scholarly journals Endovascular treatment of acute ischemic stroke: the end or just the beginning?

2014 ◽  
Vol 36 (1) ◽  
pp. E5 ◽  
Author(s):  
Maxim Mokin ◽  
Alexander A. Khalessi ◽  
J Mocco ◽  
Giuseppe Lanzino ◽  
Travis M. Dumont ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Randomized Trials ◽  
Intravenous Thrombolysis ◽  
Lessons Learned ◽  
Neurological Deficits ◽  
Medical Community ◽  
Current Status

Various endovascular intraarterial approaches are available for treating patients with acute ischemic stroke who present with severe neurological deficits. Three recent randomized trials—Interventional Management of Stroke (IMS) III, Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE), and Synthesis Expansion: A Randomized Controlled Trial on Intra-Arterial Versus Intravenous Thrombolysis in Acute Ischemic Stroke (SYNTHESIS Expansion)—evaluated the efficacy of endovascular treatment of acute ischemic stroke and, after failing to demonstrate any significant clinical benefit of endovascular therapies, raised concerns and questions in the medical community regarding the future of endovascular treatment for acute ischemic stroke. In this paper, the authors review the evolution of endovascular treatment strategies for the treatment of acute stroke and provide their interpretation of findings and potential limitations of the three recently published randomized trials. The authors discuss the advantage of stent-retriever technology over earlier endovascular approaches and review the current status and future directions of endovascular acute stroke studies based on lessons learned from previous trials.

Endovascular Treatment Versus Intravenous Thrombolysis for Acute Ischemic Stroke: a Quantitative Review and Meta-Analysis of 21 Randomized Trials

2016 ◽  
Vol 54 (2) ◽  
pp. 1369-1378 ◽  
Author(s):  
Chen-Chen Tan ◽  
Hui-Fu Wang ◽  
Jin-Long Ji ◽  
Meng-Shan Tan ◽  
Lan Tan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Randomized Trials ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Quantitative Review

Abstract W P8: "Double Trouble": Endovascular Treatment of Tandem Arterial Occlusions in Acute Ischemic Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Mikayel Grigoryan ◽  
Diogo Haussen ◽  
Andrey Lima ◽  
Jonathan Grossberg ◽  
Shannon Doppelheuer ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Arterial Occlusion ◽  
Intravenous Thrombolysis ◽  
Imaging Data ◽  
Stroke Patients ◽  
Symptomatic Intracerebral Hemorrhage

Background: Tandem extracranial/intracranial arterial occlusions in acute stroke present treatment challenges both due to suboptimal response to systemic intravenous thrombolysis as well as complex endovascular approach. We report our experience in treating this cohort of acute stroke patients with the analysis of angiographic and clinical outcomes Materials and Methods: We retrospectively reviewed clinical and imaging data of all consecutive acute stroke patients with proximal intracranial arterial occlusion and additional extracranial occlusion/critical stenosis, treated with endovascular techniques between February 2011 and February 2014 at two hospitals. We analyzed patients’ demographics, clinical presentation, treatment strategies, time to recanalization, imaging and clinical outcomes. Results: A total of 66 patients were included. The mean NIHSS on presentation was 19. Extracranial carotid with concomitant intracranial anterior circulation occlusions were present in 95% of the patients (63/66), while 5% (3/66) had tandem vertebrobasilar occlusions. 41% of the patients (27/66) received intravenous rt-PA. With regards to endovascular treatment, in 70% of the cases (46/66), extracranial lesion was treated with a stent placement. Stentrievers were used in 50% (33/66) of the patients for intracranial thrombectomy. Thrombolysis in Cerebral Infarction (TICI) >= 2B reperfusion was achieved in 77% of all the patients (51/66) and in 97% (32/33) of the stentriever patients. Good clinical outcome at 90 days (mRS<=2) was seen in 42% of the patients. Symptomatic intracerebral hemorrhage (PH-2)occurred in 9% (6/66) of the patients. Conclusions: Endovascular treatment of tandem arterial occlusions in acute ischemic stroke is relatively safe, feasible, and may yield excellent angiographic and good clinical outcomes.

scholarly journals Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

2021 ◽  
Vol 14 ◽  
pp. 175628642110211
Author(s):  
Georgios Magoufis ◽  
Apostolos Safouris ◽  
Guy Raphaeli ◽  
Odysseas Kargiotis ◽  
Klearchos Psychogios ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Time Windows ◽  
Intravenous Thrombolysis ◽  
Inclusion Criteria ◽  
Stroke Patients ◽  
Treatment Algorithms ◽  
Late Presenters

Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.

