Therapeutic results of intra-arterial thrombolysis after full-dose intravenous tissue plasminogen activator administration

Proper Indication of Decompressive Craniectomy for the Patients with Massive Brain Edema after Intra-arterial Thrombectomy

OBJECTIVE

Numerous studies have indicated that early decompressive craniectomy (DC) for patients with major infarction can be life-saving and enhance neurological outcomes. However, most of these studies were conducted by neurologists before the advent of intra-arterial thrombectomy (IA-Tx). This study aims to determine whether neurological status significantly impacts the final clinical outcome of patients who underwent DC following IA-Tx in major infarction.

METHODS

This analysis included 67 patients with major anterior circulation major infarction who underwent DC after IA-Tx, with or without intravenous tissue plasminogen activator. We retrospectively reviewed the medical records, radiological findings, and compared the neurological outcomes based on the "surgical time window" and neurological status at the time of surgery.

RESULTS

For patients treated with DC following IA-Tx, a Glasgow coma scale (GCS) score of 7 was the lowest score correlated with a favorable outcome (p=0.013). Favorable outcomes were significantly associated with successful recanalization after IA-Tx (p=0.001) and perfusion/diffusion (P/D)-mismatch evident on magnetic resonance imaging performed immediately prior to IA-Tx (p=0.007). However, the surgical time window (within 36 hours, p=0.389; within 48 hours, p=0.283) did not correlate with neurological outcomes.

CONCLUSION

To date, early DC surgery after major infarction is crucial for patient outcomes. However, this study suggests that the indication for DC following IA-Tx should include neurological status (GCS ≤7), as some patients treated with early DC without considering the neurological status may undergo unnecessary surgery. Recanalization of the occluded vessel and P/D-mismatch are important for long-term neurological outcomes.

Brain Injury: Response to Injury Wound-Healing Mechanisms and Enlarged Perivascular Spaces in Obesity, Metabolic Syndrome, and Type 2 Diabetes Mellitus

Embryonic genetic mechanisms are present in the brain and ready to be placed into action upon cellular injury, termed the response to injury wound-healing (RTIWH) mechanism. When injured, regional brain endothelial cells initially undergo activation and dysfunction with initiation of hemostasis, inflammation (peripheral leukocytes, innate microglia, and perivascular macrophage cells), proliferation (astrogliosis), remodeling, repair, and resolution phases if the injurious stimuli are removed. In conditions wherein the injurious stimuli are chronic, as occurs in obesity, metabolic syndrome, and type 2 diabetes mellitus, this process does not undergo resolution and there is persistent RTIWH with remodeling. Indeed, the brain is unique, in that it utilizes its neuroglia: the microglia cell, along with peripheral inflammatory cells and its astroglia, instead of peripheral scar-forming fibrocytes/fibroblasts. The brain undergoes astrogliosis to form a gliosis scar instead of a fibrosis scar to protect the surrounding neuropil from regional parenchymal injury. One of the unique and evolving remodeling changes in the brain is the development of enlarged perivascular spaces (EPVSs), which is the focus of this brief review. EPVSs are important since they serve as a biomarker for cerebral small vessel disease and also represent an impairment of the effluxing glymphatic system that is important for the clearance of metabolic waste from the interstitial fluid to the cerebrospinal fluid, and disposal. Therefore, it is important to better understand how the RTIWH mechanism is involved in the development of EPVSs that are closely associated with and important to the development of premature and age-related cerebrovascular and neurodegenerative diseases with impaired cognition.

Recanalization Rate and Clinical Outcomes of Intravenous Tissue Plasminogen Activator Administration for Large Vessel Occlusion Stroke Patients

OBJECTIVE

Stroke caused from large vessel occlusion (LVO) has emerged as the most common stroke subtype worldwide. Intravenous tissue plasminogen activator administration (IV-tPA) and additional intraarterial thrombectomy (IA-Tx) is regarded as standard treatment. In this study, the authors try to find the early recanalization rate of IV-tPA in LVO stroke patients.

METHODS

Total 300 patients undertook IA-Tx with confirmed anterior circulation LVO, were analyzed retrospectively. Brain computed tomography angiography (CTA) was the initial imaging study and acute stroke magnetic resonance angiography (MRA) followed after finished IV-tPA. Early recanalization rate was evaluated by acute stroke MRA within 2 hours after the IV-tPA. In 167 patients undertook IV-tPA only and 133 non-recanalized patients by IV-tPA, additional IA-Tx tried (IV-tPA + IA-Tx group). And 131 patients, non-recanalized by IV-tPA (IV-tPA group) additional IA-Tx recommend and tried according to the patient condition and compliance.

