Endovascular Treatment of Acute Stroke and Occlusive Cerebrovascular Disease

Endovascular therapy for cerebrovascular disease is widespread. Patients with brain aneurysms, acute stroke, brain vascular malformations, and tumors are treated with endovascular techniques primarily or in conjunction with other traditional surgical and medical approaches. Postprocedural concerns unique to endovascular treatment include complications related to access or arterial puncture, contrast nephrotoxicity, and radiation dose complications (eg, alopecia and skin burns). Other complications, such as stroke and hemorrhage, that are not unique are discussed below.

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Procedural Complications During Early Versus Late Endovascular Treatment in Acute Stroke

Stroke ◽

10.1161/strokeaha.120.031349 ◽

2021 ◽

Author(s):

Errikos Maslias ◽

Stefania Nannoni ◽

Federico Ricciardi ◽

Bruno Bartolini ◽

Davide Strambo ◽

...

Keyword(s):

Endovascular Treatment ◽

Acute Stroke ◽

Time Window ◽

National Institutes Of Health ◽

Late Time ◽

Short Term ◽

Term Outcome ◽

Stroke Registry ◽

Short Term Outcome ◽

Procedural Complications

Background and Purpose: Endovascular treatment (EVT) in acute ischemic stroke is effective in the late time window in selected patients. However, the frequency and clinical impact of procedural complications in the early versus late time window has received little attention. Methods: We retrospectively studied all acute ischemic strokes from 2015 to 2019 receiving EVT in the Acute Stroke Registry and Analysis of Lausanne. We compared the procedural EVT complications in the early (<6 hours) versus late (6–24 hours) window and correlated them with short-term clinical outcome. Results: Among 695 acute ischemic strokes receiving EVT (of which 202 were in the late window), 113 (16.3%) had at least one procedural complication. The frequency of each single, and for overall procedural complications was similar for early versus late EVT (16.2% versus 16.3%, P adj =0.90). Procedural complications lead to a significantly less favorable short-term outcome, reflected by the absence of National Institutes of Health Stroke Scale improvement in late EVT (delta-National Institutes of Health Stroke Scale-24 hours, −2.5 versus 2, P adj =0.01). Conclusions: In this retrospective analysis of consecutive EVT, the frequency of procedural complications was similar for early and late EVT patients but very short-term outcome seemed less favorable in late EVT patients with complications.

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Abstract TP9: Safety of Endovascular Treatment in Acute Stroke Patients Taking Oral Anticoagulants

Stroke ◽

10.1161/str.47.suppl_1.tp9 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Timo Uphaus ◽

Oliver C Singer ◽

Joachim Berkefeld ◽

Christian H Nolte ◽

Georg Bohner ◽

...

Keyword(s):

Clinical Outcome ◽

Endovascular Treatment ◽

Acute Stroke ◽

Positive Impact ◽

Therapeutic Option ◽

Oral Anticoagulants ◽

Intravenous Thrombolysis ◽

Vessel Occlusion ◽

Stroke Treatment ◽

Male Patients

Introduction: The endovascular treatment (EVT) of cerebral ischemia in the case of large vessel occlusion has been established over recent years. Randomized trials showed a positive impact on the clinical outcome of endovascular treatment in addition to thrombolysis with respect to clinical outcome and safety, so that this therapeutic option will be implemented in future guidelines. The role of EVT in patients treated with oral anticoagulants remains uncertain. Hypothesis: We assessed the hypothesis that application of EVT is safe with regard to the occurrence of intracranial bleeding and clinical outcome in patients taking anticoagulants. Methods: The ENDOSTROKE-Registry is a commercially independent, prospective observational study in 12 stroke centers in Germany and Austria launched in January 2011. An online tool served for data acquisition of pre-specified variables concerning endovascular stroke therapy. Results: Data from 815 patients (median age 70, 57% male) undergoing EVT and known anticoagulation status were analyzed. A total of 85 (median age 76, 52% male) patients (10.4%) took oral anticoagulants prior to EVT. Anticoagulation status as measured with INR was 2.0-3.0 in 24 patients (29%), <2.0 in 52 patients (63%) and above 3.0 in 7 patients (8%) of 83 patients with valid INR data prior to EVT. Patients taking anticoagulants were significantly older (median age 76 vs. 69, p < 0.001). Comparing those patients taking anticoagulants and those not, there were no differences concerning NIHSS at admission (with anticoagulants Median-NIHSS 17 vs. without Median-NIHSS 15, p = 0.492, Mann Whitney Test) and the rate of intracranial hemorrhage after intervention (with anticoagulants 11.8% vs. without 12.2%, p = 0.538). After adjustment for age and NIHSS at admission there were no significant differences between the two groups with regard to good clinical outcome, as measured with the modified ranking scale (mRS, 90d-mRS 0-2, 39.2% of patients not receiving anticoagulants; 25.9% of those receiving anticoagulants). Conclusion: The application of endovascular treatment in patients taking oral anticoagulants is safe and should be considered in acute stroke treatment as an important alternative to contraindicated intravenous thrombolysis.

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Clinical challenges associated with the endovascular treatment of acute stroke in a patient with infective endocarditis

Journal of Cerebrovascular and Endovascular Neurosurgery ◽

10.7461/jcen.2020.22.3.176 ◽

2020 ◽

Vol 22 (3) ◽

pp. 176-181

Author(s):

Emil Settarzade ◽

Ahmet Peker ◽

M. Akif Topcuoglu ◽

E. Murat Arsava ◽

Metin Demircin ◽

...

