 Hi, my name is Dr. Bhatankar and I am a consultant interventionist and I've been doing hyperactive stroke management since I was a consultant in Preston in 2007-2009 and I hope I can share some experience with you over the next 25 minutes about stroke treatment, particularly the way we practice in late. I'm not going to debate and I don't think there is any debate anymore about the benefits of thrombectomy. We know that NNT is 2.6 compared to coronary stenting trials which was 14. In the next 25 minutes we'll talk about case-based discussion and we'll discuss around cases. We'll see what the benefits are in tandem occlusions, different techniques, the benefits, the benefits of conscious sedation versus no sedation and GA and then I'll show you some complication but most important I'll show you some AI techniques that we use in our practice as a trial student and then we'll see some scenarios and challenges depending on how much time we got. Let's make certain things very clear. We now know that there are two basically the techniques. One is either use a stent or use an aspiration or use a combination of both with a proximal balloon guide catheter which I think is a very important adjunct in anterior circulation thrombectomies. So here is a stent regulatory or technique where you get a macro catheter across the thrombus then you deploy the stent and then you can pull the thrombus with the proximal control. Here is a case with a left MCA, a thrombus that you can see and the angiogram shows a left MCA occlusion, M1 occlusion with the ACA looks okay, the ACA looks okay and then you drop a stent through a micro catheter across the thrombus. Here is a magnified view which shows the markers of the stent and then you can bring the stent and the clot out and remove the the clot and recanalyze the artery as you see here and that stent you can see is filled with thrombus in this case. If you are a believer of aspiration techniques you need is what you need is a catheter that goes up to the thrombus and then you aspirate with again male aspirate with or without proximal control and you can use your hand or syringe or a pump and then remove the clot. Here is a patient with the right MCA occlusion and a thrombus with a good aspect scope and the CTA again shows a right MCA occlusion, angiogram here shows a right M1 occlusion with distally proximal control as you can see with an aspiration catheter at the thrombus and recanalyzation of the MCA and you can see the MCA is recanalyzed. So take a message is that combining proximal balloon guiding catheter with an aspiration stent that's aspirate retriever aspiration in anterior circulatory ischemic stroke reduces the retrieval attempts improves your first mass exacerbate and the combined technique definitely appears to get better results with better clinical results in these group. If you look at another case here which is a left hemisphere TIA and the Doppler is showing ICA occlusion. Here's another TIA and he's there now at around CT gets on 10 o'clock and he's got an MCA clot unfortunately and the day of endotrectomy he collapses and develops a stroke there is a now a left MCA stroke CTA shows a left MCA clot but we know there is an ICA occlusion we then drop a a stent across the stenosis and go distally and remove the clot from the middle cerebral artery and near the at the end of it you can see this is a standard technique and a post-op CT shows reasonably good result and the patient did extremely well. We know that 25% of our of our cases of hypericutromectomy will have tandem occlusions and they indeed do very well if you manage to open the occlusion and go distally and remove the clot and we have a pretty lot of cases and experience in these tandem occlusions. We also over the years have learned that doing them awake is probably much better than doing under GA and most of our patients now will get a conscious sedation on being awake but it is also very very important like in Scotland where you are trying to develop this stroke service to manage to keep the anesthetic covered for these cases. Here is a 60 year old I show you what happens here it's a little bit more more interesting because she's just as an NIHs of 22 with a two and a half hour onset and contraindicated if you do an awake well it does make a big difference as you can see here there's a CT scan that shows MCA occlusion there is a catheter angiogram that shows an MCA occlusion I think everybody now can read these engines not very complicated you can see them on occlusion and then you can drop a stent across because aspiration didn't work and then what do you see there is a big area which is missing your post aspiration and you know what you need to know is there is a branch here a normal practice if they are under general anesthetic I would have landed up going in trying to remove the the clot but here you can see I don't need to do that can you show me whether you can move your right hand awesome so and the CT shows completely normal on table the patient is completely normal and the next day the CT shows he's pretty much normal and she was discharged soon so I think the take a message is that if you can do awake you should do it awake you can sometimes benefit by patient being awake because you see if they're on table good