RESULTS

Early recanalization rate of LVO after IV-tPA was 12.0% (36/300). In recanalized patients, favorable outcome (modified Rankin Scale, 0-2) was 69.4% (25/36) while it was 32.1% (42/131, p<0.001) in non-recanalized patients. Among 133 patients, nonrecanalized after intravenous recombinant tissue plasminogen activator and undertook additional IA-Tx, the clinical outcome was better than not undertaken additional IA-Tx (favorable outcome was 42.9% vs. 32.1%, p=0.046). Analysis according to the perfusion/diffusion (P/D)-mismatching or not, in patient with IV-tPA with IA-Tx (133 patients), favorable outcome was higher in P/ D-mismatching patient (52/104; 50.0%) than P/D-matching patients (5/29; 17.2%; p=0.001). Which treatment tired, P/D-mismatching was favored in clinical outcome (iv-tPA only, p=0.008 and IV-tPA with IA-Tx, p=0.001).

CONCLUSION

The P/D-mismatching influences on the recanalization and clinical outcomes of IV-tPA and IA-Tx. The authors would like to propose that we had better prepare IA-Tx when LVO is diagnosed on initial diagnostic imaging. Furthermore, if the patient shows P/D-mismatching on MRA after IV-tPA, additional IA-Tx improves treatment results and lessen the futile recanalization.

Clinical Results of the Intra-Arterial Thrombolysis with Stent Retriever Device Weather Perfusion Diffusion Mismatching and Intravenous Tissue Plasminogen Activator Administration

Objective

Intraarterial thrombolysis (IA-Tx) with stent retriever is accepted as an additional treatment for selected patients and the clinical benefit is well reported. Each intravenous tissue plasminogen activator administration (IV-tPA) and perfusion diffusion mismatching (P/D-mismatching) is well known the beneficial effects for recanalization and clinical outcomes. In this report, authors analyzed the clinical outcomes of additional IA-Tx with retrieval stent device, according to the combined IV-tPA and P/D-mismatching or not.

Methods

Eighty-one treated IA-Tx with the Solitaire stent retriever device, diagnosed as anterior circulation larger vessel occlusion were included in this study. Computed tomography-angiography (CTA) was done as an initial diagnostic image and acute stroke magnetic resonance image (MRI) followed after the IV-tPA. Forty-two patients were in the tPA group and 39 patients were in the non-tPA group. Recanalization rate, clinically significant hemorrhagic (sICH) and clinical outcomes were recorded according to the IV-tPA and P/D-mismatching.

Results

Recanalization rate was 81.0% in IV-tPA group, and it was 69.2% in non-tPA group (p = 0.017). While sICH were 19.9% and 25.6%, respectively (p = 0.328). Neurologic outcomes did not influence by IV-tPA administration or not. But according to the P/D-mismatching, the recanalization rate and sICH were 91.9% and 16.7% in the mismatched group and 46.7% and 46.7% in the matched group (p = 0.008 and p = 0.019, respectively).

Conclusion

For patients treated with IA-Tx with retrieval stent, IV-tPA infusion does not influence on the sICH, recanalization rate and neurologic outcomes. But P/D-mismatching was correlated well with sICH, recanalization rate and clinical outcomes.

A suction thrombectomy technique: a rapid and effective method for intra-arterial thrombolysis

Objective

During mechanical thrombolysis, to reduce procedure-related complications and time, the authors have performed a simple suction thrombectomy technique. In this article, the authors describe the technical details and clinical outcomes of this technique.

Materials and Methods

From January 2013 to December 2013, 14 consecutive acute ischemic stroke (AIS) patients with large cerebral arterial occlusions in the middle cerebral artery (MCA; n = 7), internal cerebral artery (ICA; n = 5), basilar artery (BA; n = 1), and a tandem lesion (ICA and MCA; n = 1) were treated using this technique. The proximal part of the occluding clot was aspirated or captured and retrieved as one piece using a large bored microcatheter by applying negative suction pressure using a 50 mL syringe.

Results

Overall recanalization rate was 85.7% (12 patients). In the 8 patients in whom this technique was used alone, the recanalization rate was 87.5% (7 patients). The median procedural duration was 30 minutes (range 17-112) in these 7 patients. Distal embolism did not occur. Two patients developed post-procedural intracerebral hemorrhages and one was symptomatic. His modified Rankin Scale (mRS) score at 90 days was 4.

