Good morning. Thanks for the invitation. I'm going to talk about acute ischemic stroke and neurosurgical disease. So a brief background on stroke. I think it's familiar to everyone here. Most prevalent neurologic condition, most common discharge in a nursing home, most common diagnosis treated in rehab, and it's the leading cause of adult disability with an indirect and direct cost exceeding $60 billion a year. So currently there are over 800,000 strokes a year in this country, and as you can see here, the number is only on the rise. So we heard a lot about kind of traditional neurosurgery disease this morning. So as neurosurgeons, we think about aneurysms, subarachnoid hemorrhage, 30,000 new cases a year, brain tumor, 18,000 cases. We heard about AVM rupture, you know, dural fistulas, and even trauma, traumatic brain injury, 600,000 cases a year. So if you look at the incidence of stroke, we just talked about over 800,000 cases a year. So that in itself is more than all the other kind of cranial traditional neurosurgery disease combined. So I think, you know, as neurosurgeons, we want to make a big, big impact on patient care. We really cannot ignore stroke. So, you know, I mean, as neurosurgeons, you know, historically we think about, you know, like endoderectomies and bypass, you know, for Moyamoya, but I think the intervention at that point is way too downstream. The stroke has happened, the blood has spilled. I mean, here we're talking about secondary prevention for stroke. I think today, you know, we have different tools and different technology that really allows us to intervene at the time of the stroke and try to minimize the damage. So we're kind of going to these technologies. So currently, these are the endovascular IA therapies with 510K clearance from the FDA. So MERCI is kind of like a really archaic device. I don't think anyone even carries this device on the shelf anymore. And the freeware courses are really Penumbra, Solitaire, and TREVO. And I'll go into some details of each one of these and give some case examples. So start with Penumbra. So the idea of Penumbra is basically like a vacuum. It's a catheter, that aspirate clot. So fairly simple concept, nothing, you know, it's nothing new, but really it's the evolution of these flexible catheters that I think makes this technique kind of more efficient and more efficacious. So when I was a fellow not too long ago, we had these kind of stiff O5-4 catheters, pretty hard to track to the MCA, but since then, they have these 5MAX and now the 5MAX-AC catheter, which I think really has changed what we do quite a bit. So again, a new catheter. It's basically like a 6-French distal ID catheter that you can track reliably into the MCA. So again, designed to kind of remove clot intact, as you can see here, suck the whole clot in without fragmentation, because the previous iteration, they all have these separators that kind of fragment the clot to help clean the catheter, but these newer catheters basically remove the clot intact without fragmentation, has advanced tracking, again, big catheter to the immunosacral artery. So the technique is known as the DAP, pretty well-known among all of us who do it, direct aspiration first-pass technique. This is a paper, you know, 100 cases, 6 institutions. The technique is actually pretty simple. You just basically put the catheter approximately to the clot, and you hook up to a pump and you aspirate for about 20 seconds. And in this paper, you know, this technique alone works about 80% of the time to get what we call TIKI 2B of 3 results. So TIKI 2B is when you revascularize over half of the arterial territory, and TIKI 3 is basically a complete, perfect revascularization of average time of 32 minutes. So pretty, pretty good, pretty good overall results. So to follow, I'll just show some cases of my own. So this is a patient, a 58-year-old guy, came in M1 occlusion, 4 hours, best contraindication IV tPA. So here we have MCO occlusion. And I'm just going to see if we can play the video here. So this is basically a microwire, flossy microcatheter. And the purpose of the video is just to show this 5 max-size catheter, see how easy it is now to track to the middle cerebral artery. Just want to see if I can play it. Sorry. Okay. So again, tracking the catheter into the MCA, proximal to the clot, aspiration, and here the vessel reopened. Sorry. And this is what the clot looks like in tachymal, the catheter. So a similar case, I'll skip this case for the sake of time, but just to show that it is a triaxial access, you have a guide catheter and the petrous carotid, then the 5-max ace catheter over the felicity catheter, again aspiration, the clot comes out and the vessels reopen. So this case, a case of isaterminous, a similar concept, proximal to the clot, aspiration, the isaterminous is reopened here, the clot here. I just want to show this case to show how flexible these catheters are. So this is the patient's cervical carotid, has basically two loops to it, and with these new flexible catheters, we can really even navigate these tortuosities going to the supraclinal ICA to the ICA terminus. I think another place where aspiration is useful is when you have a big clot burden. So this is a case of cervical ICA occlusion. So a patient got IV tPA, really has a limited chance of success because of the large vessel occlusion and the clot burden. Here, because there's calcium at the ICA takeoff, so I thought I'd try a carotid stent and see if I can get lucky and reopen the vessel. So here I put a carotid wall stent here, still has a lot of clot beyond the stent here. So in this