Analyses of thrombi in acute ischemic stroke: A consensus statement on current knowledge and future directions

2017 ◽  
Vol 12 (6) ◽  
pp. 606-614 ◽  
Author(s):  
Simon F De Meyer ◽  
Tommy Andersson ◽  
Blaise Baxter ◽  
Martin Bendszus ◽  
Patrick Brouwer ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Consensus Statement ◽  
Current Knowledge ◽  
Imaging Techniques ◽  
Cerebral Arteries ◽  
Clinical Engineering ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Interdisciplinary Approaches

Limited data exist on clot composition and detailed characteristics of arterial thrombi associated with large vessel occlusion in acute ischemic stroke. Advances in endovascular thrombectomy and related imaging modalities have created a unique opportunity to analyze thrombi removed from cerebral arteries. Insights into thrombus composition, etiology, physical properties and neurovascular interactions may lead to future advancements in acute ischemic stroke treatment and improved clinical outcomes. Advances in imaging techniques may enhance clot characterization and inform therapeutic decision-making prior to treatment and reveal stroke etiology to guide secondary prevention. Current imaging techniques can provide some information about thrombi, but there remains much to evaluate about relationships that may exist among thrombus composition, occlusion characteristics and treatment outcomes. Improved pathophysiological characterization of clot types, their properties and how these properties change over time, together with clinical correlates from ongoing studies, may facilitate revascularization with thrombolysis and thrombectomy. Interdisciplinary approaches covering clinical, engineering and scientific aspects of thrombus research will be key to advancing the understanding of thrombi and improving acute ischemic stroke therapy. This consensus statement integrates recent research on clots and thrombi retrieved from cerebral arteries and provides a rationale for further analyses, including current opportunities and limitations.

scholarly journals Cerebral endothelial cell-derived small extracellular vesicles enhance neurovascular function and neurological recovery in rat acute ischemic stroke models of mechanical thrombectomy and embolic stroke treatment with tPA

2021 ◽  
pp. 0271678X2199298
Author(s):  
Chao Li ◽  
Chunyang Wang ◽  
Yi Zhang ◽  
Owais K Alsrouji ◽  
Alex B Chebl ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Extracellular Vesicles ◽  
Mechanical Thrombectomy ◽  
Infarct Volume ◽  
Artery Occlusion ◽  
Therapeutic Effects ◽  
Vessel Occlusion ◽  
Healthy Human ◽  
Stroke Treatment

Treatment of patients with cerebral large vessel occlusion with thrombectomy and tissue plasminogen activator (tPA) leads to incomplete reperfusion. Using rat models of embolic and transient middle cerebral artery occlusion (eMCAO and tMCAO), we investigated the effect on stroke outcomes of small extracellular vesicles (sEVs) derived from rat cerebral endothelial cells (CEC-sEVs) in combination with tPA (CEC-sEVs/tPA) as a treatment of eMCAO and tMCAO in rat. The effect of sEVs derived from clots acquired from patients who had undergone mechanical thrombectomy on healthy human CEC permeability was also evaluated. CEC-sEVs/tPA administered 4 h after eMCAO reduced infarct volume by ∼36%, increased recanalization of the occluded MCA, enhanced cerebral blood flow (CBF), and reduced blood-brain barrier (BBB) leakage. Treatment with CEC-sEVs given upon reperfusion after 2 h tMCAO significantly reduced infarct volume by ∼43%, and neurological outcomes were improved in both CEC-sEVs treated models. CEC-sEVs/tPA reduced a network of microRNAs (miRs) and proteins that mediate thrombosis, coagulation, and inflammation. Patient-clot derived sEVs increased CEC permeability, which was reduced by CEC-sEVs. CEC-sEV mediated suppression of a network of pro-thrombotic, -coagulant, and -inflammatory miRs and proteins likely contribute to therapeutic effects. Thus, CEC-sEVs have a therapeutic effect on acute ischemic stroke by reducing neurovascular damage.

‘Stroke Room': Diagnosis and Treatment at a Single Location for Rapid Intraarterial Stroke Treatment

2015 ◽  
Vol 40 (5-6) ◽  
pp. 251-257 ◽  
Author(s):  
Andreas Ragoschke-Schumm ◽  
Umut Yilmaz ◽  
Panagiotis Kostopoulos ◽  
Martin Lesmeister ◽  
Matthias Manitz ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Treatment Time ◽  
Diagnosis And Treatment ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Single Location ◽  
Before And After ◽  
Therapeutic Procedures ◽  
Therapeutic Measures

