Endovascular therapy for acute stroke: Quo vadis?

Abstract Endovascular therapy (EVT) has gained vogue in the management of patients with acute stroke. Newer stent-retriever devices have led to better recanalization rates. In many centers, EVT is slowly being used as an add on to or in some instances, even as an alternative to intravenous tissue plasminogen activator (IV tPA). The publication of the results of the SYNTHESIS expansion, Interventional Management of Stroke III and Mechanical Retrieval Recanalization of Stroke Clots Using Embolectomy trials in 2013 has questioned the enthusiastic use of EVT in acute stroke. They demonstrate that EVT (using a variety of devices) is no superior to IV tPA in the management of acute stroke. In the light of these controversial findings, we review the current status of EVT in the management of acute stroke.

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Endovascular therapy in acute ischemic stroke: The way forward after results from the IMS 3, SYNTHESIS and MR Rescue trials

Indian Journal of Neurosurgery ◽

10.4103/2277-9167.118108 ◽

2013 ◽

Vol 02 (02) ◽

pp. 115-118 ◽

Cited By ~ 2

Author(s):

Bijoy Menon ◽

Mayank Goyal

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Endovascular Therapy ◽

Current Status ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen ◽

Iv Tpa

AbstractEndovascular therapy (EVT) has gained vogue in the management of patients with acute stroke. Newer stent-retriever devices have led to better recanalization rates. In many centers, EVT is slowly being used as an add on to or in some instances, even as an alternative to intravenous tissue plasminogen activator (IV tPA). The publication of the results of the SYNTHESIS expansion, Interventional Management of Stroke III and Mechanical Retrieval Recanalization of Stroke Clots Using Embolectomy trials in 2013 has questioned the enthusiastic use of EVT in acute stroke. They demonstrate that EVT (using a variety of devices) is no superior to IV tPA in the management of acute stroke. In the light of these controversial findings, we review the current status of EVT in the management of acute stroke.

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The randomized study of endovascular therapy with versus without intravenous tissue plasminogen activator in acute stroke with ICA and M1 occlusion (SKIP study)

International Journal of Stroke ◽

10.1177/1747493019840932 ◽

2019 ◽

Vol 14 (7) ◽

pp. 752-755 ◽

Cited By ~ 10

Author(s):

Kentaro Suzuki ◽

Kazumi Kimura ◽

Masataka Takeuchi ◽

Masafumi Morimoto ◽

Ryuzaburo Kanazawa ◽

...

Keyword(s):

Acute Stroke ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Endovascular Therapy ◽

Randomized Study ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

Bridging Therapy ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen

Rationale Bridging therapy with endovascular therapy (EVT) and intravenous thrombolysis (IVT) has been reported to improve outcomes for acute stroke patients with large-vessel occlusion in the anterior circulation. While the IVT may increase the reperfusion rate, the risk of hemorrhagic complications increases. Whether EVT without IVT (direct EVT) is equally effective as bridging therapy in acute stroke remains unclear. Aim This randomized study of endovascular therapy with versus without intravenous tissue plasminogen activator for acute stroke with ICA and M1 occlusion aims to clarify the efficacy and safety of direct EVT compared with bridging therapy. Methods and design This is an investigator-initiated, multicenter, prospective, randomized, open-treatment, blinded-endpoint clinical trial. The target patient number is 200, comprising 100 patients receiving direct EVT and 100 receiving bridging therapy. Study outcome The primary efficacy endpoint is a modified Rankin Scale score of 0–2 at 90 days. Safety outcome measures are any intracranial hemorrhage at 24 h. Discussion This trial may help determine whether direct EVT should be recommended as a routine clinical strategy for ischemic stroke patients within 4.5 h from onset. Direct EVT would then become the choice of therapy in stroke centers with endovascular facilities. Trial registration UMIN000021488.

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Utilization rates of tissue plasminogen activator and mechanical thrombectomy in patients with acute stroke and underlying malignancy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014480 ◽

2019 ◽

Vol 11 (8) ◽

pp. 768-771 ◽

Cited By ~ 2

Author(s):

Lorenzo Rinaldo ◽

Harry J Cloft ◽

Leonardo Rangel Castilla ◽

Alejandro A Rabinstein ◽

Waleed Brinjikji

Keyword(s):

Acute Stroke ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Mechanical Thrombectomy ◽

