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Tekieli L, Dzierwa K, Grunwald IQ, Mazurek A, Urbanczyk-Zawadzka M, Wiewiorka L, Banys RP, Dabrowski W, Podlasek A, Weglarz E, Stefaniak J, Nizankowski RT, Musialek P. Outcomes in acute carotid-related stroke eligible for mechanical reperfusion: SAFEGUARD-STROKE Registry. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:231-248. [PMID: 39007556 DOI: 10.23736/s0021-9509.24.13093-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
BACKGROUND Carotid-related strokes (CRS) are largely unresponsive to intravenous thrombolysis and are often large and disabling. Little is known about contemporary CRS referral pathways and proportion of eligible patients who receive emergency mechanical reperfusion (EMR). METHODS Referral pathways, serial imaging, treatment data, and neurologic outcomes were evaluated in consecutive CRS patients presenting over 18 months in catchment area of a major carotid disease referral center with proximal-protected CAS expertise, on-site neurology, and stroke thrombectomy capability (Acute Stroke of CArotid Artery Bifurcation Origin Treated With Use oF the MicronEt-covered CGUARD Stent - SAFEGUARD-STROKE Registry; companion to SAFEGUARD-STROKE Study NCT05195658). RESULTS Of 101 EMR-eligible patients (31% i.v.-thrombolyzed, 39.5% women, age 39-89 years, 94.1% ASPECTS 9-10, 90.1% pre-stroke mRS 0-1), 57 (56.4%) were EMR-referred. Referrals were either endovascular (Comprehensive Stroke Centre, CSC, 21.0%; Stroke Thrombectomy-Capable CAS Centre, STCC, 70.2%) or to vascular surgery (VS, 1.8%), with >1 referral attempt in 7.0% patients (CSC/VS or VS/CSC or CSC/VS/STCC). Baseline clinical and imaging characteristics were not different between EMR-treated and EMR-untreated patients. EMR was delivered to 42.6% eligible patients (emergency carotid surgery 0%; STCC rejections 0%). On multivariable analysis, non-tandem CRS was a predictor of not getting referred for EMR (OR 0.36; 95%CI 0.14-0.93, P=0.03). Ninety-day neurologic status was profoundly better in EMR-treated patients; mRS 0-2 (83.7% vs. 34.5%); mRS 3-5 (11.6% vs. 53.4%), mRS 6 (4.6% vs. 12.1%); P<0.001 for all. CONCLUSIONS EMR-treatment substantially improves CRS neurologic outcomes but only a minority of EMR-eligible patients receive EMR. To increase the likelihood of brain-saving treatment, EMR-eligible stroke referral and management pathways, including those for CSC/VS-rejected patients, should involve stroke thrombectomy-capable centres with endovascular carotid treatment expertise.
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Affiliation(s)
- Lukasz Tekieli
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland -
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland -
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland -
| | - Karolina Dzierwa
- Cardiovascular Imaging Laboratory, St. John Paul II Hospital, Krakow, Poland
| | - Iris Q Grunwald
- Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, UK
- Department of Radiology, University of Dundee Ninewells Hospital, Dundee, UK
| | - Adam Mazurek
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
| | | | - Lukasz Wiewiorka
- Department of Radiology, St. John Paul II Hospital, Krakow, Poland
| | - R Pawel Banys
- Department of Radiology, St. John Paul II Hospital, Krakow, Poland
| | - Wladyslaw Dabrowski
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
- Precison Imaging Beacon, Radiological Sciences, University of Nottingham, Nottingham, UK
| | - Ewa Weglarz
- Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Nursing, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Justyna Stefaniak
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Krakow, Poland
| | - Rafal T Nizankowski
- Quality Promotion in Healthcare, Sano Center for Computational Medicine, Krakow, Poland
| | - Piotr Musialek
- Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
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2
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Kargiotis O, Psychogios K, Safouris A, Spiliopoulos S, Karapanayiotides T, Bakola E, Mantatzis M, Dardiotis E, Ellul J, Giannopoulos S, Magoufis G, Tsivgoulis G. Diagnosis and treatment of acute isolated proximal internal carotid artery occlusions: a narrative review. Ther Adv Neurol Disord 2022; 15:17562864221136335. [PMID: 36437850 PMCID: PMC9685148 DOI: 10.1177/17562864221136335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/16/2022] [Indexed: 07/27/2023] Open
Abstract
