Endovascular Treatment of Stroke

2018 ◽  
pp. 153-168
Author(s):  
Mandy J. Binning ◽  
Daniel R. Felbaum
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Heart Association ◽  
Standard Of Care ◽  
Class I ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Stroke Treatment ◽  
Intravenous Alteplase

This chapter will review the main endovascular principles of ischemic stroke treatment. Endovascular therapy has been revolutionized by the advent of modern devices for thrombectomy. Class I evidence in multiple trials has proven that intravenous alteplase plus endovascular thrombectomy is superior to intravenous alteplase alone. The combination of these factors has advanced the standard of care for patients who present with acute ischemic stroke who are also found to have a large vessel occlusion and salvageable brain tissue. The chapter will include information based on recently concluded Class I trials and American Heart Association guidelines. The chapter will review available imaging, current guidelines, controversies surrounding endovascular thrombectomy, recent advances in thrombectomy devices, and recent management principles pertinent to the endovascular treatment of acute ischemic stroke. Cases will be presented regarding diagnosis, management, and treatment paradigms currently being practiced.

Systematic evaluation of stroke thrombectomy in clinical practice: The German Stroke Registry Endovascular Treatment

2018 ◽  
Vol 14 (4) ◽  
pp. 372-380 ◽  
Author(s):  
Anna C Alegiani ◽  
Franziska Dorn ◽  
Moriz Herzberg ◽  
Frank A Wollenweber ◽  
Lars Kellert ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Active Sites ◽  
Intravenous Thrombolysis ◽  
Standard Of Care ◽  
Systematic Evaluation ◽  
Stroke Treatment ◽  
Stroke Registry

Background Endovascular treatment has become standard of care for the treatment of acute ischemic stroke with large vessel occlusion. However, patients treated in clinical practice differ from the selected populations randomized in clinical trials. Aims The German Stroke Registry Endovascular Treatment (GSR-ET) aims at a systematic evaluation of outcome, safety, and process parameters of endovascular stroke treatment in standard of care in Germany. Methods The GSR-ET is an academic, independent, prospective, multicenter, observational registry study. Participating stroke centers from all over of Germany consecutively enroll patients transferred to the angiography suite with an intention to be treated with endovascular stroke treatment. Patients receive regular care. Data are collected as part of clinical routine. Baseline clinical and procedural information and clinical follow-up information after 90 days are recorded. Here, we present an analysis of baseline data of the first 1662 patients included in the GSR-ET. Results The registry was established in June 2015. By 31 December 2017, 1662 patients were enrolled in 23 active sites. Mean age was 72 ± 13 years, 50% were female, and median National Institutes of Health Stroke Scale on admission was 15 (IQR 10–19), 88% had anterior circulation occlusion. Median ASPECT score was 8 (IQR 7–10) prior to intervention. Fifty-nine percent of patients received intravenous thrombolysis prior to thrombectomy. Mean “onset-to-groin” time was 224 ± 176 min. Conclusions Baseline characteristics of stroke patients undergoing thrombectomy in clinical practice differ from those in the randomized trials. The GSR-ET will provide valuable insights into practices of endovascular treatment in routine care of acute ischemic stroke. (GSR-ET ClinicalTrials.gov Identifier: NCT03356392.)

scholarly journals Endovascular Acute Ischemic Stroke Treatment with FlowGate Balloon Guide Catheter: A Single-Center Observational Study of FlowGate Balloon Guide Catheter Use

2018 ◽  
Vol 7 (6) ◽  
pp. 327-333 ◽  
Author(s):  
Mohamed S. Teleb
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Guide Catheter ◽  
Stent Retrievers ◽  
Number Of Passes ◽  
Single Center Observational Study

