#WeekendLecture
#HistoryofEVT

It’s no secret that #EVT for AIS has been a complete game changer for the field resulting in dramatic reduction in death & disability

Join us to explore the #history of EVT in collaboration with @SVINJournal, to celebrate the inaugural issue Image
Many thanks to @Mahmoudneuro, #RaulNogueira and @DiogoHaussen whose review entitled:
👉“Tx Advancements in the Endovascular Management of Stroke” celebrates the advances in #ETV

🆓 #openaccess

ahajournals.org/doi/full/10.11…
1st #Fun fact: Interventional treatment of AIS dates all the way back to 1950s‼️
Sussman & Fitch reported 3 cases of IA infusion of fibrinolytics
Didn’t work 😫. Probably because they were performed in a non-hyperacute fashion
But this laid the foundation for years of refinement Image
The dramatic improvement in #endovascular stroke care has since then been moved forward by:
⭐️Refinement in patient #selection
⭐️Improvement in the reperfusion #technology
⭐️Integrating #systems of care
✅Patient Selection
With the approval of IV tPA, a wave of trials were designed to explore if EVT+IV tPA🆚tPA alone would improve outcome
☝️These were plagued by issues of patient selection and bias and there was no requirement for the presence of an LVO for historical controls
An example of problematic patient selection is illustrated in #IMS III trial
👉Did not require confirmation of the presence of a vascular occlusion before randomization
👉~ 1/4 of pt did not receive EVT
👉Half of EVT pt were treated with IA tPA only
pubmed.ncbi.nlm.nih.gov/23390923/ Image
Because of this, #IMS III achieved poor reperfusion rates, and thus was stopped early for futility

☝️Similar issues with selection #bias, lack of #LVO, poor workflow or lack of appropriate #stent-retriever technology also plagued trials of that time
The result of these negative outcomes was a focus on:
💥 Finding the right #patient
💥 Optimizing #workflow.

By 2015, 5 RCTs reported overwhelming #superiority of #EVT over standard medical treatment in anterior circulation #LVOs
✅This success was built on early time #selection and imaging selection!

These trials mandated the inclusion of patients with
🔹proximal occlusions
🔹parenchymal viability👉ASPECTS to grade CTs

The result was excluding pt with larger #cores unlikely to have a dramatic benefit
The result of these trials was presented in the #HERMES collaboration
👉Combined patient level meta-analysis
👉1287 patients
👉Confirmed the large benefit of #thrombectomy for anterior circulation proximal arterial occlusions within the first 6 hours

➡️pubmed.ncbi.nlm.nih.gov/26898852/ Image
In the #HERMES cohort the #NNT was a stunning 2.6 to reduce #disability by at least one level on mRS💪

👉The change of achieving functional independence (mRS 0-2) nearly doubled‼️

✅The benefit extended across broad patient populations Image
Concurrent with an improvement in patient selection was the improvement in #devices and the integration of #systems of care to get patients to a #thrombectomy capable center

☝️EVT went from a procedure that disrupted the clot with a #microguidewire

ncbi.nlm.nih.gov/pmc/articles/P… Image
...to using much more advanced #stent-retrieving #devices which allowed trials to be designed to assess the clinical benefits of the new technology over the best #medical treatment

👉link.springer.com/chapter/10.100… Image
🧠The stunning proof of concept driven by the reports of the 5 #trials from 2015 (which were hyper focused on selecting only the very most likely to benefit patients) paved the way for the ongoing #expansion in the use of #endovascular treatment
If the effect is outstanding within 6 hours… then what about 16 or even 24 hours after last time seen well?

💥 Enter #DAWN and #DEFUSE3! 💥

Demonstrating incredibly low #NNT for #imaging selected patients, which continued to revolutionize the field ImageImage
In many ways, as you’ll hear if you check out the #podcast with Drs. Nogueira & @TudorGJovin⬇️we’ve come full circle to IMS III…

With a super selective approach (advanced imaging) we can offer dramatic benefits to those w/prespecified treatment criteria
ahajournals.org/svin/podcast
But, how can the field now apply the improved #technology to a more diverse, perhaps less optimized patient population with still some benefit?
How can #MT become a more widely #available procedure?
How might we optimize #workflows?
And, will #TNK improve clot lysis pre-EVT?
👉Optimizing #workflow has been addressed by recent RCTs of EVT+rTPA vs EVT alone with different results
These studies DO NOT apply to any 1ry stroke centers or MT-capable centers w/ suboptimal EVT workflow

👉Check this #WeekendLecture about #TNK in AIS
The #endovascular field continues to innovate & refine the ways in which stroke patients achieve better outcomes.
"At @SVINJournal we are committed to making this research #openaccess and promptly available"

Read #History of Endovascular Treatment to see where we have been
We hope that you’ll follow @SVINJournal to see where the field is going!
👉ahajournals.org/journal/svin
And we invite you to visit @WorldStrokeEd website for more #stroke education
👉world-stroke-academy.org
#WeekendLecture
#HistoryofEVT

Thanks to @caseyalbin for accepting to work with us in this collaborative tweetorial, and to the authors of this historical #review about #endovascular stroke treatment
💪🤓
Edited by @interneurona Image

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More from @WorldStrokeEd

17 Oct
#WeekendLecture
#Tenecteplase #TNK
Part 1
✅3rd generation rtPA
🧬Targeted genetic upgrade
3 specific alterations to #alteplase molecule:
👉⬆️Half life
👉⬆️Binding affinity for #fibrin
👉⬆️Resistance to inactivation by #PAI-1
bit.ly/3pqbEb1 Image
#WeekendLecture
#TNK