The clinical manifestations of proximal (extracranial) internal carotid artery occlusions (pICAOs) may range from asymptomatic to acute, large, and devastating ischemic strokes. The etiology and pathophysiology of the occlusion, intracranial collateral status and patient's premorbid status are among the factors determining the clinical presentation and outcome of pICAOs. Rapid and accurate diagnosis is crucial and may be assisted by the combination of carotid and transcranial duplex sonography, or a computed tomography/magnetic resonance angiography (CTA/MRA). It should be noted that with either imaging modalities, the discrimination of a pseudo-occlusion of the extracranial internal carotid artery (ICA) from a true pICAO may not be straightforward. In the absence of randomized data, the management of acute, symptomatic pICAOs remains individualized and relies largely on expert opinion. Administration of intravenous thrombolysis is reasonable and probably beneficial in the settings of acute ischemic stroke with early presentation. Unfortunately, rates of recanalization are rather low and acute interventional reperfusion therapies emerge as a potentially powerful therapeutic option for patients with persistent and severe symptoms. However, none of the pivotal clinical trials on mechanical thrombectomy for acute ischemic stroke randomized patients with isolated extracranial large vessel occlusions. On the contrary, several lines of evidence from non-randomized studies have shown that acute carotid endarterectomy, or endovascular thrombectomy/stenting of the ICA are feasible and safe, and pοtentially beneficial. The heterogeneity in the pathophysiology and clinical presentation of acute pICAOs renders patient selection for an acute interventional treatment a complicated decision-making process. The present narrative review will outline the pathophysiology, clinical presentation, diagnostic challenges, and possible treatment options for pICAOs.
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Affiliation(s)
| | | | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus,
Greece
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
- Aktios Rehabilitation Center, Koropi,
Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional
Radiology Unit, ‘Attikon’ University General Hospital, Athens, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of
Medicine, Faculty of Health Sciences, AHEPA University General Hospital,
Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Bakola
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
| | - Michail Mantatzis
- Department of Radiology, Interventional
Neuroradiology Unit, AHEPA University General Hospital, Aristotle University
of Thessaloniki, Thessaloniki, Greece
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital
of Larissa, School of Medicine, University of Thessaly, Larissa,
Greece
| | - John Ellul
- Department of Neurology, University General
Hospital of Patras, Patras, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
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3
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Al-Mufti F, Amuluru K, Manning NW, Khan I, Peeling L, Gandhi CD, Prestigiacomo CJ, Pushchinska G, Fiorella D, Woo HH. Emergent carotid stenting and intra-arterial abciximab in acute ischemic stroke due to tandem occlusion. Br J Neurosurg 2017; 31:573-579. [PMID: 28298139 DOI: 10.1080/02688697.2017.1297377] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Acute occlusions of the extracranial internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous tissue plasminogen activator (tPA) and present an endovascular challenge. The aim of our study was to retrospectively delineate the feasibility of the combined use of emergent carotid stenting and intra-arterial (IA) Abciximab with intracranial revascularization in the setting of acute ischemic stroke and carotid occlusions at our institution. METHODS Eleven patients with complete cervical carotid occlusion with or without concomitant intracranial ICA and/or MCA occlusion were identified from a single center, retrospective review of patients admitted to the Stroke unit. We evaluated all cases for complications of emergent cervical ICA recanalization employing carotid stenting and IA Abciximab. RESULTS All patients had complete cervical carotid occlusion with (n = 8) or without (n = 3) concomitant intracranial ICA and/or MCA occlusion. Successful emergent cervical ICA recanalization was achieved in all cases. All patients were administered IA Abciximab (dose range 6-17 mg, average 11.4 mg) immediately following the cervical carotid stenting. There was complete recanalization in all patients with no procedural morbidity or mortality. A single case (1/11, 9%) developed asymptomatic hemorrhagic transformation. Upon discharge, 9 patients (9/11, 82%) had a mRS of 0-2 and 2 patients (2/11, 18%) had a mRS of 3. CONCLUSIONS In acute ICA-MCA/distal ICA occlusions, extracranial stenting followed by intracranial IA Abciximab and thrombectomy appears feasible, effective, and safe. Further evaluation of this treatment strategy is warranted.
