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Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next? Transl Stroke Res 2021; 12:369-381. [PMID: 33409732 PMCID: PMC8055567 DOI: 10.1007/s12975-020-00879-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 12/18/2022]
Abstract
In the past 5 years, the success of multiple randomized controlled trials of recanalization therapy with endovascular thrombectomy has transformed the treatment of acute ischemic stroke with large vessel occlusion. The evidence from these trials has now established endovascular thrombectomy as standard of care. This review will discuss the chronological evolution of large vessel occlusion treatment from early medical therapy with tissue plasminogen activator to the latest mechanical thrombectomy. Additionally, it will highlight the potential areas in endovascular thrombectomy for acute ischemic stroke open to exploration and further progress in the next decade.
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Guo J, Mao L, Yu X, Song C, Zhao X. Design and Biomechanical Analysis of a Novel Retrievable Peripheral Vascular Stent. J Med Device 2020. [DOI: 10.1115/1.4046796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Abstract
Structurally retrievable drug-eluting stents may have valuable clinical applications because they do not leave any foreign materials inside the patient's body. This article presents a novel design of retrievable peripheral vascular stent and the results from biomechanical analysis of its performance. Using the finite element analysis method, principal parameters of the stent were studied. Moreover, to ensure the practicability of the retrieval process, simulation, and in vitro experiments were performed. The retrieval force reached the maximum value when the whole retrievable part had been retrieved. Furthermore, the force was gradually increased during the retrieval process and remained constant after the main part had been retrieved. When the stent was being compressed, the maximum strain of the stent occurred at the connection between the stent's retrieval part and the main body part, at a value of 4%. The index of nonuniformity of the stent was too small to be counted both at the end of the compression and self-expansion processes. With the increase of moment, the bending stiffness (EI) of the stent decreased gradually. After bending moment was applied, the large strain region was mainly located in the stent's main body part rather than the retrieval part. The results of preliminary stent retrieval experiments demonstrated that the stent could be retrieved successfully. This novel retrievable stent displays promising biomechanical performance. The preliminary experiments demonstrated that the stent could be retrieved smoothly from the blood vessels.
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Affiliation(s)
- Jingzhen Guo
- Shanghai Institute for Minimally Invasive Therapy, School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, 516 Jungong Road, Shanghai 200093, China
| | - Lin Mao
- Shanghai Institute for Minimally Invasive Therapy, School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, 516 Jungong Road, Shanghai 200093, China
| | - Xitong Yu
- Shanghai Institute for Minimally Invasive Therapy, School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, 516 Jungong Road, Shanghai 200093, China
| | - Chengli Song
- Shanghai Institute for Minimally Invasive Therapy, School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, 516 Jungong Road, Shanghai 200093, China
| | - Xue Zhao
- Department of Cardiology, Shanghai Eastern Hepatobiliary Surgery Hospital, 225 Changhai Road, Shanghai 200438, China
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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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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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Qureshi AI, Qureshi MH, Lobanova I, Bashir A, Khan AA, Bologna SM, Peterson M, Suri MFK. Histopathological Characteristics of IV Recombinant Tissue Plasminogen -Resistant Thrombi in Patients with Acute Ischemic Stroke. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2016; 8:38-45. [PMID: 26958152 PMCID: PMC4762410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Adnan I. Qureshi
- Zeenat Qureshi Stroke Institute, St Cloud, MN, and CentraCare Health, St. Cloud, MN, USA
| | - Mushtaq H. Qureshi
- Zeenat Qureshi Stroke Institute, St Cloud, MN, and CentraCare Health, St. Cloud, MN, USA
| | - Iryna Lobanova
- JFK New Jersey Neuroscience Institute at Seton Hall University, Edison, NJ, USA
| | - Asif Bashir
- Zeenat Qureshi Stroke Institute, St Cloud, MN, and CentraCare Health, St. Cloud, MN, USA
| | - Asif A. Khan
- Zeenat Qureshi Stroke Institute, St Cloud, MN, and CentraCare Health, St. Cloud, MN, USA
| | - Stephen M. Bologna
- Zeenat Qureshi Stroke Institute, St Cloud, MN, and CentraCare Health, St. Cloud, MN, USA
| | - Michelle Peterson
- Zeenat Qureshi Stroke Institute, St Cloud, MN, and CentraCare Health, St. Cloud, MN, USA
| | - M. Fareed K. Suri
- Zeenat Qureshi Stroke Institute, St Cloud, MN, and CentraCare Health, St. Cloud, MN, USA
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Kim SM, Sohn SI, Hong JH, Chang HW, Lee CY, Kim CH. The Effectiveness of Additional Treatment Modalities after the Failure of Recanalization by Thrombectomy Alone in Acute Vertebrobasilar Arterial Occlusion. J Korean Neurosurg Soc 2015; 58:419-25. [PMID: 26713141 PMCID: PMC4688310 DOI: 10.3340/jkns.2015.58.5.419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 11/03/2015] [Accepted: 11/04/2015] [Indexed: 11/27/2022] Open
Abstract
Objective Acute vertebrobasilar artery occlusion (AVBAO) is a devastating disease with a high mortality rate. One of the most important factors affecting favorable clinical outcome is early recanalization. Mechanical thrombectomy is an emerging treatment strategy for achieving a high recanalization rates. However, thrombectomy alone can be insufficient to complete recanalization, especially for acute stroke involving large artery atheromatous disease. The purpose of this study is to investigate the safety and efficacy of mechanical thrombectomy in AVBAO. Methods Fourteen consecutive patients with AVBAO were treated with mechanical thrombectomy. Additional multimodal treatments were intra-arterial (IA) thrombolysis, balloon angioplasty, or permanent stent placement. Recanalization by thrombectomy alone and multimodal treatments were assessed by the Thrombolysis in Cerebral Infarction (TICI) score. Clinical outcome was determined using the National Institutes of Health Stroke Scale (NIHSS) at 7 days and the modified Rankin Scale (mRS) at 3 months. Results Thrombectomy alone and multimodal treatments were performed in 10 patients (71.4%) and 4 patients (28.6%), respectively. Successful recanalization (TICI 2b-3) was achieved in 11 (78.6%). Among these 11 patients, 3 (27.3%) underwent multimodal treatment due to underlying atherosclerotic stenosis. Ten (71.4%) of the 14 showed NIHSS score improvement of >10. Overall mortality was 3 (21.4%) of 14. Conclusion We suggest that mechanical thrombectomy is safe and effective for improving recanalization rates in AVBAO, with low complication rates. Also, in carefully selected patients after the failure of recanalization by thrombectomy alone, additional multimodal treatment such as IA thrombolysis, balloons, or stents can be needed to achieve successful recanalization.
