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Kuram E, Karadeli HH. Fabrication of Shape Memory Polymer Endovascular Thrombectomy Device for Treating Ischemic Stroke. Macromol Rapid Commun 2024; 45:e2400146. [PMID: 38704791 DOI: 10.1002/marc.202400146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/28/2024] [Indexed: 05/07/2024]
Abstract
Stroke is the second result for death and ischemic stroke constitutes most of all stroke cases. Ischemic stroke takes place when blood clot or embolus blocks cerebral vessel and interrupts blood flow, which often leads to brain damage, permanent disability, or death. There is a 4.5-h (golden hour) treatment window to restore blood flow prior to permanent neurological impairment results. Current stroke treatments consist mechanical system or thrombolytic drug therapy to disrupt or dissolve thrombus. Promising method for stroke treatment is mechanical retrieving of thrombi employing device deployed endovascularly. Advent of smart materials has led to research fabrication of several minimally invasive endovascular devices that take advantage of new materials capabilities. One of these capabilities is shape memory, is capability of material to store temporary form, then activate to primary shape as subjected to stimuli. Shape memory polymers (SMPs) are employed as good materials for thrombectomy device fabrication. Therefore, current review presents thrombectomy device development and fabrication with SMPs. Design, performance, limitations, and in vitro or in vivo clinical results of SMP-based thrombectomy devices are identified. Review also sheds light on SMP's future outlook and recommendations for thrombectomy device application, opening a new era for advanced materials in materials science.
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Affiliation(s)
- Emel Kuram
- Department of Mechanical Engineering, Gebze Technical University, Kocaeli, 41400, Turkey
| | - Hasan Hüseyin Karadeli
- Department of Neurology, Istanbul Medeniyet University Göztepe Prof. Dr. Süleyman Yalçın City Hospital, Istanbul, 34722, Turkey
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2
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Buecke P, Cohen J, Klisch J, Felber S, Bäzner H, Henkes H. The History of Endovascular Stroke Treatment: From Local Intraarterial Fibrinolysis to Stent Retriever Thrombectomy. ROFO-FORTSCHR RONTG 2024; 196:682-689. [PMID: 38065543 DOI: 10.1055/a-2206-6223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Affiliation(s)
- Philipp Buecke
- Department of Neurology, Inselspital University Hospital Bern, Switzerland
| | - José Cohen
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University Jerusalem, Israel
| | - Joachim Klisch
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, HELIOS Klinikum Erfurt, Germany
| | - Stephan Felber
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, Stiftungsklinikum Mittelrhein Koblenz, Germany
| | | | - Hans Henkes
- Neuroradiological Clinic, Klinikum Stuttgart, Germany
- Medical Faculty, Universität Duisburg-Essen, Germany
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3
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Oo TT. Ischemic stroke and diabetes: a TLR4-mediated neuroinflammatory perspective. J Mol Med (Berl) 2024; 102:709-717. [PMID: 38538987 DOI: 10.1007/s00109-024-02441-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 02/14/2024] [Accepted: 03/20/2024] [Indexed: 05/21/2024]
Abstract
Ischemic stroke is the major contributor to morbidity and mortality in people with diabetes mellitus. In ischemic stroke patients, neuroinflammation is now understood to be one of the main underlying mechanisms for cerebral damage and recovery delay. It has been well-established that toll-like receptor 4 (TLR4) signaling pathway plays a key role in neuroinflammation. Emerging research over the last decade has revealed that, compared to ischemic stroke without diabetes mellitus, ischemic stroke with diabetes mellitus significantly upregulates TLR4-mediated neuroinflammation, increasing the risk of cerebral and neuronal damage as well as neurofunctional recovery delay. This review aims to discuss how ischemic stroke with diabetes mellitus amplifies TLR4-mediated neuroinflammation and its consequences. Additionally covered in this review is the potential application of TLR4 antagonists in the management of diabetic ischemic stroke.
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Affiliation(s)
- Thura Tun Oo
- Department of Biomedical Sciences, University of Illinois at Chicago, College of Medicine Rockford, Rockford, IL, USA.
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4
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Shiraz Bhurwani MM, Snyder KV, Waqas M, Mokin M, Rava RA, Podgorsak AR, Chin F, Davies JM, Levy EI, Siddiqui AH, Ionita CN. Use of quantitative angiographic methods with a data-driven model to evaluate reperfusion status (mTICI) during thrombectomy. Neuroradiology 2021; 63:1429-1439. [PMID: 33415348 PMCID: PMC8409249 DOI: 10.1007/s00234-020-02598-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/03/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Intra-procedural assessment of reperfusion during mechanical thrombectomy (MT) for emergent large vessel occlusion (LVO) stroke is traditionally based on subjective evaluation of digital subtraction angiography (DSA). However, semi-quantitative diagnostic tools which encode hemodynamic properties in DSAs, such as angiographic parametric imaging (API), exist and may be used for evaluation of reperfusion during MT. The objective of this study was to use data-driven approaches, such as convolutional neural networks (CNNs) with API maps, to automatically assess reperfusion in the neuro-vasculature during MT procedures based on the modified thrombolysis in cerebral infarction (mTICI) scale. METHODS DSAs from patients undergoing MTs of anterior circulation LVOs were collected, temporally cropped to isolate late arterial and capillary phases, and quantified using API peak height (PH) maps. PH maps were normalized to reduce injection variability. A CNN was developed, trained, and tested to classify PH maps into 2 outcomes (mTICI 0,1,2a/mTICI 2b,2c,3) or 3 outcomes (mTICI 0,1,2a/mTICI 2b/mTICI 2c,3), respectively. Ensembled networks were used to combine information from multiple views (anteroposterior and lateral). RESULTS The study included 383 DSAs. For the 2-outcome classification, average accuracy was 81.0% (95% CI, 79.0-82.9%), and the area under the receiver operating characteristic curve (AUROC) was 0.86 (0.84-0.88). For the 3-outcome classification, average accuracy was 64.0% (62.0-66.0), and AUROC values were 0.85 (0.83-0.87), 0.74 (0.71-0.77), and 0.78 (0.76-0.81) for the mTICI 0,1,2a, mTICI 2b, and mTICI 2c,3 classes, respectively. CONCLUSION This study demonstrated the feasibility of using hemodynamic information in API maps with data-driven models to autonomously assess intra-procedural reperfusion during MT.
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Affiliation(s)
- Mohammad Mahdi Shiraz Bhurwani
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, 14228, USA
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
| | - Kenneth V Snyder
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, 14203, USA
| | - Muhammad Waqas
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, 14203, USA
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, 33606, USA
| | - Ryan A Rava
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, 14228, USA
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
| | - Alexander R Podgorsak
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, 14228, USA
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
| | - Felix Chin
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, 14203, USA
| | - Jason M Davies
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, 14203, USA
| | - Elad I Levy
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, 14203, USA
| | - Adnan H Siddiqui
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, 14203, USA
| | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, 14228, USA.
- Canon Stroke and Vascular Research Center, Buffalo, NY, 14203, USA.
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, 14203, USA.
