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|LETTER TO EDITOR
|Year : 2016 | Volume
| Issue : 4 | Page : 796-798
ADAPT for emergent stroke treatment: Newer technique, Indian experience
Vikram Huded, Vikram Bohra, Romnesh deSouza, Ritesh Nair
Interventional Neurology and Stroke, NH Institute of Neurosciences, NH Health City, Bengaluru, Karnataka, India
|Date of Web Publication||5-Jul-2016|
Interventional Neurology and Stroke, NH Institute of Neurosciences, NH Health City, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Huded V, Bohra V, deSouza R, Nair R. ADAPT for emergent stroke treatment: Newer technique, Indian experience. Neurol India 2016;64:796-8
Endovascular therapy for acute ischemic strokes due to occlusion of the internal carotid artery (ICA) or proximal middle cerebral artery (MCA) (M1) using stent retrievers with or without intravenous tissue plasminogen activator (IV-tPA) has become the first line treatment modality. ADAPT stands for A Direct Aspiration first Pass Technique and is the most recently described method for achieving vessel recanalization. It can be used alone or in combination with other stent retrievers for mechanical thrombectomy. We describe the use of this technique at our center along with its potential advantages and disadvantages over other methods. To our knowledge, this is the first report of the use of the ADAPT technique from India.
A 59-year-old male patient, a known case of atrial septal defect with bidirectional shunt, underwent catheter ablation for atrial flutter. There was no heart clot in his preprocedural two dimensional echocardiogram. Immediately after the procedure, the patient had a dense right hemiplegia with global aphasia with National Institutes of Health Stroke Scale (NIHSS) of 17. Computed tomography (CT) of the brain showed the hyperdense MCA sign on the left side [Figure 1] with Alberta stroke program early CT score (ASPECTS) of 8. The patient had received heparin during the ablation procedure an hour back and the likelihood of large vessel occlusion was high, as suggested by the high NIHSS. IV-tPA was not administered. Right femoral artery vascular access was taken using a 7F long sheath. Preprocedural angiogram showed non-opacification of the left anterior cerebral artery (ACA) (A1) and the distal branches of MCA with a filling defect in the left MCA (M1) signifying a thrombus [Figure 2]. A large bore 5 MAX ACE (Penumbra) catheter was introduced through the long sheath into the left ICA [Figure 3]. Through the 5 MAX ACE catheter, we telescoped the 3 MAX ACE catheter, using a microwire, till the proximal end of the clot. The 3 MAX ACE catheter was later removed and suction was applied through the Penumbra aspiration pump. Stoppage of blood aspiration confirmed the approximation of the catheter to the clot. After waiting for 20 s, the whole system was slowly withdrawn with continuous aspiration. Immediate angiogram showed the restoration of flow to both the left ACA and MCA territory with no filling defect [Figure 4]. A 5.5 cm long clot was aspirated [Figure 5]. Time to recanalization from the groin puncture was 30 min. After the procedure, the patient's weakness improved, and at 24 hours post procedure, his NIHSS was 8 with a residual mild motor aphasia and right hemiparesis. Repeat CT brain at 24 h did not show any infarct or hemorrhage. The patient was discharged a week later on dual antiplatelets with improving neurological status.
|Figure 1: Computed tomography brain showing the hyperdense middle cerebral artery sign on the left side|
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|Figure 2: Pre-procedural angiogram showing the filling defect in the ACA (A1) and the middle cerebral artery (M1) [arrows]|
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|Figure 4: Postprocedural angiogram showing the reperfusion in the left ACA and middle cerebral artery territories with absence of filling defect|
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ADAPT is a recently described technique available for emergent stroke management. It involves passing a large bore aspiration catheter (that the target vessel can accommodate) to the proximal end of clot. After assuring the engagement of clot into the aspiration catheter, the entire system is withdrawn slowly under continuous aspiration with either a syringe or the Penumbra aspiration system., The catheters used have a large bore thus providing a greater area for the aspiration of clot. In addition, the catheters are more flexible and less traumatic than those used previously. This facilitates their ease of use and the safety of the procedure. The procedure is less technically demanding than the previous procedures, and because there is no need to traverse the clot, there are lesser chances of clot fragmentation and migration to the distal territories. Due to the wide bore of the aspiration catheters, there is an added advantage of using another clot retriever device simultaneously, if needed, further increasing the chances of a successful outcome. The aspiration of clot using ADAPT does not put traction on the artery and the regional perforators; therefore, there are lesser chances of dissection or hemorrhage following the procedure, which is reflected in the very minimal rate of symptomatic intracerebral hemorrhages reported in the studies using the ADAPT techniques., Solumbra is the technique when a Solitaire FR device is used simultaneously. Restoration of flow to modified Thrombolysis in Cerebral Infarction (TICI) 2b or 3 grade is achieved in approximately 78% of patients using ADAPT alone and can reach up to 95% by using the two methods simultaneously. The results for ADAPT alone are comparable to the other devices used alone and even better when two methods are used simultaneously., The time taken for revascularization from groin puncture is also better than that achieved in the trials using other devices. Good functional outcome (mRS 0–2) and mortality rates are comparable to the other devices.
Our hospital is a stroke ready hospital with active stroke management program in place and we have published our experience of endovascular treatment for acute ischemic stroke earlier. In our experience, ADAPT is a faster and simpler technique for emergent stroke management with the potential for lesser complications. An important aspect for the families of stroke patient to agree to undergoing this procedure is the involved expenditure. We feel that using 3 MAX ACE or 5 MAX ACE catheter along with an aspiration syringe is more economical then the usage of other devices for mechanical thrombectomy. The ability to use other devices simultaneously, if the ADAPT procedure is unsuccessful alone, provides an added advantage for the use of this method as the first line treatment.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]