I'd like to go over with you some of the ideas and techniques around acute stroke, it's something personally I'm very passionate about. We're not the busiest center for acute stroke but we're relatively busy and I think that you can't go into this space, you can't go into neuroradiology, interventional neurology or surgery without having some component of your make-up, being excited about acute care, being excited about the patient comes in, they're stressed, they're devastated and you take steps and make adjustments and provide care that makes a dramatic difference in their life and that they live or die on. So we deal with live or die disease states and that's what acute stroke is and it's very satisfying in that way. So, briefly, these are my disclosures. Therapy in positive or randomized trials related to stroke, otherwise, and there's some, in the last respect, there's a stroke treatment technology but it's not part of this talk at all. Those are stroke trial grants. So, brief background, leading cause of long-term disability in the U.S., fourth leading cause of death, it's actually a larger cause of death in developing countries, huge estimate of indirect costs, the numbers are building through the roof as our populations age, and so I'd like to start with just a brief case where I can highlight some of the techniques that get used to give you an idea and sort of show you what my standard is. So, this is a woman who comes in, she's 47 years old, she has mechanical valve, it's a belted thing. Her INR is therapeutic, she's 2.5 on her commitment. Her NIH Stroke Scale is 14, she's a dead tenant, Legion Neglect. This is her CTA, because I'm a neurosurgeon, my radiology colleagues helped me out with an arrow to show me where the problem is, once I wore a gown, and you can see there's a T occlusion right here. So, there's some flow getting by it, whether it's collateral or sort of timmy, one or two A kind of flow, but she's got a dense defect as a result of this. You can also look, it's kind of fuzzy and irregular, which to me made me worry right away that this was going to be problematic. Here, I do CT perfusion, I'll talk about that in a second. We do CT perfusion in Vanderbilt. This is what the picture looks like. She has a little bit of stroke anteriorly, but most of the territory is salvageable and we feel it's worthwhile to pursue. So this is my first line, this is what I tend to do right away, and I'm going to start with that, and I'm not going to advocate that one is better than the other, I'll tell you probably, I'm actually 100% confident that Joey has more stroke than I do, and he has a different mechanism by which he does that, and he gets equally, or if not better, good results. The point is that you have a methodology that you do, that your techs know, and that you're doing, and that's your foundation, and that's what you're going to do essentially every time. And that foundation allows you to be fast. We'll talk about that in a second, time is of the utmost in this care. So, never rush for rushing's sake. If you're rushing just to try to be fast, then you will do something wrong, and you'll end up causing more damage than benefit, or certainly not have a good time. But you should be fast because you know what you're doing, your team knows what you're doing, and you've worked out all the steps of efficiency. So those of you that came by my table for some of you today, I talked about some of those things that I'm always thinking about. How do you get the coil to the person that's next to you to maximize the efficiency so that there's no floods? How do you plan your case as you're approaching it? This is what I do. So, patient gets on the table, whether they get anesthesia or not, I am not a zealot either way. I do not believe the patient should get anesthesia, I don't believe that they should get anesthesia, I tend to go either way. We have a great, we're a level one trauma center, we have neuroanesthesia present in every case, and because we're a large trauma center, they're very good at rapid intubation. So if the patient is moving around a lot, if they're swirly, if they don't understand what's going on, I have very little problem saying, go ahead and intubate, but it needs to be done in five minutes, and the blood pressure can't go below 160. As long as you do those things, I don't believe that that is a detriment. If you look at the literature that talks about anesthesia use, it's almost always related to hypotension that occurs on induction, which is extreme delays. Two of my friends, who are the biggest advocates for no, not using anesthesia, when I actually talk to them over beers about doing it, they say, well, we could call it anesthesia, it's an hour delay. Well, of course you're going to have worse outcomes, because they don't do the same thing all the time. We don't use general anesthesia for every case, but they're there, so that whether we use it or not, it's not a huge time differential difference in what we do. But either way, the patient gets on the table, we go on the leg, immediately go over the long wire, we don't bother with it, normally I do it at the beginning of every case, as long as there's no challenge with access, wire goes straight up to the arch, put a Neuron Max, as the sheath, right up to the arch, at which point, I put a 125 centimeter V-Tech, if you guys don't know what that is, it's a short, stiff, sort of shepherd's crook catheter, there's different versions of it, I like to cook one that's the stiffest, because I want it to be stiff, and then you click over the arch, I do that every time, yes, sometimes you can use a VIRB, sometimes you can use various, a slip cath, you can do all kinds of things, I like that, because no matter what the arch is, whether it's type 3 or type 1, I can