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5
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Singh R, Jo J, Riegel M, Forrest ML, Yang X. The feasibility of ultrasound-assisted endovascular laser thrombolysis in an acute rabbit thrombosis model. Med Phys 2021; 48:4128-4138. [PMID: 34214203 DOI: 10.1002/mp.15068] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/27/2021] [Accepted: 06/21/2021] [Indexed: 12/31/2022] Open
Abstract
PURPOSE This study aimed to test the feasibility of combined ultrasound and laser technique, namely, ultrasound-assisted endovascular laser thrombolysis (USELT), for thrombolysis by conducting in vivo tests in a rabbit thrombosis model. MATERIALS AND METHODS An acute thrombus was created in the right jugular vein of rabbit and then was treated with ultrasound only, laser only, and USELT to dissolve the blood clot. A total of 20 rabbits were used. Out of which, the first three rabbits were used to titrate the laser and ultrasound parameters. Then, five rabbits were treated with ultrasound only, five rabbits were treated with laser only, and seven rabbits were treated with USELT. During USELT, 532-nm laser pulses were delivered endovascularly directly to the clot through a fiber optic, and 0.5 MHz ultrasound pulses were applied noninvasively to the same region. A laser fluence of 4 to 12 mJ/cm2 and ultrasound amplitude of 1 to 2 MPa were used. Recanalization of the jugular vein was assessed by performing ultrasound Doppler imaging immediately after the treatment. The maximum blood flow speed after the treatment as compared to its value before the treatment was used to calculate the blood flow recovery in vessel. RESULTS The blood flow was fully recovered (100%) in three rabbits, partially recovered in two rabbits (more than 50% and less than 100%) with mean percentage recovery of 69.73% and poorly recovered in two rabbits (<50%) with mean percentage recovery of 6.2% in the USELT group. In contrast, the treatment group with ultrasound or laser alone did not show recanalization of vein in any case, all the five rabbits were poorly/not recovered with a mean percentage recovery of 0%. CONCLUSIONS The USELT technology was shown to effectively dissolve the blood clots in an acute rabbit jugular vein thrombosis model.
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Affiliation(s)
- Rohit Singh
- Institute for Bioengineering Research and Department of Mechanical Engineering, University of Kansas, Lawrence, Kansas, USA
| | - Janggun Jo
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA.,Vesarex LLC, Lawrence, Kansas, USA
| | - Matthew Riegel
- Animal Care Unit, University of Kansas, Lawrence, Kansas, USA
| | - M Laird Forrest
- Department of Pharmaceutical Chemistry, University of Kansas, Lawrence, Kansas, 66045, USA
| | - Xinmai Yang
- Institute for Bioengineering Research and Department of Mechanical Engineering, University of Kansas, Lawrence, Kansas, USA
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6
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Jo J, Forrest ML, Yang X. Ultrasound-assisted laser thrombolysis with endovascular laser and high-intensity focused ultrasound. Med Phys 2020; 48:579-586. [PMID: 33280145 DOI: 10.1002/mp.14636] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/15/2020] [Accepted: 11/29/2020] [Indexed: 12/20/2022] Open
Abstract
PURPOSE The combination of laser and ultrasound can significantly improve the efficiency of thrombolysis through an enhanced cavitation effect. We developed a fiber optics-based laser-ultrasound thrombolysis device and tested the feasibility and efficiency of this technology for restoring blood flow in an in vitro blood clot model. METHODS An in vitro blood flow-clot model was setup, and then an endovascular laser thrombolysis system was combined with high-intensity focused ultrasound to remove the clot. The laser and ultrasound pulses were synchronized and delivered to the blood clot concurrently. The laser pulses of 532 nm were delivered to the blood clot endovascularly through an optical fiber, whereas the ultrasound pulses of 0.5 MHz were applied noninvasively to the same region. Effectiveness of thrombolysis was evaluated by the ability to restore blood flow, which was monitored by ultrasound Doppler. RESULTS As laser powers increased, the ultrasound threshold pressures for effective thrombolysis decreased. For laser fluence levels of 0, 2, and 4 mJ/cm2 , the average negative ultrasound threshold pressures were 1.26 ± 0.114, 1.05 ± 0.181, and 0.59 ± 0.074 MPa, respectively. The periods of time needed to achieve effective thrombolysis were measured at 0.8, 2, and 4 mJ/cm2 laser fluence levels and 0.42, 0.70, and 0.98 MPa negative ultrasound pressures. In general, thrombolysis could be achieved more rapidly with higher laser powers or ultrasound pressures. CONCLUSIONS Effective thrombolysis can be achieved by combining endovascular laser with noninvasive ultrasound at relatively low power and pressure levels, which can potentially improve both the treatment efficiency and safety.
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Affiliation(s)
- Janggun Jo
- Vesarex LLC, Lawrence, KS, 66047, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, 48109, USA
| | - M Laird Forrest
- Department of Pharmaceutical Chemistry, the University of Kansas, Lawrence, Kansas, 66045, USA
| | - Xinmai Yang
- Institute for Bioengineering Research and Department of Mechanical Engineering, the University of Kansas, Lawrence, Kansas, 66045, USA
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7
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Zhang SR, Phan TG, Sobey CG. Targeting the Immune System for Ischemic Stroke. Trends Pharmacol Sci 2020; 42:96-105. [PMID: 33341247 DOI: 10.1016/j.tips.2020.11.010] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 12/11/2022]
Abstract
Stroke is responsible for almost 6 million deaths and more than 10% of all mortalities each year, and two-thirds of stroke survivors remain disabled. With treatments for ischemic stroke still limited to clot lysis and/or mechanical removal, new therapeutic targets are desperately needed. In this review, we provide an overview of the complex mechanisms of innate and adaptive immune cell-mediated inflammatory injury, that exacerbates infarct development for several days after stroke. We also highlight the features of poststroke systemic immunodepression that commonly leads to infections and some mortalities, and argue that safe and effective therapies will need to balance pro- and anti-inflammatory mechanisms in a time-sensitive manner, to maximize the likelihood of an improved long-term outcome.
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Affiliation(s)
- Shenpeng R Zhang
- Department of Physiology, Anatomy, and Microbiology, and Centre for Cardiovascular Biology and Disease Research, School of Life Sciences, La Trobe University, Bundoora, Victoria, Australia
| | - Thanh G Phan
- Clinical Trials, Imaging, and Informatics (CTI) Division, Stroke and Ageing Research (STARC), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Christopher G Sobey
- Department of Physiology, Anatomy, and Microbiology, and Centre for Cardiovascular Biology and Disease Research, School of Life Sciences, La Trobe University, Bundoora, Victoria, Australia.
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8
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Abstract
Photoacoustic imaging has demonstrated its potential for diagnosis over the last few decades. In recent years, its unique imaging capabilities, such as detecting structural, functional and molecular information in deep regions with optical contrast and ultrasound resolution, have opened up many opportunities for photoacoustic imaging to be used during image-guided interventions. Numerous studies have investigated the capability of photoacoustic imaging to guide various interventions such as drug delivery, therapies, surgeries, and biopsies. These studies have demonstrated that photoacoustic imaging can guide these interventions effectively and non-invasively in real-time. In this minireview, we will elucidate the potential of photoacoustic imaging in guiding active and passive drug deliveries, photothermal therapy, and other surgeries and therapies using endogenous and exogenous contrast agents including organic, inorganic, and hybrid nanoparticles, as well as needle-based biopsy procedures. The advantages of photoacoustic imaging in guided interventions will be discussed. It will, therefore, show that photoacoustic imaging has great potential in real-time interventions due to its advantages over current imaging modalities like computed tomography, magnetic resonance imaging, and ultrasound imaging.