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Affiliation(s)
- Seong Mook Kim
- Department of Neurosurgery, Keimyung University School of Medicine, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Hyuk-Won Chang
- Department of Interventional Neuroradiology, Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Young Lee
- Department of Neurosurgery, Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University School of Medicine, Daegu, Korea
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Impact of the Implementation of Thrombectomy with Stent Retrievers on the Frequency of Hemicraniectomy in Patients with Acute Ischemic Stroke. Clin Neuroradiol 2015; 27:193-197. [PMID: 26637183 DOI: 10.1007/s00062-015-0478-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 10/19/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND The increasing use of endovascular treatments has led to higher recanalization rates and better clinical outcomes compared with intravenous thrombolysis alone. Stent retrievers represent the latest development for recanalization of large vessel occlusions. Decompressive hemicraniectomy has proved beneficial in patients suffering from rising intracranial pressure after malignant stroke. AIMS AND/OR HYPOTHESIS We investigated the effect of the implementation of stent retriever treatment on the frequency of hemicraniectomy as a surrogate marker for infarct size and thus for poor neurological outcome. METHODS Patients with acute ischemic stroke were retrospectively studied. We compared the frequency of hemicraniectomy following proximal artery occlusion of the internal carotid artery and middle cerebral artery main stem in the years before (2009 and 2010) and after (2012 and 2013) introducing stent retrievers. RESULTS Overall, 497 patients with proximal arterial occlusion were included in the study. Of 253 patients admitted in the years 2009 and 2010 44 (17.4 %) and of 244 patients admitted in 2012 and 2013, 20 (8.2 %) received a hemicraniectomy. This decrease in the proportion of hemicraniectomies was statistically significant (p < 0.01). CONCLUSIONS The findings in this study illustrate a significantly reduced rate of hemicraniectomies in patients with proximal artery occlusions after implementation of thrombectomy with stent retriever. Hereby, we could show a significant reduction of malignant infarctions after thrombectomy with stent retriever.
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Considerations about Occlusion of the Intracranial Distal Internal Carotid Artery. Clin Neuroradiol 2015; 27:169-174. [PMID: 26603997 DOI: 10.1007/s00062-015-0480-1] [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] [Received: 08/20/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Abstract
Occlusion of the intracranial distal internal carotid artery (ICA) is one of the most critical conditions among the cases of acute stroke in the anterior circulation. The introduction of selective endovascular treatment first using thrombolytic agents replaced later by the mechanical thrombectomy using various devices has improved the prognosis in a certain number of these patients. Among the factors influencing the prognosis of these patients, one is the collateral circulation which in these cases is mainly characterized by leptomeningeal anastomoses. The collateral can, however, be impaired, by distal embolization and by anomalies of the Circle of Willis: the aim of this study is to describe these aspects.
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Liang QJ, Jiang M, Wang XH, Le LL, Xiang M, Sun N, Meng D, Chen SF. Pre-existing interleukin 10 in cerebral arteries attenuates subsequent brain injury caused by ischemia/reperfusion. IUBMB Life 2015; 67:710-9. [PMID: 26337686 DOI: 10.1002/iub.1429] [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] [Received: 04/30/2015] [Accepted: 07/20/2015] [Indexed: 01/05/2023]
Abstract
Recurrent stroke is difficult to treat and life threatening. Transfer of anti-inflammatory gene is a potential gene therapy strategy for ischemic stroke. Using recombinant adeno-associated viral vector 1 (rAAV1)-mediated interleukin 10 (IL-10), we investigated whether transfer of beneficial gene into the rat cerebral vessels during interventional treatment for initial stroke could attenuate brain injury caused by recurrent stroke. Male Wistar rats were administered rAAV1-IL-10, rAAV1-YFP, or saline into the left cerebral artery. Three weeks after gene transfer, rats were subjected to occlusion of the left middle cerebral artery (MCAO) for 45 min followed by reperfusion for 24 h. IL-10 levels in serum were significantly elevated 3 weeks after rAAV1-IL-10 injection, and virus in the cerebral vessels was confirmed by in situ hybridization. Pre-existing IL-10 but not YFP decreased the neurological dysfunction scores, brain infarction volume, and the number of injured neuronal cells. AAV1-IL-10 transduction increased heme oxygenase (HO-1) mRNA and protein levels in the infarct boundary zone of the brain. Thus, transduction of the IL-10 gene in the cerebral artery prior to ischemia attenuates brain injury caused by ischemia/reperfusion in rats. This preventive approach for recurrent stroke can be achieved during interventional treatment for initial stroke.
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Affiliation(s)
- Qiu-Juan Liang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Shanghai, 200032, China
| | - Mei Jiang
- Department of Neurology, Gongli Hospital, Shanghai, 200135, China
| | - Xin-Hong Wang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Shanghai, 200032, China
| | - Li-Li Le
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Shanghai, 200032, China
| | - Meng Xiang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Shanghai, 200032, China
| | - Ning Sun
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Shanghai, 200032, China
| | - Dan Meng
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Shanghai, 200032, China
| | - Si-Feng Chen
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Shanghai, 200032, China
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Kabbasch C, Mpotsaris A, Chang DH, Hiß S, Dorn F, Behme D, Onur O, Liebig T. Mechanical thrombectomy with the Trevo ProVue device in ischemic stroke patients: does improved visibility translate into a clinical benefit? J Neurointerv Surg 2015; 8:778-82. [PMID: 26276075 DOI: 10.1136/neurintsurg-2015-011861] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/22/2015] [Indexed: 11/04/2022]
Abstract
PURPOSE To investigate the efficacy and safety of the Trevo ProVue (TPV) stent retriever in stroke patients with large artery occlusions, with particular attention to the full structural radiopacity of the TPV. MATERIALS AND METHODS Case files and images of TPV treatments were reviewed for clinical and technical outcome data, including revascularization rates, device and procedure related complications, and outcome at discharge and after 90 days. RESULTS 76 patients were treated with TPV. Mean National Institutes of Health Stroke Scale (NIHSS) score was 18 and 68% had additional intravenous thrombolysis. 63 occlusions were in the anterior circulation: 44 M1 (58%), 8 M2 (11%), 8 internal carotid artery-terminus (11%), 2 internal carotid artery- left (3%), 1 A2 (1%), and 13 vertebrobasilar (17%). 58 of 76 (76%) were solely treated with TPV; the remainder were treated with additional stent retrievers. Mean number of passes in TPV only cases was 2.2 (SD 1.2). In rescue cases, 3.2 (SD 2.2) passes were attempted with the TPV followed by 2.6 rescue device passes (SD 2). TPV related adverse events occurred in 4/76 cases (5%) and procedural events in 6/76 cases (8%). Mean procedural duration was 64 min (SD 42). Thrombolysis in Cerebral Infarction (TICI) 2b/3 recanalization was achieved in 69/76 patients (91%), including 50% TICI 3. Of 56 survivors (74%), 37 (49%) showed a favorable outcome at 90 days (Solitaire With the Intention for Thrombectomy trial criteria), statistically associated with age, baseline NIHSS, onset to revascularization time, and TICI 2b-3 reperfusion. TPV radiopacity allowed for visual feedback, changing the methodology of stent retriever use in 44/76 cases (58%). CONCLUSIONS Neurothrombectomy with TPV is feasible, effective, and safe. The recanalization rate compares favorably with reported data in the literature. Improved structural radiopacity may facilitate neurothrombectomy or influence the course of action during retrieval.
