scholarly journals The History of Neurosurgical Management of Ischemic Stroke

2021 ◽  
Author(s):  
Lydia Kaoutzani ◽  
Scott Y. Rahimi

Stroke remains a major public health issue and the second leading cause of death worldwide. The Hippocratic Corpus used the word apoplexy to describe a person collapsing while retaining pulse and respiration. This is believed to be the first written description of stroke. The theories of what caused stroke evolved over the years. When autopsies were performed stroke was attributed to emboli and thrombi formation. Carotid endarterectomies (CEA) were then performed for the treatment of stroke. Originally CEA were seen with skepticism but the North American Symptomatic Carotid Endarterectomy trial (NASCET) and the European Carotid Surgery trial (ECS) helped restore their efficacy in the management of ischemic stroke. A milestone in the management of ischemic stroke was the use of intravenous tissue plasminogen activator (tPA). Secondary to the limitations of the use of tPA other avenues were sought which included intraarterial recombinant prourokinase and mechanical thrombectomy. The field of mechanical thrombectomy continues to be rapidly changing and evolving. Various randomized controlled trials and meta-analysis have been conducted in order to evaluate who will benefit from mechanical thrombectomies, the timing, the best device to use and the role of combining this intervention with the administration of intravenous tPA.

2021 ◽  
Vol 12 ◽  
Author(s):  
Gautam Adusumilli ◽  
John M. Pederson ◽  
Nicole Hardy ◽  
Kevin M. Kallmes ◽  
Kristen Hutchison ◽  
...  

Background: Mechanical thrombectomy (MT) is now the standard-of-care treatment for acute ischemic stroke (AIS) of the anterior circulation and may be performed irrespective of intravenous tissue plasminogen activator (IV-tPA) eligibility prior to the procedure. This study aims to understand better if tPA leads to higher rates of reperfusion and improves functional outcomes in AIS patients after MT and to simultaneously evaluate the functionality and efficiency of a novel semi-automated systematic review platform.Methods: The Nested Knowledge AutoLit semi-automated systematic review platform was utilized to identify randomized control trials published between 2010 and 2021 reporting the use of mechanical thrombectomy and IV-tPA (MT+tPA) vs. MT alone for AIS treatment. The primary outcome was the rate of successful recanalization, defined as thrombolysis in cerebral infarction (TICI) scores ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS) 0–2, 90-day mortality, distal embolization to new territory, and symptomatic intracranial hemorrhage (sICH). A separate random effects model was fit for each outcome measure.Results: We subjectively found Nested Knowledge to be highly streamlined and effective at sourcing the correct literature. Four studies with 1,633 patients, 816 in the MT+tPA arm and 817 in the MT arm, were included in the meta-analysis. In each study, patient populations consisted of only tPA-eligible patients and all imaging and clinical outcomes were adjudicated by an independent and blinded core laboratory. Compared to MT alone, patients treated with MT+tPA had higher odds of eTICI ≥2b (OR = 1.34 [95% CI: 1.10; 1.63]). However, there were no statistically significant differences in the rates of 90-day mRS 0-2 (OR = 0.98 [95% CI: 0.77; 1.24]), 90-day mortality (OR = 0.94 [95% CI: 0.67; 1.32]), distal emboli (OR = 0.94 [95% CI: 0.25; 3.60]), or sICH (OR = 1.17 [95% CI: 0.80; 1.72]).Conclusions: Administering tPA prior to MT may improve the rates of recanalization compared to MT alone in tPA-eligible patients being treated for AIS, but a corresponding improvement in functional and safety outcomes was not present in this review. Further studies looking at the role of tPA before mechanical thrombectomy in different cohorts of patients could better clarify the role of tPA in the treatment protocol for AIS.


2021 ◽  
Vol 12 ◽  
Author(s):  
Hubert Lee ◽  
Ayman M. Qureshi ◽  
Nils H. Mueller-Kronast ◽  
Osama O. Zaidat ◽  
Michael T. Froehler ◽  
...  