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Affiliation(s)
- Madhumithra S Karthikesh
- Bioengineering Program and Institute for Bioengineering Research, University of Kansas, Lawrence, KS 66045, USA
| | - Xinmai Yang
- Bioengineering Program and Institute for Bioengineering Research, University of Kansas, Lawrence, KS 66045, USA
- Department of Mechanical Engineering, University of Kansas, Lawrence, KS 66045, USA
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9
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Minchell E, Finch E, Rumbach A. The effects of thrombolysis and endovascular clot retrieval on dysphagia: a scoping review. SPEECH, LANGUAGE AND HEARING 2019. [DOI: 10.1080/2050571x.2019.1660460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Ellie Minchell
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Centre for Functioning and Health Research, Metro South Health, Brisbane, Australia
| | - Emma Finch
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
- Centre for Functioning and Health Research, Metro South Health, Brisbane, Australia
- Speech Pathology Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Anna Rumbach
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
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10
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Bhaskar S, Stanwell P, Cordato D, Attia J, Levi C. Reperfusion therapy in acute ischemic stroke: dawn of a new era? BMC Neurol 2018; 18:8. [PMID: 29338750 PMCID: PMC5771207 DOI: 10.1186/s12883-017-1007-y] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 12/14/2017] [Indexed: 12/14/2022] Open
Abstract
Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging-based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes.
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Affiliation(s)
- Sonu Bhaskar
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Peter Stanwell
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Dennis Cordato
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
| | - John Attia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
- Centre for Clinical Epidemiology & Biostatistics, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW Australia
| | - Christopher Levi
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
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11
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Kang DH, Park J. Endovascular Stroke Therapy Focused on Stent Retriever Thrombectomy and Direct Clot Aspiration: Historical Review and Modern Application. J Korean Neurosurg Soc 2017; 60:335-347. [PMID: 28490161 PMCID: PMC5426444 DOI: 10.3340/jkns.2016.0809.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/02/2017] [Accepted: 01/11/2017] [Indexed: 01/19/2023] Open
Abstract
Intravenous recombinant tissue plasminogen activator had been the only approved treatment for acute ischemic stroke since its approval in 1995. However, the restrictive time window, numerous contraindications, and its low recanalization rate were all limitations of this modality. Under those circumstances, endovascular stroke therapy went through a great evolution during the past two decades of intravenous thrombolysis. The results of the 2013 randomized trials for endovascular stroke therapy were neutral, although they were limited by insufficient imaging screening at enrollment, early-generation devices with less efficacy, and treatment delays. Huge progress was made in 2015, as there were five randomized clinical trials which all demonstrated the safety and efficacy of endovascular stroke treatment. Despite differences in detail patient enrollment criteria, all 5 trials employed key factors for good functional recovery; (1) screening with non-invasive imaging to identify the proximal occlusion and exclude a large infarct core, (2) using highly effective modern thrombectomy devices mainly with stent retriever, and (3) establishment of a fast workflow to achieve effective reperfusion. The results of those trials indicate that modern thrombectomy devices can allow for faster and more effective reperfusion, which can lead to improved clinical outcomes compared to intravenous thrombolysis alone. These advances in mechanical thrombectomy are promising in the global fight against ischemic stroke-related disability and mortality. Two current mainstreams among such mechanical thrombectomy techniques, “stent retriever thrombectomy” and “direct clot aspiration”, are the topic of this review. Stent retriever thrombectomy using Solitaire and Trevo retriever will be firstly discussed. And, the commonalities and the differences between two major clot aspiration thrombectomy techniques; a direct aspiration first pass technique (ADAPT) and forced arterial suction thrombectomy (FAST), will be additionally explained. Finally, details regarding the combination of direct clot aspiration and stent retriever thrombectomy, the switching strategy and the Solumbra technique, will be described.
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Affiliation(s)
- Dong-Hun Kang
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu-Gyeongbuk Cardiocerebrovascular Center, School of Medicine, Kyungpook National University, Daegu, Korea.,Department of Radiology, Kyungpook National University Hospital, Daegu-Gyeongbuk Cardiocerebrovascular Center, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jaechan Park
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu-Gyeongbuk Cardiocerebrovascular Center, School of Medicine, Kyungpook National University, Daegu, Korea
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12
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Abstract
Several developments in endovascular technology have greatly expanded the application of these techniques to treat extra- and intracranial cerebrovascular diseases. This review explores the indications, techniques, and clinical results for endovascular treatment of ischemic stroke and intracranial stenoses, aneurysms, and arteriovenous malformations.
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Affiliation(s)
- Kunio Ohta
- Department of Pediatrics, Angiogenesis, and Vascular Development, Graduate School of Medical Science, Kanazawa, Japan.
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13
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14
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Mordasini P, Gralla J. Developments in mechanical thrombectomy devices for the treatment of acute ischemic stroke. Expert Rev Med Devices 2016; 13:71-81. [DOI: 10.1586/17434440.2015.1124019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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15
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Sakes A, Regar E, Dankelman J, Breedveld P. Treating Total Occlusions: Applying Force for Recanalization. IEEE Rev Biomed Eng 2016; 9:192-207. [DOI: 10.1109/rbme.2016.2580218] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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16
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The Year Embolectomy Won: a Review of Five Trials Assessing the Efficacy of Mechanical Intervention in Acute Stroke. Curr Cardiol Rep 2015; 17:102. [DOI: 10.1007/s11886-015-0657-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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17
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Yeung JT, Matouk CC, Bulsara KR, Sheth KN. Endovascular revascularization for basilar artery occlusion. INTERVENTIONAL NEUROLOGY 2015; 3:31-40. [PMID: 25999990 DOI: 10.1159/000368968] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Basilar artery occlusion is one of the most devastating neurological conditions known to man. Though rare, patients with clinical syndromes localized to this anatomical region are often referred to acute stroke and endovascular units. Recent studies evaluating the efficacy of endovascular approaches to stroke have focused on anterior circulation syndromes. In this review, we examine the approaches to stroke syndromes due to basilar artery thrombosis. We share the relevant data for intravenous and intra-arterial tissue plasminogen activator as well as mechanical approaches to restoring perfusion in this critical area of the brain.
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Affiliation(s)
- Jacky T Yeung
- Department of Neurosurgery, Yale School of Medicine, New Haven, Conn., USA
| | - Charles C Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, Conn., USA
| | - Ketan R Bulsara
- Department of Neurosurgery, Yale School of Medicine, New Haven, Conn., USA
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, Conn., USA
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18
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Yun JW, Ahn SW, Kim YH, Min J, Choi YS, Chae YK, Lee ES, Kang Y. Intraarterial mechanical thrombectomy for the treatment of postoperative cerebral infarction: a case report. Korean J Anesthesiol 2014; 66:402-6. [PMID: 24910735 PMCID: PMC4041962 DOI: 10.4097/kjae.2014.66.5.402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 04/22/2013] [Accepted: 04/22/2013] [Indexed: 12/03/2022] Open
Abstract
Perioperative ischemic stroke is an uncommon event associated with significant morbidity and mortality. The complexity of the surgical procedure and surgery induced hypercoagulable status also influence the incidence of stroke. The management of stroke involves a decision regarding the quickest suitable revascularization method. Endovascular mechanical thrombectomy, such as intra-arterial mechanical thrombectomy (IAMT), can restore vascular patency of the vessels, providing an alternative or synergistic method to restore blood flow. Although, there are no recommended treatment guidelines, IAMT is eligible to be a treatment of choice for perioperative ischemic stroke. We experienced a case of a patient who demonstrated hemiplegia and aphasia, the early symptom of acute ischemic stroke, in the post-anesthesia care unit and performed IAMT successfully. Thus we report the case with a review of the relevant literature.
