scholarly journals Stimulating the Facial Nerve to Treat Ischemic Stroke: A Systematic Review

2021 ◽  
Vol 12 ◽  
Author(s):  
Turner S. Baker ◽  
Justin Robeny ◽  
Danna Cruz ◽  
Alexis Bruhat ◽  
Alfred-Marc Iloreta ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Absolute Number ◽  
Clinical Findings ◽  
Recent Trial ◽  
Future Directions ◽  
Tissue Plasminogen ◽  
Facial Nerves ◽  
Stimulation Of ◽  
Viable Treatment

Acute ischemic stroke (AIS) is a common devastating disease that has increased yearly in absolute number of cases since 1990. While mechanical thrombectomy and tissue plasminogen activator (tPA) have proven to be effective treatments, their window-of-efficacy time is very short, leaving many patients with no viable treatment option. Over recent years there has been a growing interest in stimulating the facial nerves or ganglions to treat AIS. Pre-clinical studies have consistently demonstrated an increase in collateral blood flow (CBF) following ganglion stimulation, with positive indications in infarct size and neurological scores. Extensive human trials have focused on trans-oral electrical stimulation of the sphenopalatine ganglion, but have suffered from operational limitations and non-significant clinical findings. Regardless, the potential of ganglion stimulation to treat AIS or elongate the window-of-efficacy for current stroke treatments remains extremely promising. This review aims to summarize results from recent trial publications, highlight current innovations, and discuss future directions for the field. Importantly, this review comes after the release of four important clinical trials that were published in mid 2019.

ERic Acute StrokE Recanalization: A study using predictive analytics to assess a new device for mechanical thrombectomy

2017 ◽  
Vol 12 (6) ◽  
pp. 659-666 ◽  
Author(s):  
Susanne Siemonsen ◽  
Nils D Forkert ◽  
Martina Bernhardt ◽  
Götz Thomalla ◽  
Martin Bendszus ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Trial Design ◽  
Mechanical Thrombectomy ◽  
Predictive Analytics ◽  
Stroke Patients ◽  
Tissue Plasminogen

Aim and hypothesis Using a new study design, we investigate whether next-generation mechanical thrombectomy devices improve clinical outcomes in ischemic stroke patients. We hypothesize that this new methodology is superior to intravenous tissue plasminogen activator therapy alone. Methods and design ERic Acute StrokE Recanalization is an investigator-initiated prospective single-arm, multicenter, controlled, open label study to compare the safety and effectiveness of a new recanalization device and distal access catheter in acute ischemic stroke patients with symptoms attributable to acute ischemic stroke and vessel occlusion of the internal cerebral artery or middle cerebral artery. Study outcome The primary effectiveness endpoint is the volume of saved tissue. Volume of saved tissue is defined as difference of the actual infarct volume and the brain volume that is predicted to develop infarction by using an optimized high-level machine learning model that is trained on data from a historical cohort treated with IV tissue plasminogen activator. Sample size estimates Based on own preliminary data, 45 patients fulfilling all inclusion criteria need to complete the study to show an efficacy >38% with a power of 80% and a one-sided alpha error risk of 0.05 (based on a one sample t-test). Discussion ERic Acute StrokE Recanalization is the first prospective study in interventional stroke therapy to use predictive analytics as primary and secondary endpoint. Such trial design cannot replace randomized controlled trials with clinical endpoints. However, ERic Acute StrokE Recanalization could serve as an exemplary trial design for evaluating nonpivotal neurovascular interventions.

scholarly journals Stent retriever thrombectomy with aneurysm in target vessel: Technical note

2016 ◽  
Vol 22 (5) ◽  
pp. 544-547 ◽  
Author(s):  
Jasmeet Singh ◽  
Stacey Q Wolfe
Keyword(s):  
Ischemic Stroke ◽  
Internal Carotid ◽  
Mechanical Thrombectomy ◽  
Technical Note ◽  
Stent Retriever ◽  
Left Internal Carotid Artery ◽  
Target Vessel ◽  
Bifurcation Aneurysm ◽  
Tissue Plasminogen ◽  
Iv Tpa

Aneurysms within large occluded target vessels can present significant challenges for neuro interventionists because rupture can be catastrophic. We recently encountered a case of left internal carotid artery–middle cerebral artery (MCA) ischemic stroke with an incidental MCA bifurcation aneurysm that we were already aware of. IV tissue plasminogen activator (tPA) with mechanical thrombectomy (MTE) was performed with a stent retriever, proximal to the aneurysm. TICI 2b recanalization was achieved. MTE and IV tPA may not be withheld from patients with acute stroke with known target vessel aneurysms.

scholarly journals Cost-effectiveness analysis of mechanical thrombectomy in acute ischemic stroke

