scholarly journals Emerging therapies in acute ischemic stroke

F1000Research ◽  
2020 ◽  
Vol 9 ◽  
pp. 546
Author(s):  
Nicholas Liaw ◽  
David Liebeskind
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Collateral Circulation ◽  
Mechanical Thrombectomy ◽  
Systems Of Care ◽  
Stroke Units ◽  
Emerging Therapies ◽  
Number Of Patients ◽  
Care Models ◽  
Stroke Systems Of Care

Thrombolysis and mechanical thrombectomy have revolutionized the care of patients with acute ischemic stroke. The number of patients who can benefit from these treatments continues to increase as new studies demonstrate that not just time since stroke onset but also collateral circulation influences outcome. Technologies such as telestroke, mobile stroke units, and artificial intelligence are playing an increasing role in identifying and treating stroke. Stroke-systems-of-care models continue to streamline the delivery of definitive revascularization in the age of mechanical thrombectomy.

Abstract 164: Variation in Acute Ischemic Stroke Metrics for Nationally Certified versus Self-Attested Comprehensive Stroke Centers in the Florida Stroke Registry

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Erika T Marulanda-Londono ◽  
Antonio Bustillo ◽  
Charles Sand ◽  
Mark D Landreth ◽  
Carolina Gutierrez ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Systems Of Care ◽  
Recent Change ◽  
National Agency ◽  
Healthcare Facilities ◽  
Stroke Registry ◽  
Treatment Measures ◽  
Stroke Systems Of Care ◽  
Hospital Registry

Background: The Florida Stroke Act set criteria for comprehensive stroke centers (CSC). Hospitals could be certified by a national agency (The Joint Commission (TJC), Det Norske Veritas (DNV), Healthcare Facilities Accreditation Program (HFAP)) or could self-attest as fulfilling CSC criteria. This study aimed to evaluate whether nationally certified (NC) and self-attested hospitals (SA) have similar quality of care in acute ischemic stroke (AIS). Methods: The study population included AIS cases from 37 CSCs (74% of FL CSCs) in the FL-Stroke Registry, a multi-hospital registry using Get With the Guidelines-Stroke data from Jan 2013-Dec 2018. Hospital and patient level characteristics and stroke metrics were evaluated using unadjusted and adjusted (age, sex, race and NIH) analyses. Results: 13 NC-CSCs with 32,061 AIS cases and 24 SA-CSCs with 46,363 AIS cases were included. NCs were larger, with younger patients (71 (60-81) vs 72 (61-82)) and more severe strokes (median NIH; 5 vs 4, NIH ≥ 16; 15.4 vs 11.9% p <.0001). Overall IV tPA utilization (15.4% vs 13.9% p <.0001) and EVT treatment (9.8% vs 7.3% p <.0001) were better in NC CSCs. Median door to CT (23 min (11-76) vs 30 (12-75) p <.001) and door to needle time (38 min (27-51) vs 43(30-56) p <.001) were faster in NC CSCs. In adjusted analysis those arriving to NC by 3 hrs were more likely to get tPA in extended 3-4.5-hour window (OR 1.65, 95% CI 1.10, 2.47 p =.01). Conclusion: Among FL-Stroke Registry CSCs, AIS performance and treatment measures are superior in NC CSC when compared to SA CSCs. These findings have crucial implications for stroke systems of care in Florida and supported recent change in legislation regarding CSC center certification.

Frequency, predictors, and outcomes of readmission to index versus non-index hospitals after mechanical thrombectomy in patients with ischemic stroke

2019 ◽  
Vol 12 (2) ◽  
pp. 136-141 ◽  
Author(s):  
Kristina Shkirkova ◽  
Michelle Connor ◽  
Krista Lamorie-Foote ◽  
Arati Patel ◽  
Qinghai Liu ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Systems Of Care ◽  
Multivariable Logistic Regression Analysis ◽  
Complication Rates ◽  
Hub And Spoke ◽  
Vast Number ◽  
Number Of Patients ◽  
Index Hospital