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Affiliation(s)
- Christoph Kabbasch
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - Anastasios Mpotsaris
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - De-Hua Chang
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - Sonja Hiß
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - Franziska Dorn
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Oezguer Onur
- Department of Neurology, University Hospital of Cologne, Cologne, Germany
| | - Thomas Liebig
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
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Yub Lee S, Won Youn S, Kyun Kim H, Rok Do Y. Inadvertent Detachment of a Retrievable Intracranial Stent: Review of Manufacturer and User Facility Device Experience. Neuroradiol J 2015; 28:172-6. [PMID: 25923678 DOI: 10.1177/1971400915576650] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Few systematic surveys have dealt with the potential procedural risks associated with the use of retrievable intracranial stents [Solitaire Flow Restoration (Solitaire FR)], which have become effective tools for recanalizing acutely occluded cerebral arteries. The aim of this study was to present the real-world experiences of Solitaire-FR-related adverse events by reviewing the MAUDE (Manufacturer and User Facility Device Experience) as published on the United States Food and Drug Administration website. In total, 85 adverse events related to the use of the Solitaire FR stent were reported between March 2012 and October 2014. In 80 patients these adverse events were attributable to inadvertent detachment of the device. Thirteen of these 80 patients (16%) died after the procedure. Morbidity data were available in 62 patients, among whom 11 (18%) had suffered a procedure-related injury. Detachment occurred at the first, second, and third pass in nine (21%), 21 (49%), and 13 (30%) of the 43 patients for whom this information was available, respectively. Resistance was perceived by the physician during retrieval of the device in 12 patients, and lesion characteristics were noted in 13. A rescue maneuver was reported in 20 (25%) of the 80 patients in whom the adverse event was attributable to detachment of the device, resulting in flow reestablishment in 13 (65%). The risk of inadvertent detachment during stent retrieval cannot be overemphasized in real-world scenarios, and careful consideration of the "dos and don'ts" is essential for the achievement of a safe procedure.
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Affiliation(s)
- Sang Yub Lee
- Department of Radiology, The Armed Forces Capital Hospital, Sungnam, Korea
| | | | | | - Young Rok Do
- Department of Neurology, Catholic University of Daegu Medical School, Daegu, Korea
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Bhagavati S. Intravenous thrombolysis for ischaemic strokes: a call for reappraisal. Brain 2015; 138:e341. [DOI: 10.1093/brain/awu282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Gill HL, Siracuse JJ, Parrack IK, Huang ZS, Meltzer AJ. Complications of the endovascular management of acute ischemic stroke. Vasc Health Risk Manag 2014; 10:675-81. [PMID: 25506222 PMCID: PMC4259256 DOI: 10.2147/vhrm.s44349] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Acute ischemic stroke is a significant source of morbidity and mortality across the globe. Currently, the only US Food and Drug Administration approved medical treatment of acute ischemic stroke is intravascular (IV) alteplase. While IV thrombolysis has been shown to decrease morbidity and mortality from acute ischemic stroke, it is limited in both its efficacy in certain types of stroke, as well as in its generalizability. It has been shown that time to revascularization is one of the most important predictors of outcomes in acute ischemic stroke, and thus clinicians have turned to endovascular options in efforts to improve outcomes from stroke. Direct intra-arterial thrombolysis was one of the first of such efforts to improve efficacy rates and increase the timeline for thrombolytic therapy. More recently, investigators and clinicians have turned to newer endovascular options in attempts to further improve recanalization rates. Many different endovascular techniques have been employed and are growing exponentially in use. Examples include stenting, as well as mechanical thrombectomy with both older-generation devices and newer stent retrieval technology. While the majority of the literature focuses on the effectiveness of different techniques, such as recanalization rates and major overall outcomes such as death and disability, there is very little literature on the complications of the different techniques. The purpose of this article is to review the different forms of endovascular treatment of acute ischemic stroke and their associated complications.
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Affiliation(s)
- Heather L Gill
- Division of Vascular and Endovascular Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Weill Cornell Medical College, New York, NY, USA
| | - In-Kyong Parrack
- Division of Vascular and Endovascular Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Zhen S Huang
- Division of Vascular and Endovascular Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Andrew J Meltzer
- Division of Vascular and Endovascular Surgery, Weill Cornell Medical College, New York, NY, USA
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Acute stroke patients treated with stent retrievers in carotid "T" occlusions have improved recanalization and outcome. Can J Neurol Sci 2014; 41:709-13. [PMID: 25410249 DOI: 10.1017/cjn.2014.109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Recanalization rates and patient outcomes in acute occlusion of the carotid terminus have previously been poor. The use of stent-retrievers has resulted in better recanalization and patient outcomes. We sought to compare outcomes in patients treated with stent-retrievers to outcomes in older techniques. METHODS We retrospectively compared a stent-retriever cohort to a historical cohort. We evaluated recanalization rates and good outcomes (defined as mRS < 2 at 30 days or 10 point drop in NIHSS). RESULTS There were twenty patients treated with stent-retrievers versus nine without. The recanalization rate in patients treated with stent retrievers was significantly higher than that of other modalities (90% vs 33%, p=0.004). Good outcomes were significantly higher in the stent retriever cohort (70% vs 22%, p=0.041). CONCLUSION The use of stent-retrievers in patients with carotid "T" occlusions shows promise in comparison to older techniques. A randomized trial comparing stent-retriever therapy to IV thrombolysis is warranted to determine the efficacy of this new generation of devices.