2009 ◽  
Vol 110 (3) ◽  
pp. 508-513 ◽  
Author(s):  
Chirag G. Patil ◽  
Elisa F. Long ◽  
Maarten G. Lansberg
Keyword(s):  
Ischemic Stroke ◽  
Cost Effectiveness ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Medical Therapy ◽  
Mechanical Thrombectomy ◽  
Cost Effective ◽  
Standard Medical Therapy ◽  
Tissue Plasminogen

Object Mechanical thrombectomy is increasingly being used for the treatment of large-vessel ischemic stroke in patients who arrive outside of the 3-hour tissue plasminogen activator time window. In this study, the authors evaluated the cost and effectiveness of mechanical thrombectomy compared with standard medical therapy in patients who are ineligible to receive tissue plasminogen activator. Methods Clinical outcomes of an open-label study of mechanical thrombectomy were compared with a hypothetical control group with a lower recanalization rate (18 vs 60%) and a lower rate of symptomatic intracranial hemorrhage (0.6 vs 7.8%) than the active treatment group. A Markov cost-effectiveness model was built to compare the health benefits and costs associated with mechanical thrombectomy compared with standard medical therapy. All probabilities, quality-of-life factors, and costs were estimated from the published literature. Univariate sensitivity analyses were performed to assess how variations in model parameters affect health and economic outcomes. Results Treatment of acute ischemic stroke with mechanical thrombectomy increased survival time by 0.54 quality-adjusted life years (QALYs), compared with standard medical therapy (2.37 vs 1.83 QALYs), at an increased cost of $6600. This yielded an incremental cost-effectiveness ratio (ICER) of $12,120 per QALY gained, a value generally considered cost-effective. Sensitivity analysis showed that mechanical thrombectomy remained cost-effective (ICER < $50,000 per QALY gained) for all model inputs varied over a reasonable range, except for age at stroke treatment. For patients older than 82 years of age, the treatment was only borderline cost-effective (ICER of $50,000–100,000 per QALY gained). Conclusions The treatment of large-vessel ischemic stroke with mechanical thrombectomy appears to be costeffective. These results require validation when data from a randomized, controlled trial of mechanical thrombectomy become available.

scholarly journals Efficacy of beveled tip aspiration catheter in mechanical thrombectomy for acute ischemic stroke

2020 ◽  
pp. neurintsurg-2020-016695
Author(s):  
Jan Vargas ◽  
Jonathan Blalock ◽  
Anand Venkatraman ◽  
Vania Anagnostakou ◽  
Rrobert M King ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Infarction ◽  
Acute Ischemic Stroke ◽  
Retrospective Analysis ◽  
Mechanical Thrombectomy ◽  
Modified Rankin Scale ◽  
Aspiration Thrombectomy ◽  
Patient Demographics ◽  
Significant Difference ◽  
Tissue Plasminogen

BackgroundDirect aspiration thrombectomy techniques use large bore aspiration catheters for mechanical thrombectomy. Several aspiration catheters are now available. We report a bench top exploration of a novel beveled tip catheter and our experience in treating large vessel occlusions (LVOs) using next-generation aspiration catheters.MethodsA retrospective analysis from a prospectively maintained database comparing the bevel shaped tip aspiration catheter versus non-beveled tip catheters was performed. Patient demographics, periprocedural metrics, and discharge and 90-day modified Rankin Scale (mRS) scores were collected. Patients were divided into two groups based on which aspiration catheter was used.ResultsOur data showed no significant difference in age, gender, IV tissue plasminogen activator administration, admission NIH Stroke Scale score, baseline mRS, or LVO location between the beveled tip and flat tip groups. With the beveled tip, Thrombolysis in Cerebral Infarction (TICI) 2C or better recanalization was more frequent overall (93.2% vs 74.2%, p=0.017), stent retriever usage was lower (9.1% vs 29%, p=0.024), and patients had lower mRS on discharge (median 3 vs 4, p<0.001) and at 90 days (median 2 vs 4, p=0.008).ConclusionPatients who underwent mechanical thrombectomy with the beveled tip catheter had a higher proportion of TICI 2C or better and had a significantly lower mRS score on discharge and at 90 days.

scholarly journals Outcome of mechanical thrombectomy in the very elderly for the treatment of acute ischemic stroke: the real world experience

2015 ◽  
Vol 4 (9) ◽  
pp. 205846011559942 ◽  
Author(s):  
Chiu Yuen To ◽  
Sina Rajamand ◽  
Ratnesh Mehra ◽  
Stephanie Falatko ◽  
Yaser Badr ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Elderly Patients ◽  
Acute Ischemic Stroke ◽  
Patient Outcomes ◽  
Mechanical Thrombectomy ◽  
Very Elderly ◽  
Symptomatic Intracranial Hemorrhage ◽  
Viable Treatment