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Affiliation(s)
- Fawaz Al-Mufti
- a Department of Neurosurgery , Rutgers University School of Medicine , Newark , NJ , USA
| | - Krishna Amuluru
- a Department of Neurosurgery , Rutgers University School of Medicine , Newark , NJ , USA
| | - Nathan W Manning
- b Department of Neurosurgery , Columbia University Medical Center , New York , NY , USA
| | - Imad Khan
- c Department of Neurology , University of Maryland Medical Center , Baltimore , MD , USA
| | - Lissa Peeling
- d Department of Neurosurgery , University of Saskatchewan , Saskatoon , SK , Canada
| | - Chirag D Gandhi
- a Department of Neurosurgery , Rutgers University School of Medicine , Newark , NJ , USA
| | | | - Galyna Pushchinska
- e Department of Neurosurgery , State University of New York at Stony Brook , Stony Brook , NY , USA
| | - David Fiorella
- e Department of Neurosurgery , State University of New York at Stony Brook , Stony Brook , NY , USA
| | - Henry H Woo
- e Department of Neurosurgery , State University of New York at Stony Brook , Stony Brook , NY , USA
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AbuRahma A. Part Two: Against the Motion. Carotid Endarterectomy is not Safer than Stenting in the Hyperacute Period After Onset of Symptoms. Eur J Vasc Endovasc Surg 2015; 49:627-633. [DOI: 10.1016/j.ejvs.2015.03.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Naylor AR, AbuRahma AF. Debate: Whether carotid endarterectomy is safer than stenting in the hyperacute period after onset of symptoms. J Vasc Surg 2015; 61:1642-51. [PMID: 26004334 DOI: 10.1016/j.jvs.2015.02.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The carotid artery has been a regular battleground for debates regarding many issues, including appropriate management of symptomatic and asymptomatic lesions, the conduct, timing, and safety of such interventions, and now, whether endarterectomy or stenting is safer in the hyperacute period. Our discussants agree that, as a prophylactic procedure, a carotid intervention should occur early after index symptoms to prevent as many strokes as possible. However, which intervention is best?
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Affiliation(s)
- A Ross Naylor
- Vascular Research Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, Leicester, United Kingdom.
| | - Ali F AbuRahma
- Division of Vascular Surgery & Endovascular Surgery, West Virginia University, Charleston, WVa.
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6
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Mishra A, Stockley H, Goddard T, Sonwalker H, Wuppalapati S, Patankar T. Emergent extracranial internal carotid artery stenting and mechanical thrombectomy in acute ischaemic stroke. Interv Neuroradiol 2015; 21:205-14. [PMID: 25943850 DOI: 10.1177/1591019915583213] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Tandem occlusions involving both the extracranial internal carotid artery (ICA) and an intracranial artery typically respond poorly to intravenous (IV) tissue plasminogen activator (t-PA). We retrospectively review our experience with proximal ICA stenting and stent-assisted thrombectomy of the distal artery. METHODS The data included patients that underwent carotid stenting and mechanical thrombectomy between 2012-2013. Radiographic, clinical, and procedural data were drawn from case notes, imaging records and discharge reports. Clinical outcomes were evaluated using the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin scale (mRs). RESULTS Seven patients, with a mean age of 66.4 years and a mean admission NIHSS of 18.3, underwent this procedure and were included. Each presented with an occlusion of the proximal ICA, with additional occlusions of the ICA terminus (n = 3), middle cerebral artery (n = 5), or anterior cerebral artery (n = 1). Recanalisation of all identified occlusions was achieved in all patients, with a Thrombolysis in Myocardial Infarction (TIMI) score of 3 and a Thrombolysis in Cerebral Infarction (TICI) score >2b achieved in each case. Mean time from onset of stroke symptoms to recanalisation was 287 min; mean time from first angiography to recanalisation was 52 min. Intracranial haemorrhages occurred in two patients, with no increase in NIHSS. There were no mortalities. Mean NIHSS at discharge was 4.9, and mRs at 90 days was one in all patients. CONCLUSIONS Treatment of tandem extracranial ICA and intracranial occlusions in the setting of acute ischaemic stroke with extracranial carotid artery stenting followed by adjunctive intracranial mechanical thrombectomy is both safe and effective, but further evaluation of this treatment modality is necessary.
