A Simple Imaging Guide for Endovascular Thrombectomy in Acute Ischemic Stroke: From Time Window to Perfusion Mismatch and Beyond

Acute ischemic stroke (AIS) remains a leading cause of death and long-term disability. The paradigms on prehospital care, reperfusion therapies, and postreperfusion management of patients with AIS continue to evolve. After the publication of pivotal clinical trials, endovascular thrombectomy has become part of the standard of care in selected cases of AIS since 2015. New stroke guidelines have been recently published, and the time window for mechanical thrombectomy has now been extended up to 24 hours. This review aims to provide a focused up-to-date review for the early management of adult patients with AIS and introduce the new upcoming areas of ongoing research.

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Advances in imaging acute ischemic stroke: evaluation before thrombectomy

Reviews in the Neurosciences ◽

10.1515/revneuro-2020-0061 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Guangchen He ◽

Liming Wei ◽

Haitao Lu ◽

Yuehua Li ◽

Yuwu Zhao ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Time Window ◽

Imaging Modalities ◽

Current Evidence ◽

Endovascular Thrombectomy ◽

Treatment Paradigm ◽

Revascularization Therapy ◽

Magnetic Resonance Imaging Mri

Abstract Recent advances in neuroimaging have demonstrated significant assessment benefits and appropriate triage of patients based on specific clinical and radiological features in the acute stroke setting. Endovascular thrombectomy is arguably the most important aspect of acute stroke management with an extended time window. Imaging-based physiological information may potentially shift the treatment paradigm from a rigid time-based model to a more flexible and individualized, tissue-based approach, increasing the proportion of patients amenable to treatment. Various imaging modalities are routinely used in the diagnosis and management of acute ischemic stroke, including multimodal computed tomography (CT) and magnetic resonance imaging (MRI). Therefore, these imaging methods should provide information beyond the presence or absence of intracranial hemorrhage as well as the presence and extent of the ischemic core, collateral circulation and penumbra in patients with neurological symptoms. Target mismatch may optimize selection of patients with late or unknown symptom onset who would potentially be eligible for revascularization therapy. The purpose of this study was to provide a comprehensive review of the current evidence about efficacy and theoretical basis of present imaging modalities, and explores future directions for imaging in the management of acute ischemic stroke.

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Endovascular treatment of acute ischemic stroke

Journal of Neurosciences in Rural Practice ◽

10.4103/0976-3147.118787 ◽

2013 ◽

Vol 04 (03) ◽

pp. 298-303 ◽

Cited By ~ 10

Author(s):

Paramdeep Singh ◽

Rupinderjeet Kaur ◽

Amarpreet Kaur

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Standard Treatment ◽

Time Window ◽

High Rate ◽

Endovascular Thrombectomy ◽

Stroke Treatment ◽

Important Approach ◽

Stent Retrievers ◽

Retrievable Stent

ABSTRACTEarly recanalization of the occluded artery leads to better clinical outcomes in patients with acute ischemic stroke (AIS) through protection of the time-sensitive penumbra. Intravenous administration of pharmacologic thrombolytic agents has been a standard treatment for AIS. To get better rates of recanalization, enhance the time window, and diminish the possibility of intracranial hemorrhage, endovascular thrombectomy was launched, with first authorization of the Merci clot retriever, a corkscrew-like apparatus, followed by approval of the Penumbra thromboaspiration system. Both devices lead to a high rate of recanalization. On the other hand, time to recanalization was on an average of 45 minutes, with most of the patients attaining only partial recanalization. More lately, retrievable stents have shown promise in decreasing the time to recanalization, and attaining a superior rate of complete clot resolution. The retrievable stent can be released within the clot to engage it within the struts of the stent, and afterwards it is taken back by pulling it under flow arrest. Neurointerventional techniques have a persistently ever-increasing and stimulating role in the management of AIS, as indicated by the advent of several important techniques. Stent retrievers have the capability to be ascertained as the most important approach to endovascular stroke treatment.

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P-003 Association between baseline serology and symptomatic intracranial hemorrhage after endovascular thrombectomy for acute ischemic stroke

10.1136/neurintsurg-2021-snis.39 ◽

2021 ◽

Author(s):

J Diestro ◽

C Parra-Farinas ◽

M Balas ◽

Z Zador ◽

N Almusalam ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Endovascular Thrombectomy ◽

Symptomatic Intracranial Hemorrhage

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Endovascular Thrombectomy for Acute Ischemic Stroke

Current Cardiology Reports ◽

10.1007/s11886-019-1217-6 ◽

2019 ◽

Vol 21 (10) ◽

Author(s):

Tasneem F. Hasan ◽

Nathaniel Todnem ◽

Neethu Gopal ◽

David A. Miller ◽

Sukhwinder S. Sandhu ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Thrombectomy