BackgroundStroke systems of care employ a hub-and-spoke model, with fewer centers performing mechanical thrombectomy (MT) compared with stroke-receiving centers, where a higher number offer high-level, centralized treatment to a large number of patients.ObjectiveTo characterize rates and outcomes of readmission to index and non-index hospitals for patients with ischemic stroke who underwent MT.MethodsThis study leveraged a population-based, nationally representative sample of patients with stroke undergoing MT from the Nationwide Readmissions Database between 2010 and 2014. Descriptive, logistic regression analyses, and univariate and multivariate logistic regression models were carried out to determine patient- and hospital-level factors, mortality, complications, and subsequent readmissions associated with index and non-index hospitals' 90-day readmissions.ResultsIn the study, 2111 patients with a stroke were treated with MT, of whom 534 were readmitted within 90 days. The most common reasons for readmission were: septicemia (5.9%), atrial fibrillation (4.8%), and cerebral artery occlusion with infarct (4.8%). Among readmitted patients, 387 (74%) were readmitted to index and 136 (26%) to non-index hospitals. On multivariable logistic regression analysis, non-index hospital readmission was not independently associated with major complications (p=0.09), mortality (p=0.34), neurological complications (p=0.47), or second readmission (p=0.92).ConclusionOne-quarter of patients with a stroke treated with MT were readmitted within 90 days, and one quarter of these patients were readmitted to non-index hospitals. Readmission to a non-index hospital was not associated with mortality or increased complication rates. In a hub-and-spoke model it is important that follow-up care for a specialized procedure can be performed effectively at a vast number of non-index hospitals covering a large geographic area.

scholarly journals Mechanical Thrombectomy-Ready Comprehensive Stroke Center Requirements and Endovascular Stroke Systems of Care: Recommendations from the Endovascular Stroke Standards Committee of the Society of Vascular and Interventional Neurology (SVIN)

2015 ◽  
Vol 4 (3-4) ◽  
pp. 138-150 ◽  
Author(s):  
Joey D. English ◽  
Dileep R. Yavagal ◽  
Rishi Gupta ◽  
Vallabh Janardhan ◽  
Osama O. Zaidat ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Ischemic Stroke ◽  
Endovascular Therapy ◽  
Mechanical Thrombectomy ◽  
Systems Of Care ◽  
Open Label ◽  
Comprehensive Stroke Center ◽  
Stroke Systems Of Care ◽  
Stroke Center ◽  
New Evidence

Five landmark multicenter, prospective, randomized, open-label, blinded end point clinical trials have recently demonstrated significant clinical benefit of endovascular therapy with mechanical thrombectomy in acute ischemic stroke (AIS) patients presenting with proximal intracranial large vessel occlusions. The Society of Vascular and Interventional Neurology (SVIN) appointed an expert writing committee to summarize this new evidence and make recommendations on how these data should guide emergency endovascular therapy for AIS patients.

scholarly journals Collateral Circulation Augmentation and Neuroprotection as Adjuvant to Mechanical Thrombectomy in Acute Ischemic Stroke

Neurology ◽  
2021 ◽  
Vol 97 (20 Supplement 2) ◽  
pp. S178-S184
Author(s):  
Shashvat M. Desai ◽  
Ruchira M. Jha ◽  
Italo Linfante
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Collateral Circulation ◽  
Mechanical Thrombectomy ◽  
Cell Structure ◽  
Neuronal Loss ◽  
Functional Independence ◽  
Complication Rates ◽  
Vessel Occlusion ◽  
Ischemic Core

Purpose of the ReviewMechanical thrombectomy (MT)–mediated endovascular recanalization has dramatically transformed treatment and outcomes after acute ischemic stroke caused by a large vessel occlusion (LVO). Current guidelines recommend MT up to 24 hours from stroke onset in carefully selected patients based on favorable clinical and imaging parameters. Despite optimal patient selection and low complication rates with current recanalization technology, approximately 1 in 2 patients with LVO stroke do not achieve functional independence at 3 months. This ceiling effect of MT efficacy may be explained by ischemic core expansion into the ischemic penumbra before recanalization and neuronal loss occurring after recanalization. Factors affecting the efficacy of MT, or the degree of irreversible injury, include time from symptom onset to recanalization, collateral circulation status, and differences in neuronal vulnerability. The purpose of this brief review is to discuss potential targets for neuroprotection, present and future potential pharmacologic and nonpharmacologic agents, and the data available in the literature.Recent FindingsIn experimental ischemia models, several authors reported that pharmacologic and nonpharmacologic agents are able to slow the progression of ischemic core expansion. However, in the era of unsuccessful recanalization of the occluded artery, several neuroprotective agents that were promising in the preclinical stage failed phase II/III clinical trials.SummaryProviding neuroprotection before and after recanalization of an LVO may play an important role in improving outcomes in the era of MT. Neuroprotection is classically defined as a process that results in the salvage, recovery, or regeneration of neuronal (and other supporting CNS cell) structure or function. The advent of successful recanalization of acute LVO by MT in the majority of patients may spur the growth of effective neuroprotection.

scholarly journals Do acute ischemic stroke patients receive the right treatment in non-stroke units?