click into the origin of whatever the vessel is, that's a subsequent thing, and I can do it every single time, the same way. As soon as I do that, I do a single, sort of, depending on what I know from the CTA, either a road map or a puff or something, to see the neck and where I am, I use an 038 exchange flat wire, and put that up directly into the internal, now if the patient has Crohn's disease, which we'll discuss later, then you have to deal with that first, or evaluate how you're going to deal with that, but I've had a CTA from arch to vertex for planning, so I know what the neck looks like, put the 038 directly into the internal, the VTEC stays in the arch, just barely engaged, just approximately engaged in the vessel, the 038's up, with that construct, you can climb the neuron max, I don't care what the anatomy, I mean, there's always going to be some triple loop thing that won't happen, but 99.5% of any type of arch, you will be able to get the neuron max to track over the VTEC and the 038 by, so you can go directly up to the internal, my first run is that target head run, or that VIRB run, to look at the target lesion, at which I use a Fathom, it's a 16 wire, it's very damp, very good wire, someone else mentioned it earlier for, I think an out start, mentioned it for radius XT27 up, so I use a Fathom, 16, it's got some good stability, it's easily steerable, it's most like a single 14, it's like a bigger single 14, and a 3 max and an ace. I like that combination, there's some people who use a velocity, there's some people who just take the ace directly over the Fathom, again, I want to do the same thing every time and never run into problems, I don't want to have it get caught up at the siphon, so by having the 3 max, that's the most robust inner catheter I can have inside the 5 max, with that combination, there's, there really has never been a time, I mean, I can't think of one, if my fellow's here, he can be honest, I cannot think of a case where I couldn't get the ace into the MCA. It just doesn't, it's easy, it's not, it's not something you'd work on, with the Fathom and the 3 max inside the ace, it goes up every single time, and it goes up quickly, and so that's what I do, it's the same thing every time, my techs have already had it all pulled, they're already hooking up all the drips, it's all set up, and we fly, not because we're trying to rush, but because we're extremely efficient and fast, now, you know, Joey can talk about his setup, and I bet he does the same, it's totally different tools, but I bet it's the exact same concept, that when he walks in the room, the techs have already pulled the stuff, the drips are already getting set up, while he's getting access, the techs, my techs are fellows that have already put the 3 max through the 5 max in the Fathom, it's all teed up and ready, by the time they have access, so Joey has to- I put them both on flush, with catheters that big, I really worry about it, because, so let me talk about the subsequent steps, but I put the wire through the clock, I do not put the 3 max through the clock, so if you look at the original ADAPT people that they wrote, they described, Quill uses the velocity, which is fine, but why not go with a bigger catheter, so I use the 3 max, and he brings the velocity through the clock, whereas I do not, I stop before it, Dave Fiorello, who's been coming out for a while, he's been coming out for a while, he's been coming out for a while, he's been coming out for a while, he's been coming out for a while, he's been coming out for a while, he's been coming out for a while, he's been coming out for a while, he's been coming out for a while, he's been coming out for a while, he's been coming out for a while, he's been for a while, he's been coming out for a while, he's been coming out for a while, he's been coming out for a while, he's been coming out for a while, he's been coming out for a while, The patient moved, we're doing this one awake. But what we'll do is have the ACE before the clot, approximately, and then deploy the stent retriever. So this is solitary deployed across the stenosis. You can see the run here showing the clot trapped in the stent and the flow going by. Now at this point, there are two different schools of thought on what to do next. I like sort of a sandwich technique. So it's sort of, it's adapted, we'll move the stent retriever as well. So I'll go on aspiration, advance the ACE until I engage the clot, the aspiration stops, so I have that additional suction on the clot, and then I will pull both of them out. And that gives me this kind of a picture, which I have a number of those. And so that's my sort of second line technique. I have tried, this is the other technique. This is again, this is from the MUSC guys, but what they like to do is put the stent retriever and then pull it fully into the aspiration catheter and pull it out. I've tried both techniques. When stent retrievers first came out, before we had figured out using the adapted technique as a first line, I was using stent retrievers on every stroke. And so I was experimenting with both techniques. For me personally, I like that sort of sandwich pull of both, and they navigate so well, I don't feel like I lose more than 30 seconds going back up if I need to. I just didn't see good success with pulling it into the ACE. Again, there are lots of people who say that is the way to go. So I don't, I'm sorry, but you're a stent retriever. What do you do? No, we, I do what you do normally. You pull them both together? Yeah. I actually like the idea that if you go back to your picture and you think of when you show it on, I mean, look at the clot burden there and think about pulling that into the fine max. Yeah. As big as the fine max is, it's also the clot burden is