Thrombectomy in acute ischemic stroke: estimations of increasing demands

BackgroundNew recommendations for mechanical thrombectomy in acute ischemic stroke suggest that thrombectomy should be considered for eligible patients with a large artery occlusion in the anterior circulation within 6 hours of stroke onset. The resources are unevenly spread and, in order to be able to meet a potentially increased demand, we have estimated the future need for thrombectomy.MethodsThe new treatment recommendations are similar to those that have been in use at the Karolinska University Hospital since 2007. Using our local thrombectomy data (2009–2011), we calculated the proportion of thrombectomies performed at our hospital by level of stroke severity according to the National Institutes of Health Stroke Scale score (0–5, 6–11, 12–19, and 20–35). We then estimated the total number of potential thrombectomies expected in Sweden by extrapolating our treatment proportions to the rest of Sweden through the use of data from the Swedish National Stroke Registry.ResultsThe number of potential thrombectomies would have been more than five times higher (1268 estimated compared with 232 actually reported in the National Stroke Registry) if the new recommendations for thrombectomy in acute ischemic stroke had been implemented in 2013 (the year from which we had the most recent available data from the Swedish Stroke Registry).ConclusionsWhen the new recommendations are implemented broadly, there may be a substantial increase in demand for thrombectomies. Our study highlights the need for policymakers and healthcare professionals to prepare for the increasing demands for advanced endovascular stroke treatment.

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Endovascular Recanalization in Early Recurrent Ischemic Stroke: A Treatment Challenge

Case Reports in Neurology ◽

10.1159/000507185 ◽

2020 ◽

Vol 12 (Suppl. 1) ◽

pp. 49-55

Author(s):

Huong Bich Thi Nguyen ◽

Thang Huy Nguyen

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Time Window ◽

Recurrent Stroke ◽

Reperfusion Therapy ◽

Artery Occlusion ◽

Large Artery ◽

Limited Information ◽

Anterior Circulation ◽

Endovascular Recanalization

Reperfusion therapy is the most effective treatment for acute ischemic stroke. At present, many clinical studies have shown that mechanical thrombectomy is efficient and safe for acute ischemic stroke of large artery occlusion disease in the time window of 24 h. However, there is limited information on the safety and effectiveness of this technique in cases of recurrent ischemic stroke. We report a case of early recurrent stroke of the anterior circulation after a week of the first stroke. Imaging examinations showed that there existed occlusion of corresponding vessels and obvious ischemic penumbra. Symptoms of the patient were progressive worsening and medical treatment failed; therefore, the corresponding vessel was opened. The low perfusion status in brain tissue and clinical defect symptoms of the patients have improved a lot. In conclusion, thrombectomy for early recurrent ischemic stroke may be effective. Moreover, there may be a wider reperfusion time window for ischemic stroke patients.

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Abstract WMP5: Predictors and Clinical Relevance of Hemorrhagic Transformation after Endovascular Therapy for Acute Ischemic Stroke: a Multicenter Retrospective Analysis of 1122 Patients

Stroke ◽

10.1161/str.44.suppl_1.awmp5 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Raul G Nogueira ◽

Rishi Gupta ◽

Tudor G Jovin ◽

Elad I Levy ◽

David Liebeskind ◽

...

Keyword(s):