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Minimally invasive and rapid surgical embolectomy (MIRSE) as rescue treatment following failed endovascular recanalization for acute ischemic stroke. Acta Neurochir (Wien) 2014; 156:2041-9; discussion 2049. [PMID: 25085542 DOI: 10.1007/s00701-014-2179-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 07/08/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND An intra-arterial (IA) mechanical thrombectomy has increased the recanalization rates for acute occlusion of proximal intracranial arteries. However, the current failure rate of endovascular recanalization remains at approximately 10%, resulting in the need for surgical rescue treatment. The authors applied a minimally invasive and rapid surgical embolectomy (MIRSE) as a final rescue treatment after the failure of endovascular recanalization, and investigated the incidence, technical feasibility, and treatment results. METHODS For two years, from 2012 to 2013, a total of 131 patients with acute occlusion of proximal intracranial arteries underwent an IA mechanical thrombectomy using a Penumbra System and a Solitaire stent, yet ten (7.6%) patients still experienced final recanalization failure. Four (40%) of these ten patients subsequently underwent a MIRSE consisting of a superciliary keyhole approach, arteriotomy to remove the embolus, and arteriotomy repair techniques using aneurysm clips as the final repair material, or a temporary compartmentalizing clip. RESULTS Four patients aged 39 to 78 years with an embolic occlusion in the middle cerebral artery (n = 1) and internal carotid artery (n = 3) were treated using a MIRSE. Complete recanalization was achieved in all four patients, and the time from skin incision to reperfusion was 40-50 minutes. The modified Rankin Scale (mRS) scores at 3 months after surgery were 1 (n = 2), 2 (n = 1), and 3 (n = 1), respectively. CONCLUSIONS A MIRSE can be an effective rescue treatment after the failure of endovascular recanalization therapies for acute occlusion of proximal intracranial arteries if the patient is within the therapeutic time window.
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Goktekin O, Tasal A, Uyarel H, Vatankulu MA, Sonmez O, Kul S, Ay N, Yamac H, Altintas O, Karadeli H, Kolukisa M, Aralasmak A, Asil T. Endovascular therapy of acute ischaemic stroke by interventional cardiologists: single-centre experience from Turkey. EUROINTERVENTION 2014; 10:876-83. [DOI: 10.4244/eijv10i7a149] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Klisch J, Sychra V, Strasilla C, Taschner CA, Reinhard M, Urbach H, Meckel S. Double solitaire mechanical thrombectomy in acute stroke: effective rescue strategy for refractory artery occlusions? AJNR Am J Neuroradiol 2014; 36:552-6. [PMID: 25324495 DOI: 10.3174/ajnr.a4133] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy by using a single stent retriever system has demonstrated high efficacy for recanalization of large-artery occlusions in acute stroke. We aimed to evaluate the feasibility, safety, and efficacy of a novel double Solitaire stent retriever technique as an escalating treatment for occlusions that are refractory to first-line single stent retriever mechanical thrombectomy. MATERIALS AND METHODS All patients treated with the double stent retriever technique by using the Solitaire system were retrospectively selected from 2 large neurointerventional centers. Time to recanalization, angiographic (TICI) and clinical outcomes (mRS), and complications were assessed. RESULTS Ten patients (median NIHSS score, 16; mean age, 70 years) with MCA M1 segment (n = 5) and terminal ICA (n = 5 including 2 ICA tandem) occlusions were included. Prior single stent retriever mechanical thrombectomy had been performed in 9 patients (median number of passes, 3). Median time to recanalization was 60 minutes (interquartile range, 45-87 minutes). Procedure-related complications occurred in 1 patient; overall mortality was 20%. Recanalization of the target vessel (TICI 2b/3) was achieved in 80%. Good clinical outcome (mRS 0-2) was 50%. CONCLUSIONS In this preliminary feasibility study, the double Solitaire stent retriever technique proved to be an effective method for recanalization of anterior circulation large-artery occlusions refractory to standard stent retriever mechanical thrombectomy.
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Affiliation(s)
- J Klisch
- From the Institute of Diagnostic und Interventional Radiology and Neuroradiology (J.K., V.S., C.S.), Helios Klinikum, Erfurt, Germany
| | - V Sychra
- From the Institute of Diagnostic und Interventional Radiology and Neuroradiology (J.K., V.S., C.S.), Helios Klinikum, Erfurt, Germany
| | - C Strasilla
- From the Institute of Diagnostic und Interventional Radiology and Neuroradiology (J.K., V.S., C.S.), Helios Klinikum, Erfurt, Germany
| | - C A Taschner
- Departments of Neuroradiology (C.A.T., H.U., S.M.)
| | - M Reinhard
- Neurology (M.R.), University Hospital Freiburg, Freiburg, Germany
| | - H Urbach
- Departments of Neuroradiology (C.A.T., H.U., S.M.)
| | - S Meckel
- Departments of Neuroradiology (C.A.T., H.U., S.M.)
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Abstract
Early recanalization of the occluded artery leads to better clinical outcomes in patients with acute ischemic stroke (AIS) through protection of the time-sensitive penumbra. Intravenous administration of pharmacologic thrombolytic agents has been a standard treatment for AIS. To get better rates of recanalization, enhance the time window, and diminish the possibility of intracranial hemorrhage, endovascular thrombectomy was launched, with first authorization of the Merci clot retriever, a corkscrew-like apparatus, followed by approval of the Penumbra thromboaspiration system. Both devices lead to a high rate of recanalization. On the other hand, time to recanalization was on an average of 45 minutes, with most of the patients attaining only partial recanalization. More lately, retrievable stents have shown promise in decreasing the time to recanalization, and attaining a superior rate of complete clot resolution. The retrievable stent can be released within the clot to engage it within the struts of the stent, and afterwards it is taken back by pulling it under flow arrest. Neurointerventional techniques have a persistently ever-increasing and stimulating role in the management of AIS, as indicated by the advent of several important techniques. Stent retrievers have the capability to be ascertained as the most important approach to endovascular stroke treatment.
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Affiliation(s)
- Paramdeep Singh
- Department of Radiology, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot (Punjab), India
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Stent-Retriever Thrombectomy: Impact on the Future of Interventional Stroke Treatment. Clin Neuroradiol 2014; 24:17-22. [DOI: 10.1007/s00062-014-0299-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 02/12/2014] [Indexed: 10/25/2022]
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Manning NW, Campbell BCV, Oxley TJ, Chapot R. Acute ischemic stroke: time, penumbra, and reperfusion. Stroke 2014; 45:640-4. [PMID: 24399376 DOI: 10.1161/strokeaha.113.003798] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Nathan W Manning
- From the Florey Institute of Neuroscience and Mental Health (N.W.M., B.C.V.C., T.J.O.) and Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (B.C.V.C., T.J.O.), University of Melbourne, Parkville, Australia; and Department of Intracranial Endovascular Therapy, Alfried-Krupp Krankenhaus Hospital, Essen, Germany (R.C.)