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Affiliation(s)
- Jong-Won Yun
- Department of Anesthesiology and Pain Medicine, Myoungji Hospital, Goyang, Korea
| | - So Woon Ahn
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Yong-Ho Kim
- Department of Anesthesiology and Pain Medicine, Myoungji Hospital, Goyang, Korea
| | - Jinhye Min
- Department of Anesthesiology and Pain Medicine, Myoungji Hospital, Goyang, Korea
| | - Young Soon Choi
- Department of Anesthesiology and Pain Medicine, Kwandong Uiversity Medical School, Seoul, Korea
| | - Young Keun Chae
- Department of Anesthesiology and Pain Medicine, Myoungji Hospital, Goyang, Korea
| | - Eun Sang Lee
- Department of Anesthesiology and Pain Medicine, Myoungji Hospital, Goyang, Korea
| | - Yoo Kang
- Department of Anesthesiology and Pain Medicine, Myoungji Hospital, Goyang, Korea
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Lutsep HL. Thrombolytic and newer mechanical device treatment for acute ischemic stroke. Expert Rev Neurother 2014; 6:1099-105. [PMID: 16831122 DOI: 10.1586/14737175.6.7.1099] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
For 8 years, only intravenous tissue plasminogen activator was approved by the US FDA for acute stroke treatment. The US FDA has now cleared the Merci Retriever (Concentric Medical, Inc.), a corkscrew-like device attached to a catheter, for the removal of clots causing ischemic strokes. Since the clearance was based on nonrandomized treatment trials, practitioners must scrutinize available data describing effects of the device on recanalization of the vessel, outcomes and important adverse events, such as symptomatic intracranial hemorrhage. This article reviews the study findings that are likely to contribute to current treatment decisions.
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Affiliation(s)
- Helmi L Lutsep
- Oregon Stroke Center and Associate Professor, Oregon Health & Science University, Department of Neurology, 3181 SW Sam Jackson Park Road, CR 131 Portland, OR 97239-3098, USA.
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20
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Schumacher HC, Gupta R, Higashida RT, Meyers PM. Advances in revascularization for acute ischemic stroke treatment. Expert Rev Neurother 2014; 5:189-201. [PMID: 15853489 DOI: 10.1586/14737175.5.2.189] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Intravenous thrombolysis with recombinant tissue plasminogen activator is the established treatment for acute ischemic stroke patients presenting within 3 h after stroke onset. In a significant number of patients, however, intravenous thrombolysis with recombinant tissue plasminogen activator remains ineffective. New thrombolytic agents, such as reteplase, tenecteplase or desmoteplase, offer pharmacokinetic and dynamic advantages over recombinant tissue plasminogen activator and have been or are currently being tested for safety and efficacy in clinical trials. Endovascular revascularization is an evolving treatment option enabling mechanical clot disruption or extraction in combination with thrombolysis. Several new endovascular devices have been successfully tested for safety in acute ischemic stroke patients and are now being tested for efficacy in larger clinical trials. Continued innovation and refinement of endovascular technology and techniques is expected to increase technical success with a minimal procedure-related morbidity in the treatment of acute ischemic stroke.
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Affiliation(s)
- H Christian Schumacher
- Doris and Stanley Tananbaum Stroke Center, Neurological Institute, New York-Presbyterian Hospital, College of Physicians & Surgeons, Columbia University, 710 West 168th Street, Box 163, NY 10032, USA.
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21
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Eesa M, Schumacher HC, Higashida RT, Meyers PM. Advances in revascularization for acute ischemic stroke treatment: an update. Expert Rev Neurother 2014; 11:1125-39. [DOI: 10.1586/ern.11.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Nie L, Chen X. Structural and functional photoacoustic molecular tomography aided by emerging contrast agents. Chem Soc Rev 2014; 43:7132-70. [PMID: 24967718 PMCID: PMC4569000 DOI: 10.1039/c4cs00086b] [Citation(s) in RCA: 269] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Photoacoustic tomography (PAT) can offer structural, functional and molecular contrasts at scalable observation level. By ultrasonically overcoming the strong optical scattering, this imaging technology can reach centimeters penetration depth while retaining high spatial resolution in biological tissue. Recent extensive research has been focused on developing new contrast agents to improve the imaging sensitivity, specificity and efficiency. These emerging materials have substantially accelerated PAT applications in signal sensing, functional imaging, biomarker labeling and therapy monitoring etc. Here, the potentials of different optical probes as PAT contrast agents were elucidated. We first describe the instrumental embodiments and the measured functional parameters, then focus on emerging contrast agent-based PAT applications, and finally discuss the challenges and prospects.
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Affiliation(s)
- Liming Nie
- Laboratory of Molecular Imaging and Nanomedicine (LOMIN), National Institute of Biomedical Imaging and Bioengineering (NIBIB), National Institutes of Health (NIH), Bethesda, Maryland 20892, USA.
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Bidinger J, Ackermann R, Cattaneo G, Kammel R, Nolte S. A feasibility study on femtosecond laser thrombolysis. Photomed Laser Surg 2013; 32:17-22. [PMID: 24328610 DOI: 10.1089/pho.2013.3581] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE In this feasibility study, we investigate possible femtosecond laser thrombolysis. BACKGROUND DATA Because of low pulse energies, femtosecond laser surgery inherently minimizes side effects on the surrounding tissue. Moreover, current femtosecond laser sources as well as fiber technology allow consideration of catheter-based treatments. METHODS Two femtosecond laser systems (λ=800 nm, λ=1030 nm) along with a three dimensional (3D) scanner system (NA ~0.1) were used in this study. In vitro experiments were performed on porcine thrombi and blood vessels. Ablation thresholds were determined in air, by determining the pulse energy at which single shot ablation was visible under the optical microscope. Ablation rates were determined in physiological saline. Additionally, ablation of thrombi and blood vessels was monitored by means of a fiber spectrometer. RESULTS Depending upon the scan velocity, typical ablation rates for thrombi were ~0.04 mm(3)/sec. Ablation thresholds of thrombi and blood vessels differ by factors of 3 and 1.5 at laser wavelengths of 800 and 1030 nm, respectively. At a distance of 5 mm above the surface, second harmonic generation was observed in blood vessels, but not within thrombi. CONCLUSIONS The results show that a typical thrombus volume can be destroyed within a reasonable time frame. Because of the higher threshold difference of thrombi and blood vessels, the use of a laser wavelength of 800 nm is preferable. Furthermore, the detection of the second harmonic could provide a feedback mechanism to protect the vascular wall from mechanical and laser damage.