Predictors of futile recanalization after endovascular treatment in acute ischemic stroke: a meta-analysis

2021 ◽  
pp. neurintsurg-2021-017963
Author(s):  
Gang Deng ◽  
Jun Xiao ◽  
Haihan Yu ◽  
Man Chen ◽  
Ke Shang ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Systolic Blood Pressure ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Serum Glucose ◽  
Female Sex ◽  
Symptomatic Intracerebral Hemorrhage

BackgroundDespite successful recanalization after endovascular treatment, many patients with acute ischemic stroke due to large vessel occlusion still show functional dependence, namely futile recanalization.MethodsPubMed and Embase were searched up to April 30, 2021. Studies that reported risk factors for futile recanalization following endovascular treatment of acute ischemic stroke were included. The mean difference (MD) or odds ratio (OR) and 95% confidence interval (95% CI) of each study were pooled for a meta-analysis.ResultsTwelve studies enrolling 2138 patients were included. The pooled analysis showed that age (MD 5.81, 95% CI 4.16 to 7.46), female sex (OR 1.40, 95% CI 1.16 to 1.68), National Institutes of Health Stroke Scale (NIHSS) score (MD 4.22, 95% CI 3.38 to 5.07), Alberta Stroke Program Early CT Score (ASPECTS) (MD −0.71, 95% CI −1.23 to –0.19), hypertension (OR 1.73, 95% CI 1.43 to 2.09), diabetes (OR 1.78, 95% CI 1.41 to 2.24), atrial fibrillation (OR 1.24, 95% CI 1.01 to 1.51), admission systolic blood pressure (MD 4.98, 95% CI 1.87 to 8.09), serum glucose (MD 0.59, 95% CI 0.37 to 0.81), internal carotid artery occlusion (OR 1.85, 95% CI 1.17 to 2.95), pre-treatment intravenous thrombolysis (OR 0.67, 95% CI 0.55 to 0.83), onset-to-puncture time (MD 16.92, 95% CI 6.52 to 27.31), puncture-to-recanalization time (MD 12.37, 95% CI 7.96 to 16.79), and post-treatment symptomatic intracerebral hemorrhage (OR 6.09, 95% CI 3.18 to 11.68) were significantly associated with futile recanalization.ConclusionThis study identified female sex, comorbidities, admission systolic blood pressure, serum glucose, occlusion site, non-bridging therapy, and post-procedural complication as predictors of futile recanalization, and also confirmed previously reported factors. Further large-scale prospective studies are needed.

scholarly journals tPA for Acute Ischemic Stroke and Its Controversies: A Review

2019 ◽  
Vol 10 (1) ◽  
pp. 5-10 ◽  
Author(s):  
Brian Dewar ◽  
Michel Shamy
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Historical Context ◽  
Building Blocks ◽  
Medical Community ◽  
Emergency Physicians ◽  
Historical Sources ◽  
Historical Building ◽  
Intravenous Tissue Plasminogen Activator

Background and Purpose:Although neurologists consider intravenous tissue plasminogen activator (tPA) to be standard of care in the treatment of patients with acute ischemic stroke, its use remains contentious within the broader medical community, and particularly among emergency physicians. Why might this be? We provide a historical context to this ongoing controversy by reviewing how neurologists have conceptualized the acute stroke and its treatment, with the aim of bridging this gap.Methods:Based on historical sources in the Mackie Family History of Neuroscience Collection at the University of Calgary, as well as online resources, we trace the evolution of the concept of the “acute stroke,” which has come to mean a stroke that is potentially treatable with tPA. We frame this conceptualization in relation to historical “building blocks” in anatomy, pathology, and physiology. We then use these building blocks to explain why neurologists understand tPA to be effective and why emergency physicians often do not.Results and Conclusions:Arguments against the use of tPA reiterate 20-year-old concerns about its efficacy and safety. We believe these persistent concerns can be framed as a lack of understanding of the “building blocks” upon which neurologists’ conception of tPA is built. Our view suggests that the way forward to bridge the gap between neurology and other disciplines is not to conduct more trials but to offer a shared conceptualization of the trials already completed and of the intellectual tradition from which they emerged.

