Endovascular Intervention for Acute Ischemic Stroke in Light of Recent Trials

Three recently published trials, MR RESCUE, IMS III, and SYNTHESIS Expansion, evaluating the efficacy and safety of endovascular treatment of acute ischemic stroke have generated concerns about the future of endovascular approach. However, the tremendous evolution that imaging and endovascular treatment modalities have undergone over the past several years has raised doubts about the validity of these trials. In this paper, we review the role of endovascular treatment strategies in acute ischemic stroke and discuss the limitations and shortcomings that prevent generalization of the findings of recent trials. We also provide our experience in endovascular treatment of acute ischemic stroke.

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Abstract 2825: History of Cancer Predicts Mortality After Acute Endovascular Treatment for Ischemic Stroke

Stroke ◽

10.1161/str.43.suppl_1.a2825 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Karl Meisel ◽

Mahesh Jayaraman ◽

Jonathan Grossberg ◽

Anthony Kim

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Hospice Care ◽

Exploratory Analysis ◽

Endovascular Intervention ◽

Consecutive Series ◽

History Of ◽

History Of Cancer

Introduction: Endovascular treatment is an emerging therapy for acute ischemic stroke. There is no clear consensus about how best to select patients that may benefit from intervention. We conducted an exploratory analysis of clinical risk factors to predict mortality after endovascular intervention in order to better understand how to improve outcomes for patients with acute ischemic stroke. Methods: We identified consecutive series of patients treated with endovascular therapy for acute ischemic stroke at two academic hospitals between 2005 to 2010. Key clinical data elements and clinical outcomes at the time of discharge were abstracted from medical records. We evaluated univariate and multivariable associations using logistic regression and compared mean NIH Stroke Scale between those with and without a history of cancer using the t-test. Results: We identified 88 patients who received endovascular intervention with intra-arterial tissue plasminogen activator (t-PA) and/or mechanical thrombectomy. The mean age of the cohort was 68.2 (SD 16.6) and 44 (55%) were female. A total of 23 (26.1%) patients died during the index hospitalization or were discharged to hospice care. A history of cancer was documented in 20 (22.7%) patients. A history of cancer was associated with a 3.2-fold (95% CI 1.1-9.1) higher odds of mortality. This association persisted after adjusting for age greater than 80 years and hypertension (OR of 4.0, 95% CI 1.3-12). The average NIH Stroke Scale was 15.6 in those with cancer compared to 14.6 without (p=0.53). A history of cancer was not associated with parenchymal hemorrhagic transformation (OR 1.2, 95% CI 0.3-4.9), IV tPA (OR 0.5, 95% CI 0.1-2.3), a TIMI score of 2b or 3 (OR 0.5, 95% CI 0.2-1.3), or an internal carotid artery occlusion (OR 1.7, 95% CI 0.5-5.1). Conclusions: In an exploratory analysis of consecutive patients with acute ischemic stroke treated with endovascular therapy, a history of cancer was strongly associated with significantly increased odds of mortality. One possible explanation could be that patients with cancer may have earlier withdrawal of care but the reasons for this observed association are unclear. Further investigation is necessary to verify and explain the reasons for this observation in order to improve outcomes for acute ischemic stroke patients.

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Endovascular treatment for the acute ischemic stroke: the past and the future

AME Medical Journal ◽

10.21037/amj.2017.12.11 ◽

2018 ◽

Vol 3 ◽

pp. 15-15

Author(s):

Rui Liu ◽

Wei Li ◽

Erwin Stolz

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

The Past ◽

The Future

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Efficacy and Safety of Endovascular Treatment versus Intravenous Thrombolysis for Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials

PLoS ONE ◽

10.1371/journal.pone.0077849 ◽

2013 ◽

Vol 8 (10) ◽

pp. e77849 ◽

Cited By ~ 6

Author(s):

Chao Lin ◽

Nan Li ◽

Kang Wang ◽

Xin Zhao ◽

Bai-Qiang Li ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Randomized Controlled Trials ◽

Acute Ischemic Stroke ◽

Meta Analysis ◽

Intravenous Thrombolysis ◽

Controlled Trials ◽

Efficacy And Safety ◽

Randomized Controlled

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Endovascular Treatment for Acute Ischemic Stroke: Updates and Future Implications

Interventional Neurology ◽

10.1159/000438778 ◽

2015 ◽

Vol 4 (1-2) ◽

pp. 43-47 ◽

Cited By ~ 2

Author(s):

Jie Gao ◽

Qiliang Dai ◽

Xinfeng Liu

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Randomized Clinical Trials ◽