2017 ◽  
Vol 31 (3) ◽  
pp. 263-271
Author(s):  
D. Adam ◽  
Gina Burduşa ◽  
D. Iftimie
Keyword(s):  
Intensive Care ◽  
Ischemic Stroke ◽  
Blood Glucose ◽  
Acute Ischemic Stroke ◽  
Primary Diagnosis ◽  
Stroke Units ◽  
Glucose Levels ◽  
Blood Glucose Levels ◽  
Number Of Patients ◽  
The Right

Abstract Background: Modern treatment of acute ischemic stroke includes thrombolysis and thrombectomy performed for eligible patients in specialized stroke centers. However, a number of patients are admitted in Neurosurgical or Intensive Care Departments of emergency hospitals, units where routine treatment strategies are applied. Objective: To evaluate the management of patients admitted in these departments that do not benefit from thrombolytic or endovascular treatment. Methods: A retrospective analysis was performed, including all patients admitted to the Neurosurgery Department and Intensive Care Unit (ICU) of the “St. Pantelimon” Clinical Emergency Hospital with the primary diagnosis of acute ischemic stroke in the year 2016. The following data was retrospectively collected: patient age and sex, comorbidities, risk factors for ischemic stroke, level of consciousness at admission, neurological deficits, stroke location, blood glucose levels, interval from stroke onset to admission, treatment and discharge status. Results: In 2016, 63 patients with primary diagnosis of acute ischemic stroke confirmed by head CT scan were admitted in our hospital. None presented indication for decompressive craniectomy. Over a half of them (57,14%) were comatose. The majority of patients admitted to the ICU (76,47%) received glucose 10% infusions in the first 24 hours from admission, despite increased blood glucose levels at admission. A number of 38 (60,32%) of these patients died. Conclusions: Patients with acute ischemic stroke should be treated in stroke units with proper equipment and specialists. National public health institutions should take the necessary measures in order to ensure that patients get to the best facility in order to receive the right therapy in the right amount of time.

scholarly journals Mechanical Thrombectomy for Acute Ischemic Stroke in Nepal

2021 ◽  
Vol 1 (1) ◽  
pp. 35-37
Author(s):  
Pravesh Rajbhandari ◽  
Saujanya Rajbhandari ◽  
Anish Neupane ◽  
Pritam Gurung
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Time Window ◽  
Treatment Strategies ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Stroke Imaging ◽  
Number Of Patients ◽  
Causes Of Mortality

Stroke is one of the leading causes of mortality and the number one cause of dependency in the world. Endovascular therapy has emerged as promising treatment strategy in the patient with acute ischemic stroke due to large vessel occlusion in anterior circulation. Moreover, the time window for mechanical thrombectomy have also been expanded based on the recent DAWN and DEFUSE-3 trial. It is evident that this trend could dramatically increase the number of potential patients for the treatment. Moreover, advancement in stroke imaging have guided physicians to make wisest decision in identifying suitable patient who can get benefit from the recent treatment strategies. The stroke management is evolving and continues to improve, making better outcome of the patient possible. In context of our country Nepal, it is also necessary to educate and aware medical staffs including physicians, nurses, laboratory/ radiology personnel to design a proper acute stroke team to deliver successful therapy which will eventually make a sound impact in a large number of patients with stroke. Herein, we report a case of a 69-year-old gentleman who presented with right middle cerebral artery territory infarction within 3hours of onset of symptoms and underwent mechanical thrombectomy as a part of the treatment.

scholarly journals Fifty Years of Acute Ischemic Stroke Treatment: A Personal History

2021 ◽  
pp. 1-15
Author(s):  
James C. Grotta
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Ischemia ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Systems Of Care ◽  
Medical Science ◽  
Tissue Type ◽  
Stroke Units ◽  
Stroke Treatment

