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Ren Z, Mokin M, Bauer CT, Miao Z, Burgin WS, Wang Y. Indications for Mechanical Thrombectomy—Too Wide or Too Narrow? World Neurosurg 2019; 127:492-499. [DOI: 10.1016/j.wneu.2019.04.116] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 10/27/2022]
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Barry M, Hallam DK, Bernard TJ, Amlie-Lefond C. What is the Role of Mechanical Thrombectomy in Childhood Stroke? Pediatr Neurol 2019; 95:19-25. [PMID: 30795888 DOI: 10.1016/j.pediatrneurol.2019.01.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 01/07/2019] [Accepted: 01/09/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Like adults, most children have lifelong morbidity after stroke. Revascularization therapies such as intravenous tissue plasminogen activator and mechanical thrombectomy may be options to decrease this morbidity in selected children, although currently there are no evidence-based recommendations to guide treatment. The utility and safety of mechanical thrombectomy in childhood stroke is unknown because of the lack of safety trials, case-controlled trials, and comprehensive retrospective studies. As such, the current rationale for the use of mechanical thrombectomy in childhood is based on extrapolation from adult experience, as well as consensus at individual institutions with many centers deciding care on a case-by-case basis. Nevertheless, the increasing use of recanalization therapies in appropriately selected adults with acute arterial ischemic stroke has led to an increase in consideration and use in childhood, and there are enough case reports and series, as well as experience, to suggest that some children with large vessel occlusion will likely benefit. METHODS We reviewed current literature regarding mechanical thrombectomy in childhood. RESULTS There are differences between pediatric and adult stroke which may impact safety, efficacy, and individual decision-making, including patient size, pathophysiology of stroke, deficit, experience, and lack of data regarding natural history of stroke in children. CONCLUSIONS Hospitals planning to perform mechanical thrombectomy in children should establish local procedures and guidelines for considering thrombectomy. In our experience, care is best provided through multidisciplinary teams including a pediatric vascular neurologist, neurointerventionalist with pediatric experience, and pediatric neurocritical care.
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Affiliation(s)
- Megan Barry
- Section of Pediatric Neurology, Department of Pediatrics, University of Colorado, Denver, Colorado
| | - Danial K Hallam
- Department of Radiology, University of Washington, Seattle, Washington; Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Timothy J Bernard
- Section of Pediatric Neurology, Department of Pediatrics, University of Colorado, Denver, Colorado; Hemophilia and Thrombosis Center, University of Colorado, Denver, Colorado
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de Castro Afonso LH, Borghini Pazuello G, Seizem Nakiri G, Monsignore LM, Antunes Dias F, Pontes-Neto OM, Giansante Abud D. Thrombectomy for M2 occlusions and the role of the dominant branch. Interv Neuroradiol 2019; 25:697-704. [PMID: 31088246 DOI: 10.1177/1591019919847693] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The benefits of thrombectomy for occlusion of M2 segments remain controversial. The aim of this study is to assess thrombectomy's efficacy and safety in patients with M2 segment occlusion and associations between occlusion sites and anatomic variations of M1 division. MATERIALS AND METHODS A prospective series of 30 patients with acute ischemic stroke (AIS) resulting from M2 segment occlusion of the middle cerebral artery (MCA) who underwent thrombectomy was analyzed. The primary endpoint was assessed by the Extended Treatment in Cerebral Infarction scale (eTICI). The secondary endpoints were the incidence of symptomatic hemorrhagic transformation (sICH), mortality and good functional outcome at three months. RESULTS The mean patient age was 69.2 years. The mean National Institutes Health Stroke Scale score (NIHSS) upon hospital admission was 16. The recanalization rates were eTICI 2b/3 in 90% and 2c/3 in 60% of the patients. Total recanalization of the M2 branch was achieved in 53% of patients. sICH incidence was 6.6%, the mortality rate was 30%, and a good functional outcome (mRS ≤2) was observed in 50% of the patients. Twenty-seven patients (90%) had a dominant M2 branch and all were occluded. Regarding the site of M2 occlusions, 74% of patients had proximal M2 occlusions. CONCLUSIONS Thrombectomy appears to be a safe and effective method for the treatment of acute M2 segment occlusions of the MCA. Most of the cases had a dominant M2 branch, and all of them were occluded. Larger studies are needed to verify the benefits of thrombectomy for different settings of M2 occlusions.