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Bae YJ, Jung C, Kim JH, Choi BS, Kim E, Han MK, Bae HJ, Han MH. Potential for the use of the Solitaire stent for recanalization of middle cerebral artery occlusion without a susceptibility vessel sign. AJNR Am J Neuroradiol 2014; 35:149-55. [PMID: 23744693 PMCID: PMC7966480 DOI: 10.3174/ajnr.a3562] [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] [Received: 11/07/2012] [Accepted: 02/01/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Absence of the MCA susceptibility vessel sign (negative MCA susceptibility vessel sign) on gradient recalled-echo MR imaging in acute stroke is commonly associated with in situ stenosis and thrombotic occlusion. We evaluated the effectiveness and safety of the Solitaire stent as the first-line device for the recanalization of MCA occlusion with a negative MCA susceptibility vessel sign. MATERIALS AND METHODS Thirty-eight consecutive patients presenting with acute ischemic stroke due to MCA occlusion were treated by using the Solitaire AB stent alone or combined with thrombolytic drugs. Among these patients, 11 (7 men and 4 women; median age, 70 years; range, 49-89 years) who underwent multimodal stroke MR imaging before the endovascular procedure and had no MCA susceptibility vessel sign on the initial gradient recalled-echo MR imaging were included in this study. The primary end point was the recanalization of the occluded artery evaluated by the arterial occlusive lesion score. Clinical outcome was assessed at discharge and 90 days, as was the degree of residual MCA stenosis or reocclusion. RESULTS Successful recanalization (arterial occlusive lesion score ≥ II) without balloon angioplasty was obtained in 9 patients (81.8%). Six patients (54.5%) had an mRS score of ≤2 at 90 days. After a median of 147 days, no patient showed reocclusion on follow-up imaging. There were no symptomatic intracerebral hemorrhages. CONCLUSIONS The Solitaire stent is a feasible tool as the first-line device for multimodal endovascular recanalization therapy in acute ischemic stroke with a negative MCA susceptibility vessel sign. It has a good rate of successful and complete recanalization and is a fast yet safe procedure.
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Lefevre PH, Lainay C, Thouant P, Chavent A, Kazemi A, Ricolfi F. Solitaire FR as a first-line device in acute intracerebral occlusion: a single-centre retrospective analysis. J Neuroradiol 2013; 41:80-6. [PMID: 24388566 DOI: 10.1016/j.neurad.2013.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 10/05/2013] [Accepted: 10/22/2013] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Analysing the clinical and angiographical effectiveness of the Solitaire FR as a mechanical thrombectomy device in acute intracerebral occlusion. METHODS Sixty-two patients were retrospectively included between January 2010 and March 2012. All of them underwent mechanical thrombectomy with the Solitaire FR device with or without intravenous thrombolysis. Twenty-five patients had an occlusion of the basilar artery, 1 had a posterior cerebral artery occlusion. There were 16 M1 middle cerebral artery occlusions, 9 carotid T occlusions and 11 tandem occlusions. Clinical status was evaluated using the National Institute of Health Stroke Scale (NIHSS) before and 24 hours after treatment and at discharge. The Modified Rankin Scale (mRS) was evaluated at 3 months. RESULTS Mean age of patients was 64.8 years. Mean NIHSS score on admission was 19.8. Stand-alone thrombectomy was used in 47 patients (75.8%). Recanalization was successful (TICI score 2b or 3) in 23 of 26 (88.5%) patients with posterior circulation occlusion and in 23 of 36 (63.9%) patients with anterior circulation occlusion. NIHSS improved by more than 10 points for 15 of 59 patients with initial NIHSS over 10. MRS was 0-2 in 25 of 62 patients (40.3%). Overall, 23 patients out of 62 died (37%). No complications related to the Solitaire device occurred. CONCLUSION These results confirm that the Solitaire FR device is safe and effective in stand-alone thrombectomy.
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Affiliation(s)
- Pierre-Henri Lefevre
- Service de neuroradiologie et d'imagerie des urgences, CHU de Dijon, bocage central, 14, rue Paul-Gaffarel, 21000 Dijon, France.
| | - Claire Lainay
- Service de neurologie, CHU de Dijon, hôpital Général, 3, rue du Faubourg-Raines, 21000 Dijon, France
| | - Pierre Thouant
- Service de neuroradiologie et d'imagerie des urgences, CHU de Dijon, bocage central, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - Adrien Chavent
- Service de neuroradiologie et d'imagerie des urgences, CHU de Dijon, bocage central, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - Apolline Kazemi
- Service de neuroradiologie et d'imagerie des urgences, CHU de Dijon, bocage central, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - Frédéric Ricolfi
- Service de neuroradiologie et d'imagerie des urgences, CHU de Dijon, bocage central, 14, rue Paul-Gaffarel, 21000 Dijon, France
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Gratz PP, Jung S, Schroth G, Gralla J, Mordasini P, Hsieh K, Heldner MR, Mattle HP, Mono ML, Fischer U, Arnold M, Zubler C. Outcome of standard and high-risk patients with acute anterior circulation stroke after stent retriever thrombectomy. Stroke 2013; 45:152-8. [PMID: 24262328 DOI: 10.1161/strokeaha.113.002591] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Stent retrievers have become an important tool for the treatment of acute ischemic stroke. The aim of this study was to analyze outcome and complications in a large cohort of patients with stroke treated with the Solitaire stent retriever. The study also included patients who did not meet standard inclusion criteria for endovascular treatment: low or high baseline National Institutes of Health Stroke Scale score, ≥80 years of age, extensive ischemic signs in middle cerebral artery territory, and time from symptom onset to endovascular intervention>8 hours. METHODS Consecutive patients with acute anterior circulation stroke treated with the Solitaire FR were analyzed. Data on characteristics of endovascular interventions, complications, and clinical outcome were collected prospectively. Patients who met standard inclusion criteria were compared with those who did not. RESULTS A total of 227 patients were included. Mean age was 68.2±14.7 years, and median National Institutes of Health Stroke Scale score on admission was 16 (range, 2-36). Reperfusion was successful (thrombolysis in cerebral infarction, 2b-3) in 70.9%. Outcome was favorable (modified Rankin Scale, 0-2) in 57.7% of patients who met standard inclusion criteria and 30.3% of those who did not. The rates for symptomatic intracranial hemorrhage were 3.7% and 13.1%, for death 11.4% and 33.8%, and for symptomatic intraprocedural complications 2.5% and 4.8%, respectively. CONCLUSIONS Patients<80 years of age, without extensive pretreatment ischemic signs, and baseline National Institutes of Health Stroke Scale score≤30 had high rates of favorable outcome and low periprocedural complication rates after Solitaire thrombectomy. Successful reperfusion was also common in patients not fulfilling standard inclusion criteria, but worse clinical outcomes warrant further research with a special focus on optimal patient selection.