Background: For patients with acute ischemic stroke, intra-arterial treatment (IAT) is considered to be an effective strategy for removing the obstructing clot. Because outcome crucially depends on time to treatment (‘time-is-brain' concept), we assessed the effects of an intervention based on performing all the time-sensitive diagnostic and therapeutic procedures at a single location on the delay before intra-arterial stroke treatment. Methods: Consecutive acute stroke patients with large vessel occlusion who obtained IAT were evaluated before and after implementation (April 26, 2010) of an intervention focused on performing all the diagnostic and therapeutic measures at a single site (‘stroke room'). Result: After implementation of the intervention, the median intervals between admission and first angiography series were significantly shorter for 174 intervention patients (102 min, interquartile range (IQR) 85-120 min) than for 81 control patients (117 min, IQR 89-150 min; p < 0.05), as were the intervals between admission and clot removal or end of angiography (152 min, IQR 123-185 min vs. 190 min, IQR 163-227 min; p < 0.001). However, no significant differences in clinical outcome were observed. Conclusion: This study shows for the, to our knowledge, first time that for patients with acute ischemic stroke, stroke diagnosis and treatment at a single location (‘stroke room') saves crucial time until IAT.

scholarly journals Lower Intraprocedural Systolic Blood Pressure Predicts Good Outcome in Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke

2015 ◽  
Vol 4 (3-4) ◽  
pp. 151-157 ◽  
Author(s):  
Seby John ◽  
Walaa Hazaa ◽  
Ken Uchino ◽  
Gabor Toth ◽  
Mark Bain ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Independent Predictor ◽  
Hemodynamic Variable ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Nihss Score ◽  
Good Outcome

Background: It is unknown if intraprocedural blood pressure (BP) influences clinical outcomes and what BP parameter best predicts outcomes in acute ischemic stroke (AIS) patients who undergo intra-arterial therapy (IAT) for emergent large vessel occlusion. Methods: We retrospectively reviewed 147 patients who underwent IAT for anterior circulation AIS from January 2008 to December 2012 at our institution. Baseline demographics, stroke treatment variables, and detailed intraprocedural hemodynamic variables were collected. Results: The entire cohort consisted of 81 (55%) females with a mean age of 66.9 ± 15.6 years and a median National Institutes of Health Stroke Scale (NIHSS) score of 16 (IQR 11-21). Thirty-six (24.5%) patients died during hospitalization, 25 (17%) achieved a 30-day modified Rankin Scale score of 0-2, and 24 (16.3%) suffered symptomatic parenchymal hematoma type 1/2 hemorrhage. Patients who achieved a good outcome had a significantly lower admission NIHSS score, a higher baseline CT ASPECTS score, and a lower rate of ICA terminus occlusions. Successful recanalization was more frequent in the good-outcome group, while symptomatic hemorrhages occurred only in poor-outcome patients. The first systolic BP (SBP; 146.5 ± 0.2 vs. 157.7 ± 25.6 mm Hg, p = 0.042), first mean arterial pressure (MAP; 98.1 ± 20.8 vs. 109.7 ± 20.3 mm Hg, p = 0.024), maximum SBP (164.6 ± 27.6 vs. 180.9 ± 18.3 mm Hg, p = 0.0003), and maximum MAP (125.5 ± 18.6 vs. 138.5 ± 24.6 mm Hg, p = 0.0309) were all significantly lower in patients who achieved good outcomes. A lower maximum intraprocedural SBP was an independent predictor of good outcome (adjusted OR 0.929, 95% CI 0.886-0.963, p = 0.0005). Initial NIHSS score was the only other independent predictor of a good outcome. Conclusion: Lower intraprocedural SBP was associated with good outcome in patients undergoing IAT for AIS, and maximum SBP was an independent predictor of good outcome. SBP may be the optimal hemodynamic variable to monitor intraprocedurally during IAT and may predict outcome.

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%.

Abstract TP29: Endovascular Thrombectomy and Medical Therapy Versus Medical Therapy Alone in Acute Stroke (EASI): a Randomized Care Trial

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Naim N Khoury ◽  
Tim E Darsaut ◽  
Jimmy Ghostine ◽  
Yan Deschaintre ◽  
Nicole Daneault ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Medical Therapy ◽  
Standard Care ◽  
Primary Outcome ◽  
Intervention Group ◽  
Intravenous Thrombolysis ◽  
Control Group ◽  
Vessel Occlusion ◽  
Stroke Treatment

Background: Until recently, clinical benefits of endovascular stroke treatment remained unproven. Care trials can be used to simultaneously offer yet-to-be validated interventions and verify treatment outcomes. Our aim was to implement care trial methodology for patients with severe acute ischemic stroke. Methods: The study was offered to all patients considered for endovascular management of acute ischemic stroke in one Canadian hospital. Inclusion criteria were broad: onset of symptoms ≤ 5h or at any time in the presence of clinical-imaging mismatch; suspected anterior or posterior circulation large vessel occlusion; patients eligible or ineligible for intravenous thrombolysis. Exclusion criteria were few: established infarction or hemorrhagic transformation of the target symptomatic territory; poor 3-month prognosis from comorbidities. The primary outcome was mRS ≤ 2 at three months. Patients were randomly allocated to standard care (control) or standard care plus endovascular treatment (intervention group). Analyses were by intention-to-treat. (Identifier NCT02157532) Findings: Seventy-seven patients were recruited in 19 months (March 2013 - October 2014) at a single center. Randomized allocation was interrupted when other trials showed the benefits of endovascular therapy. At three months, 20 of 40 patients (50·0 %; 95% C.I.: 35%-65%) in the intervention group had reached the primary outcome, compared to 14 of 37 patients (37·8%; 95% C.I.: 24%-54%) in the control group arm (P=0·36). Eleven patients in the intervention arm died within 3 months compared to 9 patients in the standard care arm. Interpretation: EASI met all the characteristics of a care trial: inclusion of all eligible patients, no extra risk, no extra test, no extra cost, simple case report forms filled by care personnel, normal follow-up, involvement of all regular practitioners, and flexible care. The trial was prematurely interrupted, but this approach offers a promising means to manage clinical dilemmas and guide uncertain practices in the care of patients. Funding: There was no funding source for this study.