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Affiliation(s)
- Luís Henrique de Castro Afonso
- Division of Interventional Neuroradiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Guilherme Borghini Pazuello
- Division of Interventional Neuroradiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Guilherme Seizem Nakiri
- Division of Interventional Neuroradiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Lucas Moretti Monsignore
- Division of Interventional Neuroradiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Francisco Antunes Dias
- Department of Neurology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Octávio Marques Pontes-Neto
- Department of Neurology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Daniel Giansante Abud
- Division of Interventional Neuroradiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
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54
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Miura M, Yoshimura S, Sakai N, Yamagami H, Uchida K, Nagao Y, Morimoto T. Endovascular therapy for middle cerebral artery M2 segment occlusion: subanalyses of RESCUE-Japan Registry 2. J Neurointerv Surg 2019; 11:964-969. [PMID: 30852524 DOI: 10.1136/neurintsurg-2018-014627] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/20/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To compare the efficacy of endovascular therapy (EVT) with that of medical treatment in 'real-world 'patients with M2 occlusion. METHODS This was a post hoc analysis of the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan Registry 2. Among 2420 patients in the registry, we evaluated patients with isolated M2 occlusion and those with functional independence before the stroke. Multivariable logistic regression analysis was used to evaluate and compare clinical outcomes between EVT and medical treatment. Additional propensity score-matched (PSM) analyses were performed. We performed subgroup analyses of the primary outcome (modified Rankin Scale score 0-2 at 90 days) using forest plots of treatment effects. RESULTS Overall, 372 patients with M2 occlusion (n=184 EVT; n=188, medical treatment) were evaluated. The EVT group had a higher baseline National Institutes of Health Stroke Scale score (median (IQR), 15 [9-19] vs 10 [5-16]) and earlier onset to hospital door time (110 [50-258] vs 150 [60-343] min) than the medical treatment group. After adjustment, EVT was significantly associated with higher odds of primary outcome (adjusted OR=2.09; 95% CI 1.26 to 3.47) and lower odds of mortality at 90 days (adjusted OR= 0.27; 95% CI 0.08 to 0.93). After PSM analyses (184 patients were 1:1 matched with each group), EVT was effective and safe relative to medical treatment. Effects favoring EVT were present in several subgroups of interest. CONCLUSION In patients with M2 occlusion, our registry suggests that EVT is effective and safe.
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Affiliation(s)
- Masatomo Miura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.,Department of Neurology, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan.,Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe City, Hyogo, Japan
| | | | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.,Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yoichiro Nagao
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.,Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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55
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Andersson T, Wiesmann M, Nikoubashman O, Gopinathan A, Bhogal P, Yeo LLL. The Aspirations of Direct Aspiration for Thrombectomy in Ischemic Stroke: A Critical Analysis. J Stroke 2019; 21:2-9. [PMID: 30732438 PMCID: PMC6372897 DOI: 10.5853/jos.2018.02026] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 12/03/2018] [Indexed: 12/17/2022] Open
Abstract
The treatment of acute ischemic stroke by mechanical thrombectomy has been revolutionary, however most of the clinical trials were done with the use a stent retriever. At the same time, an alternative technique of thrombectomy through direct aspiration with a large bore distal access catheter at the face of the clot is rapidly gaining popularity. Nonetheless, the data supporting this new technique is not yet as mature as that available on stent retrievers. This review is a critical analysis of the evidence supporting the principle of direct aspiration thrombectomy and a discussion of its potential strengths and weaknesses in comparison to the available studies on stent retrievers. While this is by no means a conclusive review, it should serve as a yardstick of where the science is currently, and what are the next trials that are necessary.