result you could stop what is useful in the next few slides I will discuss is the the triage tool which is a AI technique that can be used because it can give you the aspect score the mismatch ratio a lot of other information regarding collateral to tell us what the to identify the right patient for treatment here you can see that there is a perfusion map where there is a TMAG created in six seconds which identifies the area which is hyper perfused and then you can also see a small core or which is the CBF less than 30 person and it identifies the core and you will tell you what the mismatch volume is so you can pick up the patient that really need to be taken urgently for treatment here is a 72 year old man with a wake up stroke at 7 a.m. and h's of 18 the CT is looking shows a good aspect score with an mc a claw and there is a perfusion abnormality there's a T junction clot that we can see here on the CT angiogram and this patient was in aspects of seven which is a good aspect which is what we want to know because it's a wake up stroke you would do a perfusion scan in fact I do perfusion in and I think the perfusion should be done as a fast protocol in every patient here you can see the TMAX which is showing about 65 ml with a very small core so this lady was then taken to a far from back to me no tear on the perfusion there is a small area in the basal ganglia which is showing the TMAX greater than 10 seconds and if you look at the perfusion when we see an angiogram with the clot and we reproduce that 24 hours CT shows an infarction in the area where the TMAX was very very very high or delayed and you can see that area matches with the basal ganglia infarction suggesting core another hand it can also help you in other cases this is an old man two hours from onset with dementia and h's of 20 and I think I didn't do a right decision although I got carried away he was a carer for his own wife and he had a CT that shows that there was not significant infarction but atrophy but the perfusion which was done shows that such area of TMAX greater than 10 seconds and with a very poor collateral score and you can see again the mismatch was not much between the TMAX and the CBF suggesting that is a big area of core and all these areas probably already dead and then I still took him because I thought I could probably make him better I didn't believe it because my mind did not want to believe it and I went in I did a thrombectomy but they didn't do very well at all as you can see the older the thrombectomy went very well the perfusion and matches the infarction that was this scene on a 24 hour CT scan if I look back now I probably wouldn't do it because I think some of these perfusion when they show such bad collateral score and a very poor mismatch and a big core I don't think they really do well and I know but this is a learning curve these trial these softwares are a good trials tool to identify the correct patients particularly patient which under DGH is as well there are other tools available I'm not going to propose any single tool because I think they are expensive and we need to be very careful which one we pick although the AHA recommends the ones which are used in the trial we have now got a number of tools and I'm looking at another one like this which again gives you the same thing that other tool gave us but it is a lot cheaper than the other one and it is again validated to give us the same information and it's something that is worth considering also and there are other tools as well when we look at some scenarios now in the next 15 minutes let's look at scenario number one this is a professor in Leeds University he was here a PE a week back and he got anti-cogulated he comes to the clinic in front of the cardiology consultant develops a stroke he's not a candidate obviously for intravenous therapy he's an IHS of 18 and he gets a CT and a CTA that shows a MCA thrombus a CTA shows a thrombus there was a very fantastic dedicated consultant in Halifax contacted army and then contacted a stroke team we accepted the patient but LGI was in red and the stroke consultant just wasn't ready to accept the patient because there was no other bed and just carried on the Halifax stroke consultant tried to contact the stroke consultant at least it wasn't happening eventually the consultant in Halifax put the patient in ambulance and transferred the patient to Leeds Army the stroke consultant had to accept and there is a the endogram that shows the conclusion with poor pro collateral in the left MCA territory and I did it under congestation you can see it very improved immediately and in fact if you look at I think the timing was 12 16 to something like 12 20 or something and in 10 15 minutes we were good what is and the post 24 CT shows a minimal infarction the professor went on to write a book and actually was very grateful but honestly I don't think he should be really grateful to the LGI team he should be very grateful to the Halifax team who actually took the decision to transfer him to LGI let's look at challenge number two this is a 55 year old which is a the MCA occlusion in ages of 15 he comes to us and time is in ages of four and we were not sure what to do we decided in this case to really go ahead and treat him and there you