1 Linformation scientifique, demain… Lancet – volume 1, numéro 1, 1823.
Update phase aguë de l'AVC€¦ · INTERACT-2 Trial: Anderson C, Lancet Neurol 2008 ATACH-2 Trial:...
Transcript of Update phase aguë de l'AVC€¦ · INTERACT-2 Trial: Anderson C, Lancet Neurol 2008 ATACH-2 Trial:...
Centre Hospitalier Universitarie Vaudois Centre cerebrovasculaire
Updatephaseaguëdel'AVC
Chef de Clinique, Centre Cérébrovasculaire Service de Neurologie,
Départment des Neurosciences Cliniques
Dr. Davide Strambo
26Septembre2019
Outline• AVCischémique
– Nouveautés• Thrombolysepourdébutinconnu/auréveil• Thrombectomietardive• Thrombolysetardive
– Perspectives• Thrombectomiedirectevs.Bridging• Tenecteplase
• Hemorragiecérébrale• Tensionarterielle• Reversiondelacrase• Transfusiondeplaquettes
REVASCULARISATIONAIGUE
REVASCULARISATIONAIGUE
Oùonétait…..
NINDS ECASS I
‘95
FDA �96
ECASS II ‘98
ATLANTIS �99
EMEA ‘02
ECASS III ‘08
IST-III ‘12
�14 MR-
CLEAN
‘13 SYNTHESIS MR-RESCUE
IMS-III
‘15 EXTEND-IA
ESCAPE SWIFT
REVASCAT
ENCHANTED ‘16
�17-’18 DAWN
DEFUSE
WAKE-UP ‘18
EXTEND-IV ‘19
Trial
Fenêtrethérapeutique
NINDS
ECASSI
ECASSII
ATLANTIS
ECASSIII
IST-3
Guidelines
ThrombolyseIV-rtPAOùonétait…
4.5h3h 6h
EmbersonJ,Lancet2014;ESOguidelines,CerebrovascDis2008;PowersW,Stroke2018
5h
ThrombectomieOùonétait…
Trial Fenêtrethérapeutique
MR-CLEAN
ESCAPE
EXTEND-IA
SWIFT-PRIME
REVASCAT
THRACE
Guidelines
6h 8h5h 12h
SaverJ,JAMA2016;TurcG,ESJ2018;PowersJ,Stroke2018
Enresumé
IV Thrombolysis rtPA
4.5 - 8 hours
Endovascular if access. proximal occlusion
0 - 4.5 hours 8 – 24 hours
Oùonétait…
Strokeonsetorlastseenwell
CourtesyofProf.PatrikMichel
Lesbarrieresàsurmonter
• Debutinconnuouaureveil
• ThrombolyseIV<4.5h
• Thrombectomie<6-8h
REVASCULARISATIONAIGUE
Lesnouveautés…
NINDS ECASS I
‘95
FDA �96
ECASS II ‘98
ATLANTIS �99
EMEA ‘02
ECASS III ‘08
IST-III ‘12
�14 MR-
CLEAN
‘13 SYNTHESIS MR-RESCUE
IMS-III
‘15 EXTEND-IA
ESCAPE SWIFT
REVASCAT
ENCHANTED ‘16
�17-’18 DAWN
DEFUSE
WAKE-UP ‘18
EXTEND-IV ‘19
Lesbarrieresàsurmonter
• Debutinconnuouaureveil
• ThrombolyseIV<4.5h
• Thrombectomie<6-8h
Debutinconnu/aureveil
ThomallaG,LancetNeurol2011
Debutinconnu/aureveil
ThomallaG,LancetNeurol2011
Debutinconnu/aureveil
OR1.61(1.09to2.36)2
1FromEmbersonJ,Lancet20142ThomallaG.NEJM2018
Favorableclinicalresponse(OR)
Harm0.5 0.6 1.0 1.5 2
<3h
3–4.5h
WAKE-UPtrial
BenefitNoeffect
OR1.26(1.05to1.51)1
OR1.75(1.35to2.27)1
ThrombolyseIV
Debutinconnu/aureveil
IV Thrombolysis rtPA
4.5 - 8 hours