Background: Treatment of large vessel occlusion acute ischemic stroke with mechanical thrombectomy has become the standard of care after recent clinical trials. However, the degree of recanalization with stent retrievers remains very important in overall outcomes. We sought to review the utility of a new balloon guide catheter (BGC) in improving the degree of recanalization in conjunction with mechanical thrombectomy. Methods: The medical records of a prospectively collected endovascular ischemic stroke database were reviewed. All consecutive strokes when a FlowGate BGC was used with a thrombectomy stent retriever were identified. Use of a FlowGate BGC, number of passes, final Thrombolysis in Cerebral Infarction (TICI) score, trackability, and use of adjunct devices were all collected and analyzed. Results: Use of a FlowGate BGC resulted in 64% (33/52) first-pass effect (FPE) of TICI 2b/3, and specifically 46% (24/52) TICI 3 FPE (true FPE). A total of 52/62 (84%) of thrombectomy cases were treated with BGCs. In the remaining 10, the BGC was not inflated or used due to the clot not being visualized or the lesions being distal and BGC use thus not deemed appropriate. Adjunct use of an aspiration catheter was seen in 12% (6/52) of cases. The overall success with FlowGate BGCs with one or more passes of TICI 2b/3 was 94% (49/52). Trackability was achieved in 92% (57/62) of cases. Conclusions: Use of the FlowGate BGC as an adjunct to mechanical thrombectomy was associated with good FPE and an overall recanalization of TICI 2b/3 of 94%.

scholarly journals Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next?

2021 ◽  
Author(s):  
Mohammad Shafie ◽  
Wengui Yu
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Standard Of Care ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Randomized Controlled ◽  
The Past ◽  
Tissue Plasminogen

AbstractIn the past 5 years, the success of multiple randomized controlled trials of recanalization therapy with endovascular thrombectomy has transformed the treatment of acute ischemic stroke with large vessel occlusion. The evidence from these trials has now established endovascular thrombectomy as standard of care. This review will discuss the chronological evolution of large vessel occlusion treatment from early medical therapy with tissue plasminogen activator to the latest mechanical thrombectomy. Additionally, it will highlight the potential areas in endovascular thrombectomy for acute ischemic stroke open to exploration and further progress in the next decade.

Implications of the use of mechanical thrombectomy on outcome in large vessel occlusion following the 2015 landmark trials

2020 ◽  
Vol 13 (1) ◽  
pp. 4-7
Author(s):  
Okkes Kuybu ◽  
Vijayakumar Javalkar ◽  
Abdallah Amireh ◽  
Arshpreet Kaur ◽  
Roger E Kelley ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Binary Logistic Regression ◽  
Standard Of Care ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Before And After

BackgroundThe effectiveness of mechanical thrombectomy (MT) was demonstrated in five landmark trials published in2015.Mechanical thrombectomy is now standard of care for acute ischemic stroke and has been growing in popularity after publication of landmark trials.ObjectiveTo analyze outcomes and trends of the use of MT and intravenous thrombolysis (IVT) in patients with acute ischemic stroke in US hospitals before and after publication of these trials.MethodsPatients discharged with a diagnosis of ischemic stroke between 2012 to 2017 were diagnosed using ICD codes from the National Inpatient Sample. Thereafter, patients given acute stroke treatment were identified using the corresponding procedure codes for IVT and MT. The primary clinical outcomes of in-hospital mortality and disability were then compared between two time periods: 2012–2014 (pre-landmark trials) and 2015–2017 (post-landmark trials). Binary logistic regression and Χ2 tests were used for statistical analysis.ResultsA total of 57 675 patients (median age 68.9 years (range 18-90), 50.1% female) were identified with acute procedures. Of these patients, 57.6% were from the post-landmark trials time period. Despite an increased number of cases, the rate of IVT decreased from 84.3% to 75.9% and the rate of IVT+MT decreased from 7.1% to 6.3%. After publication of the pivotal trials in 2015, the rates of MT increased from 8.7% to 17.8%. Significant reductions of in-hospital mortality (7.1% vs 8.7%, p<0.001) and disability (64% vs 66.2%, p<0.001) were noted.ConclusionThe analysis showed a significant increase in the proportion of patients receiving MT after 2015. This has translated into reduction of in-hospital mortality and improvement in disability.

scholarly journals Endovascular Thrombectomy preceded by intravenous Alteplase versus endovascular Thrombectomy alone in Han Chinese patients treated for acute ischemic stroke with large vessel occlusion: a single-center retrospective analysis

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Ruodong Han ◽  
Bowen Li ◽  
Yajie Yue ◽  
Guozhu Wu ◽  
Xiuxia Yan
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Retrospective Analysis ◽  
Han Chinese ◽  
Chinese Patients ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Procedural Complications ◽  
Intravenous Alteplase

