Long-Term Effect of Intra-Arterial Thrombolysis in Stroke

Mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion in Argentina: An economic analysis

OBJECTIVES

Mechanical thrombectomy (MT) after intravenous thrombolysis (IV-tPA) is an effective and cost-saving treatment for stroke due to large vessel occlusion. However, rates of MT use are low in Argentina. This study was designed to estimate the economic value and the budget impact of incorporating MT after thrombolysis, simulating scenarios from Argentinian compulsory social health insurance (Obras Sociales) and private insurances (Empresas de Medicina Prepaga).

MATERIALS AND METHODS

We adapted a previously published cost-utility and budget-impact (CUA and BIA) model to the Argentinian setting. The CUA was carried out for a lifetime horizon with efficacy inputs from the SWIFT PRIME clinical trial. For seven possible health states, we identified local costs (Argentinian Pesos AR$), utility (QALY), and transition/distribution probabilities (5% discounted rate) and performed deterministic and probabilistic sensitivity analyses. The BIA was based on a six-step approach and a static model for a five-year horizon, and two scenarios (staggered growth and no growth).

RESULTS

Despite higher incremental procedure costs, IV-tPA and MT was dominant over IV-tPA alone (AR$1,049,062 overall savings). Cost-effectiveness remained in the deterministic sensitivity analysis (100% probability of cost-effectiveness). Increased MT procedure volume resulted in savings in years three (0.96%), four (2.6%), and five (4.4%). By year five, 1,280 patients were treated with MT (versus 480) with overall savings of 1.8% (AR$817,244,417).

CONCLUSIONS

MT after IV-tPA is cost-effective in Argentina. Savings offset the incremental hospitalization and long-term costs from the third year onwards. With increased, access the superior efficacy of MT mitigates future disability and comorbidity, reducing overall expenses.

Impact of pre-stroke dependency on outcome after endovascular therapy in acute ischemic stroke

Background and purpose

Current demographic changes indicate that more people will be care-dependent due to increasing life expectancy. Little is known about impact of preexisting dependency on stroke outcome after endovascular treatment (EVT).

Methods

We compared prospectively collected baseline and outcome data of previously dependent vs. independent stroke patients (prestroke modified Rankin Scale score of 3–5 vs. 0–2) treated with EVT. Outcome measures were favorable 3-month outcome (mRS ≤ 3 for previously dependent and mRS ≤ 2 for independent patients, respectively), death and symptomatic intracranial hemorrhage (sICH).

Results

Among 1247 patients, 84 (6.7%) were dependent before stroke. They were older (81 vs. 72 years of age), more often female (61.9% vs. 46%), had a higher stroke severity at baseline (NIHSS 18 vs. 15 points), more often history of previous stroke (32.9% vs. 9.1%) and more vascular risk factors than independent patients. Favorable outcome and mortality were to the disadvantage of independent patients (26.2% vs. 44.4% and 46.4% vs. 25.5%, respectively), whereas sICH was comparable in both cohorts (4.9% vs. 5%). However, preexisting dependency was not associated with clinical outcome and mortality after adjusting for outcome predictors (OR 1.076, 95% CI 0.612–1.891; p = 0.799 and OR 1.267, 95% CI 0.758–2.119; p = 0.367, respectively).

Conclusion

Our study underscores the need for careful selection of care-dependent stroke patients when considering EVT, given a less favorable outcome observed in this cohort. Nonetheless, EVT should not systematically be withheld in patients with preexisting disability, since prior dependency does not significantly influence outcome.

Radiation Outcome in Mechanical Thrombectomy of Acute Ischemic Stroke

Objective

Mechanical thrombectomy is recommended for acute ischemic stroke (AIS) with large artery occlusion. Radiation during the endovascular procedure would increase the risk of skin diseases. We sought to identify radiation outcomes during mechanical thrombectomy.

Methodology

We prospectively collected and analyzed radiation parameters during mechanical thrombectomy in 41 patients affected with acute cerebral artery occlusion.