enormous. Yeah. So I like the idea of whether it's your neuron max or pulling that guy there, pulling into the largest board catheter. Yeah. What we end up doing over the years after experimentation is really, is really not have an intermediate catheter. If we go with the stent retriever first, which is what we tend to do, just put the neuron max up as high as we can, navigate the stent retriever, I mean, a micro catheter through the clot, put down the stent retriever without the intermediate catheter so that you won't have shearing of a problem with the intermediate catheter. Because we did that initially and we found that many times we had fragmentation or less effectiveness of the retriever. People are using a foot finger, not even using a balloon guide either. Almost all the time. What do you, you guys are, I know you like the salumbra type technique here. What, what? Similar to that. The sandwich or the pulling in? Well, I do what you do is adapt first. And I guess I've been crossing the clot less than before and see if you can just grab it. You really don't need to cross it with almost anything as that video showed. I mean, as long as you get your three max and your wire right up there, the ace will come up right to the face of the clot. I guess the thing that I found is you're basically, you go up to the clot and when you're engaged, you're not getting any flow back, correct? So you know you're engaged and then you turn on your suction. And if you don't move the ace and all of a sudden you get this big red, beautiful pool in the bucket, you've cleared it. Yeah. So that's, that's, so, so talking about that technical component, I think the key to making that adapt technique, that aspiration technique work is after you're against the clot and you've pulled your stuff out and you're on aspiration, I then advance the ace. I push it, nothing on it, directly against the face of the clot, a good five millimeters or three millimeters. I mean, I see it move. It's not just put a little pressure. You see it advance over the clot on aspiration, nothing in it. I've never seen an intracranial dissection from that whatsoever. And I mean, that's whatever my age is, you know, 40 adapt cases or 50 adapt cases. So it's not, certainly it can happen, but I've never seen it. That is, to me, the key. You sort of cork it as you're going over. That's when you really get it. The other thing that I've done is I've become more patient. Especially now with the ace, with the bigger bore, I'll wait about two minutes of it just sucking on it before I pull. And a lot of times, like Lucas just said, it'll just go, bam, and it'll clear. You'll see it first won't be flowing, and then you'll get little staccato flows, and then you'll get more staccato flows, and then it'll shoot through. But for the most part, still, I'm pulling it out as a full piece without crossing it with the aspiration stuck on the proximal end. But advancing it that extra few millimeters makes a big difference. Yes? When you're sandwiched in a treatment with the 5-Max, Yes. Do you have your 5-Max on number suction and it manually aspirating out of your knee pads? That's correct, the Neuron Max, yes. So I have a 60cc syringe on the, the truth is, with the 5-Max in, you can't really aspirate on your Neuron Max until you're almost out. But I do that anyways, in case there's anything stuck on the end or something, so that the moment I do that, I'm sucking everything out. And it's not infrequent that I get clot, organized clot, in that syringe, which I immediately pour out to check. But I bet half, most of the time, that organized clot in that syringe is coming from the end of the 5-Max as it pulls through the co-pilot. One thing that I find with the Neuron Max is frequently as you pull the things out, and you don't see a clot, but you have to detach the hub. Yeah. Because the thing is gonna be stuck in the hub. You have to make sure, because a couple of times we almost re-injected something. Well, that's a good reason why I use the 60cc to really clear that. Always make sure you clearly back bleed everything, and there's no clot in that before you do your rerun. So that's what I did in this case. So I did my usual, right? So this is what we're gonna do, the Texanoa would be fine. 3-Max, 5-Max, 8-Fathom, 16. Here's the picture. I put the low max, as you can see. This is the first run I've taken. So I go up to the arch. I take a fluoro shot. So as soon as I put the sheath in, my sheath is the Neuron Max, I take a fluoro shot just to document the time, which is not what that is. But then I do that. I go direct up to the internal. This is the run, right here. I have this fluoro shot to say when I got groin access already. And then you can see the time, just so you know I'm not lying. There's the clot. You can see all this soft, cheesy, grumpy stuff there, which I didn't know what was gonna happen with that. I went out with the 8s. I did aspiration. Got complete tic E3 recanalization. Four minutes later from that first run, and six minutes from access. This is what came out. I mean, you can see that it was somewhat fuzzy and weird on the Angio, but I mean, how ugly is that? So this is more typical, an organized clot. All this cheesy stuff, I don't know, but I was glad I was using aspiration in that case to try to pull that out. Time from the fluoro shot, as soon as I have the neuromax from the groin, wire, sheath here, I take a fluoro shot of six minutes. This is her the next day. A little bit of stroke, exactly where the perfusion told us was already established red. The rest of it salvaged. She's intact. Now, I also like to show, I show this case for two main reasons. One, that's my best time, so I like to show off that I did it in six minutes, okay? My other is to make an important point about