can see the perfusion showed significant deficit this was a little bit earlier then when we had a rapid AI software you can see the MCA occlusion you went in took the clot out and we can analyze the MCA and you can see and this patient did extremely well going home on the other hand a week later the nineties of nine in a 40 year old again young patient MCA clot I was I was on the near the scanner around four o'clock on Friday evening I usually don't have anything else to do so I am always in near the in the NGO lab so anyway you can see there is a CTA we did a triple phase here we used to do that we don't do it anymore but you can see that there is a problem in the right MCA territory you got IV thrombolitis says United States are four still with the MCA clot and here the decision by the stroke consultant was that he didn't think there was any need and the report from back to me Friday evening I wasn't gonna insist and fight for it so I you know it was pop time for me then anyway unfortunately this guy 24-hour CT you see a significant infarction this guy was in the hospital for three months then went to rehab whereas the other guy went home after a couple of days so I think the take-off messages some of these are early cases you know our technique our services improved and we have learned a lot over time take-off messages if you go to MCA occlusion and you think there is a profusion of normality get a profusion see what it looks like if there is a profusion problem then I think it is fair to go ahead and recanalyze these patients because if you don't recanalyze a lot of them may get worse and particularly may land up staying for a significant number of days or months let's look at a scenario number this is something some happy case what I would say this is a junior doctor strike so that's not very happy days but a lot of it was busy everybody was on the was doing the care work what the registrar was supposed to do I'd already done a thrombectomy and it was good I was in the costa when I got a call for another thrombectomy case and I thought okay looks like I will have to go back in and then there was a patient on the scanner here is a CT scan that you can see there is a right MCA thrombus it's a very good aspect score this was a 55er lady she was found collapsed at half past eight and her husband said that she wasn't really feeling very well she was in chest when she collapsed and she had some ECG ST elevation GCOS 9 she arrived at 10 o'clock she was with the history we found that she was independent no drug history and she had a she had an accident we should follow on the bonnet of the car and she had some groin pain legs swelling for which she didn't get any treatment she got intubated because she was agitated by the time she was there in A&E and then you can see that there was a she had a stroke we did a CT as you would expect there was a very intelligent smart neurologist a diagnostic neurologist not my one of my colleague and you can see there was an MCA clot here and then there was a clot in the in the carotid artery he also identified there were the problem and he immediately put things together got a CTA of the lung of the chest and of the whole body and you can see she had thrown multiple emboli everywhere she also seemed to have the pulmonary emboli, splinic infarct, cranial infarct and we knew by this time he'd already put in through that she probably has a shunt so then it was all decided to take a force and treat her stroke so we took her into the angiolab and saw did an angiogram show that it's an MCA occlusion which I recanalyzed with the first part while I was waiting for all the other people to comment there was a left ICA clot which I knew so I did went and outspread it and that was lucky it went okay and they both internal clot recirculation was good cardiologists came in they did a coronary angiogram they did an echo they did a peer foreclosure as you can see here and then the vascular people came in now the echocardiogram was done they did the vascular guys did a IVT filter so we had everybody working on her everything was done anti-cogulated aspirin given and obviously she remained in ICU she was woken up and her power significantly better and I just was six and she woke up and the CT scan post was showing a very small area of infarction so I think it's a great case from LGI where I think it's one of the places which I am very very very happy in the quality of the service with my colleagues provided together and I think that's one of the benefits of what I like about working at LGI looks like a challenge for as a case from one of my colleagues and friend from Canada here in a patient with NIH is of 18 in 65 minutes from onset 1220 the CT scan was done which shows an MCA occlusion 1223 in three minutes the CTA was already done on the table as you can see there is an occlusion they do triple phase and as is done the CTA clearly shows MCA occlusion and the ICA was open the teams divide the one goes to talk to family one goes to talk to NGO but 1241 so in nearly 20 minutes the patient is on the NGO table and you can see there is an IC occlusion here and then they re-canalize in about 10 minutes there is MCA re-canalized and in within 20 minutes you can see this patient's NIH has come down to three with complete