 Hi, my name is Dr. Fred Patankar and I am an Intervention Neuradiologist from Lead Gener Infirmary. Today I'm going to show you some cases of mechanical thrombectomy in hyperacute stroke and the benefits of this treatment which is probably one of the most exciting thing in medicine at the moment and it has changed lives in thousands and thousands of patients across the world. Let's look at our first case. This is a 72-year-old lady with left-sided weakness. She's a wake-up stroke, presents with a stroke at 8 o'clock, comes to any in about 15-20 minutes and is seen by the BAT team. The brain attack team records the NIH's as 22. CT scan was done pretty quickly around 9.30 where you can see that there are some low-density changes, probably aspects about 8 with the right MCA thrombus. A CT angiogram is done immediately on the table and that kind of shows that there is a significant proficient deficit. As you can see on this slide that shows signal change on the right MCA territory. Now what you need to look at mainly is the blood volume, blood flow, mean transit and the TMAX. But the rapid AI that we use, blood flow volume maps and compare them with the TMAX maps. So you can see that the cerebral blood flow is around less than 34% is around 45 ml whereas the TMAX created at 6 seconds is about 111 ml. Now when we compare that, and this is probably the most important slide where you have a TMAX and CBF side-to-side which gives you the mismatch volume about 83 ml in the right MCA territory with a mismatch ratio of about 4. So you are looking at somebody with a significant profusion deficit in the right cerebral hemisphere. By 10.15 the patient is in the angiolab and within few minutes you can see the right MCA territory has been completely recanalized. And the point that I am trying to make here that by 8.15, 8.30 the patient is in the scanner and by 10.15 the patient was recanalized completely and that is very, very important part of the procedure. Time is brain and you got to get in as soon as we can and you see the benefits on the CT scan at 24 hours one very little ischemia seen as you can see in the right temporal lobe and the basal ganglia and the 24 hour NIHS was 4 so you can see patient has significantly improved following mechanical thrombectomy and that is very important. The first lesson we all need to know is try and get the patient into the lab as soon as you can and recanalyze as soon as you can. Let's look at a second here. This is a 60 year old lady presents with a stroke and I just have 22, 2.5 hours from one side but unfortunately contraindicated for thrombolysis. A CT scan shows a dense MCA as you can see and a CTA shows a certain occlusion of the middle cerebral artery. We decided to use conscious sedation because that's what we do for most of these patients and you can see there is a cut off of the right MCA and poor collateral flow on the right side. Initial aspiration didn't work so we put a stent across the trevor which is across the stenosis with a distal axis aspiration catheter and this showed complete recanalization of the right MCA but there was some sluggish flow in the anterior temporal branch. Lateral views show some proficient deficit as you see in the anterior temporal region and then if you look at the frontal and lateral view you can see that the anterior temporal branch is a bit missing. Now would you treat this? Well in normal circumstances the patient general anesthetic that's what we would do but here you can see the blockage we have removed it and you've done very well. Can you do something for me? You know you are not moving your hand and leg can you show me whether you can move your hand? Awesome. Can you hold my hand? Oh god you've got strength now. Good. What about your leg? Can you move your leg? Awesome. Sure that's good. Can you tell me your name? Okay. How are you feeling? Very good. Super. You're going through a hard time aren't you? Yes. Okay. But we're getting there. Okay. So I'm going to put this back on. Okay. Thank you. All right. See you soon. All right. And the patient was completely normal and was discharged home. The point that I'm trying to make here is that it is very very important to remember the patient and if the patient improves on the table you might not need to pursue small occlusions or distal occlusions or some vessel missing and that is a benefit of doing this procedure in conscious sedation. Let's look at case number three. This is a young boy. He was a lead student. He presented with a stroke one and a half hours from onset and luckily the BBC were filming something in Millenium Square and they actually filmed him having a stroke. We were brought in. He got IV thrombolysis but it did not improve. You see these cans showed a dense MCA in the left side but the brain looked pretty good. Again we took him to Angio and you can see there is a filling defect in the left middle cerebral artery and a perfusion deficit in the left MCA territory. This was opened up immediately and you can see that the whole MCA territory has been recanalized with a TK3 score which is really good for a young boy and we were pretty quick in recanalizing this artery. This was a very old device that you can see. This is a revive device and it shows a clot and it was very good but not necessarily he was successful in all the cases but the point that I am trying to make is the technology has improved. This device gave us good results in the beginning but not necessarily in all the cases and the benefit of the treatment is driving the industry to actually move on and improve the devices. We are having so many new devices coming into the market and they all are significantly improving our results in recanalizing the vessels. Probably we are getting more TK3 scores than what we used to do in the past. So that's one of the beauty about the whole treatment. The last case I am going to show you is again an MCA occlusion but here you can see there is a left MCA occlusion on a CTA. It's a dominant hemisphere so it's very difficult because the patients are very restless to get a very safe and effective procedure. We will still try conscious sedation if we can but if we can't then we would give general anesthesia. It was very restless. There was no question that we were going to do GA and you can see the general anesthesia was given around 4 p.m. CTA shows an occlusion and you can see again there is very poor collateral flow in the left MCA territory and here we have used a solitaire stand as you can see the markers and the solitaire is across and there is much more closer look to show the solitaire and the complete recanalization, TK3 score seen and you can see very often now in some of these devices Trevo and solitaire, I am not working for the industry but they are my primary devices that I use and I have had good successes with both these devices and this patient again did extremely well.