Diabetes Mellitus ◽

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Retrospective Analysis ◽

Endovascular Therapy ◽

High Volume ◽

Artery Occlusion ◽

Large Artery ◽

Anterior Circulation

Background and Purpose: Endovascular techniques are frequently employed to treat large artery occlusion in acute ischemic stroke (AIS). We sought to determine the predictors and clinical impact of intracranial hemorrhage (ICH) after endovascular therapy. Methods: Retrospective analysis of consecutive patients presenting to 13 high-volume stroke centers with AIS due to proximal occlusion in the anterior circulation who underwent endovascular treatment within 8 hours from symptom onset. Logistic regression was performed to determine the variables associated with ICH, hemorrhagic infarction (HI), and parenchymal hematomas (PH) as well as 90-day poor outcome (mRS≥3), and mortality. Results: A total of 1122 patients (mean age, 67±15 years; median NIHSS, 17 [IQR13-20]) were studied. Independent predictors for HI included diabetes mellitus (OR 2.27, 95%CI [1.58-3.26], p<0.0001), pre-procedure IV tPA (1.43[1.03-2.08], p<0.037), Merci thrombectomy (1.47[1.02-2.12], p<0.032), and longer time to puncture (1.001[1.00-1.002], p<0.026). Patients with atrial fibrillation (1.61[1.01-2.55], p<0.045) had a higher risk of parenchymal hematomas (PH) while the use of intra-arterial tPA (0.57[0.35-0.90], p<0.008) was associated with lower chances of PH. Both the presence of HI (2.23[1.53-3.25], p< 0.0001) and PH (6.24[3.06-12.75], p< 0.0001) were associated with poor functional outcomes; however, only PH was associated with higher mortality (3.53[2.19-5.68], p<0.0001). Conclusions: In AIS patients undergoing endovascular therapy, diabetes mellitus, longer time to treatment, and Merci thrombectomy appear to be associated with a higher risk for HI while atrial fibrillation appears to result in a higher risk for PH. While both HI and PH are associated with poor outcomes only PH is associated with higher mortality.

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Abstract WP40: “Good” Angiographic Collateral Circulation Correlates With Lower Dwi Infarct Volumes In Acute Ischemic Stroke

Stroke ◽

10.1161/str.44.suppl_1.awp40 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Esteban Cheng-Ching ◽

Dolora Wisco ◽

Shumei Man ◽

Ferdinand Hui ◽

Gabor Toth ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Collateral Circulation ◽

Infarct Volume ◽

Artery Occlusion ◽

Grading System ◽

Large Artery ◽

Anterior Circulation ◽

Vessel Occlusion

Background and purpose Large artery occlusion leads to ischemic stroke which volume is influenced by time from symptom onset. This effect is modulated by several factors, including the presence and degree of collateral circulation. We analyze the correlation between a standard angiographic collateral grading system and DWI infarct volumes. Methods We reviewed a prospectively collected retrospective database of ischemic stroke patients admitted between august of 2006 and december of 2011. We included patients with anterior circulation acute ischemic stroke presenting within 8 hours from symptom onset with large vessel occlusion, who underwent pre-treatment MRI and endovascular therapy. DWI infarct volumes were measured by region of interest. ASITN collateral grading system was used and grouped into “good collaterals” for grades 3 and 4, and “poor collaterals” for grades 0, 1 and 2. JMP statistical software was utilized. Results 152 patients (71 (46.7%) male, mean age: 68±15 years;) were included in the initial analysis. We identified 49 patients who had angiographic collateral circulation grading. Seven patients had ASITN collateral grade 0 with mean infarct volume of 27.6 cc, 25 had collateral grade of 1 with mean infarct volume of 27.9 cc, 10 had collateral grade of 2 with mean infarct volume of 23.4 cc, 5 had collateral grade of 3 with mean infarct volume of 6.3 cc, and 2 had collateral grade of 4 with mean infarct volume of 14.6 cc. Forty two patients had “poor collaterals” with a mean infarct volume of 26.8 cc. Seven patients had “good collaterals” with mean infarct volume of 8.7 cc. When comparing the infarct volumes between these two groups, the difference was statistically significant (p=0.017). Conclusions In anterior circulation acute ischemic stroke, “good” angiographic collateral circulation defined as ASITN grading system of 3 or 4, correlates with lower infarct volumes on presentation.