stroke care, okay? This lady was completely normal, essentially a little tiny drift. They gave her two for facial and arm. I was a little annoyed at that, but that's the way it is. But she's essentially normal. She went home a few days later. She lived at home completely normal for the next two months. Remember, she had a valve. She came back two months later to get that valve replaced because it had been the source of the stroke. She died after that surgery. She's not alive. At a 90-day modified rating score outcome of two, she's a six. In a trial, she's a six. So I just, I want to highlight what that means to us when we look at these trials and we interpret them. I would call this a success. I would call this a lady who would have been hemiplegic and totally screwed, instead going home and living two months successfully before she then had her elective cardiac surgery and subsequently died as a success, yet in the context of a formal trial, she's a failure. That speaks to, number one, we need to design our trials better, and number two, these patients have a lot of baseline disease, that's why they're having a stroke, and we need to keep that in mind as we assess our outcomes and assess our trials as we move forward. So, interesting sort of result. I show her all the time because, like I said, she's my best and I like to brag, but in the end, even though I'm showing her a success, she would be registered as a failure. So, on that note, I can't help myself. I know we're doing technical and I'm gonna talk about technical stuff, but I wanna talk a little bit about sort of decision-making, just because this is gonna be a big elephant in the room. Everyone's gonna say, how do you choose your patients? I would bet there's a significant amount of variability across the faculty in this room as to how we choose our patients, and the simple answer is, we don't really know. We don't know, and I'm gonna highlight why we don't know, and then I'm gonna tell you what I think you should do when you're in practice. So, one option is cerebral perfusion, CT perfusion. I'm a big fan of this. Right now, the acute stroke working group at the NIH, there's this huge email debate going back, all the neurologists are yelling at each other. I just happen to be on it, so I get to read them all. And, uh. Is that in all caps? Yeah, everything's capped. Everyone's like, you're crazy. This is, you know, you should only do MRI. It's unethical to expose patients to radiation from a CT. Back and forth, there's all these arguments, okay? So, I'm gonna sort of show you what I think and what the arguments are either way, and then the real conclusion is we don't know. So, I'm a big fan of perfusion imaging. This is a study that myself, when I was in Florida, so it includes my Florida series, Don Fry, Swedish, Quilt Turk, and NUSC pooled our site centers. We looked at patients that we all use cerebral perfusion, CT perfusion as a selection. Patients that we treated within less than eight hours, and patients that we treated in greater than hours, 250-odd cases, and what I wanna just highlight is similar, no differences in demographics, no differences in NIH stroke scale in the cohorts, huge difference in time, which makes sense because that's how we stratify the groups. No differences in outcome, whether you're talking about independence or modified mechan three or better. No difference in mortality, no difference, in fact, if anything, also trend towards better outcomes in the delayed patients in terms of recant, no difference in intracranial hemorrhage. So, we believe that this says to us, in our hands, with CT perfusion, we can adequately select the late presentation patients to mirror early prep patients. However, there's a huge contingent of individuals who say, no, time is what matters, the only thing that matters is time, it's obviously not the only thing, but that's the thing that should drive your decision making. Paper published in Lansing looking at decreased modified Rankin scores over time, increased hemorrhages, increased mortality. Well, I believe that time is important, but I don't believe that time is an absolute. You have Pooja, who's a colleague of mine, a co-PI on therapy, she's a huge, time is, it's all about time. You shouldn't waste time with any imaging. It's all about time. IMS-3, she published for every 30 minute delay in IMS-3, there was a 10% reduction in likelihood of good outcome. So certainly time is critical. There's a debate as to whether that should be your decide. Do you just treat everyone who shows up less than six hours or less than eight hours or not? Another argument in support of time, frankly, is the randomized trials we already have. There are four successful recantalization-based trials. Okay, two for IV, that's actually ECAS-3, and two for intra-arterial linux, okay? All of those trials used early time points for targets. So clearly time is important. Does that mean it's the absolute? We don't know. But they were all early intervention trials. And then here's the real, and this is the one that kind of bothers me the most, is everyone who says, well, it's all about the core. You have to do a DWI. The DWI core is what is real, and you look at either clinical DWI mismatch or perfusion DWI mismatch, and that's what you should do. Big advocates of that. Well, this paper was just published this year where they looked at patients. This isn't IA, this is IV. Patients that were early recantalizers with IV thrombolysis who had gotten DWIs before, they found about 8% of patients demonstrated, they actually, 17% had some DWI reversal, but then later it changed back to being positive. 