Performance and training standards for endovascular ischemic stroke treatment

Stroke is the third leading cause of death in the USA, Canada, Europe, and Japan. According to the American Heart Association and the American Stroke Association, there are now 750,000 new strokes that occur each year, resulting in 200,000 deaths, or 1 of every 16 deaths, per year in the USA alone. Endovascular therapy for patients with acute ischemic stroke is an area of intense investigation. The American Stroke Association has given a qualified endorsement of intraarterial thrombolysis in selected patients. Intraarterial thrombolysis has been studied in two randomized trials and numerous case series. Although two devices have been granted FDA approval with an indication for mechanical stroke thrombectomy, none of these thrombectomy devices has demonstrated efficacy for the improvement of patient outcomes. The purpose of the present document is to define what constitutes adequate training to perform neuroendovascular procedures in patients with acute ischemic stroke and what performance standards should be adopted to assess outcomes. These guidelines have been written and approved by multiple neuroscience societies which historically have been directly involved in the medical, surgical and endovascular care of patients with acute stroke. The participating member organizations of the Neurovascular Coalition involved in the writing and endorsement of this document are the Society of NeuroInterventional Surgery, the American Academy of Neurology, the American Association of Neurological Surgeons/Congress of Neurological Surgeons Cerebrovascular Section, and the Society of Vascular & Interventional Neurology.

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Performance and training standards for endovascular acute ischemic stroke treatment

Neurology ◽

10.1212/wnl.0b013e318269595b ◽

2012 ◽

Vol 79 (Issue 13, Supplement 1) ◽

pp. S234-S238 ◽

Cited By ~ 9

Author(s):

P. M. Meyers ◽

H. C. Schumacher ◽

M. J. Alexander ◽

C. P. Derdeyn ◽

A. J. Furlan ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Treatment ◽

Training Standards ◽

And Training

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Safety of Low Dose Intravenous Cangrelor in Acute Ischemic Stroke: A Case Series

Frontiers in Neurology ◽

10.3389/fneur.2021.636682 ◽

2021 ◽

Vol 12 ◽

Author(s):

Hisham Salahuddin ◽

Giana Dawod ◽

Syed F. Zaidi ◽

Julie Shawver ◽

Richard Burgess ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Low Dose ◽

Case Series ◽

Control Group ◽

Anterior Circulation ◽

Study Objective ◽

Safety And Efficacy ◽

Stroke Treatment

Background: Neurointerventional procedures in acute ischemic stroke often require immediate antiplatelet therapy in the cases of acute stenting and occasionally re-occluding vessels. Intravenous cangrelor is a P2Y12 receptor antagonist with short onset and quick offset. The study objective was to evaluate the safety and efficacy of intravenous cangrelor in patients with acute ischemic stroke requiring urgent antiplatelet effect.Methods: Patients who received intravenous cangrelor intra-procedurally during acute ischemic stroke treatment were identified from a prospectively collected database. Cangrelor was administered as a bolus of 15 mcg/kg, followed by an infusion rate of 2 mcg/kg/min. A historical control group consisting of anterior circulation tandem occlusions was used to compare to patients with similar lesions who received intravenous cangrelor. Outcomes of interest included in-stent thrombosis, thromboembolic complications, intracranial hemorrhage, and functional outcomes at 90 days.Results: Twelve patients received intravenous cangrelor for acute ischemic stroke between October 2018 and April 2020 at a comprehensive stroke center. Eleven patients had intra or extracranial stenting performed, which included two posterior circulation lesions. No cases of symptomatic intracranial hemorrhage were reported. At 90 day follow-up, two patients had died and 10 had a good functional outcome. Patients with anterior circulation tandem occlusions who received cangrelor and those who received dual antiplatelets orally had similar radiographic and clinical outcomes.Conclusion: Low dose intravenous cangrelor is similar in safety and efficacy to oral antiplatelets in acute ischemic stroke in a small case series. Larger prospective studies on the efficacy, safety, and effect on procedure times of intravenous cangrelor in neurointervention are warranted.

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Endovascular Treatment of Stroke

Acute Stroke Management in the First 24 Hours ◽

10.1093/med/9780190856519.003.0009 ◽

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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Acute amnestic syndrome and ischemic stroke: A case series

Neurology Clinical Practice ◽

10.1212/cpj.0000000000000928 ◽

2020 ◽

pp. 10.1212/CPJ.0000000000000928

Author(s):

Malik Ghannam ◽

Qasem Alshaer ◽

Hope Ukatu ◽

Mohammed Alkuwaiti ◽

Christopher Streib

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Memory Impairment ◽

Case Series ◽

Anterograde Amnesia ◽

Acute Onset ◽

Stroke Treatment ◽

Long Term Follow Up ◽

High Degree

AbstractPurposeof Review: Stroke is an uncommon cause of amnesia. We describe in detail three cases of anterograde amnesia and confabulation secondary to acute ischemic stroke and review the available literature.Recent Findings:In our case series, all three patients presented with anterograde amnesia and two of three co-presented with prominent confabulation. These symptoms were recognized in delayed fashion and no patients received IV tPA. Although stroke infarct topology was variable, all three patients had infarction of the fornix. Long-term follow-up was obtained in two of three patients: both had persistent memory impairment and were no longer functionally independent.Summary:Acute onset anterograde amnesia and confabulation may uncommonly represent acute ischemic stroke. Delays in this diagnosis typically exclude patients from emergent stroke treatment or timely diagnostic stroke evaluation. Physicians should maintain a high degree of suspicion, especially in patients with comorbid vascular risk factors. Memory impairment secondary to ischemic stroke can produce considerable long-term disability.