scholarly journals Acute Ischemic Stroke: A Review of Imaging, Patient Selection, and Management in the Endovascular Era. Part I: Initial Management and Imaging

2018 ◽  
Vol 02 (03) ◽  
pp. 155-168
Author(s):  
Sharath Kumar G G ◽  
Chinmay Nagesh
Keyword(s):  
Ischemic Stroke ◽  
Magnetic Resonance ◽  
Acute Ischemic Stroke ◽  
Intravenous Thrombolysis ◽  
Response To Treatment ◽  
Stroke Severity ◽  
Vessel Occlusion ◽  
Initial Management ◽  
Stroke Treatment ◽  
The Core

AbstractTill recently, the mainstay of management of acute ischemic stroke (AIS) has been intravenous thrombolysis. However, response to treatment and outcomes in the presence of a large vessel occlusion (LVO) were largely suboptimal. Endovascular thrombectomy techniques with stentrievers and aspiration catheters have revolutionized stroke treatment significantly, improving outcomes in this once untreatable disease. The interventional radiologist must play an active role in the stroke team in streamlining imaging as well as endovascular management. The focus of this review article is on initial management and imaging. Initial measures consist of patient resuscitation, basic investigations and assessment of stroke severity using the National Institutes of Health Stroke Scale (NIHSS), all of which have therapeutic and prognostic implications to be considered by the neurointerventionist. Imaging must aim to be swift and efficient. Choice of a modality must be based on available infrastructure as well as clinical-radiologic factors such as the time since ictus or posterior circulation involvement. Computed tomography (CT) is the preferred modality for its speed, whereas magnetic resonance imaging (MRI) remains the gold standard problem solving technique for detection of stroke. Exclusion of hemorrhagic stroke and other stroke mimics is the first objective. Thereafter, imaging is targeted toward assessing the parenchyma and vasculature. Defining the core and penumbra is the most important goal of parenchymal imaging. The core may be defined by the presence of early ischemic changes on CT, CT angiographic source images, or diffusion restriction on MRI. The penumbra is approximated by collateral status or perfusion methods. The prime directive of vascular imaging, either CT or magnetic resonance angiography (MRA) is to establish the presence of an LVO. Once confirmed, the decision for thrombolysis and/or thrombectomy is based on clinical and imaging criteria, the most ideal being that of a moderately severe stroke with a small core and LVO on imaging.

Analyses of thrombi in cerebral arteries with endovascular thrombectomy for acute ischemic stroke: A consensus statement

2017 ◽  
Vol 26 (4) ◽  
pp. 889
Author(s):  
David S. Liebeskind ◽  
Simon F. De Meyer ◽  
Tommy Andersson ◽  
Blaise Baxter ◽  
Martin Bendszus ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Consensus Statement ◽  
Cerebral Arteries ◽  
Endovascular Thrombectomy

scholarly journals Multiple Recurrent Acute Ischemic Strokes Treated by Thrombectomy in a Patient with Acute Pulmonary Embolism

2019 ◽  
Vol 7 (5) ◽  
pp. 801-804
Author(s):  
Ton Mai Duy ◽  
Luu Vu Dang ◽  
Phuong Dao Viet ◽  
Chi Nguyen Van ◽  
Quang Anh Nguyen ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Ischemic Stroke ◽  
Case Report ◽  
Acute Ischemic Stroke ◽  
Treatment Plan ◽  
Cerebral Arteries ◽  
Pulmonary Arteries ◽  
Vessel Occlusion ◽  
Brain Vessels ◽  
The Brain

BACKGROUND: Thrombectomy is recommended to treat for an acute ischemic stroke (AIS) patient with anterior large vessel occlusion. However, there were neither detailed guidelines nor systematic reviews of acute ischemic stroke patients having multiple times or re-occluded arteries. CASE REPORT: In our case report, we struggled a multiple (4-times) AIS patient underwent by one intravenous r-tpA and 3 remaining of endovascular treatment of thrombectomy. Especially, the finding of both pulmonary embolism and cerebral arteries occlusion in this patient made us difficult to decide the appropriate treatment plan. The patient was considered having multiple cardiac thrombi pumping out to the brain and pulmonary vessels even in treatment with NOAC (New Oral Anticoagulant). Our priority, normally, was to recanalize the brain vessels compared to the pulmonary arteries. CONCLUSION: In conclusion, based on this noticed case study, we want to share our experiences on the diagnosis of ischemic stroke, the strategy in treatment and prevention with anticoagulant therapy.

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.

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.

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