Endovascular therapy in hyperacute ischaemic stroke: history and current status

Associated factors with functional prognosis of patients with acute ischemic stroke undergoing thrombectomy

INTRODUCTION

Mechanical thrombectomy (MT) has meant a change in natural history of acute ischemic stroke. Our aim is to assess the possible association between different factors and prognosis in patients treated with MT in a third degree Spanish hospital.

METHODS

Cross-sectional study including 198 patients underwent MT because of acute ischemic stroke between 2012 and 2020. Sociodemographic, vascular risk factors (VRF) and clinical-radiologic factors were recorded. Functional outcome was evaluated based on modified Rankin Scale (mRS) at 90 days, being mRS≤2 favorable and mRS≥3 unfavorable outcome.

RESULTS

Mean age 67.7±13.5 years, 50.5% women. Arterial hypertension was the most prevalent VRF (65.7%). National Institute of Health Stroke Scale (NIHSS) median value at admission was 17.0 (8.0; 22.0). 40.9% of cases also received fibrinolytic treatment. Conscious sedation was performed in 66.7% patients. Median passes of MT were 2, and median duration 41min. Successful recanalization was achieved in 79.9% and mRS≤2 at 90 days was registered at 59.5% cases. Age, type 2 diabetes (T2D), number of MT passes and procedure duration were associated with mRS≥3. Successful recanalization was associated with mRS≤2. Regression model confirmed these associations in age (OR: 1.56CI%: 1.11; 2.20); T2D (OR: 3.51CI%: 1.38; 8.97) and successful recanalization (OR: 0.07CI%: 0.02; 0.28).

CONCLUSION

Age, T2D and failed recanalization increase risk for unfavorable outcome at 90 days in patients with AIS treated with MT. Procedure time duration should be considered as a possible determinant factor in functional outcome.

Intravenous Thrombolysis and Passes of Thrombectomy as Predictors for Endovascular Revascularization in Ischemic Stroke

BACKGROUND

Patient selection for endovascular revascularization treatment (ERT) in acute ischemic stroke depends on the expected benefit-risk ratio. As rapid revascularization is a major determinant of good functional outcome, we aimed to identify its predictors after ERT.

METHODS

Consecutive stroke patients from a single stroke center with distal internal carotid artery-, proximal middle cerebral artery- or T-occlusions treated with ERT were retrospectively selected. We assessed admission noncontrast computed tomography and computed tomography angiography for thrombus location, thrombus load (clot burden score), and collateral status. Clinical data were extracted from medical charts. Univariate and multivariate regression analyses were performed to identify predictors of revascularization (thrombolysis in cerebral infarction ≥2b) after ERT.

RESULTS

A total of 63 patients were identified (median age, 73 years; interquartile range: 62-77; 40 females). Sixteen patients (25.4%) underwent intravenous thrombolysis (ivT) before ERT. Twenty-two patients (34.9%) had additional intra-arterial application of recombinant tissue plasminogen activator. The overall recanalization rate was 66.7%, and 9.5% had symptomatic intracranial bleeding. In-hospital mortality was 15%, and 30% reached good functional outcome at discharge. In the univariate analysis, preceding ivT and the number of passes for thrombectomy (dichotomized ≤2 versus >2) were associated with recanalization. There was a trend for number of thrombectomy passes (as continuous variable) and multimodal ERT. In the multivariate regression analysis, ivT prior to ERT and passes of thrombectomy were identified as independent predictors for recanalization.

CONCLUSION

ivT and lower passes of thrombectomy are associated with recanalization after ERT for ischemic stroke with proximal vessel occlusions.

A novel mechanism of neuroprotection: Blood glutamate grabber

Glutamate excitotoxicity is a primary contributor of ischemic neuronal death and other cellular components of the neurovascular unit. Several strategies have been developed against glutamate excitotoxicity, however none of them have not shown positive results in the clinical practice so far. Nowadays, the concept of blood/brain glutamate grabbing or scavenging is well recognized as a novel and attractive protective strategy to reduce the excitotoxic effect of excess extracellular glutamate that accumulates in the brain following an ischemic stroke. The main advantage of this novel therapeutic strategy is that it occurs in the blood circulation and therefore does not affect the normal brain neurophysiology, as it has been described for other drug treatments used against glutamate excitotoxicity. In this work we report all experimental data from the beginning of our studies, focused on stroke pathology, and we describe new findings about the potential application of this therapy. Future clinical trials will allow to know the real efficacy of this novel therapeutic strategy in stroke patients.

The emerging age of endovascular treatment of acute ischaemic stroke and the role of CT angiography in patient work-up: a guide for the radiologist

Recent trial evidence suggests that for patients suffering large-vessel occlusive stroke, endovascular therapy based on the stent-retriever technique is associated with superior clinical outcomes when compared to intravenous thrombolysis alone. The challenge now is how this service is to be delivered. This may involve both centralisation of services around large cities and development of robust networks to receive patients from district general hospitals situated further afield. Both diagnostic and interventional neuroradiology will need to expand. Furthermore, we suggest that it would be advantageous for radiology departments in those hospitals receiving hyperacute stroke patients to perform computed tomography (CT) angiography in addition to non-contrast CT, which also has implications for service delivery in these units. This could swiftly aid identification of patients who might benefit from thrombectomy and improve decision-making through demonstration of occlusive thrombus and of collateral status.

A Mobile Stroke Treatment Unit for Field Triage of Patients for Intraarterial Revascularization Therapy

INTRODUCTION

Favorable outcomes in intraarterial therapy (IAT) for acute ischemic stroke (AIS) are related to early vessel recanalization. The mobile stroke treatment unit (MSTU) is an on-site, prehospital, treatment team, laboratory, and CT scanner that reduces time to treatment for intravenous thrombolysis and may also shorten time to IAT.

METHODS

Using our MSTU database, we identified patients that underwent IAT for AIS. We compared the key time metrics to historical controls, which included patients that underwent IAT at our institution six months prior to implementation of the MSTU. We further divided the controls into two groups: (1) transferred to our institution for IAT and (2) directly presented to our emergency room and underwent IAT.

RESULTS

After 164 days of service, the MSTU transported 155 patients of which 5 underwent IAT. We identified 5 historical controls that were transferred to our center for IAT. Substantial reduction in times including median door to initial CT (12 minute vs. 32 minute), CT to IAT (82 minute vs. 165 minute), and door to MSTU/primary stroke center departure (37 minute vs. 106 minute) were noted among the two groups. Compared to the 6 patients who presented to our institution directly, the MSTU process times were also shorter.

CONCLUSION

Our initial experience shows that MSTU may help in early triage and shorten the time to IAT for AIS.