scholarly journals Endovascular Treatment for Acute Ischemic Stroke: Updates and Future Implications

2015 ◽  
Vol 4 (1-2) ◽  
pp. 43-47 ◽  
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.

scholarly journals Delayed Stroke Treatment during COVID-19 Pandemic in China

2020 ◽  
Author(s):  
Shiyuan Gu ◽  
Zhengze Dai ◽  
Huachao Shen ◽  
Yongjie Bai ◽  
Xiaohao Zhang ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Regression Analysis ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Logistic Regression Analysis ◽  
Multivariate Logistic Regression Analysis ◽  
Intravenous Thrombolysis ◽  
Multivariate Logistic Regression ◽  
Delayed Treatment

ABSTRACTBackgroundSocial distance, quarantine, pathogen testing and other preventive strategies implemented during COVID-19 pandemic may negatively influence the management of acute stroke.ObjectiveThe current study aimed to evaluate the impacts of COVID-19 pandemic on treatment delay of acute stroke in China.MethodsThis study included patients with acute stroke admitted in two hospitals in Jiangsu, China. Patients admitted before and after the COVID-19 epidemic outbreak (January 31, 2020, as officially announced by Chinese government) were compared for pre- (measured as onset-to-door time) and post-hospital delay (measured as door-to-needle time). The influence factors for delayed treatment (indicated as onset-to-needle time >4.5 hours) were analyzed with multivariate logistic regression analysis.ResultsOnset-to-door time increased from 202 min (IQR 65-492) before to 317 min (IQR 75-790) after the COVID-19 pandemic (P=0.001). Door-to-needle time increased from 50min (IQR 40-75) before to 65 min (IQR 48-84) after the COVID-19 pandemic (P=0.048). The proportion of patients with intravenous thrombolysis in those with acute ischemic stroke was decreased significantly after the pandemic (15.4% vs 20.1%; P=0.030). Multivariate logistic regression analysis indicated that patients after COVID-19 pandemic, lower educational level, rural residency, mild symptoms and transported by other means than ambulance were associated with delayed treatment.ConclusionsCOVID-19 pandemic has remarkable impacts on the management of acute ischemic stroke. Both pre- and post-hospital delays were prolonged significantly, and proportion of patient arrived within the 4.5-hour time window for intravenous thrombolysis treatment was decreased. Given that anti-COVID-19 measures are becoming medical routines, efforts are warranted to shorten the delay so that the outcomes of stroke could be improved.

Meta-analysis of the Smoker’s Paradox in Acute Ischemic Stroke Patients Receiving Intravenous Thrombolysis or Endovascular Treatment

2019 ◽  
Vol 21 (9) ◽  
pp. 1181-1188 ◽  
Author(s):  
Peng Zhang ◽  
Zhen-Ni Guo ◽  
Xin Sun ◽  
Yingkai Zhao ◽  
Yi Yang
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Functional Outcomes ◽  
Meta Analysis ◽  
Intravenous Thrombolysis ◽  
Cochrane Library ◽  
Stroke Patients ◽  
Good Functional Outcome