Results

There were 41 cases (68.73 ± 11.05 years) in this study, with a National Institute Health Stroke Scale (NIHSS) score of 15.66 ± 5.94. The time parameters were recorded as following: 84.45 ± 31.66 min (operation duration), 129.71 ± 81.14 s (angiographic run), 16.02 ± 11.03 min (fluoroscopy) and 18.19 ± 11.14 min (angiographic exposure). The doses produced in the procedure were: 1276.43 ± 1647.56 mGy (shot dose), 607.26 ± 412.34 mGy (fluoroscopy) and 1635.52 ± 593.65 mGy (angiographic exposure). Further analysis discovered no association between NIHSS and these time and radiation parameters (P > 0.05).

Conclusion

This study provided the description of radiation details during mechanical thrombectomy for acute cerebral artery occlusion. The stroke severity would not influence the procedure parameters.

Impact of smoking on stroke outcome after endovascular treatment

Background

Recent studies suggest a paradoxical association between smoking status and clinical outcome after intravenous thrombolysis (IVT). Little is known about relationship between smoking and stroke outcome after endovascular treatment (EVT).

Methods

We analyzed data of all stroke patients treated with EVT at the tertiary stroke centre of Berne between January 2005 and December 2015. Using uni- and multivariate modeling, we assessed whether smoking was independently associated with excellent clinical outcome (modified Rankin Scale (mRS) 0–1) and mortality at 3 months. In addition, we also measured the occurrence of symptomatic intracranial hemorrhage (sICH) and recanalization.

Results

Of 935 patients, 204 (21.8%) were smokers. They were younger (60.5 vs. 70.1 years of age, p<0.001), more often male (60.8% vs. 52.5%, p = 0.036), had less often from hypertension (56.4% vs. 69.6%, p<0.001) and were less often treated with antithrombotics (35.3% vs. 47.7%, p = 0.004) as compared to nonsmokers. In univariate analyses, smokers had higher rates of excellent clinical outcome (39.1% vs. 23.1%, p<0.001) and arterial recanalization (85.6% vs. 79.4%, p = 0.048), whereas mortality was lower (15.6% vs. 25%, p = 0.006) and frequency of sICH similar (4.4% vs. 4.1%, p = 0.86). After correcting for confounders, smoking still independently predicted excellent clinical outcome (OR 1.758, 95% CI 1.206–2.562; p<0.001).

Conclusion

Smoking in stroke patients may be a predictor of excellent clinical outcome after EVT. However, these data must not be misinterpreted as beneficial effect of smoking due to the observational study design. In view of deleterious effects of cigarette smoking on cardiovascular health, cessation of smoking should still be strongly recommended for stroke prevention.

Mechanical thrombectomy in acute ischaemic stroke: a review of the different techniques

Endovascular mechanical thrombectomy (MT) is reserved for acute ischaemic stroke secondary to large vessel occlusion. The various MT techniques employed in the treatment of hyperacute strokes are constantly evolving with new devices and improvisation of existing technology (Wahlgren, et al 2016). In this review, we describe a variety of MT techniques gained from our experience of performing over 350 procedures in 7 years of providing a 24/7 service within the national framework of a hyperacute stroke centre. We outline a number of endovascular techniques, procedure limitations, and potential complications.

Cost-effectiveness of stent-retriever thrombectomy in combination with IV t-PA compared with IV t-PA alone for acute ischemic stroke in the UK

OBJECTIVE

To evaluate the cost-effectiveness of neurothrombectomy with a stent retriever (Solitaire * Revascularization Device) in treating acute ischemic stroke patients from the UK healthcare provider perspective.