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Affiliation(s)
- Johannes Bidinger
- 1 Institute of Applied Physics, Abbe Center of Photonics, Friedrich-Schiller-Universität Jena , Jena, Germany
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24
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Abstract
Major ischaemic stroke is a leading cause of morbidity and mortality in industrialized countries. For patients with acute stroke, fast and effective vessel recanalization is important for successful treatment. Neurothrombectomy--that is, angiographically performed mechanical thrombus removal from intracranial arteries--results in higher recanalization rates than with pharmaceutical thrombolysis alone, but the value of this treatment in terms of clinical outcome remains to be established. This article summarizes the history of intra-arterial stroke treatment, outlines the recent developments and the different techniques used, and discusses the results of current studies on neurothrombectomy. Owing to the high morphological and clinical variability of stroke, careful patient selection in future randomized controlled trials will be crucial for assessment of the true potential of neurothrombectomy.
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25
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Multimodality molecular imaging of stem cells therapy for stroke. BIOMED RESEARCH INTERNATIONAL 2013; 2013:849819. [PMID: 24222920 PMCID: PMC3816035 DOI: 10.1155/2013/849819] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Accepted: 08/21/2013] [Indexed: 12/03/2022]
Abstract
Stem cells have been proposed as a promising therapy for treating stroke. While several studies have demonstrated the therapeutic benefits of stem cells, the exact mechanism remains elusive. Molecular imaging provides the possibility of the visual representation of biological processes at the cellular and molecular level. In order to facilitate research efforts to understand the stem cells therapeutic mechanisms, we need to further develop means of monitoring these cells noninvasively, longitudinally and repeatedly. Because of tissue depth and the blood-brain barrier (BBB), in vivo imaging of stem cells therapy for stroke has unique challenges. In this review, we describe existing methods of tracking transplanted stem cells in vivo, including magnetic resonance imaging (MRI), nuclear medicine imaging, and optical imaging (OI). Each of the imaging techniques has advantages and drawbacks. Finally, we describe multimodality imaging strategies as a more comprehensive and potential method to monitor transplanted stem cells for stroke.
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26
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[Mechanical recanalization in acute stroke. Torture or choice]. Radiologe 2013; 53:251-6. [PMID: 23435625 DOI: 10.1007/s00117-012-2422-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
CLINICAL/METHODICAL ISSUE Stroke is the third most common cause of death in the developed world and the leading cause of disability worldwide. The present demographic development will lead to increased numbers of stroke patients in the future. STANDARD RADIOLOGICAL METHODS Patient selection takes place by using various computer tomographic (CT) or magnetic resonance (MR) imaging modalities. For endovascular stroke treatment a modern biplane angiography suite is recommended. METHODICAL INNOVATIONS Intra-arterial chemical thrombolysis was shown to be effective in achieving recanalization and improving clinical outcome. Mechanical devices were introduced in the late 1990s and the highly effective stent retriever was recently included. PERFORMANCE Mechanical devices allows a recanalization rate of up to 90 % of affected brain vessels. ACHIEVEMENTS The advantage of a stent retriever compared to other mechanical devices seems to be an improvement in good clinical outcome. PRACTICAL RECOMMENDATIONS Currently, the stent retriever seems to be the definitive first choice in the use of mechanical devices for intra-arterial recanalization treatment in acute ischemic stroke.
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28
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Brekenfeld C, Remonda L, Nedeltchev K, v Bredow F, Ozdoba C, Wiest R, Arnold M, Mattle HP, Schroth G. Endovascular neuroradiological treatment of acute ischemic stroke: techniques and results in 350 patients. Neurol Res 2013; 27 Suppl 1:S29-35. [PMID: 16197821 DOI: 10.1179/016164105x35549] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Randomized trials have demonstrated the benefit of intra-arterial thrombolysis (IAT) for treatment of acute ischemic stroke, if performed within 6 hours of symptom onset. METHODS We report our experience with 350 acute stroke patients who were treated with IAT using urokinase at a single center. Predictors of favorable outcome were low National Institute of Health Stroke Scale (NIHSS) at admission (p<0.001), good collaterals (p<0.001) and successful endovascular recanalization (p<0.001). Recanalization rates of more than 75% could be achieved, when additional endovascular techniques such as mechanical fragmentation of the thrombus, thromboaspiration, percutaneous transluminal angioplasty, and implantation of stents were used. RESULTS AND CONCLUSIONS Predictors of unfavorable outcome were diabetes mellitus (p<0.001) and symptomatic hemorrhages (p<0.001). The latter occurred in 5% of our population. Preliminary results of new techniques including sonothrombolysis, angiojet aspiration, and laser recanalization of thromboembolic occlusions are discussed.
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Affiliation(s)
- Caspar Brekenfeld
- Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital, Switzerland
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29
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Abstract
Acute vertebrobasilar occlusion (VBO) remains a disease with a high mortality. Local intraarterial fibrinolysis (LIF) can reduce the mortality rate from about 90 to 60%. The combined therapy of i.v. Abciximab and i.a. rt-PA with additional PTA/stenting may improve neurological outcome and significantly reduce mortality, despite an increase of overall bleeding complications. Additional PTA/stenting is an important treatment factor in cases of atherothrombotic occlusion. In embolic occlusions, mechanical catheter devices, such as basket or snare devices or rheolytic systems, are promising therapies for the near future. This article describes diagnostic criteria and treatment factors in acute VBO. Different treatment strategies, such as i.v. and i.a. fibrinolysis, adjunctive application of GP IIb/IIIa inhibitors, PTA/stenting and mechanical embolectomy are addressed in detail.
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Affiliation(s)
- Bernd Eckert
- Allgemeines Krankenhaus Altona, Funktionsbereich Neuroradiologie, Hamburg, Germany.
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30
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L L Yeo L, Sharma VK. The quest for arterial recanalization in acute ischemic stroke-the past, present and the future. J Clin Med Res 2013; 5:251-65. [PMID: 23864913 PMCID: PMC3712879 DOI: 10.4021/jocmr1342w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2013] [Indexed: 01/19/2023] Open
Abstract
Ischemic stroke is one of the major causes of mortality and long-term disability. In the recent past, only very few treatment options were available and a considerable proportion of stroke survivors remained permanently disabled. However, over the last 2 decades rapid advances in acute stroke care have resulted in a corresponding improvement in mortality rates and functional outcomes. In this review, we describe the evolution of systemic thrombolytic agents and various interventional devices, their current status as well as some of the future prospects. We reviewed literature pertaining to acute ischemic stroke reperfusion treatment. We explored the current accepted treatment strategies to attain cerebral reperfusion via intravenous modalities and compare and contrast them within the boundaries of their clinical trials. Subsequently we reviewed the trials for interventional devices for acute ischemic stroke, categorizing them into thrombectomy devices, aspiration devices, clot disruption devices and thrombus entrapment devices. Finally we surveyed several of the alternative reperfusion strategies available. We also shed some light on the controversies surrounding the current strategies of treatment of acute ischemic stroke. Acute invasive interventional strategies continue to improve along with the noninvasive modalities. Both approaches appear promising. We conducted a comprehensive chronological review of the existing treatments as well as upcoming remedies for acute ischemic stroke.