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Affiliation(s)
- Ankit Mishra
- GKT School of Medical Education, King's College London, UK
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7
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Son S, Choi DS, Oh MK, Kim SK, Kang H, Park KJ, Choi NC, Kwon OY, Lim BH. Emergency carotid artery stenting in patients with acute ischemic stroke due to occlusion or stenosis of the proximal internal carotid artery: a single-center experience. J Neurointerv Surg 2014; 7:238-44. [PMID: 24634445 DOI: 10.1136/neurintsurg-2014-011141] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The feasibility, safety and effectiveness of emergency carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to proximal internal carotid artery (ICA) stenosis or occlusion are still controversial. In this study we analyzed our experience with eCAS in patients with AIS. METHODS Twenty-two eCAS procedures for proximal ICA stenosis or occlusion were performed in 22 patients at our institution between January 2011 and November 2013. The mean time from stroke symptom onset to presentation was 204 min (range 50-630 min) and the mean initial score on the National Institutes of Health Stroke Scale (NIHSS) was 12.55 (range 5-23). Ten patients had total occlusion of the proximal ICA and the remaining 12 patients had near total occlusion or severe stenosis (mean degree 90.7%, range 80-100%). Eleven patients also had tandem occlusion on the more distal intracranial arteries. RESULTS Successful stent insertion was achieved in all patients and additional thrombectomy using a Solitaire stent or Penumbra aspiration catheter achieved a Thrombolysis In Cerebral Infarction grade of more than 2a in all patients with distal tandem occlusion. Procedure-related complications occurred in one patient (cerebral hyperperfusion syndrome) who recovered successfully. The mean NIHSS score at discharge was 3.55 (range 0-18). The mean modified Rankin Scale score at 3 months was 1 ± 1.67 (range 0-6). CONCLUSIONS eCAS in patients with AIS due to proximal ICA stenosis or occlusion appears to be a technically feasible and effective method for achieving good clinical outcomes.
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Affiliation(s)
- Seungnam Son
- Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongnam Regional Cardiocerebrovascular Disease Center, Jinju, Korea
| | - Dae Seob Choi
- Gyeongnam Regional Cardiocerebrovascular Disease Center, Jinju, Korea Department of Radiology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Min Kyun Oh
- Gyeongnam Regional Cardiocerebrovascular Disease Center, Jinju, Korea Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea Rehabilitation Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Soo-Kyoung Kim
- Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongnam Regional Cardiocerebrovascular Disease Center, Jinju, Korea
| | - Heeyoung Kang
- Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ki-Jong Park
- Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Nack-Cheon Choi
- Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongnam Regional Cardiocerebrovascular Disease Center, Jinju, Korea Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Oh-Young Kwon
- Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Byeong Hoon Lim
- Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongnam Regional Cardiocerebrovascular Disease Center, Jinju, Korea Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea
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8
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Geng L, Zha C, Liu H, Xu J, Xiang Y, Zou Z. Acute carotid artery dissection treated with stenting and hematoma aspiration guided by ultrasonography. JOURNAL OF CLINICAL ULTRASOUND : JCU 2013; 41:509-513. [PMID: 22941665 DOI: 10.1002/jcu.21986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 08/06/2012] [Indexed: 06/01/2023]
Abstract
We report the successful treatment of dissection with stenosis of the carotid artery by stenting and aspiration of hematoma. A male patient, presenting with acute blurred vision and weakness and numbness of the right side of his body, was diagnosed with common carotid artery (CCA) dissection and severe stenosis of the internal carotid artery and CCA by digital subtraction arteriography and color Doppler ultrasonography (CDU). Two stents were separately implanted into the left internal carotid artery and CCA to restore blood flow and seal the opening of the dissection. The hematoma inside the CCA dissection was transcutaneously aspirated under CDU guidance after thrombolysis with tissue plasminogen activator. Three days after the operation, the dissection was still sealed. The patient was discharged 1 week later without any signs or symptoms. Follow-up examination at 70 days confirmed complete healing of the CCA dissection. Transcutaneous intradissection hematoma aspiration with CDU guidance may be applicable in treating arterial dissection, especially when conservative treatments cannot be expected to improve severe flow disturbances.