Background: The indications for mechanical thrombectomy in acute ischemic stroke continue to broaden, leading neurointerventionalists to treat vessel occlusions at increasingly distal locations farther in time from stroke onset. Accessing these smaller vessels raises the concern of iatrogenic subarachnoid hemorrhage (SAH) owing to increasing complexity in device navigation and retrieval. This study aims to determine the prevalence of SAH following mechanical thrombectomy, associated predictors, and resulting functional outcomes using a multicenter registry and compare this with a systematic review and meta-analysis of the literature.Methods: Data from STRATIS (The Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke) registry were analyzed dichotomized by the presence or absence of SAH after thrombectomy. Only patients with 24-h post-procedural neuroimaging were included (n = 841). Multivariable logistic regression was performed to identify significant predictors of SAH. A systematic review and random-effects meta-analysis was also conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) protocol.Results: The prevalence of post-thrombectomy SAH was 5.23% in STRATIS with 15.9% (1.84% overall) experiencing neurological decline. Distal location of vessel occlusion (OR 3.41 [95% CI: 1.75–6.63], p < 0.001) and more than 3 device passes (OR 1.34 [95% CI: 1.09–1.64], p = 0.01) were associated with a higher probability of SAH in contrast to a reduction with administration of intravenous tissue plasminogen activator (tPA) (OR 0.48 [95% CI: 0.26–0.89], p = 0.02). There was a trend toward a higher discharge NIHSS (8.3 ± 8.7 vs. 5.3 ± 6.6, p = 0.07) with a significantly reduced proportion achieving functional independence at 90 days (modified Rankin Score 0–2: 32.5% vs. 57.8%, p = 0.002) in SAH patients. Pooled analysis of 10,126 patients from 6 randomized controlled trials and 64 observational studies demonstrated a prevalence of 5.85% [95% CI: 4.51–7.34%, I2: 85.2%]. Only location of vessel occlusion was significant for increased odds of SAH at distal sites (OR 2.89 [95% CI: 1.14, 7.35]).Conclusions: Iatrogenic SAH related to mechanical thrombectomy is more common with treatment of distally-situated occlusions and multiple device passes. While low in overall prevalence, its effect is not benign with fewer patients reaching post-procedural functional independence, particularly if symptomatic.


Diabetes ◽  
2018 ◽  
Vol 67 (Supplement 1) ◽  
pp. 2406-PUB
Author(s):  
KONSTANTINA KANELLOPOULOU ◽  
IOANNIS L. MATSOUKIS ◽  
ASIMINA GANOTOPOULOU ◽  
THEODORA ATHANASOPOULOU ◽  
CHRYSOULA TRIANTAFILLOPOULOU ◽  
...  

2019 ◽  
Vol 24 (5) ◽  
pp. 558-571 ◽  
Author(s):  
Kartik Bhatia ◽  
Hans Kortman ◽  
Christopher Blair ◽  
Geoffrey Parker ◽  
David Brunacci ◽  
...  

OBJECTIVEThe role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge.METHODSUsing PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors’ centers was also included. The primary outcomes were the rate of good long-term (mRS score 0–2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0–1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).RESULTSThe authors’ review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0–2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age.CONCLUSIONSMechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1–18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.


2020 ◽  
pp. 7-32
Author(s):  
Katarzyna Kulczyńska ◽  
Natalia Borowicz ◽  
Karolina Piwnicka-Wdowikowska

