Pratique du Shadowing: Medium Vessel Occlusion: Should We Thrombectomize? - Apprendre l'anglais à l'oral avec la vidéo

Hello everyone, my name is Puriya Moshaydi.

I'm a vascular neurologist and neurointerventionist at Tehran University of Medical Sciences.

I'm very honored to be invited on this panel discussing thrombectomies in medium vessel occlusions.

Should we still treat them?

And my take is we should not.

I have no conflict of interest and speaking in front of a group of neurodeterventionists and say that do not do thrombectomy,

giving me a feeling that is best depicted in this slide, how I divide roles between myself and Dr. Al -Rahimi.

So let's first start with talking what is a medium vessel.

So we know what large vessel is.

Large vessel are basilar arteries, internal carotides, and the main branch of middle cerebral artery.

And anything beyond that is considered middle vessel,

medium vessel, including PCAs, ACAs, and MCA branches, M2s.

There are some nuances.

We know that there is an anatomic variability on how M2s are branching.

The main application here is sometimes you have a dominant M2s that you see here.

one m2 is bigger than the other one

and sometimes you have co -dominant m2s and obviously a non -dominant m2

so a dominant m2 is actually a large vessel occlusion as they have been included in other lvo trials

and non -dominant or co -dominant m2s are in fact medium vessels

and the medium vessel occlusion trials published so far include all the medium vessels but majority are m2s so let's

take a step back.

When Dawn trials were underway and it was published, I was a resident at UPMC, we often had this discussion with my mentor,

Tudor Joven, who would argue astonishing number needed to treat of two for any improvement after thrombectomy,

any functional outcome improvement at 90 days may indicate that we own a very effective treatment,

but may also show that we are being very over selective in a group of patients,

meaning that we are able to exclude any patient with lesser likelihood of benefiting from thrombectomy.

And so we usually select patients based on the loss known normal, degree of disability, the location of occlusion, and the infarct volume.

And so the next generation of trials, which the MEVO trials belong to them, is starting to testing those boundaries.

So going beyond the time limits,

the publication by my very good friend Shashva Desai showed that if you select patients that are in the

DAWN criteria would be included, except the time of onset, even going as far as 72 hours, they would have the same benefit as patients in DAWN.

So they successfully crossed the time limit although it's not within our guidelines yet

and then we're all aware of the large core trials uh this is the one by dr saraj

that the number needed to treat drop from 2 .1 to 7 .7

but they still show the benefit for thrombectomies but

so the second line was crossed successfully

but are we able to go from large vessel thrombectomy to medium vessel thrombectomy And even before starting the trials, was it expected to help?

So let's look at the subgroup analysis of the early time point thrombectomy trials and the Hermes meta -analysis.

So I want to draw your attention in the subgroup of M2s, which were included in some of those five trials.

the subgroup of M2s actually did not benefit from thrombectomy.

And also those that their NIH stress scale was less than 10.

So the myelore stroke symptoms.

And this is important because actually looking at the patients with medium vessel occlusions,

the presenting NIH stress scales is an average three points below large vessel occlusion.

So you're dealing with a less disabled group of patients, let's call it.

And then looking at the subgroup analysis of late -time window EVT, this is from diffuse tree, the same thing showed up.

So the subgroup of patients with milder NISOS scale, again, they did not benefit from thrombectomy.

So this is how we entered, um, the the information we have before doing the medium vessel occlusion trials

and there were some studies on the PCAs and ACA showing

that ACA thrombectomy would not change the outcome they were non -randomized

but still I think they're worth mentioning

and then there was a observational study on PCA thrombectomies

that in fact it showed that thrombectomy we call a higher rate of symptomatic ICH and a worse recovery.

So this is how we entered.

So I want to use this nice picture from the publication by Goldberg and colleagues.

We have two published trials, Distal and Escape MVO and Discount, which is not yet published.

Correct me if I'm wrong.

This is the baseline studies.

So what I want to draw your attention to is

that each study was enough powered and And they were trying patients with different time points, less than 12 hours, less than 24 hours, less than 8 hours.

And they were also variable and allowed different devices to be used.

Some obliged the operator to use the stent retriever, some gave them flexibility.