Intravenous Thrombolysis ◽

Professional Organizations ◽

Infarct Core ◽

The Past ◽

Proximal Occlusion ◽

Positive Results

Stroke constitutes the primary cause of acquired disability in adults and is a second leading cause of death worldwide. The low recanalization rate after intravenous thrombolysis calls for an alternate therapy for acute ischemic stroke. The methodology for endovascular treatment has evolved greatly over the past two decades. The past 6 months have seen great progress in this area, with several randomized clinical trials all proving the efficacy and safety of endovascular treatment. Three key factors are important for good functional outcome after endovascular treatment: fast imaging to prove proximal occlusion and to exclude large infarct core, using mainly the stent retriever thrombectomy devices and establishing an efficient workflow to achieve fast reperfusion. Although positive results of RCTs are encouraging and bring what is urgently needed in the field, transforming these positive results into clinical practice will be both a challenge and opportunity of the next 5 years. It will need hard work, leadership and cooperation of all members involved in the chain of treating a stroke patient. In the wake of these positive trials, hospitals and professional organizations are working together to save every minute when fighting against this devastating disease.

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Treatment Strategies for Tandem Occlusions in Acute Ischemic Stroke

Seminars in Interventional Radiology ◽

10.1055/s-0040-1709207 ◽

2020 ◽

Vol 37 (02) ◽

pp. 207-213

Author(s):

Joseph J. Gemmete ◽

Zachary Wilseck ◽

Aditya S. Pandey ◽

Neeraj Chaudhary

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Treatment Options ◽

Treatment Strategies ◽

Carotid Revascularization ◽

Tandem Occlusion ◽

Coil Occlusion ◽

Optimal Treatment Strategy

AbstractThere is no consensus for the treatment of a tandem occlusion (TO) in a patient presenting with an acute ischemic stroke. In this review article, we will focus on the controversial treatment strategies for TOs. First, we will discuss treatment options including retrograde, antegrade, and delayed approaches. Second, the role of carotid stent placement versus balloon angioplasty for the extracranial occlusion will be presented. Third, anticoagulation and antiplatelet regimens for the treatment TOs published in the literature will be reviewed. Finally, we will discuss whether there is a role for coil occlusion of the cervical carotid artery or whether staged carotid revascularization days after mechanical thrombectomy of the intracranial occlusion maybe appropriate. The optimal treatment strategy of TO has not been established and further larger trials need to be performed to answer the question.

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Abstract 3311: Acute stroke and endovascular outcomes in Elderly Population: A Single Center Experience.

Stroke ◽

10.1161/str.43.suppl_1.a3311 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Tanzila Shams ◽

Jitendra Sharma ◽

Richard Jung ◽

Kristine Blackham

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Prospective Trial ◽

Standard Of Care ◽

The Elderly ◽

Treatment Modalities ◽

Safety And Efficacy ◽

Symptomatic Intracerebral Hemorrhage ◽

All Cause Mortality

Background: In the setting of acute ischemic stroke, endovascular intervention, once considered experimental, is now gold standard of care of appropriately selected patients. Among the elderly, aged 80 and above, patients have multiple comorbidities, and little data exists regarding clinical outcome for those undergoing different endovascular treatment modalities. Objectives: To assess the safety and efficacy of different endovascular treatment modalities in elderly, aged 80 and above, compared to patients younger than 80 with acute ischemic stroke Methods: Restrospective chart review was performed in 150 consecutive patients who underwent endovascular treatments for acute ischemic stroke at our center between 2008 and 2011, between age range 17 -93 years. Elderly patients (EP) age 80 and above (n=34) were compared to nonelderly patients age <80 (NEP) (n=116). The patients in both groups underwent mechanical (including MERCI and or Penumbra and/or angioplasty and stenting) and/or chemical thrombolysis (intra-arterial tPA). We compared the specific outcome parameters of EP vs NEP groups, including discharge NIHSS, modified Rankin Scale (mRS), rate of partial to complete recanalization (TIMI 2-3), symptomatic intracerebral hemorrhage (ICH), and all cause mortality. Results: In EP, mean age was 84.9 ± 3.3, with 32.3% (n=11) males and 67.6% (n=23) females. In NEP mean age was 63.6 ± 13.1, with 50.9% (n=59) males and 49.1% (n=57) females. 91.3% (n=106) In EP vs NEP, mean initial NIHSS were 19±7 and 16±6, and discharge NIHSS 9±7 and 12±8, respectively. Rates of recanalization occurred in 67.6% (n=23) in EP, and 71.6% (n=83) in NEP. Discharge mRS 3 or less was 2.9% (n=1) in EP, and 17.2% (n=20) in NEP. Symptomatic ICH occurred in 20.6% (n=7) in EP and 14.7% (n=17) in NEP. All cause mortality rate at discharge in EP group was 41.2% (n=14) and 19.8% (n=23) in NEP. Conclusions: In our experience EP had poor clinical outcomes with increased mortality and hemorrhage rate compared to NEP irrespective of similar recanalization rate. Further prospective trial is warranted to evaluate safety and efficacy of endovascular treatment in patients aged 80 years old and above.

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