METHODS

A Markov model was developed to simulate health outcomes and costs of two therapies over a lifetime time horizon: stent-retriever thrombectomy in combination with intravenous tissue-type plasminogen activator (IV t-PA), and IV t-PA alone. The model incorporated an acute phase (0-90 days) and a rest of life phase (90+ days). Health states were defined by the modified Rankin Scale score. During the rest of life phase, patients remained in the same health state until a recurrent stroke or death. Clinical effectiveness and safety data were taken from the SWIFT PRIME study. Resource use and health state utilities were informed by published data.

RESULTS

Combined stent-retriever thrombectomy and IV t-PA led to improved quality-of-life and increased life expectancy compared to IV t-PA alone. The higher treatment costs associated with the use of stent-retriever thrombectomy were offset by long-term cost savings due to improved patient health status, leading to overall cost savings of £33 190 per patient and a net benefit of £79 402. Deterministic and probabilistic sensitivity analyses demonstrated that the results were robust to a wide range of parameter inputs.

LIMITATIONS

The acute and long-term costs resource use data were taken from a study based on a patient population that was older and may have had additional comorbidities than the SWIFT PRIME population, resulting in costs that may not be representative of the cohort within this model. In addition, the estimates may not reflect stroke care today as no current evidence is available; however, the cost estimates were deemed reasonable by clinical opinion.

CONCLUSIONS

Combined stent-retriever neurothrombectomy and IV t-PA is a cost-effective treatment for acute ischemic stroke compared with IV t-PA alone.

Guidelines for acute ischemic stroke treatment: part II: stroke treatment

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).

Impact of Admission Glucose and Diabetes on Recanalization and Outcome after Intra-Arterial Thrombolysis for Ischaemic Stroke

Background

Stroke patients with diabetes and admission hyperglycaemia have worse outcomes than non-diabetics, with or without intravenous thrombolysis. Poor vessel recanalization was reported in diabetics treated with intravenous thrombolysis.

Aims

This study aimed to determine the impact of admission glucose and diabetes on recanalization and outcome after intra-arterial thrombolysis.

Methods

We analysed 389 patients (213 men, 176 women) treated with intra-arterial thrombolysis. The association of diabetes and admission glucose value with recanalization, outcome, mortality, and symptomatic intracranial haemorrhage was determined. Recanalization was classified according to thrombolysis in myocardial infarction grades. Outcome was measured using the modified Rankin Scale at three-months and categorized as favourable (modified Rankin Scale 0–2) or poor (modified Rankin Scale 3–6).

Results

The rate of partial or complete recanalization (thrombolysis in myocardial infarction 2–3) did not differ between patients with and without diabetes (67% vs. 66%; P = 1·000). Mean admission glucose values were similar in patients with poor recanalization (thrombolysis in myocardial infarction 0–1) and patients with partial or complete recanalization (thrombolysis in myocardial infarction 2–3; 7·3 vs. 7·3 mmol/l; P = 0·746). Follow-up at three-months was obtained in 388 of 389 patients. Clinical outcome was favourable (modified Rankin Scale 0–2) in 189 patients (49%) and poor (modified Rankin Scale 3–6) in 199 patients (51%). Mortality at three-months was 20%. Diabetics were more likely to have poor outcome (72% vs. 48%; P = 0·001) and to be dead (30% vs. 19%; P = 0·044) at three-months. After multivariable analysis, there remained an independent relationship between diabetes and outcome ( P = 0·003; odds ratio 3·033, 95% confidence interval 1·452–6·336), but not with mortality ( P = 0·310; odds ratio 1·436; 95% confidence interval 0·714–2·888). Moreover, higher age ( P = 0·001; odds ratio 1·039; 95% confidence interval 1·017–1·061), higher baseline National Institutes of Health Stroke Scale score ( P < 0·0001; odds ratio 1·130; 95% confidence interval 1·079–1·182), location of vessel occlusion as categorical variable ( P < 0·0001), poor collaterals ( P = 0·02; odds ratio 1·587; 95% confidence interval 1·076–2·341), poor vessel recanalization ( P < 0·0001; odds ratio 4·713; 95% confidence interval 2·627–8·454), and higher leucocyte count ( P = 0·032; odds ratio 1·094; 95% confidence interval 1·008–1·188) were independent baseline predictors of poor outcome. Higher admission glucose was associated with poor outcome ( P = 0·006) and mortality ( P < 0·0001). After multivariate analyses, glucose remained independently associated with poor outcome ( P = 0·019; odds ratio 1·150; 95% confidence interval 1·023-1-292) and mortality ( P = 0·005; odds ratio 1·183; 95% confidence interval 1052–1·331). The rate of symptomatic intracranial haemorrhage was similar in diabetics and non-diabetics (6·7% vs. 4·6%; P = 0·512). Mean admission glucose was higher in patients with symptomatic intracranial haemorrhage than without (8·58 vs. 7·26 mmol/l; P = 0·010). Multivariable analysis confirmed an independent association between admission glucose and symptomatic intracranial haemorrhage ( P = 0·027; odds ratio 1·187; 95% confidence interval 1·020–1·381).

