Endovascular stroke intervention in young patients with large vessel occlusions

Object Endovascular therapy has become a widely used method for achieving arterial recanalization in patients who are ineligible for intravenous thrombolysis or those in whom it is unsuccessful. Young stroke patients with large vessel occlusions may particularly benefit from endovascular intervention. This study aims to assess the authors' experience with the use of modern endovascular techniques to treat young patients (≤ 55 years old) with acute ischemic stroke and large vessel occlusions. Methods Young patients (≤ 55 years old) undergoing endovascular intervention for acute ischemic stroke at the authors' institution were identified from a prospectively maintained database. Only those patients with a confirmed large vessel occlusion were included. Modified Rankin Scale (mRS) scores were determined at 90 days during a follow-up visit. A multivariate analysis was performed to determine predictors of outcome (mRS score 0–2). Results A total of 45 patients met the inclusion criteria. The mean age of the patients in this series was 45 ± 9.6 years. The mean admission NIH Stroke Scale score was 14.1 ± 5 (median 13.5). Mechanical thrombectomy was performed using the Solitaire FR device in 13 (29%) patients and the Merci/Penumbra systems in 32 (71%) patients. The rate of successful recanalization (Thrombolysis In Myocardial Infarction [TIMI] scale Grade II–III) was 93% (42/45). Only 1 patient (2.2%) had a symptomatic intracranial hemorrhage following intervention. One patient (2.2%) sustained a vessel perforation intraoperatively. The rate of 90-day favorable outcome (mRS score 0–2) was 77.5% and the rate of 90-day satisfactory outcome (mRS score 0–3) was 90%. The 90-day mortality rate was 7.5%. In multivariate analysis, postprocedure TIMI grade was the only statistically significant independent predictor of 90-day outcome (OR 3.3, 95% CI 1.01–1.19; p = 0.05). Conclusions The results of this study demonstrate that endovascular therapy provides remarkably high rates of arterial recanalization and favorable outcomes in young patients with acute ischemic stroke and large vessel occlusions. These findings support aggressive interventional strategies in these patients. Randomized, controlled trials reflecting modern acute ischemic stroke treatment will be needed to confirm the findings of this study.

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TRIAGE-STROKE: Treatment strategy In Acute larGE vessel occlusion: Prioritize IV or endovascular treatment—A randomized trial

International Journal of Stroke ◽

10.1177/1747493019869830 ◽

2019 ◽

Vol 15 (1) ◽

pp. 103-108 ◽

Cited By ~ 1

Author(s):

Anne Behrndtz ◽

Søren P Johnsen ◽

Jan B Valentin ◽

Martin F Gude ◽

Rolf A Blauenfeldt ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Hospital Setting ◽

Intravenous Thrombolysis ◽

Large Vessel ◽

Stroke Severity ◽

Study Results ◽

Primary Stroke Center ◽

Stroke Center

Rationale For patients with acute ischemic stroke and large vessel occlusions, intravenous thrombolysis and endovascular therapy are standard of care, but the effect of endovascular therapy is superior to intravenous thrombolysis. If a severe stroke with symptoms indicating large vessel occlusions occurs in the catchment area of a primary stroke center, there is equipoise regarding optimal transport strategy. Aim For patients presenting with suspected large vessel occlusions (PASS ≥ 2) and a final diagnosis of acute ischemic stroke, we hypothesize that bypassing the primary stroke center will result in an improved 90-day functional outcome. Sample size We aim to randomize 600 patients, 1:1. Design A national investigator-driven, multi-center, randomized assessor-blinded clinical trial. The Prehospital Acute Stroke Severity Scale has been developed. It identifies most patients with large vessel occlusions in the pre-hospital setting. Patients without a contraindication for intravenous thrombolysis are randomized to either transport directly to a comprehensive stroke centers for intravenous thrombolysis and of endovascular therapy or to a primary stroke center for intravenous thrombolysis and subsequent transport to a comprehensive stroke centers for of endovascular therapy, if needed. Outcomes The primary outcome will be the 90-day modified Rankin Scale score (mRS) for all patients with acute ischemic stroke. Secondary outcomes include 90-day mRS for all randomized patients, all patients with ischemic stroke but without large vessel occlusions, and patients with hemorrhagic stroke. The safety outcomes include severe dependency or death and time to intravenous thrombolysis for ischemic stroke patients. Discussion Study results will influence decision making regarding transport strategy for patients with suspected large vessel occlusions.