Conclusion

This technique is a feasible, fast, and safe method for treatment of AIS.

Clinical results of intraarterial thrombolysis according to tPA administration and perfusion/diffusion mismatching

BACKGROUND

IA-Tx and advanced dynamic imaging studies have been adopted for ischemic stroke patient treatment. Many patients are treated with IV-tPA, but this treatment is not always feasible. In this study, IA-Tx was used for patients for whom IV-tPA was not indicated or when IV-tPA did not result in recanalization.

METHODS

A total of 156 patients treated with IA-Tx were retrospectively reviewed. Of these, 72 patients were treated with a full dose of IV-tPA before receiving the IA-Tx; the remaining 84 patients only received IA-Tx. An initial imaging study using CTA and acute stroke MRI followed. Patients' demographics and clinical results were recorded and compared according to P/D mismatching and IV-tPA.

RESULTS

Among P/D-mismatched patients, the recanalization rate was 80 % and the symptomatic intracranial hemorrhage rate was 14.5 %, while among P/D-matched patients, the rates were 63 % and 41.3 % respectively (p < 0.05). A favorable clinical outcome occurred in 49.1 % of P/D-mismatched, but only in 21.7 % of P/D-matched patients (p < 0.05). Among patients who were treated with IV-tPA before undergoing IA-Tx, the recanalization rate was 79.2 % and the sICH rate was 27.8 %, while it was 71.4 % and 17.9 % in patients who did not receive IV-tPA (p < 0.05).

CONCLUSIONS

Patients who have P/D mismatching and are treated with IA-Tx have higher recanalization rates and a greater probability of a favorable outcome than patients who have P/D matching and receive IA-Tx. For patients who do not undergo successful recanalization after IV-tPA or who are not indicated for IV-tPA, the authors recommend IA-Tx after undergoing appropriate imaging evaluation.

Efficacy and limitations of multimodal endovascular revascularization other than clot retrieval for acute stroke caused by large-vessel occlusion

BACKGROUND

The purpose of this study was to evaluate the efficacy of multimodal endovascular treatment (EVT) other than clot retrieval for acute large-vessel occlusion (LVO).

METHODS

Fifty-six consecutive patients with a median National Institutes of Health Stroke Scale (NIHSS) score of 15 were included this study. In all cases, intravenous administration of recombinant tissue plasminogen activator had failed (n = 23) or was contraindicated (n = 33). The modes of EVT performed included intra-arterial thrombolysis, mechanical clot disruption including balloon angioplasty, and stent placement. We retrospectively analyzed the treatment efficacy of these techniques and patient outcome.

RESULTS

Successful reperfusion (Thrombolysis in Cerebral Infarction grade 2B or 3) was achieved in 40 of 56 patients (71.4%), and 26 of 56 patients (46.4%) had a favorable clinical outcome (modified Rankin Scale [mRS] score 0 to 2 at 90 days). Successful reperfusion (odds ratio [OR] 163; P = .003), age (OR 0.83; P = .007), and baseline NIHSS score (OR 0.71; P = .009) were independently associated with favorable clinical outcome by multivariate analysis. Successful reperfusion rates of internal carotid terminus or M1 proximal occlusions were significantly lower than those of other vessel occlusion (47.6% v 85.7%; P = .005). Clinically significant procedure-related complications occurred in 1.8% (1/56), and symptomatic intracerebral hemorrhage (sICH) within 48 hours after EVT was observed in 5.4% (3/56) of patients.

CONCLUSIONS

Multimodal EVT for acute LVO yields a high reperfusion rate with a minimal risk of sICH and contributes to favorable patient outcomes. These techniques should be considered when clot retrieval is unsuitable or ineffective.

Matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 expression in early focal cerebral infarction following urokinase thrombolysis in rats

Activity of matrix metalloproteinase-9 increases following cerebral ischemia/reperfusion, and is associated with cerebral microvascular permeability, blood-brain barrier destruction, inflammatory cell infiltration and brain edema. Matrix metalloproteinase-9 also likely participates in thrombolysis. A rat model of middle cerebral artery infarction was established by injecting autologous blood clots into the internal carotid artery. At 3 hours following model induction, urokinase was injected into the caudal vein. Decreased neurological severity score, reduced infarct volume, and increased expression of matrix metalloproteinase-9 and tissue inhibitor of metalloproteinase-1 were observed in the cerebral cortex 24 hours after urokinase thrombolysis. These results suggest that urokinase can suppress damage in the acute-early stage of cerebral infarction.