Conclusions

Diabetes and glucose value on admission did not influence recanalization after intra-arterial thrombolysis; nevertheless, they were independent predictors of poor outcome after intra-arterial thrombolysis and a higher admission glucose value was an independent predictor of symptomatic intracranial haemorrhage. This indicates that factors on the capillary, cellular, or metabolic level may account for the worse outcome in patients with elevated glucose value and diabetes.

Impact of Thrombolysis on Stroke Outcome at 12 Months in a Population

Background and Purpose—

Thrombolysis improves outcome of patients with acute ischemic stroke, but it is unknown whether thrombolysis has a measurable effect on long-term outcome in a defined population.

Methods—

We prospectively assessed demographic data, management, and outcome of acute ischemic stroke patients admitted within 48 hours to 18 primary care hospitals of the canton of Bern (969 299 inhabitants) during 12 months. Blinded follow-up was obtained at 3 and 12 months. Predictors of mortality and favorable outcome (modified Rankin Scale score ≤2) at 3 and 12 months using logistic regression were analyzed.

Results—

From December 2007 to December 2008, 807 patients (mean age, 72 years) were included. Median National Institutes of Health Stroke Scale score on admission was 5; 107 patients (13%) received intravenous, intra-arterial, or mechanical thrombolysis. Estimated cumulative mortality at 3 months was 20.6% and at 12 months 27.4%. Age 75 years or older, higher National Institutes of Health Stroke Scale scores, and higher Charlson comorbidity index were independent predictors of mortality at 3 and 12 months. Estimated favorable outcome at 3 months was 48.2% and at 12 months was 44.6%. Thrombolysis was the only modifiable independent predictor of favorable outcome at 3 (relative risk, 1.49; 95% CI, 1.18–1.89) and 12 months (relative risk, 1.59; 95% CI, 1.24–2.04), whereas age younger than 75 years, male gender, National Institutes of Health Stroke Scale score <4, and lower Charlson comorbidity index were nonmodifiable predictors.

Conclusions—

Thirteen percent of acute ischemic stroke patients admitted within 48 hours to Bernese hospitals underwent thrombolysis, which exerted a measurable effect on 3-month outcome in this population. This effect was sustained at 12 months. Age, stroke severity, Charlson comorbidity index, and male gender were independent nonmodifiable predictors of outcome.

Medical therapy for ischemic stroke: review of intravenous and intra-arterial treatment options

BACKGROUND

Thrombolytic therapy is of proven and substantial benefit for select patients with acute cerebral ischemia. Diagnostic options and medical treatment options for acute stroke ischemia have undergone enormous changes in the past decades. Whereas initially stroke treatment was reduced to prevention, management of symptoms, and rehabilitation, nowadays a multitude of different fibrinolytic drugs are available. The wide availability of computed tomography in the late 1980s made thrombolysis a real therapeutic option because it allowed a fast and accurate differentiation between ischemic and hemorrhagic stroke.