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Affiliation(s)
- Leonard L L Yeo
- Division of Neurology, National University Hospital, Singapore and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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31
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Endovascular thrombectomy following acute ischemic stroke: a single-center case series and critical review of the literature. Brain Sci 2013; 3:521-39. [PMID: 24961413 PMCID: PMC4061858 DOI: 10.3390/brainsci3020521] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 03/26/2013] [Accepted: 03/28/2013] [Indexed: 01/19/2023] Open
Abstract
Acute ischemic stroke (AIS) due to thrombo-embolic occlusion in the cerebral vasculature is a major cause of morbidity and mortality in the United States and throughout the world. Although the prognosis is poor for many patients with AIS, a variety of strategies and devices are now available for achieving recanalization in patients with this disease. Here, we review the treatment options for cerebrovascular thromboembolic occlusion with a focus on the evolution of strategies and devices that are utilized for achieving endovascular clot extraction. In order to demonstrate the progression of this treatment strategy over the past decade, we will also present a single-center case series of AIS patients treated with endovascular thrombectomy.
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32
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Development of endovascular vibrating polymer actuator probe for mechanical thrombolysis: in vivo study. ASAIO J 2013; 58:503-8. [PMID: 22820916 DOI: 10.1097/mat.0b013e31825f341c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
In this study, we propose a new method for the enhancement of intraarterial thrombolysis by use of an endovascular vibrating polymer actuator probe (VPAP), which is fabricated from an ionic polymer metal composite (IPMC) actuator. The endovascular VPAP was fabricated by combining 0.8 × 0.8 × 10 mm3 IPMC samples, 0.22 mm × 50 cm copper wires, and 40 cm of Teflon tube. The purpose of this study was to evaluate the thrombolysis efficiency of an endovascular VPAP in a dog model. Both renal arteries of the enrolled dogs (n = 5) were used in the current study. A distal portion of the renal artery in a mongrel dog was occluded by a blood clot from autologous venous whole blood. Intraarterial thrombolysis was performed by use of a VPAP without the actuation force (control group), by a VPAP-only (VPAP-only group), or with a combination of recombinant tissue plasminogen activator (rtPA) and a VPAP (VPAP + rtPA group). The thrombolysis efficiency was evaluated by the modified Thrombolysis in Myocardial Infarction (TIMI) grading system based on the consensus between two radiologists. The grading scales were compared according to each intraarterial thrombolysis method. The VPAP + rtPA and VPAP-only groups showed a significantly higher thrombolysis efficiency than did the control group (p < 0.05). The VPAP-only group also showed a significantly higher thrombolysis efficiency than did the control group (p < 0.05). The VPAP+ rtPA group showed a significantly higher thrombolysis efficiency than did the VPAP-only group (p < 0.05). The use of an endovascular VPAP was a feasible and useful method for intraarterial thrombolysis, and it enhanced the thrombolysis efficiency when combined with the thrombolytic agent rtPA.
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Martins SCO, Freitas GRD, Pontes-Neto OM, Pieri A, Moro CHC, Jesus PAPD, Longo A, Evaristo EF, Carvalho JJFD, Fernandes JG, Gagliardi RJ, Oliveira-Filho J. Guidelines for acute ischemic stroke treatment: part II: stroke treatment. ARQUIVOS DE NEURO-PSIQUIATRIA 2012; 70:885-93. [DOI: 10.1590/s0004-282x2012001100012] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 07/04/2012] [Indexed: 11/22/2022]
Abstract
The second part of these Guidelines covers the topics of antiplatelet, anticoagulant, and statin therapy in acute ischemic stroke, reperfusion therapy, and classification of Stroke Centers. Information on the classes and levels of evidence used in this guideline is provided in Part I. A translated version of the Guidelines is available from the Brazilian Stroke Society website (www.sbdcv.com.br).
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Pi Y, Zhang L, Yang Q, Li B, Fang C, Gao C, Wang J, Xiang J, Li J. Neurothrombectomy for the treatment of acute ischemic stroke in 1530 patients. J Clin Neurosci 2012; 19:1363-8. [DOI: 10.1016/j.jocn.2011.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 10/22/2011] [Accepted: 10/25/2011] [Indexed: 11/30/2022]
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Liu X. Beyond the time window of intravenous thrombolysis: standing by or by stenting? INTERVENTIONAL NEUROLOGY 2012; 1:3-15. [PMID: 25187761 PMCID: PMC4031767 DOI: 10.1159/000338389] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Intravenous administration of tissue plasminogen activator within 4.5 h of symptom onset is presently the 'golden rule' for treating acute ischemic stroke. However, many patients miss the time window and others reject this treatment due to a long list of contraindications. Mechanical embolectomy has recently progressed as a potential alternative for treating patients beyond the time window for IV thrombolysis. In this paper, recent progress in mechanical embolectomy, angioplasty, and stenting in acute stroke is reviewed. Despite worries concerning the long-term clinical outcomes and increased risk of intracranial hemorrhage, favorable clinical outcomes may be achieved after mechanical embolectomy in carefully selected patients even 4.5 h after stroke onset. Potential steps should be prepared and attempted in these patients whose opportunity for recovery will elapse in a flash.
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Affiliation(s)
- Xinfeng Liu
- Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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36
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Ellis JA, Youngerman BE, Higashida RT, Altschul D, Meyers PM. Endovascular treatment strategies for acute ischemic stroke. Int J Stroke 2012; 6:511-22. [PMID: 22111796 DOI: 10.1111/j.1747-4949.2011.00670.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The limitations of intravenous thrombolysis therapy have paved the way for the development of novel endovascular technologies for use in the setting of acute stroke. These technologies range from direct intraarterial thrombolysis to various thrombus disruption or retrieval devices to angioplasty and stenting. The tools in the armamentarium of the neuroendovascular interventionalist enable fast, effective revascularization to be offered to a wider population of patients that may otherwise have few therapeutic options available to them. In this paper, we review the current state-of-the-art in neuroendovascular intervention for acute ischemic stroke. Particular emphasis is placed on delineating the indications and outcomes for use of these various technologies.
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Affiliation(s)
- Jason A Ellis
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA.
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37
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Gralla J, Brekenfeld C, Mordasini P, Schroth G. Mechanical Thrombolysis and Stenting in Acute Ischemic Stroke. Stroke 2012; 43:280-5. [DOI: 10.1161/strokeaha.111.626903] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jan Gralla
- From the Department of Interventional and Diagnostic Neuroradiology, University of Bern, Bern, Switzerland
| | - Caspar Brekenfeld
- From the Department of Interventional and Diagnostic Neuroradiology, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- From the Department of Interventional and Diagnostic Neuroradiology, University of Bern, Bern, Switzerland
| | - Gerhard Schroth
- From the Department of Interventional and Diagnostic Neuroradiology, University of Bern, Bern, Switzerland
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38
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Adamczak J, Hoehn M. In vivo imaging of cell transplants in experimental ischemia. PROGRESS IN BRAIN RESEARCH 2012. [PMID: 23186710 DOI: 10.1016/b978-0-444-59544-7.00004-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The therapeutic potential of stem cells for regeneration after cerebral lesion has become of great interest. This is particularly so for neurodegenerative diseases as well as for stroke. Contrary to more conventional, cerebroprotective treatment approaches, the focus of regeneration lies in a longer time window during the chronic phase of the lesion evolution. Thus, in order to assess the true potential of a treatment strategy and to investigate the underlying mechanisms, observation of the temporal profile of both the cell dynamics as well as the organ response to the treatment is of paramount importance. This need for intraindividual longitudinal studies can be optimally met by the application of noninvasive imaging modalities. This chapter presents in breadth the potential of noninvasive imaging modalities for cell tracking with application focus to experimental stroke. While the lion's share of discussed studies is based on MRI, we have also included the contributions of positron emission tomography and of the increasingly important optical imaging modality.