Endovascular if access. proximal occlusion
0 - 4.5 hours 8 – 24 hours
Strokeonsetorlastseenwell
Ifonsetunknownoratwake-upàIVTrtPAifDWI+/FLAIR-
Lesbarrieresàsuperer
• Debutinconnuouaureveil
• ThrombolyseIV<4.5h
• Thrombectomie<6-8h
Leconceptdumismatchcore/penombre• Ischemieirreversibile
(core)– MRI-DWI– CTnatif– CTdeperfusion
• Ischemiereversible(penombre)– MRIdeperfusion– CTdeperfusion– Deficitclinique
Leconceptdumismatchcore/penombre• Ischemieirreversibile
(core)– MRI-DWI– CTnatif– CTdeperfusion
• Ischemiereversible(penombre)– MRIdeperfusion– CTdeperfusion– Deficitclinique
L’applicationduconceptdumismatch
OR1.86(1.15to2.99)
MaH,NEJM2019;CampbellB,Lancet2019;
NogueiraR,NEJM2017;AlbersG,NEJM2018;SnellingB,JNeurosciRuralPract2019
Favorableclinicalresponse(OR)
Harm0.3 1.0 3
<3h
4.5-9hMissmatch+
BenefitNoeffect
OR1.75(1.35to2.27)ThrombolyseIV
0.5 2 50.2
L’applicationduconceptdumismatch
OR1.86(1.15to2.99)
MaH,NEJM2019;CampbellB,Lancet2019;
NogueiraR,NEJM2017;AlbersG,NEJM2018;SnellingB,JNeurosciRuralPract2019
Favorableclinicalresponse(OR)
Harm0.3 1.0 3
<3h
4.5-9hMissmatch+
BenefitNoeffect
OR1.75(1.35to2.27)ThrombolyseIV
Thrombectomie<6-8h
6-24hMissmatch+
0.5 2 50.2
OR4.02(2.02to8.02)OR6.25(3.12to12.5)
OR2.49(1.76to3.53)
DAWN
DEFUSE-3
Enresumé
IV Thrombolysis rtPA
4.5 - 8 hours
Endovascular if access. proximal occlusion
0 - 4.5 hours 8 – 24 hours
Lesnouveautées…
Strokeonsetorlastseenwell
Enresumé
EmbersonJ,Lancet2014;SaverJ,JAMA2016;NogueiraR,NEJM2017;AlbersG,NEJM2018;MaH,NEJM2019;CampbellB,Lancet2019
IV Thrombolysis rtPA
4.5 - 8 hours
Endovascular if access. proximal occlusion
0 - 4.5 hours
Late IV thrombolysis rtPA if mismatch criteria met
EVT if LVO and mismatch criteria met
Lesnouveautées…
Strokeonsetorlastseenwell
Ifonsetunknown/wake-upIVTrtPAifDWI+/FLAIR-
8 - 9 - 24 hours
Enresumé
EmbersonJ,Lancet2014;SaverJ,JAMA2016;NogueiraR,NEJM2017;AlbersG,NEJM2018;MaH,NEJM2019;CampbellB,Lancet2019
IV Thrombolysis rtPA
4.5 - 8 hours
Endovascular if access. proximal occlusion
0 - 4.5 hours
Late IV thrombolysis rtPA if mismatch criteria met
EVT if LVO and mismatch criteria met
Lesnouveautées…
Strokeonsetorlastseenwell
Ifonsetunknown/wake-upIVTrtPAifDWI+/FLAIR-
8 - 9 - 24 hours
REVASCULARISATIONAIGUE
Perspectivespourl’avenir…
NINDS ECASS I
‘95
FDA �96
ECASS II ‘98
ATLANTIS �99
EMEA ‘02
ECASS III ‘08
IST-III ‘12
�14 MR-
CLEAN
‘13 SYNTHESIS MR-RESCUE
IMS-III
‘15 EXTEND-IA
ESCAPE SWIFT
REVASCAT
ENCHANTED ‘16
�17-’18 DAWN
DEFUSE
WAKE-UP ‘18
EXTEND-IV ‘19
Bridging?