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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 T P10: Therapeutic Time Window for Endovascular Therapy of Acute Ischemic Stroke Depends on THRIVE Score: A Retrospective Single-center Study

Stroke ◽

10.1161/str.46.suppl_1.tp10 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Kenichi Todo ◽

Nobuyuki Sakai ◽

Tomoyuki Kono ◽

Taku Hoshi ◽

Hirotoshi Imamura ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Time Window ◽

Medical Center ◽

Multivariate Logistic Regression Analysis ◽

Symptom Duration ◽

Vascular Events ◽

Good Outcome ◽

Therapeutic Time Window

Background and purpose: The outcome after endovascular therapy in acute ischemic stroke is associated with onset-to-reperfusion time (ORT). The Totaled Health Risks in Vascular Events (THRIVE) score is also an important pre-thrapeutic predictor of outcome. We hypothesized that the therapeutic time window is narrower in patients with the higher THRIVE score. Methods: We retrospectively studied consecutive 109 ischemic stroke patients with successful reperfusion after endovascular therapy between October 2005 and March 2014 at a single institute (Kobe City Medical Center General Hospital). Inclusion criteria was as follows: National Institutes of Health Stroke Scale (NIHSS) score ≥8, stroke symptom duration ≤8 h, premorbid modified Rankin Scale (mRS) score ≤2, and thrombolysis myocardial infarction score 2-3. We analyzed the relationships of ORT, THRIVE score, and THRIVE+ORT score with good outcome (mRS ≤2 at 3 months). The THRIVE+ORT score was defined as the sum of the THRIVE score and ORT (h). Results: Median ORT was 5.5 h (IQR; 4.4-7.1 h), median THRIVE score was 5 (IQR; 4-6), and median THRIVE+ORT score was 10.8 (IQR; 9.2-12.5). Good outcome rates for patients with ORT ≤4 h, >4 and ≤6 h, >6 and ≤8 h, and >8h were 50.0%, 45.8%, 37.0%, and 21.4%, respectively (p=0.3), those with THRIVE score ≤3, >3 and ≤5, >5 and ≤7, and >7 were 57.1%, 51.4%, 28.3%, and 20.0%, respectively (p9 and ≤11, >11 and ≤13, and >13 were 64.0%, 44.1%, 34.4%, and 16.7%, respectively (p<0.05). Multivariate logistic regression analysis revealed that THRIVE+ORT score was an independent predictor of good outcome after adjusted for THRIVE score (odds ratio [OR], 1.367; 95% confidence interval [CI], 1.082-1.728) or after adjusted for ORT (OR, 1.517: 95% CI, 1.160-1.983). Conclusion: Our study showed that THRIVE+ORT score was associated with outcome that was independent from THRIVE score or ORT. This is the first report to suggest that patients with the higher THRIVE score require the shorter ORT for good outcome.

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Abstract TMP2: Is Eptifibatide a Viable and Safe Option as Stand-alone Therapy for Acute Ischemic Stroke Patients?

Stroke ◽

10.1161/str.47.suppl_1.tmp2 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Daniel Korya ◽

Mohammad Moussavi ◽

Siddhart Mehta ◽

Jaskiran Brar ◽

Harina Chahal ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Time Window ◽

T Test ◽

Bleeding Complications ◽

Stroke Severity ◽

Paired Samples ◽

Group A ◽

Group B ◽

Iv Tpa

Introduction: The list of contraindications for IV tPA in acute ischemic stroke (AIS) is often too long and may lead to physicians opting to offer no treatment for certain strokes. An alternative treatment is proposed in cases where IV tPA is not an option due to time-window restrictions or contraindications. We compared the stroke severity, outcomes and safety of IV eptifibatide when compared with IV tPA. Methods: Patients who presented to a community based university affiliated comprehensive stroke center from 2012-15 with AIS over a two-year period were included in the study. Those who qualified for IV tPA, and were treated, were compared with patients who only received IV eptifibatide. The initial NIH Stroke Score (NIHSS), 24-hour NIHSS, discharge NIHSS (DCNIHSS), discharge mRS (DCmRS) and symptomatic ICH rates were compared with a paired samples t-test to determine significance of difference between the means. SPSS Version 22 was used for all data analysis. Results: A total of 864 patients presented with AIS in the evaluated time period and of those 166 met study criteria. There were 119 patients who received IV tPA alone (group A) and 47 patients received eptifibatide (group B). The mean initial NIHSS, 24-NIHSS, DCNIHSS, DCmRS and percent bleeding complications for group A were: 11.2, 10.8, 8.6, 3.1 and 6%. For group B the figures were: 6.7, 4.8, 4.3, 1.7 and 0%, respectively. Group A was compared with group B in a paired samples T-test and yielded -4.3, -6.2, -6, -1.5 (p=.0001 to .04) for initial, 24-hour, discharge NIHSS and discharge mRS, respectively. The difference between initial and discharge NIHSS between the two groups was -2.7 (p=.009), favoring IV tPA. Conclusion: In patients who are either outside the time-window or with contraindications to IV tPA, eptifibatide may be a safe alternative and appears to be efficacious. None of the patients who were started on eptifibatide had bleeding complications and they had a statistically significant improvement in their level of disability and stroke severity at discharge. A limitation of this study is that patients in group A had significantly worse initial NIHSS compared with group B. To better evaluate the efficacy of eptifibatide, a larger, prospective study should be initiated.