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Affiliation(s)
- Pascal P Gratz
- From the Departments of Diagnostic and Interventional Neuroradiology (P.P.G, S.J., G.S., J.G., P.M., K.H., C.Z.) and Neurology (S.J., M.R.H., H.P.M., M.-L.M., U.F., M.A.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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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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Park J. Maintenance of Cerebral Blood Flow During Microsuture Repair of the Superior Wall of the Intracranial Internal Carotid Artery. World Neurosurg 2013; 80:436.e1-5. [DOI: 10.1016/j.wneu.2013.03.075] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 03/23/2013] [Accepted: 03/27/2013] [Indexed: 11/29/2022]
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Deshaies EM. Tri-axial system using the Solitaire-FR and Penumbra Aspiration Microcatheter for acute mechanical thrombectomy. J Clin Neurosci 2013; 20:1303-5. [DOI: 10.1016/j.jocn.2012.10.037] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 10/08/2012] [Indexed: 10/26/2022]
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Dumont TM, Mokin M, Sorkin GC, Levy EI, Siddiqui AH. Aspiration thrombectomy in concert with stent thrombectomy. J Neurointerv Surg 2013; 6:e26. [DOI: 10.1136/neurintsurg-2012-010624.rep] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Dumont TM, Mokin M, Sorkin GC, Levy EI, Siddiqui AH. Aspiration thrombectomy in concert with stent thrombectomy. BMJ Case Rep 2013; 2013:bcr-2012-010624. [PMID: 23853010 DOI: 10.1136/bcr-2012-010624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
In the SWIFT and TREVO 2 trials, aspiration thrombectomy was not able to be performed. Outside these studies, in post-market application, the interventionist can use aspiration thrombectomy in addition to stent device thrombectomy. This technique is described in detail in the present report. Combined aspiration/stentriever thrombectomy may improve recanalization efforts, simplify a second thrombectomy attempt if necessary and may limit distal embolization.
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Affiliation(s)
- Travis M Dumont
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York 14203, USA
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Diener HC, Foerch C, Riess H, Röther J, Schroth G, Weber R. Treatment of acute ischaemic stroke with thrombolysis or thrombectomy in patients receiving anti-thrombotic treatment. Lancet Neurol 2013; 12:677-88. [DOI: 10.1016/s1474-4422(13)70101-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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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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Outcome of mechanical thrombectomy with Solitaire stent as first-line intra-arterial treatment in intracranial internal carotid artery occlusion. Neuroradiology 2013; 55:999-1005. [PMID: 23703034 DOI: 10.1007/s00234-013-1205-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 05/12/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Acute stroke from occlusion of the intracranial internal carotid artery (ICA) is associated with a poor clinical outcome despite a thrombolytic treatment. The purpose of this study was to evaluate the outcome of mechanical thrombectomy using the Solitaire stent for the treatment of acute stroke patients with intracranial ICA occlusion. METHODS A total of 104 consecutive patients with acute stroke were treated with mechanical thrombectomy using the Solitaire stent as a first-line intra-arterial treatment. We retrospectively reviewed data from 26 of these patients who presented with acute stroke attributable to intracranial ICA occlusion. Rescue treatments in cases of failed Solitaire thrombectomy included intra-arterial urokinase, angioplasty, and forced suction thrombectomy. Successful recanalization was defined as thrombolysis in cerebral ischemia grades 2b to 3. Outcome measure was the modified Rankin Scale (mRS) score of 0-2 at 3 months. RESULTS Successful recanalization was achieved in 77% (20/26) of patients. Recanalization was achieved with the Solitaire stent alone in 69% (18/26) of patients. Ten patients (39%) had a good clinical outcome (mRS score of 0-2) at 3 months. There was a good outcome in 50% of patients (10/20) with recanalization and no good outcome in patients (0/6) without recanalization (P = 0.027). None of eight patients who received rescue treatments showed a good outcome. No symptomatic intracerebral hemorrhage occurred. Mortality was 8% (2/26) at 3 months. CONCLUSION Mechanical thrombectomy using the Solitaire stent can achieve a high rate of successful recanalization and a very low rate of symptomatic hemorrhage and thus improve a clinical outcome in patients with acute intracranial ICA occlusion.
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Broderick JP, Schroth G. What the SWIFT and TREVO II trials tell us about the role of endovascular therapy for acute stroke. Stroke 2013; 44:1761-4. [PMID: 23686978 DOI: 10.1161/strokeaha.113.000740] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, 260 Stetson St, Suite 2300, PO Box 670525, Cincinnati, OH 45267-0525, USA.
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Yoon W, Jung MY, Jung SH, Park MS, Kim JT, Kang HK. Subarachnoid Hemorrhage in a Multimodal Approach Heavily Weighted Toward Mechanical Thrombectomy With Solitaire Stent in Acute Stroke. Stroke 2013; 44:414-9. [PMID: 23287788 DOI: 10.1161/strokeaha.112.675546] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background and Purpose—
Subarachnoid hemorrhage (SAH) may appear on computerized tomography scans after mechanical thrombectomy for acute ischemic stroke. The incidence and prognosis of this observation remain unknown. We investigated the frequency and clinical consequences of SAH after treating acute ischemic stroke with a multimodal approach heavily weighted toward mechanical thrombectomy with Solitaire stent.
Methods—
Seventy-four consecutive patients with acute ischemic stroke underwent mechanical thrombectomy with a Solitaire stent as a first-line treatment. Nonenhanced computerized tomography scans were performed before, immediately after, and 24 hours after treatment to detect SAH. Clinical outcome was assessed after treatment, on day 1, at discharge, and at 3 months. Clinical and radiological data were compared between patients with and without SAH.
Results—
Twelve patients (16.2%) exhibited SAH associated with pure SAH (n=4) or mixed SAH and contrast extravasation (n=8). The SAH was located in the ipsilateral Sylvian fissure (n=11) or bilateral parietooccipital sulci (n=1). Patients with SAH had no periprocedural vessel perforations or arterial dissections and no postprocedural neurological deteriorations. Rescue angioplasty was performed more frequently in SAH group than in control group (33.3% vs 9.7%;
P
=0.05). Patients with SAH and those without had similar recanalization rates and clinical outcomes.
Conclusions—
SAH on post-therapeutic computerized tomography scans were not uncommon after primary mechanical thrombectomy with a Solitaire stent, but they seemed to be benign. Rescue angioplasty and unidentified, small vessel ruptures due to mechanical stretch during stent retrieval might give rise to these lesions.