METHODS

This study reviews these developments and how they have shaped our current use and understanding of thrombolytics in the treatment of acute ischemic stroke.

RESULTS

Patient selection remains a central aspect of thrombolytic treatment, and to date, the use of different fibrinolytics has been studied in over 20 large randomized trials for different clinical settings, time windows, and routes of administration. These studies included over 7000 patients, and led to our current understanding of the use of thrombolysis in acute stroke.

CONCLUSIONS

Intravenous fibrinolytic therapy within the first 3 hours of ischemic stroke onset offers substantial benefits for virtually all patients with potentially disabling deficits. In the 3- to 4.5-hour treatment window, intravenous fibrinolytic therapy has been shown to offer moderate net benefits when applied to all patients with potentially disabling deficits. Intra-arterial fibrinolytic therapy in the 3- to 6-hour window offers moderate net benefits when applied to all patients with potentially disabling deficits and large-artery cerebral thrombotic occlusions.

Three-month and long-term outcomes and their predictors in acute basilar artery occlusion treated with intra-arterial thrombolysis

BACKGROUND AND PURPOSE

Intra-arterial thrombolysis can be used for treatment of basilar artery occlusion. Predictors of outcome before initiation of treatment are of special interest.

METHODS

From 1992 to 2010, we treated 106 consecutive patients with basilar artery occlusion with intra-arterial thrombolysis. Baseline characteristics, treatment, clinical course, and 3-month and long-term outcomes (≥12 months) were assessed. Outcome parameters were vessel recanalization after treatment, complications, modified Rankin scale (mRS) score, and mortality after 3 months and in the long-term.

RESULTS

At 3 months, clinical outcome was good (mRS score, 0-2) in 33.0% of the patients and moderate (mRS score, 3) in 11.3%. Mortality was 40.6%. Partial or complete recanalization was achieved in 69.8% of the patients, and symptomatic intracranial hemorrhage occurred in 1 patient (0.9%). Between 3-month and long-term follow-up, 22 survivors (40.8%) showed clinical improvement of at least 1 point on the mRS score, 29 (53.7%) were functionally unchanged, and 3 (5.7%) showed functional worsening (P<0.0001). Multivariate analysis identified diabetes as a predictor of poor vessel recanalization (P=0.028). Low baseline National Institutes of Health Stroke Scale score was identified as a predictor of good or moderate clinical outcome (P<0.0001) and survival (P=0.001) at 3 months, and younger age was identified as an additional predictor of survival (P=0.012). For prediction of long-term clinical outcome, age was also an independent predictor (P=0.018).

CONCLUSIONS

In our series, intra-arterial thrombolysis as treatment of basilar artery occlusion was safe. National Institutes of Health Stroke Scale score at admission and age were identified as predictors of outcome, and these predictors should be considered for treatment allocation in future randomized trials.

Treatment of acute middle cerebral artery occlusion with a Solitaire AB stent: preliminary experience

We report our initial experience with a Solitaire AB neurovascular remodeling stent device in performing cerebral embolectomy in seven patients presenting to our institution with acute stroke who were resistant to iv thrombolytic drug treatment. The main inclusion criteria were: National Institutes of Health Stroke Scale (NIHSS) score ≥10; treatment performed within 8 h from the onset of symptoms and no large hypodensity on CT; and occlusion of a major cerebral artery on the CT angiogram. An admission and a post-interventional NIHSS score were calculated for all patients by two different neurologists. Efficacy was assessed radiologically by post-treatment thrombolysis in myocardial infarction (TIMI) scores and clinically by a 30-day Modified Rankin Scale (MRS) score. The mean duration of neurointerventional treatment was 84 min. All interventions were successful, with TIMI scores of 2 or 3 achieved in 100% of patients. There was one procedural complication in our series owing to a self-detached stent and one patient had a small asymptomatic basal ganglia haemorrhage. There was improvement of more than 4 points on the NIHSS score in 5 (72%) of the patients following treatment, of whom 4 (57%) had a 30-day MRS score of ≤2. The use of a Solitaire stent in acute stroke was safe, time-efficient and encouraging; however, a larger sample size will be required to further evaluate the use of this device, which could benefit a significant number of stroke patients.