<b><i>Background:</i></b> It has been 50 years since the first explorations of the physiology of cerebral ischemia by measuring cerebral blood flow (CBF), and 25 years since the approval of tissue plasminogen activator for treating acute ischemic stroke. My personal career began and matured during those eras. Here, I provide my perspective on the evolution of acute stroke research and treatment from 1971 to the present, with some in-depth discussion of the National Institutes of Neurologic Disease and Stroke (NINDS) tissue-type plasminogen activator (tPA) stroke trial and development of mobile stroke units. <b><i>Summary:</i></b> Studies of CBF and metabolism in acute stroke patients revealed graded tissue injury that was dependent on the duration of ischemia. Subsequent animal research unraveled the biochemical cascade of events occurring at the cellular level after cerebral ischemia. After a decade of failed translation, the development of a relatively safe thrombolytic allowed us to achieve reperfusion and apply the lessons from earlier research to achieve positive clinical results. The successful conduct of the NINDS tPA stroke study coupled with positive outcomes from companion tPA studies around the world created the specialty of vascular neurology. This was followed by an avalanche of research in imaging, a focus on enhancing reperfusion through thrombectomy, and improving delivery of faster treatment culminating in mobile stroke units. <b><i>Key Messages:</i></b> The last half century has seen the birth and evolution of successful acute stroke treatment. More research is needed in developing new drugs and catheters to build on the advances we have already made with reperfusion and also in evolving our systems of care to get more patients treated more quickly in the prehospital setting. The history of stroke treatment over the last 50 years exemplifies that medical “science” is an evolving discipline worth an entire career’s dedication. What was impossible 50 years ago is today’s standard of care, what we claim as dogma today will be laughed at a decade from now, and what appears currently impossible will be tomorrow’s realities.

scholarly journals The Neurointerventional Revolution

Neurology ◽  
2021 ◽  
Vol 97 (20 Supplement 2) ◽  
pp. S1-S5
Author(s):  
Ashutosh P. Jadhav ◽  
Maxim Mokin ◽  
Sunil A. Sheth ◽  
Ameer E. Hassan
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Systems Of Care ◽  
Unmet Need ◽  
Related Factors ◽  
Vessel Occlusion ◽  
Short Period ◽  
Recent Developments ◽  
Stroke Systems Of Care

Purpose of the ReviewIn a short period of time, the field of interventional neurology has been transformed. Supported by strong Class IA evidence, the vascular and interventional neurology community has been empowered to realign systems of care to address the new challenges that have been introduced. Given the recent developments and accelerating pace of the field, the Society of Vascular and Interventional Neurology has collaborated with the American Academy of Neurology to provide an updated supplemental edition of Neurology® focused on endovascular therapy for acute ischemic stroke.Recent FindingsIn this supplemental edition, the authors discuss the unmet need for endovascular therapy, emerging trends in stroke systems of care, the role of imaging in patient selection, prognostication and treatment-related factors, procedural considerations, current top tier guidelines, recent advances in neuroprotection, and future directions of the field.SummaryThe field of interventional neurology continues to grow and advance, particularly since the seminal stroke trials published between 2015 and 2018. Whereas this progress has significantly improved the ability to alter outcomes after acute ischemic stroke due to large vessel occlusion, important new hurdles present themselves to the neurology community.

Single-center experience with the Tigertriever device for the recanalization of large vessel occlusions in acute ischemic stroke

2018 ◽  
Vol 11 (5) ◽  
pp. 455-459 ◽  
Author(s):  
Batuhan Kara ◽  
Hatem Hakan Selcuk ◽  
Aysun Erbahceci Salik ◽  
Hasanagha Zalov ◽  
Omer Yildiz ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Scale Score ◽  
Mechanical Thrombectomy ◽  
National Institutes Of Health ◽  
Success Rates ◽  
Single Center Experience ◽  
Number Of Patients ◽  
The Mean ◽  
Vessel Rupture

BackgroundTigertriever (Rapid Medical, Yoqneam, Israel) is a new design of stent retriever.PurposeTo evaluate the feasibility, safety, and efficacy of the Tigertriever in patients with acute ischemic stroke who have undergone mechanical thrombectomy.Materials and methodsTwo different techniques—namely, standard unsheathing (SUT) and repetitive inflation-deflation (RID) techniques, were used. Modified Thrombolysis in Cerebral Infarction (mTICI) scores of 2b and 3 were considered as successful recanalization.ResultsA total of 61 thrombectomy procedures with Tigertriever were retrospectively evaluated. The mean age of patients was 60.7 years and their National Institutes of Health Stroke Scale score was 14.7. Overall, the percentage of patients with a mTICI score of 0, 2b, and 3 was 24.6, 26.2, and 49.2, respectively. Successful recanalization and first-pass success rates were 75.4% and 37.7%, respectively. There were no statistical differences between the results of the SUT and RID techniques. No vessel rupture, dissection, or device detachment was observed. The number of patients with a good clinical outcome (modified Rankin Scale score 0–2) was 17 (27.9%).ConclusionOur results showed that the Tigertriever device is safe and efficient for mechanical thrombectomy.

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