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Endovascular Treatment of Acute Ischemic Stroke in Patients Younger than 18 Years

Journal of Clinical Interventional Radiology ISVIR ◽

10.1055/s-0041-1740568 ◽

2021 ◽

Author(s):

Sibasankar Dalai ◽

Uday Limaye ◽

Satyarao Kolli ◽

Mohan V. Sumedha Maturu ◽

Randhi Venkata Narayana ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Young Patients ◽

Major Complication ◽

Modified Rankin Scale ◽

Nihss Score ◽

Arterial Recanalization ◽

The Mean

AbstractRapid and effective revascularization is very important in the treatment of acute ischemic stroke (AIS). Endovascular treatment is a promising modality in the management of AIS in young patients. We evaluated the clinical and imaging records in 14 patients younger than 18 years presenting within 6 hours of AIS. They received endovascular therapy (ET) either by mechanical thrombectomy, thromboaspiration, or both (Solumbra) between July 2017 and June 2021 in our institute. The National Institute of Health Stroke Scale (NIHSS) score was calculated on admission and before the discharge of all patients. The 90-day modified Rankin Scale (mRS) score on disability-free outcome was also evaluated. The mean preprocedure NIHSS score was 10.78 ± 2.11 that improved to 4.5 ± 1.88 after the procedure. Thrombolysis in cerebral infarction (TICI) grade 2b and 3 blood flow could be established in 12 (85.72%) patients. One patient had TICI 2a flow and one patient had recurrent occlusion despite repeated recanalization (TICI grade 0). The disability-free outcome, mRS score at 90 days was 0 to 1 in 12 (85.72%) patients, mRS score 2 in one (7.14%) patient, and mRS score 3 in one patient (7.14%). We did not have any major complication related to the procedure. ET provides high rates of arterial recanalization and favorable disability-free outcomes in young patients with AIS.

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Faculty Opinions recommendation of Intravenous thrombolysis and endovascular therapy for acute ischemic stroke with internal carotid artery occlusion: a systematic review of clinical outcomes.

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

10.3410/f.717953732.793459347 ◽

2012 ◽

Author(s):

Mark Wainwright

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Internal Carotid ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Carotid Artery Occlusion

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Differences in Acute Ischemic Stroke Management and Prognosis between Multiple Large-Vessel Occlusion and Single Large-Vessel Occlusion: Subanalysis of the RESCUE-Japan Registry 2

Cerebrovascular Diseases ◽

10.1159/000514369 ◽

2021 ◽

Vol 50 (4) ◽

pp. 397-404

Author(s):

Kotaro Tatebayashi ◽

Kazutaka Uchida ◽

Hiroto Kageyama ◽

Hirotoshi Imamura ◽

Nobuyuki Ohara ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Patient Characteristics ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Tandem Occlusion ◽

The Mean ◽

Patient Prognosis

Introduction: The management and prognosis of acute ischemic stroke due to multiple large-vessel occlusion (LVO) (MLVO) are not well scrutinized. We therefore aimed to elucidate the differences in patient characteristics and prognosis of MLVO and single LVO (SLVO). Methods: The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2 (RESCUE-Japan Registry 2) enrolled 2,420 consecutive patients with acute LVO who were admitted within 24 h of onset. We compared patient prognosis between MLVO and SLVO in the favorable outcome, defined as a modified Rankin Scale (mRS) score ≤2, and in mortality at 90 days by adjusting for confounders. Additionally, we stratified MLVO patients into tandem occlusion and different territories, according to the occlusion site information and also examined their characteristics. Results: Among the 2,399 patients registered, 124 (5.2%) had MLVO. Although there was no difference between the 2 groups in terms of hypertension as a risk factor, the mean arterial pressure on admission was significantly higher in MLVO (115 vs. 107 mm Hg, p = 0.004). MLVO in different territories was more likely to be cardioembolic (42.1 vs. 10.4%, p = 0.0002), while MLVO in tandem occlusion was more likely to be atherothrombotic (39.5 vs. 81.3%, p < 0.0001). Among MLVO, tandem occlusion had a significantly longer onset-to-door time than different territories (200 vs. 95 min, p = 0.02); accordingly, the tissue plasminogen activator administration was significantly less in tandem occlusion (22.4 vs. 47.9%, p = 0.003). However, interestingly, the endovascular thrombectomy (EVT) was performed significantly more in tandem occlusion (63.2 vs. 41.7%; adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.1–5.0). The type of MLVO was the only and significant factor associated with EVT performance in multivariate analysis. The favorable outcomes were obtained less in MLVO than in SLVO (28.2 vs. 37.1%; aOR, 0.48; 95% CI, 0.30–0.76). The mortality rate was not significantly different between MLVO and SLVO (8.9 vs. 11.1%, p = 0.42). Discussion/Conclusion: The prognosis of MLVO was significantly worse than that of SLVO. In different territories, we might be able to consider more aggressive EVT interventions.