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INTRAARTERIAL THROMBOLYSIS FOR ACUTE ISCHEMIC STROKE

Seminars in Neurosurgery ◽

10.1055/s-2000-11562 ◽

2000 ◽

Vol 11 (01) ◽

pp. 107-132 ◽

Cited By ~ 3

Author(s):

Ronald Budzik ◽

Richard Pergolizzi ◽

Christopher Putman

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intraarterial Thrombolysis

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Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.5.peds19126 ◽

2019 ◽

Vol 24 (5) ◽

pp. 558-571 ◽

Cited By ~ 3

Author(s):

Kartik Bhatia ◽

Hans Kortman ◽

Christopher Blair ◽

Geoffrey Parker ◽

David Brunacci ◽

...

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Case Reports ◽

Meta Analysis ◽

Case Series ◽

Neurological Outcomes

OBJECTIVEThe role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge.METHODSUsing PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors’ centers was also included. The primary outcomes were the rate of good long-term (mRS score 0–2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0–1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).RESULTSThe authors’ review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0–2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age.CONCLUSIONSMechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1–18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.

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Faculty Opinions recommendation of 2015 american heart association/american stroke association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: A guideline for healthcare professionals from the american heart association/american stroke association.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.725599859.793530191 ◽

2017 ◽

Cited By ~ 1

Author(s):

Shyam Prabhakaran

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

American Heart Association ◽

Healthcare Professionals ◽

American Heart ◽

Heart Association ◽

Early Management

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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

Journal of Cerebral Blood Flow & Metabolism ◽

10.1177/0271678x21992980 ◽

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.

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Abstract W P224: Higher Pre-Hospital Blood Pressure Prolongs Door to Needle Thrombolysis Times

Stroke ◽

10.1161/str.46.suppl_1.wp224 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Digvijaya Navalkele ◽

Chunyan Cai ◽

Mohammad Rahbar ◽

Renganayaki Pandurengan ◽

Tzu-Ching Wu ◽

...

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Small Sample Size ◽

Heart Association ◽

Small Sample ◽

Categorical Variables ◽

Continuous Variables ◽

Intravenous Tissue Plasminogen Activator ◽

Number Of Patients

Background: Per American Heart Association guidelines, blood pressure (BP) should be < 185/110 to be eligible for intravenous tissue plasminogen activator (tPA). It is shown that door to needle (DTN) time is prolonged in patients who require anti-hypertensive medications prior to thrombolysis in the emergency department (ED). To our knowledge, no studies have focused on pre-hospital BP and its impact on DTN times. We hypothesize that DTN times are longer for patients with higher pre-hospital BP. Methods: We conducted a retrospective review of acute ischemic stroke patients who presented between 1/2010 and 12/2010 to our ED through Emergency Medical Services (EMS) within 3-hrs of symptom onset. Patients were identified from our registry and categorized into two groups: Pre-hospital BP ≥ 185/110 (Pre-hsp HBP) and < 185/110 (Pre-hsp LBP). BP records were abstracted from EMS sheets. Two groups were compared using two-sample t-test or Wilcoxon rank sum test for continuous variables and Chi-square test or Fisher’s exact test for categorical variables. Results: A total of 107 consecutive patients were identified. Out of these, 75 patients (70%) were treated with tPA. Among the patients who received thrombolysis, 35% had pre-hospital BP ≥ 185/110 (n= 26/75). Greater number of patients required anti-hypertensive medications in ED in high BP group compared to low BP group (Pre-hsp HBP n= 14/26, 54%; Pre-hsp LBP n= 13/49, 27%, p < 0.02). Mean door to needle times were significantly higher in Pre-hsp HBP group. (mean ± SD 87.5± 34.2 Vs. 59.7±18.3, p<0.0001). Analysis of patients only within the Pre-hsp HBP group (n= 26) revealed that DTN times were shorter if patients received pre-hsp BP medications compared to patients in the same group who did not receive pre-hsp BP medication (n= 10 vs 16; mean ± SD 76.5 ± 25.7 Vs. 94.3 ± 37.7, p = 0.20) Conclusion: Higher pre-hospital BP is associated with prolonged DTN times and it stays prolonged if pre-hospital high BP remains untreated. Although the later finding was not statistical significant due to small sample size, pre-hospital blood pressure control could be a potential area for improvement to reduce door to needle times in acute ischemic stroke.

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