8% of patients had permanent DWI reversal. So DWI is not exactly the end all, be all of what stroke is. We know that. Here's a case that we did just, I don't know, maybe a month and a half ago or two months ago. At Vandy, it was a five-year-old. He was playing with his brother. Fell and hit his head. Probably had a very small dissection that led to a thrombus. Went to an outside hospital where he sat for eight hours, had a vascular occlusion, came to us. We got to him 10 hours after presentation. He's nonverbal, no following. He withdraws the pain, right greater than left. Bilateral sensor plantar fractions. His NIH stroke scale was 22. Here's his MRI. Look at his pons. DWI positive throughout the entirety. This is the ADC as a correlate to show you. I looked at this and I said, this kid's dead. I'm not gonna, what am I gonna do? It's ADC positive. It's not T2 Shine-Thru. This is a real thing. There's no way I can help this guy. But he's five years old. Am I just gonna say he's dead? I'll try. It's probably gonna ruin my series, my outcomes. That's part of your threshold. Do you care more about what your outcomes look like? Do you care more about giving shots? I will lean towards giving a shot to somebody even though they'll probably have a bad outcome that'll make my series look worse. So I said, let's go and give it a shot. So we took him to intervention. The MRA showed the occlusion. Here's his basilar occlusion. We went up, it's in our children's hospital. We have a biopsy in the children's hospital where we don't have any stroke technology. So we ran over the adults, grabbed some boxes and ran over. In this case, I used a solitary. Because I went over, it was a kid, and I was like, oh, the muscles aren't gonna be big enough. So I brought three mags. So I thought that would be sort of the equivalent of a five mags. It turns out that's not the case. The muscles are just as big, basically, as in many adults. So the three mags, as soon as I brought it up, I'm like, that's not gonna work. So I switched, I had a solitary, and I switched to use a solitary because I brought it as a second line. And got this result. Now you can see the left PCA is still occluded. I tried a number of times to get into it, but it was such a sharp angle backwards. And the PCOM was right there, and the clot was so hard, it just kept wanting to go into the PCOM. And I did an anterior circulation, but I got good collaterals. I'm already getting to his contrast load limit because he's, you know, whatever, 40 pounds. And so I said, you know what? I'd rather just leave the PCA occlusion. I think he's gonna die anyways because his whole pons is infarcted on the DWI and ADC. I'm not gonna give him a giant hemorrhage. If I keep poking him, I'm gonna poke a perforator and cause a problem, so I stopped. Which I don't generally do. You'll see later, I'm pretty aggressive. Yes? I love that point that you're making. That is, in stroke, you have to have your goal set appropriately. And here, the elephant in the room is the basilar artery. You open up the basilar artery, fold, and get out of there. Yeah, so that's what we did. I mean, I debated it a bit. In general, I try not, but what I say is this, and you'll see some later days where I go pretty discal doing some treatments, but it's what comes easy. Don't do the thing that's hard over and over and over again. Try it. If you can get it, great. I'm all about making the picture look perfect if you can, but don't kill the patient trying to do it. So anyway, so we do that. Use the solitaire. We went home eight days later, not to rehab. We have that follow-up MRI, so we don't put it back under sedation. MRI two, and a six-week follow-up, not by me, but by the pain neurologist. And I had stroke scale zero, modified recognitive score of zero with that MRI. Now, does that mean that patients with that MRI are gonna get better? Absolutely not. But it means that we don't exactly know what we're saying when we say DWI is poor. And that other series I showed you was adults, not kids. So you might say, well, kids get better from everything, so it doesn't matter. This is a friend of mine's case, Don Fry, he's in Swedish in Denver. 29-year-old woman, pregnant, last normal at 9 a.m. She comes in with a 17, they do his rhombectomy, and I have stroke scale five. She gets an MRI right before the procedure, and then she gets it about four hours later on the exact same MRI machine. We're talking four-hour temporal difference between the pre and the post. This is the pre. This is the post. So I guess what I'm trying to say is this, as is evidenced by the discussion from the faculty, is we don't really know, okay? But you need to take a good look at the literature. You need to do it with your stroke neurology colleagues. If you're that person, I feel bad for the neurologist in the room if you're going to a place where you're the interventionist and the stroke neurologist, because I like having someone else to discuss these cases with and review them with, so that we can come to a consensus. I feel like there's strength in numbers. You guys need to- It's good for them, because that's where we are in aneurysm, right? Yeah. I don't really want to clip this. I don't really want to coil it either. Yeah, who can I send it to? Who can I send it to? Shit. Sorry. So, but the point is you need to sit down with those people and come up with a very consistent protocol, just like you do in the angio suite. You know, I talk about six minutes or 15 minutes recant or whatever. That's nothing compared to the two hours that get wasted in getting the patient to the angio suite. And so, you need to have that system. You need to decide what you're going to do at your center, and then you need to do that consistently in an evidence-based way, as best as you interpret the evidence. That's the point of the story there. So, this is what we've done. I'm not going to go into it, but it's the idea is this is decided