Morasko University Campus in Poznań – origin, spatial and functional structure, transport solutions The purpose of the paper is to characterize the most recently created part of the Adam Mickiewicz University – the Morasko Campus. The paper consists of three parts. The first concerns the origins and development of the campus. The second part presents its spatial and functional structure on the basis of a field inventory, while the third one – campus transport solutions based on a survey conducted among students. The history of the campus located in the northern, peripheral part of the city began with laying the foundation act and the cornerstone in 1977. The agricultural role of this area, dominant until the 1980s, has been replaced with new functions, mainly academic and scientific ones. The first university buildings were commissioned in the 1990s, and the construction boom began after 2000. A total of nine faculties (out of 21 existing) are housed in eight buildings in the campus, including exact and natural sciences, as well as a part of social sciences and humanities. To this day, neither student dormitories nor accommodation for PhD students have been constructed (although they are likely to be built), which would emphasize the academic function of the campus. The campus also comprises areas with recreational, sports, residential and other service functions (e.g. catering, beauty, hairdressing, and commercial services), which are complemented by areas that serve transport functions. Location in the northern periphery of the city, and above all the railway line for freight (the northern bypass of Poznań) separating the city from the campus, makes transport to this part of the city limited. The results of the survey revealed a lack of a safe bicycle path between the western and eastern part of the campus, insufficient number of parking places for motorists, a lack of paved roads from the north and west, only three narrow access roads for car commuters, and difficult access by public transport to the eastern and north-eastern parts. In the latter case, the planned extension of the tram line towards Umultowo after the year 2022 is expected to solve the problem. Zarys treści: Celem opracowania jest charakterystyka najmłodszej przestrzeni Uniwersytetu im. Adama Mickiewicza – Kampusu Morasko. Opracowanie składa się z trzech zasadniczych części. Pierwsza część artykułu dotyczy genezy powstania i rozbudowy miasteczka uniwersyteckiego. W drugiej części przedstawiono strukturę przestrzenno-funkcjonalną kampusu w oparciu o inwentaryzację terenową, w trzeciej zaś obsługę transportową na podstawie badań ankietowych przeprowadzonych wśród studentów. Historia położonego w północnej, peryferyjnej części miasta kampusu rozpoczęła się od wmurowania aktu erekcyjnego i kamienia węgielnego w 1977 r. Dominująca do lat 80. XX w. funkcja rolnicza tego obszaru została zastąpiona przez nowe funkcje, głównie akademickie i naukowe. Pierwsze budynki dydaktyczne oddano do użytku dopiero w latach 90. ubiegłego wieku, a boom budowlany rozpoczął się po roku 2000. Swoją siedzibę znalazły tutaj nauki ścisłe i przyrodnicze, a także część nauk społecznych i humanistycznych, w sumie dziewięć wydziałów (na 21 istniejących) w ośmiu budynkach. Do dzisiaj nie wybudowano akademików czy domu doktoranta (choć istnieją realne szanse na ich powstanie), co podkreśliłoby funkcję akademicką kampusu. W strukturze kampusu wyróżnia się ponadto obszary o funkcjach rekreacyjnych, rekreacyjno-sportowych, mieszkaniowych i innych o charakterze usługowym (np. usługi gastronomiczne, kosmetyczne, fryzjerskie, handel), których uzupełnieniem są obszary o funkcjach komunikacyjnych. Położenie na północnych peryferiach miasta, a przede wszystkim linia kolejowa dla przewozów towarowych (północna obwodnica Poznania) oddzielająca miasto od kampusu sprawiają, że obsługa transportowa tej części miasta jest ograniczona. Wyniki badań ankietowych wskazują na brak bezpiecznej drogi rowerowej między zachodnią i północno-wschodnią częścią kampusu, niewystarczającą liczbę miejsc parkingowych dla zmotoryzowanych, brak utwardzonych dróg od strony północnej i zachodniej, zaledwie trzy wąskie wjazdy na kampus dla dojeżdżających samochodem czy utrudniony dojazd komunikacją publiczną do części wschodniej i północno-wschodniej. W tym ostatnim przypadku rozwiązaniem ma być planowana po 2022 r. rozbudowa linii tramwajowej w kierunku Umultowa.


2018 ◽  
Vol 45 (5-6) ◽  
pp. 279-287 ◽  
Author(s):  
Frans Kauw ◽  
Richard A.P. Takx ◽  
Hugo W.A.M. de Jong ◽  
Birgitta K. Velthuis ◽  
L. Jaap Kappelle ◽  
...  

Background: Predictors of recurrent ischemic stroke are less well known in patients with a recent ischemic stroke than in patients with transient ischemic attack (TIA). We identified clinical and radiological factors for predicting recurrent ischemic stroke in patients with recent ischemic stroke. Methods: A systematic search in PubMed, Embase, Cochrane Library, and CINAHL was performed with the terms “ischemic stroke,” “predictors/determinants,” and “recurrence.” Quality assessment of the articles was performed and the level of evidence was graded for the articles included for the meta-analysis. Pooled risk ratios (RR) and heterogeneity (I2) were calculated using inverse variance random effects models. Results: Ten articles with high-quality results were identified for meta-analysis. Past medical history of stroke or TIA was a predictor of recurrent ischemic stroke (pooled RR 2.5, 95% CI 2.1–3.1). Small vessel strokes were associated with a lower risk of recurrence than large vessel strokes (pooled RR 0.3, 95% CI 0.1–0.7). Patients with stroke of an undetermined cause had a lower risk of recurrence than patients with large artery atherosclerosis (pooled RR 0.5, 95% CI 0.2–1.1). We found no studies using CT or ultrasound for the prediction of recurrent ischemic stroke. The following MRI findings were predictors of recurrent ischemic stroke: multiple lesions (pooled RR 1.7, 95% CI 1.5–2.0), multiple stage lesions (pooled RR 4.1, 95% CI 3.1–5.5), multiple territory lesions (pooled RR 2.9, 95% CI 2.0–4.2), chronic infarcts (pooled RR 1.5, 95% CI 1.2–1.9), and isolated cortical lesions (pooled RR 2.2, 95% CI 1.5–3.2). Conclusions: In patients with a recent ischemic stroke, a history of stroke or TIA and the subtype large artery atherosclerosis are associated with an increased risk of recurrent ischemic stroke. Predictors evaluated with MRI include multiple ischemic changes and isolated cortical lesions. Predictors of recurrent ischemic stroke concerning CT or ultrasound have not been published.


Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Richard S Jung ◽  
Jitendra Sharma ◽  
Tanzila Shams ◽  
Numthip Chitravas ◽  
Kristine A Blackham

Background: As is seen in the early door-to-needle times of intravenous thrombolysis in the treatment of acute ischemic stroke (AIS), prior endovascular management trials have demonstrated early revascularization can lead to improved outcomes. We aimed to study the relationship of the time from acute stroke onset to the time of arterial groin puncture (OTP) as a possible predictor of successful revascularization. Methods: We retrospectively analyzed 149 patients who presented to our hospital with AIS and underwent emergent endovascular treatment from January 1, 2008 to March 31, 2011. Charts were reviewed for baseline characteristics, OTP times, and endovascular therapies employed. Primary outcomes included successful revascularization (TIMI 2 to 3 flow), improvement of baseline NIHSS ≥ 4, symptomatic ICH (increase of NIHSS ≥ 4), in-hospital mortality, and mRS two or less at discharge. We excluded patients with OTP times greater than eight hours to ensure consistency with approved usage of mechanical thrombectomy devices. Independent samples T-tests were performed to determine relationships of OTP with our primary outcomes. Results: Of the 149 patients who underwent endovascular therapy, 120 had OTP times less than eight hours. Of these 120, 44% were male, median age was 73 years (range 17, 93), median baseline NIHSS was 18 (range 5, 28), 53% received intravenous tissue plasminogen activator (tPA), 69% received intra-arterial tPA, and mechanical thrombectomy was performed in 69%. Internal carotid artery occlusions were seen in 32% of patients, 50% had M1 segment occlusions, and only five patients had posterior circulation occlusions. Successful revascularization was achieved in 70% of interventions, 10% of patients had mRS ≤ 2 at discharge, symptomatic hemorrhage was 18%, and in-hospital mortality was 24%. Patients with TIMI 2 to 3 flow had significantly shorter mean OTP times (3.9 vs 4.5 hours; p=0.024). No significant associations of mean OTP times were found with symptomatic hemorrhage rate (4.4 vs 4.0; p=0.628), in-hospital mortality (4.0 vs 4.0; p=0.677), improvement in NIHSS (3.9 vs 4.2; p=0.283), or a mRS ≤ 2 at discharge (3.7 vs 4.1; p=0.185). Conclusions: The recanalization rate in our study is comparable to prior endovascular trials. Patients with OTP times less than 3.9 hours were more likely to result in successful revascularization. Onset to groin puncture did not predict in-hospital mortality, symptomatic hemorrhage, or condition at discharge in our study. Further study is needed to determine if advanced perfusion imaging prior to intervention may impact treatment time and ultimately clinical outcome.


Author(s):  
Karen Radner ◽  
Nadine Moeller ◽  
D. T. Potts

With the emphasis of the Oxford History of the Ancient Near East firmly placed on the political, social, and cultural histories of the states and communities shaping Egypt and Western Asia (including the Levant, Anatolia, Mesopotamia, and Iran), this introduction to the five-volume series seeks to place the region in its environmental context. It discusses the lay of the land between the North African coast and the Hindu Kush, including the role of tectonics and geomorphology. It also considers some key issues regarding climatic conditions, focusing in particular on the significance of the Inter-Tropical Convergence Zone and the potential impact of megadroughts and pandemics.


2020 ◽  
Vol 47 (2) ◽  
pp. 102
Author(s):  
Federico Cagnazzo ◽  
Imad Derraz ◽  
Cyril Dargazanli ◽  
Pierre-Henri Lefevre ◽  
Gregory Gascou ◽  
...  

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