case, I just took the 5-max ace catheter and started aspirating. And actually to my surprise, every time I aspirate, the catheter got plugged, cleaned it out, put it up again, and just basically keep going up. Here you can see into the cavernous segment already, into the middle cerebral ACA, and here into the MCA. And here we kind of pull out four tubes of clot. And in another case here, cervical ICA occlusion, failed tPA. This is the neuron max guy catheter. In this case here, I just used the guy catheter and aspirate, and the vessel here reopened. Here we can still see a distal A2 occlusion, but certainly the vessel is not, it's a lot better than what it was before. One last case on aspiration in venous stroke. This is a case I did about two weeks ago. A 23-year-old woman, known multiple PE, sagittal sinus thrombosis, outside hospital, treated on IV heparin, and she had kind of a rapid decline despite therapeutic anticoagulation. Here you can see the hemorrhagic venous infarct. MRV showing the anterior two-threaded sinus is basically completely out. Venous phase of a carotid, internal carotid injection, confirming the inflammation. And here we went for a transvenous. Again, a neuron max catheter here, 5 max ace catheter, a free-fly glide wire. And again, just with aspiration alone here, I was able to re-establish fairly good flow into the sinus. This is the clot that came out with it. So basically, a summary slide of an aspiration. I think, you know, it's good for selective cases. I mean, when it works, it's pretty fast, pretty efficient, fairly simple. You put the catheter approximately in the clot, and you aspirate. As you can see some of these slices, it removes a large piece of clot intact with fragmentation. And I think if it doesn't work, it doesn't take away other options, you can still do stent-triever, which we'll show later on. Fairly cost-effective. It can potentially save the use of separators and stent-trievers. So we're halfway there. So, sorry. So Solitaire is a stent-triever. So the concept of stent-triever is a little bit different. Here, we basically deployed a stent across the clot. So the concept. Thanks. Yeah, sorry. So, thanks, Errol. It's a lot better. So the first technique we show is a large-bore catheter aspiration. So stent-triever is a pretty simple concept. You basically deploy the stent across the clot. So the clot is integrated within the stent. So you get immediate kind of flow restoration. And then you kind of pull the stent and the clot out. And so you basically spare the patient aspirin products, and you don't have to commit the patient to a stent. So SWIFT is a study that a Solitaire stent 510K clearance, basically comparing Solitaire to the old Mercy device, showing that Solitaire has better recanalization rate, 80% TIMI 2-3 versus 30% of the Mercy. And again, better neurologic outcome, 58% of Solitaire versus 33% of the Mercy. So as a case here, a 38-year-old woman, high NYX stroke scale after PFO closure, CTA, inferior MCA branch occlusion. So there are two ways to do this, and I think there's a lot of debate in terms of how to do it in the meeting. So I'll show a case of each technique. So the first case, this case, we did a triaxial technique, basically as a shuttle, guide catheter in the neck, intermediate catheter, 5-max ace catheter in the MCA, and then a micro catheter to deploy the stent reaver. So they call this a slumber technique, because it's a penumbra adding to the Solitaire technique. So here, micro catheter crossing the lesion, run, showing that we're in the vessel itself, hasn't perforated the vessel. So we kind of leave the 5-max ace catheter over the micro catheter, deploy the stent from the velocity micro catheter. And here, we basically local aspiration and pull the stent reaver into the large ball catheter and got the vessel reopened. Like I personally think this technique is a nice technique, because it basically maintains the access. You know, if it doesn't work, you can put it up for a second try. And also, you kind of go beyond the ACA and the PCOM, so you kind of avoid the distal embolization. So this case is done the other way, the balloon guide catheter. So basically here, MCA occlusion, 70-year-old high neck stroke scale. So here, we use the balloon guide catheter, basically fluororesin the cervical ACA with aspiration, and we pull the catheter. Again, micro catheter, run, showing the distal to the occlusion. So this is the distal stent in Solitaire that we saw on the first slide, and this is the proximal part of the device. So again, the concept of immediate flow restoration. So after the stent is deployed, you see flow across the clot into the MCA. And here, basically, you pull the stent all the way down to the neck under fluororesin and aspiration, manual aspiration, and it worked very well. So I want to show two cases of vessel occlusion. So typically, because the alternative is pretty devastating, most of us would extend the window. Like I personally do, up to 24 hours, you know, if the patient has a decent and reasonable MRI. So 50-year-old guy, NIHLF18, vessel occlusion here. So this, we did a coaxial access, basically choose one PCA first to get into, micro catheter run. Again, Solitaire stent, the three tines here, proximal stent, and immediate flow restoration to the left PCA here. And on single pull, fortunately, we opened up vessel apex in both PCA, still have a left-sided SC occlusion, but we just left it at that for that particular case. Now, this case, I kind of, when they call me, I say, like, you've got to be kidding me. But I just want to show this case to show sometimes you just