Mechanical thrombectomy with the Penumbra recanalization device in acute ischemic stroke

BACKGROUND AND PURPOSE

The aim of this study was to assess the clinical outcome of patients treated with the Penumbra system (PS) for acute ischemic stroke. A retrospective, monocentric matched-pair analysis in comparison with patients treated by intraarterial thrombolysis (IAT) with alteplase was designed for this purpose.

METHODS

Twenty-two consecutive patients, (mean age 62), with acute ischemic stroke and National Institutes of Health Stroke Scale (NIHSS) scores ≥ 7 were treated with the PS. Twenty corresponding patients could be identified, treated with IAT. Matches were sought for initial NIHSS score and target vessels. Thrombolysis in myocardial infarction (TIMI) grades, mortality rates, NIHSS upon discharge, and modified Rankin scores (mRs) at 90 days were compared.

RESULTS

A total of 32 vessels in 20 patients were treated in either arm of the study. Recanalization to TIMI 2/3 was successful in 25/32 (78%) of target vessels with the PS, and 17/32 (53%) of target vessels in the IAT group. Upon discharge, 2/20 patients treated with PS and 7/20 patients treated with IAT had a NIHSS score of 0 to 1 or an improvement greater or equal to 10-point on the NIHSS scale. All cause mortality at 90 days was 3/20 patients treated with PS, and 2/20 patients treated with IAT. Three out of twenty patients treated with PS and 7/20 patients treated with IAT had a mRS of ≤ 2 at 90 days.

CONCLUSION

The Penumbra system is effective in re-opening occluded major arteries. Our data seems to indicate that not all patients benefit clinically from improved revascularization of occluded major arteries.

Percutaneous vascular interventions for acute ischaemic stroke

BACKGROUND

Most disabling strokes are due to blockage of a large artery in the brain by a blood clot. Prompt removal of the clot with intra-arterial thrombolytic drugs or mechanical devices, or both, can restore blood flow before major brain damage has occurred, leading to improved recovery. However, these so-called percutaneous vascular interventions can cause bleeding in the brain.

OBJECTIVES

To assess the safety and efficacy of percutaneous vascular interventions in patients with acute ischaemic stroke.

SEARCH STRATEGY

We searched the Trials Registers of the Cochrane Stroke Group and Cochrane Peripheral Vascular Diseases Group (last searched May 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 5), MEDLINE (1980 to May 2010), EMBASE (1980 to May 2010) and eight additional databases. We also searched trials registers, screened reference lists, contacted researchers and equipment manufacturers, and handsearched journals and conference proceedings.

SELECTION CRITERIA

Randomised, controlled and unconfounded trials of any percutaneous vascular intervention compared with control in patients with definite ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors applied the inclusion criteria, extracted data and assessed trial quality. We obtained both published and unpublished data if available

MAIN RESULTS

We included four trials involving 350 patients. Not all trials contributed data to each outcome. The trials tested either intra-arterial urokinase or recombinant pro-urokinase versus an open control. One trial used guidewire-mediated clot disruption in some patients randomised to the intervention group. Most data came from trials that started treatment up to six hours after stroke; one small trial started treatment up to a median of 12.5 hours after stroke. Most data came from trials of middle cerebral artery territory infarction. Compared with non-thrombolytic standard medical treatment, the intervention administered up to six hours after ischaemic stroke significantly increased the proportion of patients with favourable outcome (modified Rankin 0 to 2) three months after stroke (relative risk (RR) 1.47, 95% confidence interval (CI) 1.07 to 2.02). The intervention also significantly increased the risk of symptomatic intracranial haemorrhage within 24 hours of treatment (RR 3.85, 95% CI 0.91 to 16.36). There was no significant heterogeneity between the included trials.