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Affiliation(s)
- Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital Aachen RWTH, Aachen, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital Aachen RWTH, Aachen, Germany
| | - Anil Gopinathan
- Department of Diagnostic Imaging, National University Health System, Singapore
| | - Pervinder Bhogal
- Department of Neuroradiology, St. Bartholomew's and the Royal London Hospital, London, UK
| | - Leonard L L Yeo
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Division of Neurology, Department of Medicine, National University Health System, Singapore
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Procházka V, Jonszta T, Czerny D, Krajca J, Roubec M, Hurtikova E, Urbanec R, Streitová D, Pavliska L, Vrtkova A. Comparison of Mechanical Thrombectomy with Contact Aspiration, Stent Retriever, and Combined Procedures in Patients with Large-Vessel Occlusion in Acute Ischemic Stroke. Med Sci Monit 2018; 24:9342-9353. [PMID: 30578729 PMCID: PMC6320656 DOI: 10.12659/msm.913458] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background We investigated the properties and effects of 5 mechanical thrombectomy procedures in patients with acute ischemic stroke. The relationships between the type of procedure, the time required, the success of recanalization, and the clinical outcome were analyzed. Material/Methods This prospective comparative analysis included 500 patients with acute ischemic stroke and large-vessel occlusion. We compared contact aspiration thrombectomy (ADAPT, n=100), stent retriever first line (SRFL, n=196), the Solumbra technique (n=64), mechanical thrombectomy plus stent implantation (n=81), and a combined procedure (n=59). Results ADAPT provided shorter procedure (P<0.001) and recanalization times (P<0.001) than the other techniques. Better clinical outcome was achieved for ischemia in the anterior circulation than ischemia in the posterior fossa (P<0.001). Compared to the other techniques, patients treated with ADAPT procedure had increased odds of achieving better mTICI scores (P=0.002) and clinical outcome (NIHSS) after 7 days (P=0.003); patients treated with SRFL had increased odds of achieving better long-term clinical status (3M-mRS=0–2; P=0.040). Patients with SRFL and intravenous thrombolysis (IVT) had increased odds of better clinical status (3M-mRS=0–2; P=0.031) and decreased odds of death (P=0.005) compared to patients with SRFL without IVT. The other treatment approaches had no additional effect of IVT. Patients with SRFL with a mothership transfer had increased odds of achieving favorable clinical outcome (3M-mRS) compared to SRFL with the drip-and-ship transfer paradigm (P=0.015). Conclusions Our results showed that ADAPT and SRFL provided significantly better outcomes compared to the other examined techniques. A mothership transfer and IVT administration contributed to the success of the SRFL approach.
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Affiliation(s)
- Václav Procházka
- Department of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Tomas Jonszta
- Department of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Daniel Czerny
- Department of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jan Krajca
- Department of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Martin Roubec
- Department of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Eva Hurtikova
- Department of Neurology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Rene Urbanec
- Clinic of Anesthesiology, Resuscitation and Intensive Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - Dana Streitová
- Clinic of Anesthesiology, Resuscitation and Intensive Medicine, University Hospital Ostrava, Ostrava, Czech Republic.,St. Elizabeth University of Health and Social Work, Bratislava, Slovakia
| | - Lubomir Pavliska
- IT Department, University Hospital Ostrava, Ostrava, Czech Republic
| | - Adela Vrtkova
- Department of Applied Mathematics, VŠB-Technical University of Ostrava, Ostrava, Czech Republic.,Department of Deputy Director of Science and Research, University Hospital Ostrava, Ostrava, Czech Republic
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Hacein-Bey L, Heit JJ, Konstas AA. Neuro-Interventional Management of Acute Ischemic Stroke. Neuroimaging Clin N Am 2018; 28:625-638. [PMID: 30322598 DOI: 10.1016/j.nic.2018.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Restoration of cerebral blood flow is the most important step in preventing irreversible damage to hypoperfused brain cells after ischemic stroke from large-vessel occlusion. For those patients who do not respond to (or are not eligible for) intravenous thrombolysis, endovascular therapy has become standard of care. A shift is currently taking place from rigid time windows for intervention (time is brain) to physiology-driven paradigms that rely heavily on neuroimaging. At this time, one can reasonably anticipate that more patients will be treated, and that outcomes will keep improving. This article discusses in detail recent advances in endovascular stroke therapy.