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Affiliation(s)
- Joanna Adamczak
- Max-Planck-Institute for Neurological Research, In vivo NMR, Cologne, Germany
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39
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Falluji N, Abou-Chebl A, Castro CER, Mukherjee D. Reperfusion Strategies for Acute Ischemic Stroke. Angiology 2011; 63:289-96. [DOI: 10.1177/0003319711414269] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke remains a major cause of morbidity and mortality worldwide. Despite preventive measures, effective management strategies are needed to reduce the morbidity and mortality associated with this devastating condition. While the management of hemorrhagic stroke is mostly limited to supportive care, reperfusion strategies in ischemic stroke have been developed and continue to evolve. Conceptually, the pathophysiology of ischemic stroke is similar to that of acute myocardial infarction and the objective of management is similar (ie, to rapidly restore normal flow to reduce permanent damage). It is, therefore, not surprising that the management of acute ischemic stroke includes intravenous (IV) thrombolysis, the only Food and Drug Administration (FDA)-approved strategy at this point. In addition, there are a myriad of emerging endovascular interventional techniques. We review the current literature and discuss some of the technical aspects of endovascular therapy in the setting of acute ischemic stroke.
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Affiliation(s)
| | - Alex Abou-Chebl
- Department of Neurology, University of Louisville, Louisville, KY, USA
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40
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Rouchaud A, Mazighi M, Labreuche J, Meseguer E, Serfaty JM, Laissy JP, Lavallée PC, Cabrejo L, Guidoux C, Lapergue B, Klein IF, Olivot JM, Abboud H, Simon O, Schouman-Claeys E, Amarenco P. Outcomes of mechanical endovascular therapy for acute ischemic stroke: a clinical registry study and systematic review. Stroke 2011; 42:1289-94. [PMID: 21441143 DOI: 10.1161/strokeaha.110.599399] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Recanalization is a powerful predictor of stroke outcome in patients with arterial occlusion. Intravenous recombinant tissue plasminogen activator is limited by its recanalization rate, which may be improved with mechanical endovascular therapy (MET). However, the benefit and safety of MET remain to be determined. The aim of this study was to give reliable estimates of efficacy and safety outcomes of MET. METHODS We analyzed data from our prospective clinical registry and conducted a systematic review of all previous studies using MET published between January 1966 and November 2009. RESULTS From April 2007 to November 2009, 47 patients with acute stroke were treated with MET at Bichat Hospital. The literature search identified 31 previous studies involving a total of 1066 subjects. In the meta-analysis, including our registry data, the overall recanalization rate was 79% (95% CI, 73-84). Meta-analysis of clinical outcomes showed a pooled estimate of 40% (95% CI, 34-46; 27 studies) for favorable outcome, 28% (95% CI, 23-33; 28 studies) for mortality, and 8% (95% CI, 6-10; 27 studies) for symptomatic intracranial hemorrhage. The likelihood of a favorable outcome increased with the use of thrombolysis (OR, 1.99; 95% CI, 1.23-3.22) and with proportion of patients with isolated middle cerebral artery occlusion (OR per 10% increase, 1.14; 95% CI, 1.04-1.25). CONCLUSIONS MET is associated with acceptable safety and efficacy in stroke patients, and it may be a therapeutic option in those presenting with isolated middle cerebral artery occlusion.
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Affiliation(s)
- Aymeric Rouchaud
- Department of Neurology and Stroke Centre, Bichat University Hospital, INSERM U-698 and Paris-Diderot University, 46, rue Henri Huchard, 75018 Paris, France
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41
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Furlan AJ, Sharma J, Higashida R. Intraarterial Thrombolysis in Acute Ischemic Stroke. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10062-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Ansari S, Rahman M, McConnell DJ, Waters MF, Hoh BL, Mocco J. Recanalization therapy for acute ischemic stroke, part 2: mechanical intra-arterial technologies. Neurosurg Rev 2010; 34:11-20. [PMID: 21107630 DOI: 10.1007/s10143-010-0294-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2010] [Accepted: 08/29/2010] [Indexed: 10/18/2022]
Abstract
Stroke therapy has been revolutionized in the past two decades with the widespread implementation of chemical thrombolysis for acute stroke. However, chemical thrombolysis continues to be limited in its efficacy secondary to relatively short time windows and a high associated risk of hemorrhage. In an attempt to minimize hemorrhagic complications and extend the available therapeutic window, mechanical devices designed specifically for thrombus removal, clot obliteration, and arterial revascularization have experienced a recent surge in development and utilization. As such, chemical thrombolytics now represent only one of many options in acute stroke therapy. These new mechanical devices have extended the potential treatment window and now provide alternatives to patients who do not respond to conventional intravenous thrombolysis. This review will discuss the development of these devices, supporting literature, and the individual strengths that each engenders towards a life-saving therapy for stroke.
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Affiliation(s)
- Saeed Ansari
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
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43
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Nicosia A, Nikas D, Castriota F, Biamino G, Cao P, Cremonesi A, Mathias K, Moussa I, Hopkins LN, Setacci C, Sievert H, Reimers B. Classification for carotid artery stenting complications: manifestation, management, and prevention. J Endovasc Ther 2010; 17:275-94. [PMID: 20557164 DOI: 10.1583/09-2943.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Carotid artery stenting is a rapidly evolving method for treating carotid artery disease. Various intraprocedural and postprocedural complications have been reported in the literature. However, the absence of a unified classification scheme for these complications makes it difficult, if not impossible, to study their precise incidence, predictors, and management. The aim of this article is to propose the first joint classification of periprocedural complications, to analyze their incidence and etiology, and suggest possible ways to manage and prevent them. This classification is intended to be used as a common platform for prompt recognition, evaluation, treatment, and universal study of the complications during carotid stenting procedures. For this purpose, the opinions of the major experts on carotid interventions worldwide were merged with all the available information reported in the English-language literature to present as accurately as possible the management and prevention of carotid stenting complications according to this proposed classification.
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Affiliation(s)
- Antonino Nicosia
- Cardiac Catheterization Laboratory, M.P. Arezzo Hospital, Ragusa, Italy
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44
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Killer M, Ladurner G, Kunz AB, Kraus J. Current endovascular treatment of acute stroke and future aspects. Drug Discov Today 2010; 15:640-7. [PMID: 20457274 DOI: 10.1016/j.drudis.2010.04.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Revised: 03/08/2010] [Accepted: 04/23/2010] [Indexed: 11/17/2022]
Abstract
Acute ischemic stroke remains a condition of high morbidity and mortality. Until now, the only established therapy has been intravenous (IV) tissue-type plasminogen activator (tPA). Only 3-10% of patients with acute ischemic stroke receive this treatment. On the basis of data from part 3 of the European Collaborative Acute Stroke Study (ECASS III), the time window for beneficial treatment of ischemic stroke with IV tPA has been extended from 3 to 4.5h after the onset of stroke symptoms. Beyond that window of opportunity, and additionally to IV treatment, interventional stroke therapy has assumed an important role for the treatment of acute ischemic stroke. Currently, new promising pharmacological and mechanical treatment options are being established as routine procedures to achieve a further improved outcome for stroke patients.