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Abstract 2825: History of Cancer Predicts Mortality After Acute Endovascular Treatment for Ischemic Stroke

Stroke ◽

10.1161/str.43.suppl_1.a2825 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Karl Meisel ◽

Mahesh Jayaraman ◽

Jonathan Grossberg ◽

Anthony Kim

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Hospice Care ◽

Exploratory Analysis ◽

Endovascular Intervention ◽

Consecutive Series ◽

History Of ◽

History Of Cancer

Introduction: Endovascular treatment is an emerging therapy for acute ischemic stroke. There is no clear consensus about how best to select patients that may benefit from intervention. We conducted an exploratory analysis of clinical risk factors to predict mortality after endovascular intervention in order to better understand how to improve outcomes for patients with acute ischemic stroke. Methods: We identified consecutive series of patients treated with endovascular therapy for acute ischemic stroke at two academic hospitals between 2005 to 2010. Key clinical data elements and clinical outcomes at the time of discharge were abstracted from medical records. We evaluated univariate and multivariable associations using logistic regression and compared mean NIH Stroke Scale between those with and without a history of cancer using the t-test. Results: We identified 88 patients who received endovascular intervention with intra-arterial tissue plasminogen activator (t-PA) and/or mechanical thrombectomy. The mean age of the cohort was 68.2 (SD 16.6) and 44 (55%) were female. A total of 23 (26.1%) patients died during the index hospitalization or were discharged to hospice care. A history of cancer was documented in 20 (22.7%) patients. A history of cancer was associated with a 3.2-fold (95% CI 1.1-9.1) higher odds of mortality. This association persisted after adjusting for age greater than 80 years and hypertension (OR of 4.0, 95% CI 1.3-12). The average NIH Stroke Scale was 15.6 in those with cancer compared to 14.6 without (p=0.53). A history of cancer was not associated with parenchymal hemorrhagic transformation (OR 1.2, 95% CI 0.3-4.9), IV tPA (OR 0.5, 95% CI 0.1-2.3), a TIMI score of 2b or 3 (OR 0.5, 95% CI 0.2-1.3), or an internal carotid artery occlusion (OR 1.7, 95% CI 0.5-5.1). Conclusions: In an exploratory analysis of consecutive patients with acute ischemic stroke treated with endovascular therapy, a history of cancer was strongly associated with significantly increased odds of mortality. One possible explanation could be that patients with cancer may have earlier withdrawal of care but the reasons for this observed association are unclear. Further investigation is necessary to verify and explain the reasons for this observation in order to improve outcomes for acute ischemic stroke patients.

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Clinical profile of patients with acute ischemic stroke receiving intravenous thrombolysis (rtPA-alteplase)

International Journal of Advances in Medicine ◽

10.18203/2349-3933.ijam20180078 ◽

2018 ◽

Vol 5 (1) ◽

pp. 164

Author(s):

Shiva Prasad Jagini ◽

Suresh I.

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Prospective Observational Study ◽

Primary Outcome ◽

Intravenous Thrombolysis ◽

Clinical Profile ◽

Favorable Outcome ◽

Nihss Score ◽

The Mean ◽

Centre Hospital

Background: Stroke patients are at highest risk death in the first few weeks after the event, and between 20-50% die within first month depending on type, severity, age, co-morbidities and effectiveness of treatment of complications. Objective of this study was to clinical profile of patients with acute ischemic stroke receiving intravenous thrombolysis (rtPA-alteplase).Methods: Prospective Observational study of 26 cases of acute ischemic stroke receiving IV thrombolysis using rtPA-alteplase at Kovai Medical Centre Hospital, Coimbatore over a period of 1 year 9 months.Results: 21 cases had NIHSS score of range 10 to 22. The mean NIHSS score at admission is 13.5. 15 subjects (57.7%) had achieved primary outcome in this study. MRS Score of 0 to 2 is considered as favorable outcome. In this study 20 subjects (76.92 %) had favorable outcome at the end of 3 months.Conclusions: Majority of the patients receiving rtPA-alteplase had favorable outcome.

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Intravenous Thrombolysis and Endovascular Therapy for Acute Ischemic Stroke With Internal Carotid Artery Occlusion

Stroke ◽

10.1161/strokeaha.112.655621 ◽

2012 ◽

Vol 43 (9) ◽

pp. 2362-2368 ◽

Cited By ~ 56

Author(s):

Maxim Mokin ◽

Tareq Kass-Hout ◽

Omar Kass-Hout ◽

Travis M. Dumont ◽

Peter Kan ◽

...