beforehand. It's not with every patient we're figuring it out. It's done. Did you all get that last slide? No, but that's not, it's not the point of that. I'm not, I'm just saying that we have something. It's more of a- It's straightforward. It's simple. You know, it's really fast. Actually, that's it. I don't really have it. I just want to be clear. The reason why we're doing it. This is the decision. This is the patient. All this is just people's responsibilities. That doesn't have anything to do with what happens. This is the patient's path, and it is. It's one thing the whole way down, and there's a final decision made. There's not if-thens. There's not loopbacks. There's not, when I got to Bandy, there was a sheet of paper that had like 50, like you have a curve over to here, and then you go over there, and then you might do this. It's one pathway straight down. I don't want to teach you. The point is, I'm just saying, have one of these, however you make it. Now, I put you to sleep with that talk, and I want to get a picture of my kids in for this. So, let me talk about some decision making real quick, and you guys can stop me whenever you think is appropriate. But this is actually a case I did in Florida. This is before some of the newer techniques we used before step treaters. A 62-year-old man, left MCA stroke, classic symptoms, NIH Stroke CL16, on-site six hours. He had no severe carotid disease. His physician had put him on aspirin. After a few weeks, he's like, I feel fine. He stopped taking his aspirin. Comes in with this stroke. CT scan looks good. A little bit of hypodensity. Here's the occlusion. You can see there's a little branch here that's open, but the main MCA's occluded. Here's his carotid. So, to you guys, what would happen? What would you do for this carotid stenosis as your first-line treatment? Would you ignore it? Would you go by it? Just kind of force your way by at work? I was recently, I don't know where I was. It was some meeting or course, we were discussing this, and people said, well, first you, oh, I know her, it's Esmet. And they were like, blow by the carotid, get by it, treat the important thing, which is in the head, and then later you can decide what you want to do down below it. In fact, they were saying that sometimes they leave it. They don't even treat it. They just leave the severe disease or even the carotid occlusion occluded, as long as they've opened up the intracranial axon. Yeah, I've even heard people talk about going up the other carotid and across the ACOM. Yeah. But I'll just go first and say I really disagree with that, and my approach has been to treat that first with a stent, go through it with the guide catheter. You reestablish flow, which is one of our most important weapons in stroke, and then you can take care of what needs to be done. And on many collaterals. Right, and then you can take care of what needs to be done in the head in a situation where you've got flow. Any situation, whether it's a thromboembolic situation with coiling or otherwise, when there's no flow, if it gets a worse and worse situation, and when there is flow, if it gets a better and better situation. Tibor? No, I was just gonna say that I have found myself a couple of times doing exactly what the people that you referred to are saying, that you have such a terrible disease here, and the problem is, and you have a big clot in the ICA, and so instead of plying through that risk, you're putting more in the head. The problem of the patient is really the, let's say an M1 small piece of clot that went out there. So if that's the case, I shoot the contralateral carotid. That's wide open, and the collaterals are great, and I just show the M1 clot. I have gone through the contralateral EGON, not retreat, but try to slice it there, and then, you know, I think a close carotid, and then that scenario's not a disaster. I think what you were describing is exactly what, you may, maybe you heard Mandy or someone say next, that's exactly what we do in this. Your problem is brain that's infarcting. It's not the picture of this horrible-looking carotid, so what we do, what I do, is I'll take a run high up in the carotid. If I've got good flow, I'm gonna go right past that, and I'm gonna take care of the clot, and I'm gonna come back, because it's a time-sensitive. You know, we focus on door-to-needle. We focus on perfusion. It's all about time. It's time to reperfusion a tissue that's infarcted. What would you do, I'm sorry? So I do the angiogram, see how tight it is to get through. If it's really tight to get through, I'm gonna shoot the other side, and I would angioplasty it, just to get to the clot, just to see if I can not get through it without it. I'm gonna do it within a trillion miles. Why do you shoot the other side? Yeah, it's a waste of time, sorry. Why do you shoot the other side? What's that gonna tell you? Just to look at the cross-collateral of the case. Yeah, I don't do it. I mean, yeah, it's a time issue. The other thing that you do with those, what I've done with those, if they're really tight, to your point, just go up with a balloon real quick, open it up, and then go up. So I look to see, can I pass it without doing anything to it? I feel like I need to do something to get past it. I don't stent these. I try to avoid stenting these at all costs. Why? I don't like aspirin plant mix. So I would balloon it, I'd go through it. The other thing is, that's a great case for proximal control. If you need to go buy it without stenting it, or if you just want an angioplasty, or if you want to stent it, a balloon guide where you can arrest flow, arrest the possibility of throwing emboli up, then you're either addressing it or going to buy it, that you at least have control. So this is what it'll look like. Is