Background Although initial studies of neuroendovascular intervention did not review benefit over intravenous thrombolytics (iv r-tPA), recent studies have suggested otherwise. Elderly patients (age ≥80 years) are typically excluded from clinical trials. Purpose To examine the utility of mechanical thrombectomy based on patient outcomes. Material and Methods All stroke-alert activations at our health system from January 2011 to June 2014 were examined. All patients aged ≥80 years who had undergone mechanical thrombectomy were identified. Clinical characteristics included physiologic imaging findings, use of intravenous thrombolytics, baseline and postoperative National Institute of Health Stroke Scale (NIHSS), thrombolysis in cerebral infarction scores (TICI), and discharge destination. Results Mean NIHSS on presentation was 18.2 (range, 6–31), and 13.3 (range, 3–30) post thrombectomy. Three (16.6%) patients received iv r-tPA, two (11.1%) had symptomatic intracranial hemorrhage. Eight (44.4%) died, eight (44.4%) were discharged to nursing homes, and two (11.7%) were discharged to inpatient rehab and subsequently home. Favorable outcome was achieved in five (27.7%) patients. Fourteen (77.7%) patients had physiologic imaging prior to intervention. Three (75%) of four patients who did not have physiologic imaging prior to thrombectomy died. Thirteen (66.6%) patients had TICI 3 recanalization. Conclusion Our study showed that although there remains a role of mechanical thrombectomy in the treatment of acute ischemic stroke in very elderly patients, it is associated with significant higher morbidity and mortality compared to younger patients, but should remain a very viable treatment option when quality of life is the most important consideration.

Safety and Outcome of Intravenous Recombinant Tissue Plasminogen Activator (rt-PA) in the Nursing Home Residents Following an Acute Ischemic Stroke

2021 ◽  
pp. 251660852110162
Author(s):  
Elanagan Nagarajan ◽  
Lakshmi P. Digala ◽  
Anudeep Yelam ◽  
Pradeep C. Bollu ◽  
Premkumar C. Nattanmai
Keyword(s):  
Ischemic Stroke ◽  
Nursing Home ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Mechanical Thrombectomy ◽  
Recombinant Tissue Plasminogen Activator ◽  
Care Hospital ◽  
Tissue Plasminogen

Background and Purpose: Intravenous recombinant tissue plasminogen activator (IV rt-PA) is an effective treatment of acute ischemic stroke. The safety and efficacy of IV rt-PA were extensively studied in adults, including both octogenarians and nonagenarians.This study provides safety outcome of exclusive nursing home (NH) residents (dependent on activities of daily living [ADLs]) , who received IV rt-PA. Not much literature or studies are available exclusively on the NH residents. Aim: To assess the safety and outcome of IV rt-PA in patients from NHs who were admitted to our university-based tertiary care hospital, using data from a prospective stroke registry. Methods: Our study is a retrospective review of patients living in nursing facilities, admitted to our neuroscience intensive care unit after receiving IV rt-PA, from January 2010 to June 2018. We reviewed the clinical symptoms, comorbid conditions, medications, diagnostic evaluation, complications, and functional outcomes. The functional outcome was assessed based on the modified Rankin Scale (mRS) at the time of discharge, and 1- and 3-month follow-up. Results: Twenty-eight NH residents (20 [71.4%] were female with a mean age of 80.96 +/− 12.43 years) were identified who had received IV rt-PA for symptoms of acute ischemic stroke. The median mRS on admission was 3, and all of them were dependent on ADL. Twenty-seven (96.5%) patients were treated within the window (≤3 h) for IV rt-PA. There were no IV rt-PA-related violations from both our hospital and outside hospital treatment protocols. The initial computed tomographic (CT) scan of 8 (28.5%) patients revealed evidence of infarction. CT angiogram of head and neck revealed an acute intracranial blood vessel occlusion in 13 (46.4%) patients, and asymptomatic stenosis of intracranial and extracranial blood vessels in 4 (14.2%) patients. Mechanical thrombectomy was attempted in 6 (21.4%) patients and among them, the procedure was unsuccessful in 2 (7.1%) patients due to severe stenosis. One (1/21; 16.6%) patient received an intra-arterial rt-PA, and 5 (5/6;83.3%) patients developed symptomatic intracranial hemorrhage within 24 h following the procedure. Families of 9/28 (32.1%) patients decided to withdraw care. The median mRS on 30 and 90 days follow-up was 4 (interquartile range: 3-6). Conclusion: In this population, mechanical thrombectomy has a high risk for hemorrhagic conversion. IV rt-PA treatment in the NH residents may not improve the outcome of ischemic stroke.

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