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Mortality after large artery occlusion acute ischemic stroke

Scientific Reports ◽

10.1038/s41598-021-89638-x ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Rahul R. Karamchandani ◽

Jeremy B. Rhoten ◽

Dale Strong ◽

Brenda Chang ◽

Andrew W. Asimos

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Clinical Decision Making ◽

Clinical Decision ◽

Artery Occlusion ◽

Large Artery ◽

Multivariable Logistic Regression Model ◽

Stroke Registry ◽

Social Security Death Index ◽

Revascularization Therapy

AbstractDespite randomized trials showing a functional outcome benefit in favor of endovascular therapy (EVT), large artery occlusion acute ischemic stroke is associated with high mortality. We performed a retrospective analysis from a prospectively collected code stroke registry and included patients presenting between November 2016 and April 2019 with internal carotid artery and/or proximal middle cerebral artery occlusions. Ninety-day mortality status from registry follow-up was corroborated with the Social Security Death Index. A multivariable logistic regression model was fitted to determine demographic and clinical characteristics associated with 90-day mortality. Among 764 patients, mortality rate was 26%. Increasing age (per 10 years, OR 1.48, 95% CI 1.25–1.76; p < 0.0001), higher presenting NIHSS (per 1 point, OR 1.05, 95% CI 1.01–1.09, p = 0.01), and higher discharge modified Rankin Score (per 1 point, OR 4.27, 95% CI 3.25–5.59, p < 0.0001) were independently associated with higher odds of mortality. Good revascularization therapy, compared to no EVT, was independently associated with a survival benefit (OR 0.61, 95% CI 0.35–1.00, p = 0.048). We identified factors independently associated with mortality in a highly lethal form of stroke which can be used in clinical decision-making, prognostication, and in planning future studies.

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Tenacity of Collateral Perfusion in Proximal Cerebral Arterial Occlusions 6–12 h after Onset

Cerebrovascular Diseases ◽

10.1159/000489894 ◽

2018 ◽

Vol 45 (5-6) ◽

pp. 263-269 ◽

Cited By ~ 1

Author(s):

Beom Joon Kim ◽

Hyeran Kim ◽

Han-Gil Jeong ◽

Mi Hwa Yang ◽

Cheol Kyu Jung ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Binary Logistic Regression ◽

Artery Occlusion ◽

Binary Logistic Regression Analysis ◽

Stroke Patients ◽

Anterior Circulation ◽

Clinical Registry ◽

Stroke Registry ◽

Endovascular Recanalization

Background: Clinical trials have shown that benefits of endovascular recanalization (EVT) for acute ischemic stroke patients with sizable penumbral tissues seems plausible even beyond 6 h after their last seen normal (LSN). Persistency of ischemic penumbra remains unclear in delayed periods. Methods: From a prospective stroke registry database, we identified 111 acute ischemic stroke patients who had internal carotid artery or middle cerebral artery occlusion with baseline National Institutes of Health Stroke Scale scores ≥6 points and arrived 6–12 h after LSN. Baseline information and functional outcomes were prospectively collected as a clinical registry. Attending physicians made treatment decisions for EVT based on the current guidelines and institutional protocols. MR image parameters, including the volume of diffusion-restricted lesions and mapping of the hypoperfused area, were quantified using automated commercial software. Binary logistic regression analysis models, with modified Rankin Scale (mRS) scores of 0–1 at 3 months after stroke included as a dependent variable, were constructed. Results: Between 6 and 12 h after onset, 58% had a mismatch ratio of ≥1.8 at baseline and 42% had favorable imaging profiles as determined by DEFUSE 2 study. After 9 h, there was a mismatch ratio of ≥1.8 in 47 and 38% favorable profiles. EVT was performed in 54% of cases. A 3-month mRS score of 0–1 was found in 19% (25% in EVT and 12% in medical treatment groups) of cases. EVT was associated with an increased OR of having a mRS score of 0–1 at 3 months after stroke (adjusted OR 7.59 [95% CI 1.28–61.60]). Conclusions: Penumbral tissues were persistent in a substantial proportion of anterior circulation occlusion cases 6–12 h after LSN. EVT at 6–12 h in a predominantly Asian cohort resulted in better outcomes.