that something you would plasty first? I would angioplasty that. You would angioplasty first. What would you do? I'll just go buy it? Well, I don't know what is in the head. Yeah, I need to say that. It's MCA occlusion. Yeah, if I've got good flow, and I've got MCA occlusion, I would probably go right past that, and I'd go prep the clot, and then come back. You think you're going to go through that? I'm trying, but if I can't. A lot of times you can. You're looking at a picture. A lot of times you can get through that. If you get your guide right, you'll be in trouble. If you look at the CTA. So, if you look at the CTA, there's a piece of rock there. I don't know how you're going to balloon that. That's all calcium in that. I don't know. You only need a couple of those. Yeah, it's not, I'll tell you for the calcium, it's not concentric. It's not concentric calcification, just on the side. I'm more of the inclination of Adam. I see the CTA before the patient's in the OR, right? They're getting wheeled to the OR. And so, for me, I don't think there's a time sump there to say, I have the stent that I want. I've measured everything. It's all ready. It takes two minutes to put the stent, drop it, and then go up. And so that's what I do. It's good for the discussion. I know you're good. It does not take two minutes. That's exactly right. No, no, if you're, wait, wait a minute. Actually, I disagree with that. You dissect that, drop that. If you're up there, if you're a guy. No, but it happens. No, no, but let's talk, really. If your guy catheter's already here, and you're talking about what you might spend pushing by it or anything else, the time to do, all you gotta do is exchange an RX stent up, deploy it, and pull it out. That really does take two minutes. Yeah, to do a carotid stent doesn't take two minutes, but the difference between you're already there and you're gonna go up and treat your stroke, or you're just gonna RX your stent up and deploy it, and it's already pulled and been prepped before you're getting groin access because you've seen the CTA and you've set it up, it really adds negligible time, in my opinion. Yes? I think one problem, though, with the stenting is you're gonna need dual anti-platelets. You may need Integramin or Epsomab. So that's a great question, and that was Joey's point before, which is a legitimate argument to not use the double anti-platelets. And we've had patients where we drop a stent, go in there, do a thrombectomy, TQ3, and everybody's high-fiving each other, and then the next day, the stent occludes because the patient's not a platelets responder, wants to take one and wear it off. Well, yeah, that's a little bit, I don't know. So if you have the patient doing angioplasty and doing thrombectomy, if you can get past it with just angioplasty. If you have the patient on aspirin and platelets, I personally haven't had that, I mean, a large stent, a large cath, that big thing, I haven't seen that occlude. But just having them, the hemorrhagic risk on aspirin and platelets, what makes me feel more comfortable with that, and I'll show you later, I've kind of moved away, but what makes me feel more comfortable with that is we do have the SARS study, which all the patients got aspirin and platelets for intracranial stenting for occlusion, and there was not a higher rate of, it's not directly comparable, but there was no higher rate of hemorrhagic events. So it doesn't bother me as much, whereas with ruptured aneurysms, which is more like brain trauma, I'm much more worried about double anti-platelet therapy than I am with stroke. So I think it's... The other thing is your stent will stay open on heparin, and Vez and I, this is something we both agree on, I don't think we're using heparin enough in acute stroke. It is easy to immediately turn it off, it makes a big difference. When you look at the top of that slide, the external parotids are filling right all the way up, and your internal has no damn flow. And so whatever's happening in the M1 is gonna be affected by the fact that you've really got compromised flow down here. So I think you can balance an argument there where addressing the flow problem is part of your stroke therapy, and it's worth some risk. As a stroke neurologist, though, I do wanna go on record, I'm a big fan of your anagram, disagreeing completely. I think heparin has little to no role in acute stroke. And we should not be using it. We have 340 patients that we've used acute stroke. Actually, we're just about to publish this. And our rate is comparable to any study of symptomatic hemorrhage. And what we're hanging our hats on is neurology data from 80 years ago, where we didn't even, it was a CAT scan with a completed infarct. We gave a 10,000 unit bolus of heparin to hemorrhage and it would scratch their head. So now we have imaging where we can, what heparin does is it stops, the argument is, oh, it doesn't like to clot, it stops propagation. And that's where you get into trouble with a lot of these cases, where you get a great result angiographically, and then they go on, especially if you're gonna put a stent or something in it. I guess the question is, what are you using heparin for? Is it for your stent? Is it for your angiography? What are you using it for? We're using heparin in this, it's a great question, in two points. One, heparin is not a substitute for flow restoration. And that's the problem with neurology literature so far. But two, if you have had thrombosis in the absence of flow, and you're able to reestablish flow, heparin is critical to get that cascade going in the right direction. Three, if you have to put a metal in and you don't know if the patient is a clavix responder and you haven't started aspirin clavix yet, heparin can temporize, and you can shut it