AUTHORS' CONCLUSIONS

Overall, intervention results in a significant increase in the proportion of patients with a favourable outcome, despite a significant increase in intracranial haemorrhage. Further trials are needed to confirm or refute these findings and, given the cost and practical difficulties, to establish whether percutaneous techniques are feasible and cost effective in wider clinical practice.

SAFETY, EFFECTIVENESS, AND PRACTICALITY OF ENDOVASCULAR THERAPY WITHIN THE FIRST 3 HOURS OF ACUTE ISCHEMIC STROKE ONSET

OBJECTIVE

This study assesses the safety, effectiveness, and practicality of endovascular therapy for ischemic stroke within the first 3 hours of symptom onset.

METHODS

A retrospective chart review (January 2000–July 2008) was performed of 94 consecutive patients who had endovascular therapy within 3 hours after acute ischemic stroke onset. Endovascular therapy was administered in patients in whom intravenous (IV) thrombolysis failed or was contraindicated. Outcome measures analyzed were recanalization rate, intracranial hemorrhage (ICH) rate, procedural complications, modified Rankin Scale score, National Institutes of Health Stroke Scale (NIHSS) score, and mortality rate.

RESULTS

The study included 41 male and 53 female patients with a mean age of 68 years (age range, 13–98 years). The mean NIHSS score at the time of admission was 14.7. Eight-three patients had anterior circulation ischemic events, and 11 had posterior circulation ischemic events. The cause was determined to be arterioembolic in 21 patients (22%), cardioembolic in 45 (48%), arterial dissection in 2, left-to-right cardiac shunt in 1, and unknown in 25 (27%). Endovascular interventions included intra-arterial (IA) pharmacological thrombolysis (n = 44), mechanical thrombolysis (Merci Retrieval System, intracranial or extracranial stent, microwire) (n = 79), and intracranial or extracranial angioplasty (n = 32) in various combinations. The mean time from stroke onset to angiogram was 72 minutes. Thirteen patients received a half dose (n = 8) or full dose (n = 5) of IV thrombolysis (tissue plasminogen activator [tPA]) in conjunction with endovascular therapy. Twenty-two patients received IA or IV adjunctive glycoprotein IIb/IIIa inhibitor (eptifibatide). Partial-to-complete recanalization (Thrombolysis in Myocardial Infarction scale score of 2 or 3) was achieved in 62 of 89 of patients (70%) presenting with significant occlusion (Thrombolysis in Myocardial Infarction scale score of 0 or 1). Postprocedure symptomatic ICH occurred in 5 patients (5.3%), which was purely subarachnoid hemorrhage in 3 patients. Of these, 2 received IA tPA in conjunction with Merci Retrieval System passes; the others each received IA tPA, mechanical thrombectomy (guidewire), or extracranial angioplasty. The total mortality rate including procedural mortality, progression of disease, and other comorbidities was 26.6%. Sixteen patients (17%) were discharged home, 49 (52%) to rehabilitation, and 4 (4%) to long-term care facilities. Overall, 36.7% had a modified Rankin Scale score of 2 or less at discharge. The mean NIHSS score at discharge was 6.5, representing an overall 8-point improvement on the NIHSS.

CONCLUSION

Endovascular therapy within the first 3 hours of stroke symptom onset in patients in whom IV tPA therapy is contraindicated or fails is safe, effective, and practical. The risk of symptomatic ICH is low and should be viewed relative to the poor prognosis in this group of patients.

