Endovascular Stroke Management: Key Elements of Success

2016 ◽  
Vol 42 (3-4) ◽  
pp. 170-177 ◽  
Author(s):  
Nathan W. Manning ◽  
René Chapot ◽  
Philip M. Meyers
Keyword(s):  
Ischaemic Stroke ◽  
Patient Selection ◽  
Acute Ischaemic Stroke ◽  
Standard Of Care ◽  
Stroke Management ◽  
Vessel Occlusion ◽  
Critical Elements ◽  
Non Invasive ◽  
Hospital Systems ◽  
Ischaemic Penumbra

Background: In the last 12 months, treatment of acute ischaemic stroke secondary to large vessel occlusion has undergone a paradigm shift. The success of endovascular surgery, and in particular, the use of stent-retrievers, is remarkable. Summary: Beyond percentages and p values, the endovascular trials demonstrated, in their similarities and their differences, the critical elements of successful intervention in acute ischaemic stroke. Patient selection based on non-invasive neuroimaging has emerged as a critical step in acute ischaemic stroke management. The more sophisticated imaging-based selection, those assessing collateral blood flow or ischaemic penumbra appear to be associated with better outcomes and possibly fewer complications. The importance of achieving effective, quality reperfusion is also demonstrated, in a remarkably linear fashion, across the 5 published trials. This may emerge as the single most important determinant of functional outcomes. While reperfusion may succeed time as the preeminent modifiable variable, it remains clear that achieving quality reperfusion in a timely manner should remain the goal of all acute stroke programs. Key Message: Comparing the recent successful endovascular stroke trials, both between one another, and to their unsuccessful predecessors, emphasizes the importance of patient selection, time and reperfusion. Highlighting these factors allows for a better understanding of the challenges facing clinicians and the changes required to be made in hospital systems in order to achieve a new standard of care in treating acute ischaemic stroke.

scholarly journals Prehospital scales in acute ischaemic stroke management

2021 ◽  
Vol 20 (7) ◽  
pp. 504
Author(s):  
Fabio Bandini ◽  
Lucilla Vestito ◽  
Laura Filippi
Keyword(s):  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Stroke Management

scholarly journals Mechanical thrombectomy in acute ischaemic stroke patients with pre-interventional intracranial haemorrhage following intravenous thrombolysis

2021 ◽  
pp. 197140092110091
Author(s):  
Hanna Styczen ◽  
Matthias Gawlitza ◽  
Nuran Abdullayev ◽  
Alex Brehm ◽  
Carmen Serna-Candel ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Intracranial Haemorrhage ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion

Background Data on outcome of endovascular treatment in patients with acute ischaemic stroke due to large vessel occlusion suffering from intravenous thrombolysis-associated intracranial haemorrhage prior to mechanical thrombectomy remain scarce. Addressing this subject, we report our multicentre experience. Methods A retrospective analysis of consecutive acute ischaemic stroke patients treated with mechanical thrombectomy due to large vessel occlusion despite the pre-interventional occurrence of intravenous thrombolysis-associated intracranial haemorrhage was performed at five tertiary care centres between January 2010–September 2020. Baseline demographics, aetiology of stroke and intracranial haemorrhage, angiographic outcome assessed by the Thrombolysis in Cerebral Infarction score and clinical outcome evaluated by the modified Rankin Scale at 90 days were recorded. Results In total, six patients were included in the study. Five individuals demonstrated cerebral intraparenchymal haemorrhage on pre-interventional imaging; in one patient additional subdural haematoma was observed and one patient suffered from isolated subarachnoid haemorrhage. All patients except one were treated by the ‘drip-and-ship’ paradigm. Successful reperfusion was achieved in 4/6 (67%) individuals. In 5/6 (83%) patients, the pre-interventional intracranial haemorrhage had aggravated in post-interventional computed tomography with space-occupying effect. Overall, five patients had died during the hospital stay. The clinical outcome of the survivor was modified Rankin Scale=4 at 90 days follow-up. Conclusion Mechanical thrombectomy in patients with intravenous thrombolysis-associated intracranial haemorrhage is technically feasible. The clinical outcome of this subgroup of stroke patients, however, appears to be devastating with high mortality and only carefully selected patients might benefit from endovascular treatment.