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Internal Carotid ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Internal Carotid Artery Occlusion

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Abstract 3314: The Role of Bridging with Intravenous Thrombolysis in Endovascular Therapy of Acute Ischemic Stroke.

Stroke ◽

10.1161/str.43.suppl_1.a3314 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Omar Kass-Hout ◽

Tareq Kass-Hout ◽

Maxim Mokin ◽

David Orion ◽

Shadi Jahshan ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Combined Therapy ◽

Large Vessel ◽

P Value ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score

Background: Large vessel occlusions with a high clot burden are less likely to improve with the FDA-approved IV strategy. Endovascular therapy within the first 3 h of stroke symptom onset provides an effective alternative treatment in patients with large vessel occlusion. It is not clear if combination of IV thrombolysis and endovascular approach is superior to endovascular treatment alone. Methods: We retrospectively reviewed all cases of acute ischemic stroke with large vessel occlusion treated within the first 3 h stroke onset during the 2005-2010 period. First group received endovascular therapy within the first 3 h of stroke onset. Second group consisted of patients who received IV thrombolysis within the first 3 h followed by endovascular therapy. We compared the following outcomes: revascularization rates, NIHSS score at discharge, mRS at discharge and 3months, symptomatic hemorrhage rates and mortality. Results: Among 104 patients identified, 42 received combined therapy, and 62 received endovascular therapy only. The two groups had similar demographic (age and sex distribution) and vascular risk factors distribution, as well as NIHSS score on admission (14.8±4.7 and 16.0±5.3; p=0.23). We found no difference in TIMI recanalization rates (Thrombolysis in Myocardial Infarction scale score of 2 or 3) following combined or endovascular therapy alone (83.3% and 79.0%; p=0.59). A preferred outcome, defined as a mRS of 2 or less at 90 days also did not differ between the combined therapy group and the endovascular only group (37.5% and 34.5%; p=0.76). There was no difference in mortality rate (22.5% and 31.0%; p=0.36) and the rate of symptomatic intracranial hemorrhage (9.5% and 8.1%; p=0.73). There was a significant difference in mean time from symptom onset to endovascular treatment between the combined group (227±88 min) and endovascular only group (125±40 min; p<0.0001).Patients with good TIMI recanalization rate of 2 or 3 showed a trend of having a better mRS at 90 days in both bridging (16.67% vs. 41.18%, p-value: 0.3813) and endovascular groups (25% vs. 34.78%, p-value: 0.7326).When analyzing the correlation of mRS at 90 days with the site of occlusion, patients in the bridging group showed a trend of a better outcome when the site of occlusion was ICA (33.3% vs 30%) and MCA (66.67% vs. 27.59%) and worse outcome when the site of occlusion was in the posterior circulation (26.32% vs. 50%), however, these results were not statistically significant (p-values: 0.1735& 0.5366). Conclusion: Combining IV thrombolysis and endovascular therapy achieves similar rates of clinical outcomes, revascularization rates, complications and mortality rates, when compared with endovascular treatment alone. The combined therapy, however, significantly delays initiation of endovascular treatment. A randomized prospective trial comparing both treatment strategies in acute ischemic stroke is warranted

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Acute Ischemic Stroke in Late Pregnancy Treated with Intravenous Thrombolysis and Endovascular Therapy

Case Reports in Neurology ◽

10.1159/000496084 ◽

2019 ◽

Vol 11 (1) ◽

pp. 41-46 ◽

Cited By ~ 3

Author(s):

Eva Szuchy Kristiansen ◽

Hannah Holm Vestergaard ◽

Boris Modrau ◽

Lorenz Martin Oppel

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Intravenous Thrombolysis ◽

Late Pregnancy ◽

Exclusion Criterion ◽

Good Clinical Outcome ◽

Systemic Thrombolysis ◽

In Pregnancy

Pregnancy has usually been an exclusion criterion in clinical trials with thrombolysis and endovascular therapy in acute ischemic stroke. For that reason, these therapies are not recommended causing lack of evidence and vice versa. In this case report, we describe a pregnant woman in week 33 + 3 presenting with acute ischemic stroke, which was successfully treated with systemic thrombolysis and endovascular therapy, resulting in a good clinical outcome for both mother and child. The altered fibrinolytic system and the risk factors related to pregnancy constitute a challenge for clinicians when choosing the most suitable treatment modality for treating acute ischemic stroke in pregnancy. It is still uncertain whether thrombolysis in combination with endovascular therapy or endovascular therapy alone is the most appropriate treatment option. However, there is slowly growing evidence that thrombolysis and thrombectomy in pregnancy are feasible and safe with a good clinical outcome for both the mother and the child.

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