IV Thrombolysis rtPA
4.5 - 8 hours
Endovascular if access. proximal occlusion
0 - 4.5 hours 8 – 24 hours
Late IV thrombolysis rtPA if mismatch criteria met
EVT if LVO and mismatch criteria met
Perspectivespourl’avenir
Strokeonsetorlastseenwell
SWIFT-DIRECTMRCLEAN-NOIV
Ifonsetunknown/wake-upIVTrtPAifDWI+/FLAIR-
IV Thrombolysis rtPA
Tenecteplase?
4.5 - 8 hours
Endovascular if access. proximal occlusion
0 - 4.5 hours 8 – 24 hours
EVT if LVO and mismatch criteria met
Perspectivespourl’avenir
Strokeonsetorlastseenwell
TNK?
CouttsS,IntJStroke2018BurgosA&SaverJ,Stroke2019;
Hill&Michel,Stroke2019
Late IV thrombolysis rtPA if mismatch criteria met
Ifonsetunknown/wake-upIVTrtPAifDWI+/FLAIR-
TNK?
TNK?
TRAITEMENTAIGUDEL’HEMORRAGIECÉRÉBRALELesnouveautés…
Traitementaigudel’hemorragiecérébrale
• Traitementaggressifdelatensionarterielle
• Reversiondela
crase• Plaquettes
• Traitementaggressifdelatensionarterielle
• Reversiondela
crase• Transfusionde
plaquettes
Hemorragiecérébrale
• Traitementaggressifdelatensionarterielle
• Reversiondela
crase• Plaquettes
• Traitementaggressifdelatensionarterielle
• Reversiondela
crase• Transfusionde
plaquettes
OR1.11(1.05to1.17)
Favorableclinicalresponse(OR)
Harm0.5 0.6 1.0 1.5 2
10mmHgreductiondelaTA
systolique
BenefitNoeffect
INTERACT-2Trial:AndersonC,LancetNeurol2008ATACH-2Trial:QureshiA,NEJM2016
MoullaaliT,LancetNeurol2019HemphillJC,Stroke2015;SteinerT,IntJStroke2014
Dansles6heuresaprèsledebutdel’HICSilaTAsystoliqueest>150mmHgàTargetTAS<140mmHgdans1heure
Pasdeconcernesurlasecurité
Hemorragiecérébrale(sousanticoagulants)
• Traitementaggressifdelatensionarterielle
• Reversiondela
crase• Plaquettes
Dabigatranàidarucizumab(Praxbind®)• DisponibleenSuissedepuis2016• DisponibleauCHUV• Cout~3’000.-Apixaban,rivaroxaban,edoxabanàandexanetalfa(Ondexxya®)• AutoriséparEMA• BientotdisponibleenSuisse• $$$$$$$$$$$$$$$$$• Indicationsàdéfinir
• Traitementaggressifdelatensionarterielle
• Reversiondela
crase• Transfusionde
plaquettes
RE-VERSEAD:PollackC,NEJM2017ANNEXA-4:ConnollyS,NEJM2019
Hemorragiecérébrale(sousantiplaquettaires)
• Traitementaggressifdelatensionarterielle
• Reversiondela
crase• Transfusionde
plaquettes
PATCHtrial:BaharogluMI,Lancet2016
OR0.48(0.28to0.85)
Favorableclinicalresponse(OR)
Harm0.2 0.5 1.0 2 5
Transfusiondeplaquettes
BenefitNoeffect
Pasdebenefice,probablementplusd’effetssecondairesHemorragiesseveres(GCS<8)excluesdel’étude
TakehomemessagesAVCischemique• L’imagerieavancépermetdeselectionnerlespatientspour
revascularizationjusqu’à24heuresHemorragiecèrèbrale• Baisserlatensionarteriellesystolique<140mmHg• Reverserlacrase• Pasdetransfusiondeplaquettespourhemorragieslegeres/moderéssous
antiplaquettaires
Centre Hospitalier Universitarie Vaudois Centre cerebrovasculaire
Question?
Mercipourl’attention