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Affiliation(s)
- Lotfi Hacein-Bey
- Interventional Neuroradiology and Neuroradiology, Department of Medical Imaging, Sutter Health, Sacramento, CA 95815, USA; Radiology Department, University of California Davis Medical School of Medicine, 4860 Y Street, Sacramento, CA 95817, USA.
| | - Jeremy J Heit
- Division of Neuroimaging and Neurointervention, Stanford Healthcare, 300 Pasteur Drive, Grant S047, Stanford, CA 94305, USA
| | - Angelos A Konstas
- Interventional Neuroradiology and Neuroradiology, Department of Radiology, Huntington Memorial Hospital, 100 West California Boulevard, Pasadena, CA 91105, USA
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Spiotta AM, Fiorella D, Arthur AS, Frei D, Turk AS, Hirsch JA. The semiotics of distal thrombectomy: towards a TICI score for the target vessel. J Neurointerv Surg 2018; 11:213-214. [DOI: 10.1136/neurintsurg-2018-014353] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2018] [Indexed: 12/28/2022]
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Aronov MS, Popugaev KA, Udalov YD, Samoylov AS. [Endovascular treatment of acute ischemic stroke]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 82:103-108. [PMID: 30137044 DOI: 10.17116/neiro2018824103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Ischemic stroke is one of the leading causes of mortality and disability in the population of developed countries. Revascularization of the affected cerebral territory improves the prognosis and reduces mortality, which has been proven by randomized studies using systemic thrombolysis protocols. Over the last ten years, endovascular mechanical thrombus extraction using stent retrievers and/or aspiration neurointerventional catheters has been introduced into the clinical treatment of ischemic stroke, and after reporting the results of randomized studies on this topic, the technique has become ubiquitous. This work objective was to systematize the results of key studies on the treatment of acute ischemic stroke in chronological order, including the latest data of 2018.
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Affiliation(s)
- M S Aronov
- Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - K A Popugaev
- Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - Yu D Udalov
- Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | - A S Samoylov
- Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
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60
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Ganesh A, Goyal M. Thrombectomy for Acute Ischemic Stroke: Recent Insights and Future Directions. Curr Neurol Neurosci Rep 2018; 18:59. [PMID: 30033493 DOI: 10.1007/s11910-018-0869-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Mechanical thrombectomy has become the standard of care for acute ischemic stroke with proximal large vessel occlusions (LVO). This article reviews recent research relating to thrombectomy. RECENT FINDINGS Thrombectomy for anterior circulation stroke with proximal LVO was first shown to be highly efficacious within 6 h of stroke onset, but "late-window" trials have further demonstrated efficacy until 24-h postonset in select patients with salvageable tissue. However, the concept of "time is brain" remains critical. Thrombectomy trials have further stimulated worldwide efforts to develop systems of care for rapid treatment of eligible patients. Thrombectomy is cost-effective and likely to have long-term efficacy for both disability and mortality outcomes. Thrombectomy is a highly efficacious acute stroke therapy. Enduring uncertainties include efficacy in patients with premorbid disability, posterior circulation, or more distal occlusions; use of bridging thrombolysis; and optimal techniques to achieve consistent revascularization and address tandem occlusions or stenoses.
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Affiliation(s)
- Aravind Ganesh
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada. .,Department of Radiology, University of Calgary, Calgary, Canada. .,Seaman Family MR Research Centre, Foothills Medical Centre, University of Calgary, 1403 29th St NW, Calgary, AB, T2N 2T9, Canada.
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