Population Level ◽

National Database ◽

Intravenous Tissue Plasminogen Activator ◽

Underlying Malignancy ◽

Tissue Plasminogen ◽

Iv Tpa

ObjectiveRelatively little is known about the effect of malignancy on patient outcomes after acute ischemic stroke (AIS) or utilization rates of stroke interventions in this population. We aimed to assess the effect of underlying malignancy on outcomes and treatment of AIS at a population level.MethodsOutcomes after AIS between patients with and without malignancy were compared using a national database of hospital reported outcomes.ResultsThere were 351 institutions reporting the outcomes of 3 18 127 admissions for AIS. Of these admissions, 16 141 patients carried a pre-existing diagnosis of malignancy at the time of admission. Administration of intravenous tissue plasminogen activator (IV tPA) was less common in patients with malignancy compared with patients without malignancy (7.3% vs 10.7%; P<0.001) but there was no difference in the rate of mechanical thrombectomy (3.1% vs 3.1%; P=0.967). Mortality rates were higher among patients with malignancy (7.1% vs 3.7%; P<0.001), a relationship which persisted when analysis was restricted to patients receiving IV tPA (10.8% vs 6.1%; P<0.001) or thrombectomy (20.3% vs 13.5%; P<0.001). Rates of both IV tPA administration (2.5% vs 10.5%; P<0.001) and mechanical thrombectomy (2.1% vs 5.4%; P<0.001) were lower in patients with brain malignancy relative to patients with malignancy of non-CNS origin.ConclusionA diagnosis of malignancy on admission for acute stroke was associated with a higher rate of mortality. Malignancy was also associated with a lower rate of IV tPA administration but no difference in mechanical thrombectomy utilization.

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Validation of FLAIR Hyperintense Lesions as Imaging Biomarkers to Predict the Outcome of Acute Stroke after Intra-Arterial Thrombolysis following Intravenous Tissue Plasminogen Activator

Cerebrovascular Diseases ◽

10.1159/000350201 ◽

2013 ◽

Vol 35 (5) ◽

pp. 461-468 ◽

Cited By ~ 9

Author(s):

Jong-Won Chung ◽

Kyeong Joon Kim ◽

Won-Young Noh ◽

Myung Suk Jang ◽

Mi Hwa Yang ◽

...

Keyword(s):

Acute Stroke ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Imaging Biomarkers ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen ◽

Arterial Thrombolysis

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Abstract WP72: Early Experience on Intravenous Tissue Plasminogen Activator Delivery in Mobile Stroke Unit Patients with Stroke Mimics

Stroke ◽

10.1161/str.48.suppl_1.wp72 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Lila E Sheikhi ◽

Stacey Winners ◽

Pravin George ◽

Andrew Russman ◽

Zeshaun Khawaja ◽

...

Keyword(s):

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Stroke Unit ◽

Early Experience ◽

Final Diagnosis ◽

Stroke Mimics ◽

Intravenous Tissue Plasminogen Activator ◽

Mobile Stroke Unit ◽

Tissue Plasminogen ◽

Iv Tpa

Background: A mobile stroke unit (MSU) allows for early delivery for intravenous tissue plasminogen activator (IV-tPA). A proportion of IV-tPA treated patients may turn out to be stroke mimics. We evaluated the rate and complications seen in stroke mimics treated with tPA from our early experience on MSU. Methods: Retrospective review of patients treated with IV-tPA on the MSU from 2014 to 2016. Charts were reviewed for confirmed strokes by imaging (MRI or CT) and hemorrhagic transformation. Stroke mimics were defined as those without imaging evidence of infarction and a final diagnosis which was not suspected to be stroke. Results: Among 62 patients treated with IV-tPA, 14 (28.6%) had a final diagnosis consistent with a stroke mimics. The majority of these occurred in the first year of the MSU program. Most common mimics included conversion disorder (n=5) and seizures (n=5). While the last known well to IV-tPA times were similar, the MSU door-to-needle time was significantly longer in stroke mimics (38 vs 31 minutes, p = 0.03). No intracerebral hemorrhages or other IV-tPA related complications were identified in the stroke mimics group. Conclusions: In our early experience with MSU, treatment of stroke mimics occurred without IV-tPA related complications. This does not appear to be due to rushed decision making.

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Medicolegal Considerations with Intravenous Tissue Plasminogen Activator in Stroke: A Systematic Review

Stroke Research and Treatment ◽

10.1155/2013/562564 ◽

2013 ◽

Vol 2013 ◽

pp. 1-6 ◽

Cited By ~ 8

Author(s):

Archit Bhatt ◽

Adnan Safdar ◽

Dhara Chaudhari ◽

Diane Clark ◽

Amber Pollak ◽

...