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Abstract W P32: Association of Low Cerebral Blood Volume With Negative FLAIR Hyperintensity in Acute Ischemic Stroke

Stroke ◽

10.1161/str.45.suppl_1.wp32 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Nandakumar Nagaraja ◽

Marie Luby ◽

Matthew Edwardson ◽

Ramin Zand ◽

Lawrence L Latour

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Blood Volume ◽

Early Phase ◽

Cerebral Blood Volume ◽

Time Window ◽

Linear Regression Analysis ◽

Onset Time ◽

Stroke Onset ◽

Imaging Biomarker

Objective: FLAIR hyperintensity is being used in clinical trials as a surrogate imaging biomarker for stroke onset time to test the safety of thrombolysis. Studies have shown that patients with negative and positive FLAIR hyperintensity overlap at similar time points from stroke onset in the early phase of acute ischemic stroke (AIS). Hyperintensity on FLAIR MRI likely represents increased tissue water content. We sought to determine if cerebral blood volume (CBV) mediates FLAIR hyperintensity in the early phase of AIS. Methods: AIS patients seen in 2012 were included in the study if i) onset time was known, ii) an MRI with perfusion was performed within 12 hours of onset time, iii) had imaging confirmed vascular occlusion of ICA, M1, or M2. Following co-registration of raw perfusion images with FLAIR, CBV maps were generated using PMA ASIST™ software. Two raters blinded to clinical information separately evaluated the DWI, FLAIR and CBV maps and measured the signal intensity ratio (SIR) for the brightest region on FLAIR normalized by homologous contra-lateral tissue. The SIR was similarly measured for CBV in same region. FLAIR negative was defined as SIR<1.15, “Low CBV” was defined as CBV SIR <0.5. Results: One hundred eighty two patients were screened and 30 met all study criteria; 21 women, with mean age of 71 (± 16) years and median NIHSS 18 (IQR 9-22). Using linear regression analysis, CBV SIR was associated with FLAIR SIR (p <0.049). In the 0-3hr time window, overall CBV was not associated with FLAIR hyperintensity. However, in the 3-7.5hr time window, patients with negative FLAIR were more likely to have low CBV and conversely, patients with positive FLAIR were more likely to have normal CBV. Conclusion: CBV likely mediates FLAIR hyperintensity in 3-7.5hr of stroke onset but it has less impact on FLAIR hyperintensity in the first 3 hours of AIS. Low CBV could be a potential surrogate imaging biomarker in addition to FLAIR hyperintensity in the early phase of AIS.

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Acute Ischemic Stroke: A Review of Imaging, Patient Selection, and Management in the Endovascular Era. Part II: Patient Selection, Endovascular Thrombectomy, and Postprocedure Management

Journal of Clinical Interventional Radiology ISVIR ◽

10.1055/s-0038-1675882 ◽

2018 ◽

Vol 02 (03) ◽

pp. 169-183

Author(s):

Sharath Kumar G G ◽

Chinmay Nagesh

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Patient Selection ◽

Secondary Brain Injury ◽

Selection Methods ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Advantages And Disadvantages ◽

Imaging Patient ◽

Selection Of

AbstractAppropriate patient selection and expedient recanalization are the mainstay of modern management of acute ischemic stroke (AIS). Only a minority of patients (7–15%) of patients are eligible for endovascular therapy. Patient selection may be time based or perfusion based. Central to both paradigms is the selection of a patient with a small core, a significant penumbra that can be differentiated from areas of oligemia. A brief review of patient selection methods is presented. Endovascular thrombectomy techniques using stentrievers or aspiration catheters have now become the treatment of choice for AIS with large vessel occlusion. A range of devices, each with its own advantages and disadvantages, are available in the market for the neurointerventionist to choose. Techniques vary between devices and between operators, but standardization and protocolization are important within each center. Complications must be anticipated to be avoided. Once reperfusion is achieved, outcomes must be safeguarded with competent postprocedure management to prevent secondary brain injury. These aspects are reviewed in this article.

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