BackTable / VI / Podcast / Episode #189
Approach to Posterior Circulation Stroke Thrombectomy
with Dr. Ansaar Rai
Dr. Sabeen Dhand talks with Neurointerventionalist Dr. Ansaar Rai from about his approach to posterior circulation strokes, including patient selection, technique and devices, and pitfalls to avoid.
BackTable, LLC (Producer). (2022, February 21). Ep. 189 – Approach to Posterior Circulation Stroke Thrombectomy [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Ansaar Rai
Dr. Ansaar Rai is a professor and chair of the Department of Neuroradiology at West Virgina University in Morgantown, West Virginia.
Dr. Sabeen Dhand
Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.
In this episode, neurointerventional radiologist Dr. Ansaar Rai joins Dr. Sabeen Dhand to discuss posterior circulation stroke, including when to treat with thrombectomy, techniques, and advances in stroke research in recent years. They discuss factors to consider when deciding to treat posterior circulation strokes with thrombectomy. Dr. Rai reports that age is the most important factor, followed by comorbidities and severity of clinical symptoms. He discusses the variability in presentation of basilar artery strokes, ranging from mild ataxia to coma. He treats these aggressively with thrombectomy, especially for young patients. For isolated PCA strokes, he often treats with intra arterial TPA only.
Dr. Rai next discusses landmark clinical trials, as well as his own research looking at stroke burden. He found that 2% of all acute ischemic strokes occur in the posterior circulation. Importantly, he postulates that there will never be good posterior circulation trials due to lack of equipoise and difficulty in randomizing to a medical treatment only arm.
Dr. Rai uses general anesthesia for posterior circulation strokes. He prefers femoral access, and uses an 8Fr femoral short sheath and a guide catheter (ideally 088), rather than a balloon guide catheter. He then uses an 070 or 072 intermediate aspiration catheter navigated over an 024 microwire (Aristotle) or 027 microcatheter (Duo or XT-27) into the basilar. After trying many techniques, he prefers aspiration using the ADAPT technique. If he has to cross clot, he uses a stent retriever such as Trevo, Embotrap or Solitaire. Due to the delicate vasculature and high risk in posterior circulation thrombectomies, Dr. Rai always uses a J wire, biplane imaging and emphasizes that knowing the anatomy on CT is key to decreasing complications such as dissection or distal embolization.
ASPECTS score: https://www.ahajournals.org/doi/10.1161/STROKEAHA.117.016745
Route 92 Medical SUMMIT MAX Clinical trial: https://evtoday.com/news/route-92-medicals-monopoint-reperfusion-system-studied-in-pivotal-summit-max-trial#:~:text=According%20to%20Route%2092%20Medical%2C%20SUMMIT%20MAX%20is,sites%20in%20the%20United%20States%20and%20New%20Zealand.
The Greater Cincinnati Northern Kentucky Stroke Study: https://www.gcnkss.com
MR RESUE trial: https://www.ahajournals.org/doi/full/10.1161/strokeaha.113.001443
IMS3 trial: https://evtoday.com/news/ims-3-substudy-shows-delays-in-stroke-treatment-leads-to-worse-outcomes#:~:text=IMS%203%20was%20a%20multicenter%20international%20trial%20in,received%20tPA%20within%203%20hours%20of%20stroke%20onset.
SWIFT PRIME trial: https://evtoday.com/news/covidien-commences-enrollment-for-swift-prime-acute-ischemic-stroke-study#:~:text=The%20SWIFT%20PRIME%20study%20will%20evaluate%20acute%20ischemic,will%20also%20include%20an%20extensive%20health%20economics%20analysis.
ADAPT technique trial by Turc: https://www.ahajournals.org/doi/10.1161/STROKEAHA.119.025753
BEST trial: https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(19)30395-3/fulltext#:~:text=The%20BEST%20trial%20was%20a%20multicentre%2C%20prospective%2C%20open-label%2C,the%20institutional%20review%20board%20of%20each%20participating%20site.
ATTENTION trial: https://pubmed.ncbi.nlm.nih.gov/35102797/
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