So the results that would come from these trials will have generalizability to different times of onset and different device usage.

The outcome, again, this is part of the baseline characteristics.

You would see that in all the trials, both discount distal and SCAPE -MEVO,

the patients that were included as expected they were presented with mylar stroke symptoms

so you are doing a procedure on a patient

that is much less disabled remember the the average of patient in dawn were

about five or six units higher in an NHSRO scale and then the symptomatic ICH in all the trials

were really considerable and discounted with 12 percent in distal was 5 .9 percent

and 5 .4 percent in escape mevo

and then I want to again compare it with the meta -analysis of large vessel occlusion thrombectomies

that the symptomatic ICH were only 4 .4 percent so you are treating a patient

treating group of patients with milder symptoms with a more risky procedure.

So have this in mind.

And then in terms of outcomes, so we have the escape mevo and distal,

which showed no benefit in outcome at 90 days.

As you see, the confidence interval will cross the value one,

and the escape mevo in fact showed a higher rate of 90 days mortality

which was significant in interventional group so it shows

that we're not only benefiting but we are at some point harming

so one word of caution that discount results which were preliminary presented in isc

it showed that there was a significant improvement in thrombectomy patients for the MRC score equal less than 2 at 90 days.

But this was this annotation at the bottom after multiple imputation of missing data.

So I don't know what it means.

I don't know what it would turn into when it comes out as a full paper.

So we have to look out for it.

So we are talking about the thrombectomy in a group of patients or in one patient they are facing.

You're doing thrombectomy in a patient which has milder symptoms in a risky procedure.

But I want to also take this discussion into a global health level.

So this is the picture from MT Glasses study,

mission thrombectomy, which shows the access of different countries to thrombectomies.

As you can see, even the good countries are colored in green, only about a third of patients eligible for thrombectomy have access to it.

The situation for other countries is dismal.

Majority of MENA countries have less than 10 % access to thrombectomies.

So what I'm feeling that as neurointerventionists, although we have the duty to bring the best for our patient,

but it seems that we have a more pressing and urgent challenge, meaning that

improving access to thrombectomies for large vessel occlusion you know we are living in a world

that the resources are limited

100

so we can invest in finer devices for middle vessel occlusion thrombectomies as we we saw

101

that the thrombectomies in this population is more risky

102

so maybe we can already our devices is not uh prepared for it

103

but we can also invest that time and effort and money in making LVO device thrombectomies more available.

104

And that is the subject of grassroots trials,

105

bringing a stent retriever in with the lesser cost so that it could widen its coverage.

106

It actually came out from the Mission Thrombectomy Initiative.

107

And I think it got approval in India, if I'm not wrong, it got approval in Thailand before it.

108

So, So as an interventionist, when I'm facing the MEVO study,

109

we can talk about like different pieces of information that we have.

110

That for MEVO, we are treating patients with milder symptoms.

111

Our procedure is more risky, causing higher degree of symptomatic ICH, even mortality.

112

We have less successful reperfusion and no proven functional outcome.

113

But I think as a next step, if I have a choice of going after improving the devices

114

and refining trials for smaller vessels or trying to widen the very dismal global coverage for mechanical thrombectomy for LVO,

115

I would definitely choose the second one.

116

So, my answer to doing thrombectomies in medium vessel occlusions is no,

117

then I'm leaving a stage to my very good colleague, Dr. Rohini.

118

This is a picture of Tehran from the hospital that I work with.

119

Hopefully, we can all meet there.

120

And thank you for your attention.

Qu'est-ce que la technique du Shadowing ?

Le Shadowing est une technique d'apprentissage des langues fondée sur la science, développée à l'origine pour la formation des interprètes professionnels. Le principe est simple mais puissant : vous écoutez de l'anglais natif et le répétez immédiatement à voix haute — comme une ombre suivant le locuteur avec un décalage de 1 à 2 secondes. Les recherches montrent une amélioration significative de la précision de la prononciation, de l'intonation, du rythme, des liaisons, de la compréhension orale et de la fluidité.

Pratique du Shadowing: Medium Vessel Occlusion: Should We Thrombectomize? - Apprendre l'anglais à l'oral avec la vidéo

À propos de cette leçon

Qu'est-ce que la technique du Shadowing ?