Abstract Introduction The existence of the smoker’s paradox is controversial and potential mechanisms have not been explained. We aimed to explore the association between cigarette smoking and functional outcome at 3 months in patients with acute ischemic stroke who were treated with intravenous thrombolysis (IVT) or endovascular treatment (EVT). Methods This meta-analysis was conducted in accordance with the PRISMA guidelines. Studies exploring the association between smoking and good functional outcome (modified Rankin Scale score ≤ 2) following IVT or EVT were searched via the databases of PubMed, Embase, and the Cochrane Library from inception to August 8, 2018. Information on the characteristics of included studies was independently extracted by two investigators. Data were pooled using a random-effects or fixed-effects meta-analysis according to the heterogeneity of included studies. Results Among 20 identified studies, 15 reported functional outcomes following IVT, and five reported functional outcomes following EVT. Unadjusted analyses showed that smoking increased the odds of good functional outcomes with a pooled odds ratio (OR) of 1.48 (95% confidence interval [CI]: 1.36–1.60) after IVT and 2.10 (95% CI: 1.47–3.20) after EVT. Of IVT studies, only eight reported outcomes adjusted for covariates and none of the EVT studies reported adjusted outcomes. After adjustment, the relation between smoking and good functional outcome following IVT lost statistical significance (OR 1.14 [95% CI: 0.81–1.59]). Conclusion Our meta-analysis suggested that smoking was not associated with good functional outcome (mRS ≤ 2) at 3 months in patients with acute ischemic stroke who were treated with intravenous thrombolysis. Implications The existence of the smoker’s paradox is controversial. A previous letter by Plas et al. published in 2013 reported a positive result for the association between smoking and good functional outcome at 3 months in acute ischemic stroke patients who received intravenous thrombolysis (IVT). However, a major limitation of their meta-analysis was that the process of data synthesis was based on unadjusted data. Therefore, we conducted this meta-analysis to investigate the association based on adjusted data and a larger sample size. Our meta-analysis suggested that smoking was not associated with good functional outcome after adjusting for covariates.

Abstract P532: Does Atrial Fibrillation Impact Rate of Symptomatic Intracranial Hemorrhage in Acute Ischemic Stroke Patients Treated With rt-PA and/or Endovascular Treatment?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Reza Bavarsad Shahripour ◽  
Benjamin Shifflett ◽  
Edward Labin ◽  
Morgan Figurelle ◽  
Anna Barminova ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Smoking Status ◽  
Intravenous Thrombolysis ◽  
Significant Difference ◽  
Chi Squared ◽  
Symptomatic Intracranial Hemorrhage

Background: Patients with acute ischemic stroke (AIS) due to atrial fibrillation (afib) may have increased complications from intravenous thrombolysis or endovascular treatment (ET) compared to other stroke subtypes. The purpose of this study was to compare the rates of symptomatic intracranial hemorrhage (sICH) in patients with and without a history of a fib treated with IV rt-PA and/or ET. Methods: Consecutive stroke code activations were retrospectively analyzed from January 2004-June 2020 at an academic comprehensive stroke center. Patients were included if they were treated with IV rt-PA and/or ET within 24 hours of stroke onset. Patients were stratified into the six groups:1-No hx of a fib with ET only, 2-Hx of a fib with ET only, 3-No hx of a fib with IV rt-PA plus ET, 4-Hx of a fib with IV rt-PA plus ET, 5-No hx of a fib with IV rt-PA only, 6-Hx of a fib with IV rt-PA only. Primary outcome was defined as any sICH within 72 hours of treatment using the NINDS definition. Baseline demographics were compared. Chi squared was used to assess differences in sICH rates and logistic regression to compare individual groups. Analyses were both unadjusted and adjusted for baseline NIHSS, age, sex, baseline blood pressure, pre-stroke mRS, smoking status, and baseline glucose. Results: We identified 720 AIS patients who received acute treatment (IV rt-PA: n=578; ET: n=100; IV rt-PA+ET:n=18). There was a significant difference in sex (p=0.005); Hispanic ethnicity (p=0.002); current smoking (p=<0.001); current alcohol use (p=0.03), CHF (p=0.01); and age (p<0.0001) between groups. Baseline NIHSS was significantly higher in Group 4 (23, SD 8, p=<0.001).In adjusted analysis, there was no significant difference in sICH in patients with a fib after receiving IVtPA (OR 1.53, CI 0.47-4.99, p=0.48), ET (OR 0.93 , CI 0-∞, p=1.00), or both (OR 0.25,CI 0.00-9.07, p=0.45) compared to those without afib. There was no significant difference in sICH in adjusted analyses in patients with and without a fib overall (OR 0.93, CI 0-∞, p=1.00). Conclusion: In this study, atrial fibrillation did not have a significant impact on rates of sICH in AIS patients treated with IV rt-PA, ET, or both. This study supports the safety of IV rt-PA, ET, and combination therapy in the atrial fibrillation population.

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