Abstract Background The American Heart Association/ American Stroke Association and the Chinese Stroke Association guidelines are recommending intravenous alteplase intervention before endovascular thrombectomy if patients are eligible to do so but the benefits of endovascular thrombectomy are different in Chinese patients with stroke than those of the white patients. The objective of the study was to compare outcomes of patients with acute ischemic stroke treated with endovascular thrombectomy with intravenous alteplase against those treated with endovascular thrombectomy alone. Methods A report is a retrospective analysis of comparing demographics, imaging, clinical and adverse outcomes in the Han Chinese patient who underwent mechanical thrombectomy for acute ischemic stroke with large vessel occlusion, with or without preceding intravenous alteplase administration. Patients with terminus and non-terminus intracranial occlusions and ≤ 2 points neurologic deficit underwent endovascular thrombectomy preceded by 0.9 mg/ kg intravenous alteplase (ET cohort, n = 184) and those who had contra-indication for intravenous alteplase were treated with endovascular thrombectomy alone (EA cohort, n = 141). Results The most common procedural complications were embolization into new territory (p = 0.866) and uneventful artery vasospasm (p = 0.712). Insignificant differences were reported for any procedural complications (p = 0.991), imaging outcomes, the modified Rankin scale score (p = 0.663), and death (28 vs. 24, p = 0.761) within 90 days between patients of both cohorts. At the discharge of the hospital, the National Institutes of Health Stroke Scale scores of patients of the ET cohort were lower than those of the EA cohort (8.58 ± 3.79 vs. 10.23 ± 4.97, p = 0.003). The Barthel Index of survivors at 90 days after endovascular thrombectomy was higher for patients of the ET cohort than those of the EA cohort (87.47 ± 12.58 vs. 84.01 ± 13.47, p = 0.032). The most common adverse effect was asymptomatic intracranial hemorrhage (p = 0.297). Insignificant differences were reported for adverse effects after thrombectomy between survivors of both cohorts. Conclusions Outcome measures in Han Chinese patients with acute ischemic stroke treated with endovascular thrombectomy alone were statistically the same as those treated with endovascular thrombectomy plus intravenous alteplase. Level of evidence Iii Technical efficacy stage 4.

A review of acute ischemic stroke triage protocol evidence: a context for discussion

2018 ◽  
Vol 10 (11) ◽  
pp. 1047-1052 ◽  
Author(s):  
Alexander G Chartrain ◽  
Hazem Shoirah ◽  
Edward C Jauch ◽  
J Mocco
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Standard Of Care ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Triage Protocol ◽  
Prehospital Triage ◽  
Clinical Benefits ◽  
Hospital Systems ◽  
The Subject

Endovascular thrombectomy (EVT) is now the standard of care for eligible patients with acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO). However, there remains uncertainty in how hospital systems can most efficiently route patients with suspected ELVO for EVT treatment. Given the relative geographic distribution of centers with and without endovascular capabilities, the value of prehospital triage directly to centers with the ability to provide EVT remains debated. While there are no randomized trial data available to date, there is substantial evidence in the literature that may offer guidance on the subject. In this review we examine the available data in the context of improving the existing AIS triage systems and discuss how prehospital triage directly to endovascular-capable centers may confer clinical benefits for patients with suspected ELVO.

Revascularization and functional outcomes after mechanical thrombectomy for acute ischemic stroke in elderly patients

2020 ◽  
Vol 132 (4) ◽  
pp. 1182-1187 ◽  
Author(s):  
Carrie E. Andrews ◽  
Nikolaos Mouchtouris ◽  
Evan M. Fitchett ◽  
Fadi Al Saiegh ◽  
Michael J. Lang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Elderly Patients ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Multivariate Logistic Regression Analysis ◽  
Standard Of Care ◽  
Stroke Severity ◽  
Vessel Occlusion ◽  
Younger Patients ◽  
Success Of Treatment

OBJECTIVEMechanical thrombectomy (MT) is now the standard of care for acute ischemic stroke (AIS) secondary to large-vessel occlusion, but there remains a question of whether elderly patients benefit from this procedure to the same degree as the younger populations enrolled in the seminal trials on MT. The authors compared outcomes after MT of patients 80–89 and ≥ 90 years old with AIS to those of younger patients.METHODSThe authors retrospectively analyzed records of patients undergoing MT at their institution to examine stroke severity, comorbid conditions, medical management, recanalization results, and clinical outcomes. Univariate and multivariate logistic regression analysis were used to compare patients < 80 years, 80–89 years, and ≥ 90 years old.RESULTSAll groups had similar rates of comorbid disease and tissue plasminogen activator (tPA) administration, and stroke severity did not differ significantly between groups. Elderly patients had equivalent recanalization outcomes, with similar rates of readmission, 30-day mortality, and hospital-associated complications. These patients were more likely to have poor clinical outcome on discharge, as defined by a modified Rankin Scale (mRS) score of 3–6, but this difference was not significant when controlled for stroke severity, tPA administration, and recanalization results.CONCLUSIONSOctogenarians, nonagenarians, and centenarians with AIS have similar rates of mortality, hospital readmission, and hospital-associated complications as younger patients after MT. Elderly patients also have the capacity to achieve good functional outcome after MT, but this potential is moderated by stroke severity and success of treatment.