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Affiliation(s)
- Monika Killer
- Christian Doppler University Clinic Salzburg, Ignaz Harrer Strasse 79, 5020 Salzburg, Austria.
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45
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Connors JJ, Sacks D, Black CM, McIff EB, Stallmeyer MJB, Cole JW, Rowley HA, Wojak JC, Mericle RA, Murphy KJ, Cardella JF. Training guidelines for intra-arterial catheter-directed treatment of acute ischemic stroke: a statement from a special writing group of the Society of Interventional Radiology. J Vasc Interv Radiol 2010; 20:1507-22. [PMID: 19944980 DOI: 10.1016/j.jvir.2009.10.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 10/11/2009] [Accepted: 10/13/2009] [Indexed: 10/20/2022] Open
Affiliation(s)
- J J Connors
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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46
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Karpiouk AB, Wang B, Emelianov SY. Development of a catheter for combined intravascular ultrasound and photoacoustic imaging. THE REVIEW OF SCIENTIFIC INSTRUMENTS 2010; 81:014901. [PMID: 20113121 PMCID: PMC2814830 DOI: 10.1063/1.3274197] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Accepted: 11/23/2009] [Indexed: 05/18/2023]
Abstract
Atherosclerosis is characterized by formation and development of the plaques in the inner layer of the vessel wall. To detect and characterize atherosclerotic plaques, we previously introduced the combined intravascular ultrasound (IVUS) and intravascular photoacoustic (IVPA) imaging capable of assessing plaque morphology and composition. The utility of IVUS/IVPA imaging has been demonstrated by imaging tissue-mimicking phantoms and ex vivo arterial samples using laboratory prototype of the imaging system. However, the clinical realization of a IVUS/IVPA imaging requires an integrated intravascular imaging catheter. In this paper, two designs of IVUS/IVPA imaging catheters--side fire fiber-based and mirror-based catheters--are reported. A commercially available IVUS imaging catheter was utilized for both pulse-echo ultrasound imaging and detection of photoacoustic transients. Laser pulses were delivered by custom-designed fiber-based optical systems. The optical fiber and IVUS imaging catheter were combined into a single device. Both designs were tested and compared using point targets and tissue-mimicking phantoms. The results indicate applicability of the proposed catheters for clinical use.
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Affiliation(s)
- Andrei B Karpiouk
- Department of Biomedical Engineering, University of Texas at Austin, 1 University Station C0800, Austin, Texas 78712, USA
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47
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Divani AA, Rasmussen K, Vazquez G, Rao GHR. Effect of Blood Soluble Clotting Factors on Coagulation Profile. Clin Appl Thromb Hemost 2009; 16:475-9. [DOI: 10.1177/1076029609342095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: Recently, mechanical thrombolytic therapy has been introduced as an alternative or adjunct to pharmaceutical thrombolytic therapy in removing thrombus from vascular system. Recurrent thrombosis has been a challenge for thrombolytic therapies. We hypothesize that soluble clotting factors released during a mechanical thrombectomy procedure may be responsible for creating a localized hypercoagulable state and could be one of the underlying causes of recurrent thrombosis. Method: Blood samples were obtained from 20 participants with no history of hypertension, vascular disease, and antiplatelet/anticoagulation therapy. For each whole blood (WB) sample, we measured activated clotting time (ACT) and clotting rate (CR) at the baseline and then with added agitated and nonagitated clot serums. The same set of measurements was performed on platelet-rich plasma (PRP) samples of each participant. We tested for changes in coagulation profile between baseline samples and those with added supernatant serums obtained from autologous blood clot. Result: We observed a significant decrease in ACT for WB with agitated and nonagitated clot serums (49%, P < .0001 and 25%, P = .01, respectively) compared to the baseline WB. The same trend was observed for PRP samples with agitated and nonagitated clot serums (28%, P = .002 and 18%, P = .05, respectively). The CR was increased (a steeper slope) by 83% for samples with added agitated clot serum only (P = .007). Conclusion: We observed a significant change for ACT in WB samples with added clot serums as compared to the baseline WB samples. The results of this study suggest that the soluble substances released from clotting blood have profound procoagulant effects.
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Affiliation(s)
- Afshin A. Divani
- Zeenat Quresh Stroke Center and Minnesota Stroke Initiatives: Department of Neurology, University of Minnesota, Minneapolis, MN, , Department of Neurosurgery, University of Minnesota, Minneapolis, Department of Radiology, University of Minnesota, Minneapolis
| | - Kirsten Rasmussen
- Zeenat Quresh Stroke Center and Minnesota Stroke Initiatives: Department of Neurology, University of Minnesota, Minneapolis
| | - Gabriela Vazquez
- Zeenat Quresh Stroke Center and Minnesota Stroke Initiatives: Department of Neurology, University of Minnesota, Minneapolis
| | - Gundu H. R. Rao
- Department of Laboratory Medicine and Pathology, Lillehei Heart Institute, University of Minnesota, Minneapolis, Minnesota
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48
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Eckert B. Acute Stroke Therapy 1981–2009*. Clin Neuroradiol 2009; 19:8-19. [DOI: 10.1007/s00062-009-8033-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Accepted: 11/03/2008] [Indexed: 11/25/2022]
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Roth C, Papanagiotou P, Hartmann K, Reith W. [Mechanical recanalization]. Radiologe 2009; 49:328-34. [PMID: 19387603 DOI: 10.1007/s00117-008-1774-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Although several studies and registries have focused on new interventional systems for the treatment of acute ischemic stroke, a standard procedure has not yet been established. The procedure itself is still controversially discussed but studies have shown that patients who were successfully treated with mechanical recanalization had a better clinical outcome.
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Affiliation(s)
- C Roth
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum des Saarlandes, Kirrberger Strasse, 66421, Homburg / Saar, Deutschland.
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50
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Nogueira RG, Schwamm LH, Hirsch JA. Endovascular approaches to acute stroke, part 1: Drugs, devices, and data. AJNR Am J Neuroradiol 2009; 30:649-61. [PMID: 19279271 DOI: 10.3174/ajnr.a1486] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Despite years of research and pioneering clinical work, stroke remains a massive public health concern. Since 1996, we have lived in the era of US Food and Drug Administration-approved intravenous (i.v.) recombinant tissue plasminogen activator (rtPA). This treatment, despite its promise, continues to exhibit its limitations. Endovascular therapy has several theoretic advantages over i.v. rtPA, including site specificity, longer treatment windows, and higher recanalization rates. In this article, we will review the various pharmacologic strategies for acute stroke treatment, providing both a historic context and the state of the art. The drugs will be classified on the basis of their theoretic rationale for therapy. Next, we will review the various devices and strategies for mechanical revascularization with an aim toward comprehensiveness. These range from wire disruption of thrombus to preclinical trials for novel mechanical solutions. This first installment of this 2-part series will end with an analysis of retrograde reperfusion techniques.
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Affiliation(s)
- R G Nogueira
- Endovascular Neurosurgery/Interventional Neuroradiology Section, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. 02114, USA.
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