scholarly journals Prehospital scales in acute ischaemic stroke management – Authors' reply

2021 ◽  
Vol 20 (7) ◽  
pp. 504-505
Author(s):  
Martijne H C Duvekot ◽  
Esmee Venema ◽  
Henk Kerkhoff ◽  
Diederik W J Dippel ◽  
Bob Roozenbeek
Keyword(s):  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Stroke Management

scholarly journals European Stroke Organisation (ESO) – European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischaemic StrokeEndorsed by Stroke Alliance for Europe (SAFE)

2019 ◽  
Vol 4 (1) ◽  
pp. 6-12 ◽  
Author(s):  
Guillaume Turc ◽  
Pervinder Bhogal ◽  
Urs Fischer ◽  
Pooja Khatri ◽  
Kyriakos Lobotesis ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Patient Selection ◽  
Acute Ischaemic Stroke ◽  
Randomized Trials ◽  
Mechanical Thrombectomy ◽  
Treatment Modalities ◽  
Stroke Severity ◽  
Prehospital Management ◽  
Grade Approach

Background Mechanical thrombectomy (MT) has become the cornerstone of acute ischaemic stroke management in patients with large vessel occlusion (LVO). The aim of this guideline document is to assist physicians in their clinical decisions with regard to MT. Methods These Guidelines were developed based on the standard operating procedure of the European Stroke Organisation and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. An interdisciplinary working group identified 15 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. Results We found high quality evidence to recommend MT plus best medical management (BMM, including intravenous thrombolysis whenever indicated) to improve functional outcome in patients with LVO-related acute ischaemic stroke within 6 hours after symptom onset. We found moderate quality of evidence to recommend MT plus BMM in the 6-24h time window in patients meeting the eligibility criteria of published randomized trials. These guidelines further detail aspects of prehospital management, patient selection based on clinical and imaging characteristics, and treatment modalities. Conclusions MT is the standard of care in patients with LVO-related acute stroke. Appropriate patient selection and timely reperfusion are crucial. Further randomized trials are needed to inform clinical decision making with regard to the mothership and drip-and-ship approaches, anesthaesia modalities during MT, and to determine whether MT is beneficial in patients with low stroke severity or large infarct volume.

A quantitative analysis of CT angiography, large vessel occlusion, and thrombectomy rates in acute ischaemic stroke

2019 ◽  
Vol 74 (9) ◽  
pp. 731.e21-731.e25 ◽  
Author(s):  
E. Griffin ◽  
D. Herlihy ◽  
R. Hayden ◽  
M. Murphy ◽  
J. Walsh ◽  
...  
Keyword(s):  
Quantitative Analysis ◽  
Ischaemic Stroke ◽  
Ct Angiography ◽  
Acute Ischaemic Stroke ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Endovascular treatment for acute ischaemic stroke with large vessel occlusion: the experience of a regional stroke service

2015 ◽  
Vol 70 (12) ◽  
pp. 1408-1413 ◽  
Author(s):  
M.W. McCusker ◽  
S. Robinson ◽  
S. Looby ◽  
S. Power ◽  
J.P. Ti ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischaemic Stroke ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Stroke Service

G397(P) A Review of acute ischaemic stroke management from two tertiary centres

2017 ◽  
Author(s):  
K Hampson ◽  
T Smallbone ◽  
C Higgins ◽  
D Ram ◽  
G Vassallo ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Stroke Management

scholarly journals Mild fever as a catalyst for consumption of the ischaemic penumbra despite endovascular reperfusion

2020 ◽  
Vol 2 (2) ◽  
Author(s):  
Seena Dehkharghani ◽  
Shadi Yaghi ◽  
Meredith T Bowen ◽  
Leonardo Pisani ◽  
Erica Scher ◽  
...  
Keyword(s):  
At Risk ◽  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Odds Ratio ◽  
Regression Models ◽  
Primary Outcome ◽  
Ct Perfusion ◽  
Interquartile Range ◽  
Ischaemic Penumbra ◽  
Mild Fever