scholarly journals Outcome of endovascular treatment within and beyond 6 h without perfusion software

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Zhen Jing ◽  
Hao Li ◽  
Shengming Huang ◽  
Min Guan ◽  
Yongxin Li ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
General Anesthesia ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Symptom Onset ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Group A ◽  
Group B

AbstractEndovascular treatment (EVT) has been accepted as the standard of care for patients with acute ischemic stroke. The aim of the present study was to compare clinical outcomes of patients who received EVT within and beyond 6 h from symptom onset to groin puncture without perfusion software in Guangdong district, China. Between March 2017 and May 2018, acute ischemic stroke patients who received EVT from 6 comprehensive stroke centers, were enrolled into the registry study. In this subgroup study, we included all patients who had acute proximal large vessel occlusion in the anterior circulation. The demographic, clinical and neuroimaging data were collected from each center. A total of 192 patients were included in this subgroup study. They were divided into two groups: group A (n = 125), within 6 h; group B (n = 67), 6–24 h from symptom onset to groin puncture. There were no substantial differences between these two groups in terms of 90 days favorable outcome (modified Rankin scale [mRS] ≤ 2, P = 0.051) and mortality (P = 0.083), and the risk of symptomatic intracranial hemorrhage at 24 h (P = 0.425). The NIHSS (median 16, IQR12-20, group A; median 12, IQR8-18, group B; P = 0.009) and ASPECTS (median 10, IQR8-10, group A; median 9, IQR8-10, group B; P = 0.034) at baseline were higher in group A. The anesthesia method (general anesthesia, 21.3%, group A vs. 1.5% group B, P = 0.001) were also statistically different between the two groups. The NIHSS and ASPECTS were higher, and general anesthesia was also more widely used in group A. Clinical outcomes were not significantly different within 6 h versus 6–24 h from symptom onset to groin puncture in this real world study.

Effect of “drip-and-ship” and “drip-and-drive” on endovascular treatment of acute ischemic stroke with large vessel occlusion: a single-center retrospective study

2021 ◽  
pp. 028418512110068
Author(s):  
Yu Hang ◽  
Zhen Yu Jia ◽  
Lin Bo Zhao ◽  
Yue Zhou Cao ◽  
Huang Huang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Primary Stroke Center ◽  
Secondary Endpoints ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) were usually transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (drip-and-ship [DS]), while driving the doctor from a CSC to a PSC to perform a procedure is an alternative strategy (drip-and-drive [DD]). Purpose To compare the efficacy and prognosis of the two strategies. Material and Methods From February 2017 to June 2019, 62 patients with LVO received endovascular treatment via the DS and DD models and were retrospectively analyzed from the stroke alliance based on our CSC. Primary endpoint was door-to-reperfusion (DTR) time. Secondary endpoints included puncture-to-recanalization (PTR) time, modified Thrombolysis in Cerebral Infarction (mTICI) rates at the end of the procedure, and modified Rankin Scale (mRS) at 90 days. Results Forty-one patients received the DS strategy and 21 patients received the DD strategy. The DTR time was significantly longer in the DS group compared to the DD group (315.5 ± 83.8 min vs. 248.6 ± 80.0 min; P < 0.05), and PTR time was shorter (77.2 ± 35.9 min vs. 113.7 ± 69.7 min; P = 0.033) compared with the DD group. Successful recanalization (mTICI 2b/3) was achieved in 89% (36/41) of patients in the DS group and 86% (18/21) in the DD group ( P = 1.000). Favorable functional outcomes (mRS 0–2) were observed in 49% (20/41) of patients in the DS group and 71% (15/21) in the DD group at 90 days ( P = 0.089). Conclusion Compared with the DS strategy, the DD strategy showed more effective and a trend of better clinical outcomes for AIS patients with LVO.

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