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Malpractice Litigation ◽

Extensive Search ◽

Intravenous Tissue Plasminogen Activator ◽

Increased Risk ◽

Tissue Plasminogen ◽

Iv Tpa

Background.Intravenous tPA (tissue plasminogen activator) therapy remains underutilized in patients with Acute Ischemic Stroke (AIS). Anecdotal data indicates that physicians are increasingly liable for administering and for failure to administer tPA.Methods.An extensive search of Medline, Embase, Westlaw, LexisNexis Legal, and Google Scholar databases was performed. Case studies that involved malpractice litigation in ischemic stroke and thrombolytic therapy were analyzed systematically.Results.We identified 789 ischemic stroke litigation cases, of which 46 cases were related to intravenous tPA and stroke litigation. Case descriptions of 40 cases were available. Data for verdicts were available for 38 patients. The most frequent plaintiff claim was related to failure to administer intravenous tPA (38, 95%). Only 2 (5.0%) claim involved complications of treatment with tPA. Hospitals were defendants in majority of the 36 cases. Physicians were involved in 33 cases. While ED physicians were involved in 25 (60.52%) cases, neurologists were involved in 8 (20.0%) cases. There were 26 (65%) defendant-favored and 12 (30%) plaintiff-favored verdicts.Conclusion.Physicians and hospitals are at an increased risk of litigation in patients with AIS when in IV-tPA is being considered for treatment. While majority of the cases litigated were cases where tPA was not administered, only about 1 in 20 cases was litigated when complications occurred.

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Acute stroke thrombolysis with intravenous tissue plasminogen activator in an Australian tertiary hospital

The Medical Journal of Australia ◽

10.5694/j.1326-5377.2003.tb05223.x ◽

2003 ◽

Vol 178 (7) ◽

pp. 324-328 ◽

Cited By ~ 33

Author(s):

Cassandra E I Szoeke ◽

Mark W Parsons ◽

Kenneth S Butcher ◽

Tracey A Baird ◽

Peter J Mitchell ◽

...

Keyword(s):

Acute Stroke ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Tertiary Hospital ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen ◽

Stroke Thrombolysis

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Abstract 114: 24/7 Stroke Nurse Team Coverage Reduced Door-to-needle Time and Improved Tissue Plasminogen Activator Utilization Rates in a Stroke Level 1 Community Hospital

Stroke ◽

10.1161/str.48.suppl_1.114 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Zohaib Haque ◽

Marsha Enchelmeier ◽

Stephanie Bern ◽

Maheen Malik

Keyword(s):

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Community Hospital ◽

Heart Association ◽

Rapid Response Team ◽

Complication Rates ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen ◽

Primary Stroke Center ◽

Iv Tpa

Background: Although the American Heart Association has placed particular emphasis on the importance of improving door-to-imaging (DTI) and door-to-needle (DTN) times, treatment with intravenous tissue Plasminogen Activator (IV tPA) remains nationally low in Acute Ischemic Stroke (AIS) patients, especially for community hospitals due to a lack of in-house neurovascular physician coverage. We sought to remedy this problem by implementing round-the-clock coverage of the Emergency Department by Stroke-trained nurses for patients presenting with AIS who may be appropriate to receive IV tPA. Methods: AIS patients treated with IV tPA at a Community Hospital and Primary Stroke Center in St. Louis, Missouri were studied between 2013 and 2016. A 24/7 Rapid Response Team of nurses was trained as specialized stroke responders for which the DTI time, DTN time, and IV tPA utilization rates were then compared between pre-implementation (12 months) and post-implementation (30 months). Results: We studied 189 Stroke Code patients who were treated with IV tPA (40 pre-implementation and 149 post). The median DTI time was reduced from 16 minutes (interquartile range [IQR]10-21) to 11 minutes (IQR 6-12) (P < .05), and the median DTN time was reduced from 64 minutes (IQR 44-79) to 51 minutes (IQR 39-65) (P<.05). Compliance within the 60-minute benchmark DTN time improved from 55% (27 of 44 patients) to 76.1% (113 of 149 patients) treated in less than 60 minutes with 53.5% (80 of 149 patients) being treated in less than 45 minutes (P<.05). The tPA treatment rates also increased pre and post-implementation by 77.5% (40 to 71 patients) (P<.05) while IV tPA complication rates decreased from 7.3% to 2.7% (P<.10). Conclusions: Implementation of round-the-clock on-site stroke nurse coverage for Acute Stroke Code significantly reduced the DTI and DTN time while increasing treatment rates and decreasing complications amongst patients with AIS treated with IV tPA.

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