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Cortical Venous Changes on Susceptibility-Weighted Imaging Predict the Cerebral Collateral Circulation as Confirmed by Digital Subtraction Angiography

Frontiers in Neurology ◽

10.3389/fneur.2021.691430 ◽

2021 ◽

Vol 12 ◽

Author(s):

Yun-Hao Zhan ◽

Yang-Kun Chen ◽

Run-Xiong Li ◽

Gen-Pei Luo ◽

Zhi-Qiang Wu ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Collateral Circulation ◽

Artery Occlusion ◽

Susceptibility Weighted Imaging ◽

Large Artery ◽

Digital Subtraction ◽

Stroke Patients ◽

Severe Stenosis ◽

Anterior Circulation

Objective: Asymmetrical cortical vein sign (ACVS) shown on susceptibility-weighted imaging (SWI) can reflect regional hypoperfusion. We investigated if ACVS could predict the cerebral collateral circulation (CC) as assessed by digital subtraction angiography (DSA) in acute ischemic stroke patients with ipsilateral severe stenosis/occlusion of the anterior circulation.Methods: Clinical data and imaging data of 62 acute ischemic stroke patients with ipsilateral severe stenosis or occlusion of the anterior circulation confirmed by DSA were collected retrospectively. Participants underwent magnetic resonance imaging, including an SWI sequence. ACVS was defined as more and/or larger venous signals in the cerebral cortex of one side of SWI than that in the contralateral side. ACVS was measured using the Alberta Stroke Program Early Computed Tomography score based on SWI. The grading of the cerebral CC was judged using DSA.Results: Of the 62 patients, 30 patients (48.4%) had moderate-to-severe ACVS. According to DSA assessment, 19 patients (30.6%) had a good CC (grade 3–4), and 43 (69.4%) patients had a poor-to-moderate CC (grade 0–2). Among the 30 patients with moderate-to-severe ACVS, only three (10%) patients had a good CC, and 27 (90%) patients had a poor-to-moderate CC; among the 32 patients with none or mild ACVS, 16 (50%) of them had a good CC, and the other 50% had a moderate-to-severe CC. We constructed two logistic regression models with ACVS grading and none or mild ACVS entered into the models, respectively, together with age and large-artery occlusion. In model 1, no ACVS (compared with severe ACVS; OR = 40.329, 95%CI = 2.817–577.422, P = 0.006), mild ACVS (compared with severe ACVS; OR = 17.186, 1.735–170.224, 0.015) and large-artery occlusion (OR = 45.645, 4.603–452.592, 0.001) correlated with a good CC. In model 2, none or mild ACVS (OR = 36.848, 95%CI = 5.516–246.171, P < 0.001) was significantly associated with a good CC as judged by DSA, adjusted by age and large-artery occlusion.Conclusions: Cortical venous changes in SWI may be a useful indicator for the cerebral CC as confirmed by DSA.

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ENDOVASCULARAPPROACHES TOACUTE ISCHEMIC STROKE- INDIAN PERSPECTIVE

PERSPECTIVES IN MEDICAL RESEARCH - 2 ◽

10.47799/pimr.0703.02 ◽

2020 ◽

Vol 7 (3) ◽

pp. 7-14

Author(s):

Pramod Dhonde ◽

N. Kadam

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Review Literature ◽

Large Artery ◽

Stroke Event ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Indian Perspective