never know. This patient is 95 years old, probably the oldest person I've ever done a stroke intervention on, and they call me 4.30 in the morning. And to make it worse, it's a wake-up stroke, so time of onset is not really known for this particular patient. INX stroke scale, vessel occlusion, I say, well, 95-year-old guys, probably there's not much to do. Now, but the only thing is that they got the MRI, and the MRI on this patient is actually not so bad, just has some kind of cerebellar peduncle, cerebellar kind of strokes, and some thalamic infarcts. So the stroke burden is not this, I mean, it's not terrible. So I thought I'd give it a try, you know, we did a triaxial system here. That's kind of how I do these strokes these days with the vasula. So I have a neuron max in the subclavian, four max into the vasula, and floss into one of the PCAs, then I deploy a stenotriever. So here, again, we pick the right PCA first, reopen, you know, the right PCA, then we go into left PCA, you know, the four max calf in the vasula, direct aspiration retrieval, and here we still have an occlusion beyond P2. And this patient, surprisingly, she came in essentially in a coma, and after a week or so, she actually went to rehab with a few cuts. I think sometimes you just never know, and I think some of these patients, vasoconclusion deserves a chance. So very quickly, the last five minutes, Trivo. So Trivo is a similar technology as Salter. The cell types are a little bit different, the cell genomes are a little bit different. This is the older version, and I'll show a case of the older and the new one. So the distal tip on the newer version now is gone, basically. The similar idea, basically deploying the stent across the clot, and retrieving it, and then negating the commitment of the patient to astroplavics in the setting of an acute stroke. So similar to SWIFT, Trivo II is a study that gained 510K clearance for Trivo, again, showing Trivo is better than Mercy for both revascularization and also for neurologic outcome in three months. So I want to show a little bit more detail in this case, just to highlight some of the thought process behind acute stroke. So this is a young patient, two and a half hours out from a stroke, basically high in that stroke scale. My personal cutoff is a nine, anything above a nine, like I would consider intervening because of the high stroke burden. And two and a half hours out, so well within the IV tPA window, I think if there's no constriction, it's certainly a standard of care to give IV tPA. The patient in this case did not get better, got a pretty significant headache afterwards, so you always got to think about the 5% risk of hemorrhage after IV tPA. So basically, anyone who got IV tPA before intervention, I get a quick CAT scan on the way up to the angio-suite, to make sure they don't have hemorrhage, because if they have hemorrhage, then I don't, obviously I don't do anything at that point. So in this case here, the patient had CT that was pretty clean, no hemorrhage and no obvious hypo-density, got a good aspect score. There's a hyper-dense MCA sign suggestive of a right MCA occlusion. So CT perfusion, again, showing a good penumbra and a right MCA distribution. So basically, the cerebral blood volume is preserved, showing there's good collaterals, but the flow is down because of the large vessel occlusion we see here on the CT angiogram. So this is an older case. I think in this case, probably did as a fellow. So proximal MCA occlusion, the older trivo, so here crossing the lesion, microcatheter run. So this is the old trivo. You can see the atriumatic tip here. You can't really see the stent, but the proximal stent is here. And here, with a single pass, we're able to retrieve the clot and had a TIKI3 flow with a good capillary blush in this case. So the patient, this is obviously like a pulser case. The patient kind of started lifting his arm up in the angio-suite. You know, the gaze deviation improved, and they draw from 16 and 15 on the table. A day later, basically has very minor symptoms, complete recoveral symptoms, and two days later, basically became normal. So these cases can happen. They don't happen all the time, but it can happen. So last case here, to show the new trivo device, 42-year-old, NXR13, two hours, got TPA with no improvement. So basically, the whole MCA is out here. You can see it. So this is the ADAPT technique that we show. So it doesn't work all the time. You know, in this case, we aspirate proximally. There's still a huge clot there, even though there's some flow into the distal MCA vessel. And here, we just basically put the fallacy catheter out, deploy a trivo stent. You can see that the distal tip is gone now, and you can see the stent pretty nicely on the device. So here, we use the triaxial system, and the vessel is revascularized. So I think, in summary, I think stroke is a, as we saw in these slices, a very prevalent disease with a large burden on society. And I think now is an exciting time because, you know, the positive study for IA therapy is emerging. So recently, we know of at least three, you know, possibly a fourth and fifth trial coming out, you know, that is showing now for the first time some positive data for IA therapy. So I think as endovascular neurosurgeons, we really have a good, you know, now we have good tools, as we saw, for revascularization. And I think, you know, we really need to embrace stroke as a neurosurgical disease, just to, as part of disease that we treat. Thank you very much.

acute ischemic stroke

neurosurgical disease

endovascular interventions

Penumbra

IA therapies