👉⬆️T1/2 allows single bolus dosing and⬆️clot exposure to TNK
👉Higher affinity to fibrin-rich clots & + potent/faster clot #lysis vs alteplase
👉 < consumption of fibrinogen/plasminogen/ a2- antiplasmin👉⬇️systemic fibrinolytic effect👉⏬risk for bleeding Image
#WeekendLecture
#TNK
First analysis in stroke patients was a #dose-scalation safety study
There was no #symptomatic ICHs in dosis of 0.1-0.2-0.4mg/kg, and 15% (2 of 13) in 0.5mg/kg
No differences in clinical outcomes
bit.ly/3DNHamV ImageImage
Read 11 tweets
11 Oct
#WeekendLecture
Intracranial Atherosclerotic Disease #ICAD

#ICAD leads to changes ranging from minor wall thickening to #hemodynamically significant luminal stenosis and is one of the most #common causes of #stroke worldwide
ahajournals.org/doi/10.1161/CI…

🧵 Image
#WeekendLecture
#ICAD

✅10% of stroke, based on autopsy studies
bit.ly/3v6Lhrd
✅More prevalent in #African Americans, #Hispanics, and #Asians as compared with whites
bit.ly/3AuSiDt

Other risk factors in table Image
#WeekendLecture
#ICAD

In postmortem studies
👉degree of luminal #stenosis
👉% of the plaques containing >40% #lipid area
👉prevalence of intraplaque #hemorrhage, #neovasculature and #thrombus,
were higher in those #plaques associated with #infarct
🔹karger.com/Article/Abstra… Image
Read 13 tweets
4 Oct
#WeekendLecture
#GeneticsAndStroke

#Genetics is involved in several #stroke related conditions, such as small vessel disease #SVD, aneurysms, dissections, cavernomas, and intracranial #hemorrhages

Check this 🧵!
Prepared by @J_Rosales_MD
Edited by @interneurona Image
#Weekendlecture

#Genetic & #SVD
🧬🧠

✅1,5% of cerebral #SVD are #monogenic disorders
✅AR, AD or X-linked
☝🏼Absence of family history doesn't rule out diagnosis because of
👉de novo mutation
👉reduced expression or
👉incomplete penetrance
ahajournals.org/doi/10.1161/ST…
#Weekendlecture

#Genetic & #SVD

When to #suspect?🕵️‍♀️

✅early onset stroke without vascular RFs
✅systemic features and neuroimaging of an specific monogenic disorder
✅consanguinity
✅negative work up for other causes of SVD

👉ahajournals.org/doi/10.1161/ST… Image
Read 15 tweets
29 Aug
#WeekendLecture
#CarotidArteryDisease #CAD

#CAD causes ~ 10-20% of #strokes
Atherosclerosis occurs most frequently at carotid #bifurcation, an area of low vessel-wall shear stress and oscillatory/turbulent blood flow

Welcome to this mini review!
#WeekendLecture
#CAD
Endothelial dysfunction
⬇️
Inflammatory response to Lp retention in arterial wall
⬇️
Accelerated accumulation of Lp in subendothelial matrix
⬇️
Macrophages
⬇️
VSCM migrate/proliferate to fibroblast-like cells👉 production of EC matrix
atm.amegroups.com/article/view/7…
#WeekendLecture
#CAD
Stroke Mechanisms
#artery_to_artery embolization: retinal (amaurosis fugax) or cerebral circulation
#thrombosis in situ
#Flow reduction in high grade stenosis: #watershed infarcts, repetitive and brief TIAs (ie limb shaking)

nejm.org/doi/full/10.10…
Read 12 tweets
15 Aug
#WeekendLecture
Stroke outcome #prognostication

☝️#Stroke clinicians are routinely asked by patients and families regarding prognosis.
🧠The cognitive process underlying prognostication is #complex, poorly understood, and sometime #biased by personal experiences Image
#WeekendLecture
#StrokePrognostication

#Fact: Clinicians, even those with expertise in stroke, perform poorly in predicting clinical outcomes
In this case-based study, overall accuracy for predicting death or disability at discharge was <20%😩
#JURaSSIC
n.neurology.org/content/81/5/4… Image
#WeekendLecture
#StrokePrognostication

☝️Several prognostic #models have been developed to aid prognostication after ischemic stroke
These models #outperform clinician #judgment in predicting stroke outcomes
ie:
onlinelibrary.wiley.com/doi/10.1111/en…
@GeorgeNtaios Image
Read 12 tweets
1 Aug
#WeekendLecture
#PregnancyAndStroke

#Pregnancy and #puerperium confer an ⬆️ risk for ischemic as well as hemorrhagic stroke, with incidence rates being 3-fold higher as compared with nonpregnant women

👉doi.org/10.1016/j.ncl.…

a short 🧵 Image
#WeekendLecture
#PregnancyAndStroke

@DrRickSwartz @patrice_lindsay et al metaanalysis
👉11 studies
👉>85 million #pregnancy and #postpartum admissions in various countries
👉overall incidence of #stroke was 30 per 100,000 hospitalizations👈
@IntJStroke

journals.sagepub.com/doi/10.1177/17… ImageImage
#WeekendLecture
#PregnancyAndStroke
RFs:
☑️Age, >40yo OR3.1
☑️Race/ethnicity
☑️Migraine, thrombophilia, SLE, 🫀disease, HTN, thrombocytopenia, diabetes
☑️Pregnancy complications
✅For hemorrhagic stroke: aneurysms, AVM, Hypertensive Disorders of Pregnancy

journals.lww.com/greenjournal/F… ImageImage
Read 12 tweets

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