Keyword(s):

Infective Endocarditis ◽

Endovascular Treatment ◽

Acute Stroke

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Endovascular treatment of acute stroke

Schweizer Archiv für Neurologie und Psychiatrie ◽

10.4414/sanp.2011.02252 ◽

2011 ◽

Vol 162 (02) ◽

pp. 57-59

Keyword(s):

Endovascular Treatment ◽

Acute Stroke

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Abstract P153: SARS-CoV-2 (COVID-19) Protection Efforts on Acute Stroke Treatment

Stroke ◽

10.1161/str.52.suppl_1.p153 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Jessica Greenwood ◽

Starlie Belnap ◽

Rodney Bedgio ◽

Guilherme Dabus ◽

Italo Linfante ◽

...

Keyword(s):

Stroke Volume ◽

Endovascular Treatment ◽

Acute Stroke ◽

Symptom Onset ◽

Onset Time ◽

Fold Increase ◽

Medical Attention ◽

Hospital Treatment ◽

Significant Delay ◽

The Impact

Introduction: It is unclear how the interventions designed to restrict community and in-hospital exposure to the SARS-CoV-2 virus affected the care for stroke patients seeking acute treatment. The objective of the following study was to determine the impact COVID-19 has had on the treatment times for patients evaluated as acute stroke alerts at Baptist Hospital of Miami (BHM). A co-primary objective of the study was to assess the risk of contracting SARS-CoV-2 within 2 weeks from hospital discharge. Methods: This retrospective, two phase study was conducted between December 2019 and April 2020. In phase one, we assessed time from symptom onset to hospital arrival, number of strokes with witnessed onset, and in-hospital treatment times pre & post implementation of Covid-19 preventive exposure measures. In phase two of the study, a telephone survey was conducted on the post implementation group to assess the risk of patients developing symptoms or testing positive for SARS-CoV-2 from hospital admission up to two weeks post discharge. Results: Phase I demonstrated there was a 40% decline in stroke volume, but no significant delay to seek medical attention post implementation of the SARS prevention strategies. On average individuals in the pre-group (n=155) waited approximately 260 minutes (SE=24) to seek medical attention vs. 203 minutes (SE=27) minutes for the post-group (n=87). However, there was nearly a six-fold increase in the percentage of cases with unknown symptom onset post implementation of COVID-19 safety precautions. There was significant delay in administering IV alteplase, increasing from 24 mins (n=16) to 33 mins (n=21) post implementation; delays observed for endovascular treatment were not significant (pre, n=13 mean= 73 mins, post n=12 mean= 82 mins). The volume of patients treated with either IV alteplase and/or endovascular treatment remained similar. Phase II of the study is on-going, results will be available for the ISC. Discussion: The COVID-19 crisis in our community was associated with a six-fold increase in the percentage of cases with unknown stroke onset time. Besides a marked decrease in stroke volume, we did not evidence significant delays to either seek or provide acute stroke care outside a modest increase in door to needle time.

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Abstract TMP12: Does Prehospital Magnesium Sulfate Differentially Improve Outcome in Hyperacute Stroke Patients With Higher Pretreatment Blood Pressure?

Stroke ◽

10.1161/str.47.suppl_1.tmp12 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Phoebe H Johnson-Black ◽

Sidney Starkman ◽

Nerses Sanossian ◽

David Liebeskind ◽

Samuel Stratton ◽

...

Keyword(s):

Blood Pressure ◽

Cerebrovascular Disease ◽

Acute Stroke ◽

Magnesium Sulfate ◽

Controlled Trial ◽

Functional Independence ◽

Forest Plot ◽

Stroke Patients ◽

Improve Outcome ◽

Acute Cerebral Ischemia

Introduction: Magnesium sulfate (Mg) has blood pressure (BP) lowering, cerebral blood flow enhancing, and neuroprotective effects in preclinical and clinical studies. In the IMAGES phase 3 trial, Mg up to 12h after onset showed no benefit in acute stroke, but was associated with improved outcome in patients with higher blood pressure at entry. Hypothesis: We tested the hypothesis that ultra-early Mg improves functional outcome in acute stroke patients with higher baseline BP. Methods: FAST-MAG is a multicenter, double-blind, randomized, placebo-controlled trial of paramedic-initiated Mg, administered to patients with suspected stroke within 2h of symptom onset. The primary analysis showed neutral effect of Mg. This secondary analysis examines rates of functional independence (mRS 0-2) at 3m for Mg and placebo for different field BP groups. Results: Among 1622 patients with acute cerebrovascular disease, age was 69.6 (±13.4), 42% female, entry deficit severity in the field was LAMS 3.8 (±1.2), and first post-enrollment NIHSS in the ED was 11.5 (±9.9). Systolic blood pressure prior to enrollment was higher among patients with intracerebral hemorrhage (ICH) than acute cerebral ischemia (ACI), 175 (±25) vs 155 (±27), p < .001. The Figure shows the Forest plot for Mg vs placebo and functional independence among blood pressure groups. Heterogeneity of treatment effect was noted in the all-cerebrovascular patients population (p < .01), with fewer independent outcomes with Mg than placebo among patients with higher entry BPs. Analysis of Functional Independence (mRS 0-2) at 90 Days in Prespecified Subgroups Conclusion: This analysis did not confirm the prior finding of magnesium sulfate benefit among acute stroke patients with elevated blood pressure (and actually provided a signal in the opposing direction). Mg was not demonstrated to improve outcome when started in the first 2h of onset among patients with acute cerebrovascular disease and higher blood pressures.

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