Aim: To review literature about endovascular approaches to acute ischemic stroke and provide Indian perspective about managing these cases. Brief Summary: In acute ischemic stroke cases, intravenous thrombolysis (IVT) with altepase within 4.5 hours has been the standard of care. Due to certain limitations of IVT, in pooled patientlevel data from 5 trials (HERMES [Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials], which included the 5 trials MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND-IA), mechanical thrombectomy (MT) is indicated for patients with acute ischemic stroke due to a large artery occlusion (LVO) in the anterior circulation who can be treated within 24 hours of the time last known to be well (ie, at neurologic baseline), regardless of whether they received intravenous alteplase for the same ischemic stroke event. The maximum benefit can be achieved within 6 hours of onset of symptoms. There are studies suggesting the benefit of MT in posterior circulation stroke as well as in distal arteries. We are going to review the methodology of endovascular techniques in brief alongwith Indian perspective on feasibility of this treatment approach in AIS. Conclusion: Mechnicalthrombectomy is certainly an effective modality of treatment in large vessel occlusion in anterior circulation within 24 hours. More awareness regarding the approach in India, can reduce the stroke morbidity and mortality in many of the cases in future

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Prognosis of asymptomatic intracranial hemorrhage after endovascular treatment

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-013848 ◽

2018 ◽

Vol 11 (2) ◽

pp. 123-126 ◽

Cited By ~ 5

Author(s):

Yonggang Hao ◽

Wenhua Liu ◽

Huaiming Wang ◽

Wenjie Zi ◽

Dong Yang ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Functional Outcomes ◽

Artery Occlusion ◽

Favorable Outcome ◽

Large Artery ◽

Anterior Circulation ◽

Excellent Outcome

ObjectiveAsymptomatic intracranial hemorrhage (aSICH) is a common phenomenon after endovascular treatment of acute ischemic stroke, but its prognostic impacts remain unclear. This study evaluated functional outcomes of thrombectomy in patients with and without aSICH.MethodsPatients with acute ischemic stroke due to large artery occlusion in the anterior circulation who were treated with thrombectomy were enrolled in 21 centers. According to CT scans performed within 72 hours of endovascular procedures, patients with aSICH or without intracranial hemorrhage were included while patients with symptomatic intracranial hemorrhage (SICH) were excluded. Baseline data and functional outcomes were compared between patients with aSICH and those without intracranial hemorrhage. Logistic regression analysis was applied to evaluate the impacts of aSICH on functional outcomes.ResultsOf the 632 patients with endovascular treatment, 101 (16.0%) were classified as having SICH, 212 (33.5%) as having aSICH, and 319 (50.5%) as being without intracranial hemorrhage. Patients with aSICH after endovascular treatment had a lower ratio of excellent outcome (mRS 0–1, OR 0.53; 95% CI 0.33 to 0.84, P=0.007) than those without intracranial hemorrhage. There were no significant differences concerning favorable outcome (mRS 0–2, OR 0.76; 95% CI 0.50 to 1.14, P=0.185) or mortality (OR 0.64; 95% CI 0.38 to 1.09, P=0.101) between patients with aSICH and those without intracranial hemorrhage.ConclusionsIn an Asian population, aSICH after thrombectomy may decrease the likelihood of an excellent functional outcome but does not influence a favorable outcome and mortality in patients with ischemic stroke due to large artery occlusion in the anterior circulation.

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Abstract TP51: Comparison of Recanalization Rate Between Intravenous Actilyse and Intravenous Actilyse With Mechanical Thrombectomy in Larger Artery Occlusion Ischemic Stroke Patients

Stroke ◽

10.1161/str.51.suppl_1.tp51 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Sanghyuk Im ◽