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Affiliation(s)
- Liming Geng
- Center of Cerebrovascular Disease, No. 404 Hospital of PLA, 8 Baoquan Street, Weihai 264200, China
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Natarajan SK, Eller JL, Snyder KV, Hopkins LN, Levy EI, Siddiqui AH. Endovascular treatment of acute ischemic stroke. Neuroimaging Clin N Am 2013; 23:673-94. [PMID: 24156858 DOI: 10.1016/j.nic.2013.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Endovascular stroke therapy has revolutionized the management of patients with acute ischemic stroke in the last decade and has facilitated the development of sophisticated stroke imaging techniques and a multitude of thrombectomy devices. This article reviews the scientific basis and current evidence available to support endovascular revascularization and provides brief technical details of the various methods of endovascular thrombectomy with case examples.
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Affiliation(s)
- Sabareesh K Natarajan
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Kaleida Health, 100 High Street, Suite B4, Buffalo, NY 14203, USA
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10
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Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJB, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870-947. [PMID: 23370205 DOI: 10.1161/str.0b013e318284056a] [Citation(s) in RCA: 3215] [Impact Index Per Article: 292.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. METHODS Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. RESULTS The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. CONCLUSIONS Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.
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11
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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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12
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Meretoja A, Tatlisumak T. Novel thrombolytic drugs: will they make a difference in the treatment of ischaemic stroke? CNS Drugs 2008; 22:619-29. [PMID: 18601301 DOI: 10.2165/00023210-200822080-00001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Treatment of acute ischaemic stroke aims to recanalize the occluded artery, salvage the at-risk brain tissue and thus minimize neurological sequelae. Efforts a decade ago have led to the only currently approved medical treatment for acute ischaemic stroke, i.e. intravenous alteplase given within 3 hours of stroke onset. Recanalization occurs in only one-half of the patients receiving alteplase, and only approximately 5% of all ischaemic stroke patients in industrialized countries receive this treatment. Studies are currently being carried out to determine whether intravenous alteplase would be safe and effective for up to 4.5 hours after ischaemic stroke onset, and whether it should be followed by an intra-arterial approach. Two novel thrombolytic drugs being studied for acute ischaemic stroke are desmoteplase and tenecteplase. Although the first trials were promising, the most recent evidence suggests that desmoteplase is not superior to placebo, even in carefully selected patients, in the 3- to 9-hour time window after stroke onset. Tenecteplase has only been studied for acute ischaemic stroke in a single noncontrolled, dose-finding trial in the 3-hour time window after stroke onset, which suggested a similar efficacy to that demonstrated in the historical data from the alteplase trials. A trial to compare the safety and efficacy of tenecteplase versus alteplase is ongoing. Safer and more effective thrombolytic drugs for the treatment of ischaemic stroke are thus being sought. Such agents will be welcome, but they are not here yet. While waiting we are likely to see the emergence of additive therapies, including ultrasound insonation, neuroprotective/regenerative agents and invasive intra-arterial techniques. Novel thrombolytic drugs, or other novel therapies, possess great potential to make a difference in the future, but the most urgent priority now is in the organization of stroke treatment in such a way that more patients receive the currently available optimal treatments.
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Affiliation(s)
- Atte Meretoja
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.
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Taylor RA, Qureshi AI. Steno-occlusive carotid artery disease in the setting of acute ischemic stroke: to stent or not to stent? J Endovasc Ther 2007; 14:289-92. [PMID: 17723016 DOI: 10.1583/06-2040c.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Robert A Taylor
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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