reperfusion in the right MCA territory and that's a fantastic result and 24 hours not surprisingly shows only minimal ischemia this is one of our cases and I don't want to be I want to say specifically this is not recent case and we have got really better but this is where we were sometime back 72 year old lady NHS of 22 at a wake up stroke at eight o'clock CT scan was done at 919 you can see a right MCA thrombus and then CTA was done after 10 minutes which was the shows an MCA cloud perfusion was done using AI software but there is a significant mismatch of 83 angiogram was done in a one hour from the CTA 1016 but it was re-canalized within 10 minutes so I think I think we are very good and I think I'm very proud to think my team is very good and we have got a fantastic result at 24 hours she still did very well and NHS was four but I think we could do better we are doing better we now have a regional service and we are our timings are getting better but it's still nowhere close to the timing that we see we have seen in Canada from Canada and on Calgary so I think we have got a long way to go but we are we are definitely moving in the right direction let's do use a case number five this is an interesting case because it was a young lady I remember this very well she collabed she CS 12 it was evening time she had a CT scan clearly shows good good aspects go with an infarct and you can see the CTA shows a monoclusion and there you can see unfortunately to the conscious sedation pressure and this was a very nice job it's then put in no problem but patient moved and she was agitated as soon as put a stent in and there it was a rupture and then Tony very well tried to control it put the balloon across and managed to control the bleed but then it is not possible to him to save some of these patients particularly if they have a on-table massive bleed like that that you see here and then unfortunately she died from this so you can see the important point and a take-off message this is an interventional procedure it does carry race in his training you got to be well trained you remember there are the complications and the service should be provided in the right environment in the right setting so that we can make sure the patients are very safe but you also need to make sure that they can be treated in a very timely efficient manner last case and I'm going to show you this is a recent case in a 47 year old it was a Saturday just a couple of weeks back you know two hours from the stroke patient develop a presented to our leader any within ages of 20 and you can see that we have a very good aspect which is anything about six is a good aspect for me and that looks like the left mca cta gets done and you can see aspects is about eight sorry and cta shows an occlusion as you see an M1 occlusion I think now you've seen enough cta you don't need any more training to identify a clot in the mca territory profusion shows a mismatch between tmax rated in six seconds to a cb of less than 30 of 47 male and I came in you can see this is about 9 30 or something and there's an mc occlusion this wasn't a conscious sedation and then you have an mca which was removed and by about 10 minutes the mca was removed in first part the clot was removed and the mca was recanolized and you can see there's complete recanolation there was a bit of a nice small dissection in the neck because of the balloon but the ct shows 24 hours a small area of infarction he did very well and I just improved to four annual discharge in three days and I hope that everybody gets this and this is what we would want on the same day Saturday few hours later young man again presents with an edges again of 20 just down the road 10 miles away has a left mca clot and this was unfortunately did not receive from back to me and in the night he wasn't you can see that now he's got he's developing a significant area of infarction and he then was brought in after two days for a decompressive cronectomy and he's still in the hospital whereas the other guy who turned who was who presented to Lee Zaini did very well and was discharged so this is this is unfortunate but I'm hoping as time goes as a service grows and we improve and improve over 24 hour service we will stop any of these postcode law trace as you can see we have improved over the technique we have got better our timings have improved although not similar to the the timing still we see in Calgary or some of the big stroke centers you know hopefully this year we will probably reach about 100 thrombotomies and numbers are going up and up and up our techniques are getting better we are getting better we are we're using AI pretty much even in our district general hospitals I think using a fast CT protocol with CT CTA and CTP which will really make a big difference in identifying the patient bringing them in checking what their collateral score is so we can bring them fast get them treated and we will we are getting better now we have in Leeds a regional service so we have a daytime service at the moment and that thing will improve so that we can avoid any time lottery or any postcode lottery in West Yorkshire and hopefully we are getting there and we are at the moment really improving our results across the Yorkshire thank you very much