Do-Sung Yoo ◽

MinHyung Lee ◽

Byung-Rae Cho ◽

Jin Eun ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Imaging Study ◽

Additional Treatment ◽

Complication Rates ◽

Large Artery ◽

Anterior Circulation ◽

Stroke Treatment ◽

Intravenous Tissue Plasminogen Activator ◽

Iv Tpa

Background and Purpose: According to the guidelines for acute ischemic stroke treatment, intravenous tissue plasminogen activator (IV-tPA) administration is the first line treatment and intraarterial thrombolysis (IA-Tx) with retrieval stent is regarded as additional treatment. But recanalization rate of large artery intracranial occlusion disease (LAICOD) after IV-tPA is very low and inconsistent according to the reports. Authors tried to find out the early recanalization rate of IV-tPA in patients with LAICOD. Methods: 278 with anterior circulation occlusion patients were included in this analysis. Brain CT-angiography (CTA) was an initial imaging study and acute stroke MRI was following after the IV-tPA. Recanalization rate was studied with initial CTA and followed MRA image. And other clinical outcomes were compared with IV-tPA, IA-Tx or perfusion/diffusion-mismatching (P/D-mismatching) or not. Results: The overall recanalization rate of LAICOD after IV-tPA was 15.5% (43/278), 86.0% (86/100) in patients treated with IA-Tx after IV-tPA, and 78.7% (48/61) in IA-Tx without IV-tPA. In patients who underwent IA-Tx after IV-tPA, P/D-mismatching patients showed higher recanalization rate (88.2% = 67/76 vs. 66.7% = 16/27, p = 0.020), and higher incidence of favorable outcomes (63.2% = 48/76 vs. 12.5% = 3/27, p = 0.000) compared to P/D-matching patients. Conclusion: This study suggests that recanalization rate after IV-tPA for the patients with acute ischemic stroke due to LAICOD is very low and IV-tPA before IA-Tx does not significantly influence on the neurologic outcomes and complication rates. Bridging treatment is effective, for stroke patient management, but authors would like to propose that IA-Tx might be applied as the first therapy option, just like in the management of acute myocardial infarction patients.

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Influence of Renal Function on Treatment Results after Stroke Thrombectomy

Cerebrovascular Diseases ◽

10.1159/000481147 ◽

2017 ◽

Vol 44 (5-6) ◽

pp. 351-358 ◽

Cited By ~ 8

Author(s):

Mona Laible ◽

Markus Alfred Möhlenbruch ◽

Johannes Pfaff ◽

Ekkehart Jenetzky ◽

Peter Arthur Ringleb ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Multivariate Regression ◽

Stroke Severity ◽

Stroke Patients ◽

Anterior Circulation ◽

Stroke Treatment ◽

Poor Outcome ◽

Increased Risk

Background: Renal dysfunction (RD) may be associated with poor outcome in ischemic stroke patients treated with mechanical thrombectomy (MT), but data concerning this important and emerging comorbidity do not exist so far. Here, we investigated the influence of RD on postprocedural intracerebral hemorrhage (ICH), clinical outcome, and mortality in a large prospectively collected cohort of acute ischemic stroke patients treated with MT. Methods: Consecutive patients with anterior-circulation stroke treated with MT between October 2010 and January 2016 were included. RD was defined as glomerular filtration rate (GFR) <60 mL/min/1.73 m2. In a prospective database, clinical characteristics were recorded and brain images were analyzed for the presence of ICH after treatment in all patients. Clinical outcome was assessed by the modified Rankin Scale (mRS) after 3 months. To evaluate associations between clinical factors and outcomes uni- and multivariate regression analyses were conducted. Results: In total, 505 patients fulfilled all inclusion criteria (female: 49.7%, mean age: 71.0 years). RD at admission was present in 20.2%. RD patients were older and had cardiovascular risk factors more often. Multivariate regression analysis after adjustment for age, stroke severity, diabetes, hypertension, GFR, previous stroke, MT alone, or additional thrombolysis and recanalization results revealed that lower GFR was not independently associated with poor outcome (mRS 3-6; OR 1.13, 95% CI 0.99-1.28; p = 0.072) or ICH. However, lower GFR at admission was associated with a higher risk of mortality (OR 1.15, 95% CI 1.01-1.31; p = 0.038). Compared to admission, GFR values were higher at discharge (mean: 77.9 vs. 80.8 mL/min/1.73 m2; p = 0.046). Conclusions: We did not find evidence for an association of lower GFR with an increased risk of poor outcome and ICH, but lower GFR was a determinant of 90-day mortality after endovascular stroke treatment. Our findings encourage also performing MT in this relevant subgroup of acute ischemic stroke patients.

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