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Affiliation(s)
- Woong Yoon
- From the Departments of Radiology (W.Y., M.Y.J., S.H.J., H.K.K.) and Neurology (M.S.P., J.T.K.), Chonnam National University Medical School, Chonnam National University Hospital, Dong-gu, Gwangju, South Korea
| | - Min Young Jung
- From the Departments of Radiology (W.Y., M.Y.J., S.H.J., H.K.K.) and Neurology (M.S.P., J.T.K.), Chonnam National University Medical School, Chonnam National University Hospital, Dong-gu, Gwangju, South Korea
| | - Se Hee Jung
- From the Departments of Radiology (W.Y., M.Y.J., S.H.J., H.K.K.) and Neurology (M.S.P., J.T.K.), Chonnam National University Medical School, Chonnam National University Hospital, Dong-gu, Gwangju, South Korea
| | - Man Seok Park
- From the Departments of Radiology (W.Y., M.Y.J., S.H.J., H.K.K.) and Neurology (M.S.P., J.T.K.), Chonnam National University Medical School, Chonnam National University Hospital, Dong-gu, Gwangju, South Korea
| | - Joon Tae Kim
- From the Departments of Radiology (W.Y., M.Y.J., S.H.J., H.K.K.) and Neurology (M.S.P., J.T.K.), Chonnam National University Medical School, Chonnam National University Hospital, Dong-gu, Gwangju, South Korea
| | - Heoung Keun Kang
- From the Departments of Radiology (W.Y., M.Y.J., S.H.J., H.K.K.) and Neurology (M.S.P., J.T.K.), Chonnam National University Medical School, Chonnam National University Hospital, Dong-gu, Gwangju, South Korea
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Kondziella D, Cortsen M, Eskesen V, Hansen K, Holtmannspötter M, Højgaard J, Stavngaard T, Søndergaard H, Wagner A, Welling KL. Update on acute endovascular and surgical stroke treatment. Acta Neurol Scand 2013; 127:1-9. [PMID: 22881403 DOI: 10.1111/j.1600-0404.2012.01702.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2012] [Indexed: 02/02/2023]
Abstract
Emergency stroke care has become a natural part of the emerging discipline of neurocritical care and demands close cooperation between the neurologist and neurointerventionists, neurosurgeons, and anesthesiologists. Endovascular treatment (EVT), including intra-arterial thrombolysis, mechanical thrombectomy and angioplasty/stenting, is under rapid development. Although EVT has yet to be shown in randomized controlled trials to improve clinical outcome compared to intravenous thrombolysis, it is far better in achieving recanalization of occluded large cerebral vessels, which is crucial for rescuing the penumbra. Moreover, decompressive craniectomy is now a well-established treatment option for malignant middle cerebral artery infarction and cerebellar stroke. Using a case-based approach, this article reviews recent achievements in advanced treatment options for patients with acute ischemic stroke.
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Affiliation(s)
- D. Kondziella
- Department of Neurology; Rigshospitalet, Copenhagen University Hospital; Copenhagen; Denmark
| | - M. Cortsen
- Department of Neuroradiology; Rigshospitalet, Copenhagen University Hospital; Copenhagen; Denmark
| | - V. Eskesen
- Department of Neurosurgery; Rigshospitalet, Copenhagen University Hospital; Copenhagen; Denmark
| | - K. Hansen
- Department of Neurology; Rigshospitalet, Copenhagen University Hospital; Copenhagen; Denmark
| | - M. Holtmannspötter
- Department of Neuroradiology; Rigshospitalet, Copenhagen University Hospital; Copenhagen; Denmark
| | - J. Højgaard
- Department of Neurology; Rigshospitalet, Copenhagen University Hospital; Copenhagen; Denmark
| | - T. Stavngaard
- Department of Neuroradiology; Rigshospitalet, Copenhagen University Hospital; Copenhagen; Denmark
| | - H. Søndergaard
- Department of Neurology; Rigshospitalet, Copenhagen University Hospital; Copenhagen; Denmark
| | - A. Wagner
- Department of Neuroradiology; Rigshospitalet, Copenhagen University Hospital; Copenhagen; Denmark
| | - K.-L. Welling
- Department of Neuroanesthesiology; Rigshospitalet, Copenhagen University Hospital; Copenhagen; Denmark
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Castro-Afonso LHD, Abud TG, Pontes-Neto OM, Monsignore LM, Nakiri GS, Cougo-Pinto PT, Oliveira LD, Santos DD, Dias FA, Fábio SCR, Coletto FA, Abud DG. Mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke in a Brazilian population. Clinics (Sao Paulo) 2012; 67:1379-86. [PMID: 23295590 PMCID: PMC3521799 DOI: 10.6061/clinics/2012(12)06] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 08/10/2012] [Accepted: 08/14/2012] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Large vessel occlusion in acute ischemic stroke is associated with low recanalization rates under intravenous thrombolysis. We evaluated the safety and efficacy of the Solitaire AB stent in treating acute ischemic stroke. METHODS Patients presenting with acute ischemic stroke were prospectively evaluated. The neurological outcomes were assessed using the National Institutes of Health Stroke Scale and the modified Rankin Scale. Time was recorded from the symptom onset to the recanalization and procedure time. Recanalization was assessed using the thrombolysis in cerebral infarction score. RESULTS Twenty-one patients were evaluated. The mean patient age was 65, and the National Institutes of Health Stroke Scale scores ranged from 7 to 28 (average 17 ± 6.36) at presentation. The vessel occlusions occurred in the middle cerebral artery (61.9%), distal internal carotid artery (14.3%), tandem carotid occlusion (14.3%), and basilarartery (9.5%). Primary thrombectomy, rescue treatment and a bridging approach represented 66.6%, 28.6%, and 4.8% of the performed procedures, respectively. The mean time from symptom onset to recanalization was 356.5 ± 107.8 minutes (range, 80-586 minutes). The mean procedure time was 60.4 ± 58.8 minutes (range, 14-240 minutes). The overall recanalization rate (thrombolysis in cerebral infarction scores of 3 or 2b) was 90.4%, and the symptomatic intracranial hemorrhage rate was 14.2%. The National Institutes of Health Stroke Scale scores at discharge ranged from 0 to 25 (average 6.9 ± 7). At three months, 61.9% of the patients had a modified Rankin Scale score of 0 to 2, with an overall mortality rate of 9.5%. CONCLUSIONS Intra-arterial thrombectomy with the Solitaire AB device appears to be safe and effective. Large randomized trials are necessary to confirm the benefits of this approach in acute ischemic stroke.