Abstract Cerebrovascular ischaemia is potentiated by hyperthermia, and even mild temperature elevation has proved detrimental to ischaemic brain. Infarction progression following endovascular reperfusion relates to multiple patient-specific and procedural variables; however, the potential influence of mild systemic temperature fluctuations is not fully understood. This study aims to assess the relationship between systemic temperatures in the early aftermath of acute ischaemic stroke and the loss of at-risk penumbral tissues, hypothesizing consumption of the ischaemic penumbra as a function of systemic temperatures, irrespective of reperfusion status. A cross-sectional, retrospective evaluation of a single-institution, prospectively collected endovascular therapy registry was conducted. Patients with anterior circulation, large vessel occlusion acute ischaemic stroke who underwent initial CT perfusion, and in whom at least four-hourly systemic temperatures were recorded beginning from presentation and until the time of final imaging outcome were included. Initial CT perfusion core and penumbra volumes and final MRI infarction volumes were computed. Systemic temperature indices including temperature maxima were recorded, and pre-defined temperature thresholds varying between 37°C and 38°C were examined in unadjusted and adjusted regression models which included glucose, collateral status, reperfusion status, CT perfusion-to-reperfusion delay, general anaesthesia and antipyretic exposure. The primary outcome was the relative consumption of the penumbra, reflecting normalized growth of the at-risk tissue volume ≥10%. The final study population comprised 126 acute ischaemic stroke subjects (mean 63 ± 14.5 years, 63% women). The primary outcome of penumbra consumption ≥10% occurred in 51 (40.1%) subjects. No significant differences in baseline characteristics were present between groups, with the exception of presentation glucose (118 ± 26.6 without versus 143.1 ± 61.6 with penumbra consumption, P = 0.009). Significant differences in the likelihood of penumbra consumption relating to systemic temperature maxima were observed [37°C (interquartile range 36.5 − 37.5°C) without versus 37.5°C (interquartile range 36.8 − 38.2°C) with penumbra consumption, P = 0.001]. An increased likelihood of penumbra consumption was observed for temperature maxima in unadjusted (odds ratio 3.57, 95% confidence interval 1.65 − 7.75; P = 0.001) and adjusted (odds ratio 3.06, 95% confidence interval 1.33 − 7.06; P = 0.009) regression models. Significant differences in median penumbra consumption were present at a pre-defined temperature maxima threshold of 37.5°C [4.8 ml (interquartile range 0 − 11.5 ml) versus 21.1 ml (0 − 44.7 ml) for subjects not reaching or reaching the threshold, respectively, P = 0.007]. Mild fever may promote loss of the ischaemic penumbra irrespective of reperfusion, potentially influencing successful salvage of at-risk tissue volumes following acute ischaemic stroke.

scholarly journals Diagnosis and management of acute ischaemic stroke

2020 ◽  
Vol 20 (4) ◽  
pp. 304-316 ◽  
Author(s):  
Robert Hurford ◽  
Alakendu Sekhar ◽  
Tom A T Hughes ◽  
Keith W Muir
Keyword(s):  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Neuronal Damage ◽  
Early Recognition ◽  
Intravenous Thrombolysis ◽  
Stroke Care ◽  
Close Monitoring ◽  
Endovascular Thrombectomy ◽  
Early Neurological Deterioration ◽  
Ischaemic Penumbra

Acute ischaemic stroke is a major public health priority and will become increasingly relevant to neurologists of the future. The cornerstone of effective stroke care continues to be timely reperfusion treatment. This requires early recognition of symptoms by the public and first responders, triage to an appropriate stroke centre and efficient assessment and investigation by the attending stroke team. The aim of treatment is to achieve recanalisation and reperfusion of the ischaemic penumbra with intravenous thrombolysis and/or endovascular thrombectomy in appropriately selected patients. All patients should be admitted directly to an acute stroke unit for close monitoring for early neurological deterioration and prevention of secondary complications. Prompt investigation of the mechanism of stroke allows patients to start appropriate secondary preventative treatment. Future objectives include improving accessibility to endovascular thrombectomy, using advanced imaging to extend therapeutic windows and developing neuroprotective agents to prevent secondary neuronal damage.

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