read it with the radiologist.

 

[Rendar5]

we do CTA and CTP these patients, but that's because we have a neurointerventional team that will do their thing instead of tPA in the right candidates. They actually did that for one of our attendings who came in with I believe an M2 blockage with a significant penumbra. That attending's going to be coming back to work soon with no obvious deficits.

 

[southerndoc]

I ordered a CTA on a patient with an artificial aortic valve with an INR of 2.7. Presented within 50 minutes of symptom onset. Obviously not a TPA candidate because of her INR, but the neurointerventionalist took her to the lab (even though I told him the INR, he said they still do interventions on patients on warfarin with an INR that high). She had a heavy clot burden in the M2 segment of the right MCA. Went from total paralysis to being discharged with no problems at all a week later. Had the neurointerventionalist option not been available, this woman likely would've been paralyzed for life.

 

[emrox]

Our stroke protocol also calls for CTA/CTP after non-con CT also, because of the option of neurointerventional therapy. Pretty amazing stuff.

If they are not candidates for tPA or neurointerventional, then many times they will just get non con CT then MRI stroke protocol.

 

[thorg12]

im gonna play devils advocate here and ask how do u we know this neurointerventional stuff works? i understand the ct-perfusion and they have a penumbra so they go after the clot. Is there any evidence to support it works. anecdotally my last 2 had some right sided weakness and facial droop when to neurointerventional and dc'd home 3 weeks later trached and peg'd. I feel like lots of this is anecdotal without any hard evidence behind.
anyone else's thoughts

 

[WilcoWorld]

im gonna play devils advocate here and ask how do u we know this neurointerventional stuff works? i understand the ct-perfusion and they have a penumbra so they go after the clot. Is there any evidence to support it works. anecdotally my last 2 had some right sided weakness and facial droop when to neurointerventional and dc'd home 3 weeks later trached and peg'd. I feel like lots of this is anecdotal without any hard evidence behind.
anyone else's thoughts

You are not mistaken. We don't know.

On the other hand, we still live in an interventionalist society where doctors can be successfully sued for not performing interventions that are supported by equivocal evidence at best.

 

[ORL10]

We tend to get CTA's at our shop as well, but I do this knowing that the data for a neurointerventionist to come in and use a retrieval device is pretty poor. To my knowledge there is the MERCI trial and multi- MERCI (smith WS et al published in stroke), the PROACT II Study (JAMA 1999), and the penumbra pivotal stroke trial (stroke 2009.)

The Multi-Merci trial is really where our IR guys always say the data supports the need for intervention.

The problem is that the multi-merci trial is not randomized, there is no control arm, there was significant heterogeneity in procedures performed (some got IA tPA when the snare didn't work, some got IV tPA prior to enrollment and there were 11% off protocol violations).
- In addition there was 30.5% asymptomatic ICH, and 9.8% symptomatic ICH (meaning NIHSS decline > or = 4 and a bleed on CT, which if you ask me a decline of 4 on the NIHSS is an enormous change in functional outcome especially if your initial score is low.)

The argument is that IR results in increased recanalization rates FASTER, and thus saves the ischemic penumbra. The natural history for most strokes is to get better, however, and recanalization occurs in 24.1% of patients <24 hrs spontaneously and 52.7% of patients > 24 hours spontaneously. In the multi-merci trial recanalization occurred between 55-68% of patients.

I digress to say I'm not nihilistic, but I'm holding out for a better study. In the end if Im 50 years old and threw a clot and I may never use my right arm again, I might roll the dice. That does't mean that the intervention is any better than blood letting , however.

The impact of recanalization on ischemic stroke outcome: A meta-analysis Joung Ho-Rha and Jeffery. L. Saver Stroke 2007

Smith WS et al. Mechanical Thrombectomy for Acute Ischemic Stroke Final Results of the Multi MERCI Trial. Stroke 2008.

Smith WS et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke. 2005;36: 1432&#8211;1438.

 

[Arcan57]

We tend to get CTA's at our shop as well, but I do this knowing that the data for a neurointerventionist to come in and use a retrieval device is pretty poor. To my knowledge there is the MERCI trial and multi- MERCI (smith WS et al published in stroke), the PROACT II Study (JAMA 1999), and the penumbra pivotal stroke trial (stroke 2009.)

The Multi-Merci trial is really where our IR guys always say the data supports the need for intervention.

The problem is that the multi-merci trial is not randomized, there is no control arm, there was significant heterogeneity in procedures performed (some got IA tPA when the snare didn't work, some got IV tPA prior to enrollment and there were 11% off protocol violations).
- In addition there was 30.5% asymptomatic ICH, and 9.8% symptomatic ICH (meaning NIHSS decline > or = 4 and a bleed on CT, which if you ask me a decline of 4 on the NIHSS is an enormous change in functional outcome especially if your initial score is low.)

The argument is that IR results in increased recanalization rates FASTER, and thus saves the ischemic penumbra. The natural history for most strokes is to get better, however, and recanalization occurs in 24.1% of patients <24 hrs spontaneously and 52.7% of patients > 24 hours spontaneously. In the multi-merci trial recanalization occurred between 55-68% of patients.

I digress to say I'm not nihilistic, but I'm holding out for a better study. In the end if Im 50 years old and threw a clot and I may never use my right arm again, I might roll the dice. That does't mean that the intervention is any better than blood letting , however.

The impact of recanalization on ischemic stroke outcome: A meta-analysis Joung Ho-Rha and Jeffery. L. Saver Stroke 2007

Smith WS et al. Mechanical Thrombectomy for Acute Ischemic Stroke Final Results of the Multi MERCI Trial. Stroke 2008.

Smith WS et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke. 2005;36: 1432–1438.

I agree that the evidence behind embolectomy is poor, but would disagree that the natural history of the type of strokes that get taken to the lab is to get better. The rate of bleeding into the stroke damaged area without intervention with MCA occlusions is pretty high (~30% if I'm remembering correctly), and there is often significant edema that results in worsening neuro deficits after they've gone upstairs.

And I think we can all agree that recanalization rate at 24hrs is not a useful marker of functional outcome. Given the decent failure rate of IV-tPA to lyse MCA clots (most patients given IV tPA are neither helped nor harmed by it), we need something better and the angio lab is probably going to be where that something better is found.

 

[xaelia]

ORL10 is absolutely right with his summation of the literature that the devices and studies out there in support of them are inadequate, riddled with sponsorship bias, and the therapy remains experimental.

Most of what I see our interventionalists take to the lab are posterior circulation strokes that are 100% screwed otherwise.