off immediately, it's not like any bloodless, until you can get them into a more stable situation. And it also has a rheologic effect. Okay, well I'll just say, I'm more of a jurist, I'm cautious with heparin in these stroke cases, but the point is, we don't know. So I stented it, go up, here's the occlusion we saw in the CTA. This is again, before stent retrievers, I used the old penumbra aspiration system, and get, hold on, now I go there, get this result. So now the question is, is like, for you guys, how many of the fellows, I wanna see fellows actually raise your hand, nobody not raise your hand, if you do, I'm gonna fail you for the course. Raise your hand, are you happy here, would you stop, or would you wanna do anything further? If you're happy here, or at your center, would your physicians be happy, would you stop now, or would you do more? I'd throw a wingspan. Raise your hand if you would stop. Raise your hand if you would do more. You're all failing if you don't raise your hands. All right. So I would, if you look here, there's still a significant MCA occlusion, right there in the M2 branch. So, go out, do further thromboaspiration, get that open right there. That's the spinal result. This is the post. Patient has a little bit of stroke, not surprisingly. Here he is doing great. Can we either speed up or cut you off here so we can get to the lab? Can we do one more? Yeah. It's along the discussions that we just had. So, similar discussion that we just had, but a little different approach to it, depending on the pathology. Right side of weakness, three hours after, and extra of the 14. Left ICAs occluded, INRs therapeutic. Aphasic, some right side movement, but not any gravity. Oh, sorry, here's the perfusion. You can see on the CTA, there's a little back flow, and then there's no flow here. And this is the one I'm interested in, the other group. Here's, now here's this carotid occlusion. So you have thrombus, chunks of thrombus, all the way up and down the carotid. Now, what would people want to do here? Ansar, what would you do in this circumstance? So, I'm sorry, I missed that, the thrombus and MC is occluded as well? Yes. I would, so I had a case like this, and I used a, do you think the underlying carotid is dissected, or is it just a thrombus? There's not a lot of atheromatous on the CTA from the other side, so it's probably not a lot of, either it's like a ruptured plaque that's now propagated thrombus, or a very small dissection. There's no obvious dissection, there's moderate. Right, so what, in a case like what I did was, I had a neuromax that gave me documentation. I put a filter up the distance where the petriscope is, and I used a bimax case to aspirate the carotid. Over the filter wire, up to the filter? No, I put the, if you had a balloon, then you had to do a bimax. Double puncture, and I put the filter beside it, and I aspirated the carotid. Anyone else? I had a case where I did do this, and I just bought the entire carotid out of the carotid, and did a bimax. That's what the CTA did. Okay, what is it then? I cleaned the carotid, took the filter out, and then I went double puncture through the dissection. You just put the neuromax aside like a suction. That's what I did. Any other thoughts, Joe? I consider a balloon guy catheter, and there's a big bimax case, something to aspirate the carotid. Aspirate the carotid. So we did, that's, I did what Tebow just said. I just took the neuromax and went out on an aspiration. Well, that's the max, so that's a 088 guy catheter, and these are all the huge chunks of organized clotting that sort of sucked out, which was pretty cool. That said, in the bowl, there was still some thrombus sitting there, and so, consistent with what we talked about before, I put a stem down to cover that residual amount of organized thrombus. The max, I was never gonna get the max to sort of go out in the bowl, but I didn't want to knock it loose. What kind of stem did you use, closed cell? I used a wall stem, yeah. Yeah, exactly. So I'll tell you, on that note, technique-wise, I really, really like the wall stem for stroke, because it's closed cell, it's very retrievable, and it's really long to breathe. So if you oversize it, you can cover a tremendous amount, unlike all the other ones are cut tubes, so they just pop open to their 40 centimeters, but if you take a 40-centimeter wall, like a 10 by 40, you can get 90 centimeters of coverage if that's what you want. So that's what I prefer for strokes. Use a thermal and aspirin bottle? Yes. Yep. So here's the occlusion. I just want to do this to show you you need various tools. I do adapt with the ACE. Two poles get two plugs that come out on it. So now I have this, but there's this sort of distal M1, you know, genu bifurcation clot. I do one more aspiration, that doesn't come out, so I switch to a stentriever, and pull that out with the stentriever on that point. That looks like the same clot from the last picture. It's not. Yeah, I just took the clot, and put it next to it, and put it over. I don't know, the techs take the pictures for me, so they may, while I'm still finishing up. I'll blame it on Cal, if he's in here. Anyways, this is the result with titany three reperfusion. She improved to a six. Her aphasia essentially went away. I was gonna put 90% aphasia for the percent issues, but her aphasia essentially went away. She had a little bit of speech delay, and she became antigravity, but still weak. But otherwise, did well. So just, hopefully this just highlighted like all the conversations that we have, and the debate as to how we do this. That's it. Thank you.

acute stroke treatment

CT perfusion

late-presentation patients

debate on treatment selection

multidisciplinary approach

stenting

thromboaspiration

stroke outcomes