Endovascular approaches to acute stroke, part 2: a comprehensive review of studies and trials

Reperfusion remains the mainstay of acute ischemic stroke treatment. Endovascular therapy has become a promising alternative for patients who are ineligible for or have failed intravenous (IV) thrombolysis. The conviction that recanalization of properly selected patients is essential for the achievement of good clinical outcomes has led to the rapid and widespread growth in the adoption of endovascular stroke therapies. However, comparisons of the recent reperfusion studies have brought into question the strength of the association between revascularization and improved clinical outcome. Despite higher rates of recanalization, the mechanical thrombectomy studies have demonstrated substantially lower rates of good outcomes compared with IV and/or intra-arterial thrombolytic trials. However, such analyses disregard important differences in clot location and burden, baseline stroke severity, time from stroke onset to treatment, and patient selection in these studies. Many clinical trials are testing novel devices and drugs as well as the paradigm of physiology-based stroke imaging as a treatment-selection tool. The objective of this article is to provide a comprehensive review of the relevant past, current, and upcoming data on endovascular stroke therapy with a special focus on the prospective studies and randomized clinical trials.

Quality of life in survivors after cervical artery dissection

BACKGROUND AND PURPOSE

Little data exists about longterm outcome, quality of life (QOL) and its predictors after spontaneous cervical artery dissections (sCAD).

METHODS

Clinical and radiological data of 114 patients with sCAD were collected prospectively. Six patients died within 3 months, the remaining 108 were contacted after a mean of 1498 days (range: 379-3455), 99 survivors (92 %) replied. QOL, assessed with the stroke-specific QOL scale (SSQOL), and functional abilities, measured with modified Rankin Scale (mRS) were compared, and predictors of QOL were analyzed. Subgroup analyses were performed for patients with ischemic stroke, those with isolated local symptoms or transient ischemic symptoms and those without significant disabilities (mRS 0-1) at follow-up.

RESULTS

Seventy-one of 99 patients (72 %) had no significant disability, but only 53 (54 %) reported a good QOL (SS-QOL > or = 4). Compared to the self-rated premorbid QOL of all patients, SS-QOL was impaired after sCAD (p < 0.001); impairment of QOL was observed in patients with ischemic stroke (p < 0.001), in patients with isolated local or transient ischemic symptoms (p < 0.038) and those without significant disabilities at follow-up (p = 0.013). Nevertheless, low mRS was associated with better overall QOL (Kendall's tau > 0.5). High National Institute of Health Stroke Scale score on admission and higher age were independent predictors of impaired QOL (p < 0.05).

CONCLUSION

QOL is impaired in almost half of long-term survivors after sCAD, even in patients with local or transient symptoms or without functional disability. Impairment of QOL is a surprisingly frequent long-term sequela after sCAD and deserves attention as an outcome measure in these patients.

Stroke

Stroke is the second most common cause of death and major cause of disability worldwide. Because of the ageing population, the burden will increase greatly during the next 20 years, especially in developing countries. Advances have occurred in the prevention and treatment of stroke during the past decade. For patients with acute stroke, management in a stroke care unit, intravenous tissue plasminogen activator within 3 h or aspirin within 48 h of stroke onset, and decompressive surgery for supratentorial malignant hemispheric cerebral infarction are interventions of proven benefit; several other interventions are being assessed. Proven secondary prevention strategies are warfarin for patients with atrial fibrillation, endarterectomy for symptomatic carotid stenosis, antiplatelet agents, and cholesterol reduction. The most important intervention is the management of patients in stroke care units because these provide a framework within which further study might be undertaken. These advances have exposed a worldwide shortage of stroke health-care workers, especially in developing countries.

Guidelines for management of ischaemic stroke and transient ischaemic attack 2008

This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.

Empty microcatheter technique for the deployment of a self-expanding stent to treat refractory middle cerebral artery occlusion in the setting of severe proximal tortuosity

We report a case of an acute middle cerebral artery (M2 segment) occlusion that was refractory to intravenous tissue plasminogen activator (IV t-PA), thrombectomy with the Merci device, intra-arterial infusion of urokinase and eptifibatide, and balloon angioplasty. The artery was so tortuous that over-the-wire stent placement failed and a salvage technique was required to place the self-expanding stent.