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Affiliation(s)
- Luis Henrique de Castro-Afonso
- University of São Paulo, Medical School of Ribeirão Preto, Division of Interventional Neuroradiology, Ribeirão Preto/SP, Brazil
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Kim TK, Rhim JK, Lee CJ, Oh SH, Chung BS. The Limitations of Thrombectomy with Solitaire™ AB as First-line Treatment in Acute Ischemic Stroke: A Single Center Experience. J Cerebrovasc Endovasc Neurosurg 2012; 14:203-9. [PMID: 23210048 PMCID: PMC3491215 DOI: 10.7461/jcen.2012.14.3.203] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 09/05/2012] [Accepted: 09/11/2012] [Indexed: 11/29/2022] Open
Abstract
Objective A self-expanding retrievable intracranial stent, such as Solitaire AB, is useful for mechanical thrombectomy, producing novel results in the treatment of acute ischemic stroke. On the other hand, difficult situations can arise after a thrombectomy when using as in first-line treatment. Methods This was a retrospective, single-center study of 23 patients with an acute ischemic stroke attributable to a large artery occlusion within the first eight hours from symptom onset. The occlusion sites were the T segment in five patients, proximal middle cerebral artery in six patients, distal middle cerebral artery in three patients, vertebral and/or basilar artery in five patients, proximal internal cerebral artery in one patient and tandem in three patients. All patients underwent a mechanical thrombectomy using the Solitaire™ stent system as the first-line treatment but required additional procedures due to the unsatisfactory results of a thrombectomy. Results Only six patients achieved complete recanalization by a thrombectomy using the Solitaire. Permanent stent deployment after the thrombectomy was performed in ten patients. Stent and balloon angioplasty was performed after a stent-based thrombectomy in six patients. Balloon angioplasty after thrombectomy was performed in one patient. Conclusion Mechanical thrombectomy with the Solitaire™ stent as a first-line treatment can produce unfortunate results that will require additional procedures.
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Affiliation(s)
- Tae Kwon Kim
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Sungnam, Korea
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Mordasini P, Schroth G, Gralla J. Mechanical recanalization in acute stroke treatment. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.permed.2012.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Pereira VM, Narata AP, Gonzalez AM, Sztajzel R, Lovblad KO. Use of stentrievers in acute stroke: tips, tricks, and current results. Tech Vasc Interv Radiol 2012; 15:68-77. [PMID: 22464305 DOI: 10.1053/j.tvir.2011.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Stentrievers are stent-like devices used in the treatment of acute ischemic stroke. They have demonstrated efficacy in restoring the intracranial blood flow with low procedural times. This article is a synopsis of the available devices and different techniques. An extensive review of the literature summarizing all the data that have been published demonstrating their clinical impact and complications is also presented.
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Affiliation(s)
- Vitor Mendes Pereira
- Department of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland.
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Mattle HP, Brainin M, Chamorro A, Diener HC, Hacke W, Leys D, Norrving B, Ward N. European Stroke Science Workshop. Cerebrovasc Dis 2012; 34:95-105. [PMID: 22846653 DOI: 10.1159/000341728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Accepted: 05/09/2012] [Indexed: 01/09/2023] Open
Abstract
The European Stroke Organisation held its first European Stroke Science Workshop in Garmisch-Partenkirchen, Germany (December 15-17, 2011). Stroke experts based in Europe were invited to present and discuss their current research. The scope of the workshop was to review the most recent findings of selected topics in stroke, to exchange ideas, to stimulate new research, and to enhance collaboration between European stroke research groups. Seven scientific sessions were held, each starting with a keynote lecture to review the state of the art of the given topic, followed by 4 or 5 short presentations by experts. They were asked to limit their presentations to 10 slides containing only recent information. The meeting was organized by the executive committee of the European Stroke Organisation (Heinrich Mattle, chairman, Michael Brainin, Angel Chamorro, Werner Hacke, Didier Leys) and supported by the European Stroke Conference (Michael Hennerici). The following sections summarize the content of the workshop.
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Affiliation(s)
- Heinrich P Mattle
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland.
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Dávalos A, Pereira VM, Chapot R, Bonafé A, Andersson T, Gralla J. Retrospective multicenter study of Solitaire FR for revascularization in the treatment of acute ischemic stroke. Stroke 2012; 43:2699-705. [PMID: 22851547 DOI: 10.1161/strokeaha.112.663328] [Citation(s) in RCA: 147] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to evaluate safety and efficacy of the Solitaire FR device in the treatment of patients with acute ischemic stroke secondary to large artery occlusion. METHODS We conducted a retrospective study of consecutive patients presenting with acute ischemic stroke treated with Solitaire FR as the first-line device to restore blood flow in 6 experienced European centers. This study was entirely funded and supported by Coviden Neurovascular. An independent Corelab determined modified Thrombolysis in Cerebral Infarction scores on the preprocedure and postprocedure angiograms. Complete revascularization was defined as modified Thrombolysis in Cerebral Infarction 2b or 3 post-Solitaire FR device use. Symptomatic intracranial hemorrhage was defined as parenchymal hemorrhage Type 2 associated with a decline of ≥ 4 points in the National Institutes of Health Stroke Scale score within 24 hours or causing death. Favorable functional outcome was considered as modified Rankin Scale score ≤ 2 at Day 90. RESULTS We studied 141 patients (mean age, 66 years; median National Institutes of Health Stroke Scale, 18); 74 patients received intravenous tissue-type plasminogen activator before endovascular treatment. Complete revascularization was achieved in 120 of 142 occlusion sites (85%) and good outcome in 77 of 141 (55%) patients. Good outcome was more frequent in patients treated with intravenous tissue-type plasminogen activator than in those without (66% versus 42%; P<0.01). Symptomatic intracranial hemorrhage was reported in 5 patients (4%) and 29 of 141 (20%) patients died or were lost during follow-up (3 cases). CONCLUSIONS This retrospective study with centralized evaluation shows that the use of Solitaire FR is safe and achieves good revascularization rates and functional outcomes in patients with acute ischemic stroke and large artery occlusion.
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Affiliation(s)
- Antoni Dávalos
- Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Ctra Canyet s/n, 08916, Badalona, Barcelona, Spain.
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Mattle HP, Brainin M, Chamorro A, Diener HC, Hacke W, Leys D, Norrving B, Ward N. European stroke science workshop. Stroke 2012; 43:e81-8. [PMID: 22836350 DOI: 10.1161/strokeaha.112.655373] [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]
Abstract
The European Stroke Organisation held its first European Stroke Science Workshop in Garmisch-Partenkirchen, Germany (December 15-17, 2011). Stroke experts based in Europe were invited to present and discuss their current research. The scope of the workshop was to review the most recent findings of selected topics in stroke, to exchange ideas, to stimulate new research, and to enhance collaboration between European stroke research groups. Seven scientific sessions were held, each starting with a keynote lecture to review the state of the art of the given topic, followed by 4 or 5 short presentations by experts. They were asked to limit their presentations to 10 slides containing only recent information. The meeting was organized by the executive committee of the European Stroke Organisation (Heinrich Mattle, chairman, Michael Brainin, Angel Chamorro, Werner Hacke, Didier Leys) and supported by the European Stroke Conference (Michael Hennerici). The following sections summarize the content of the workshop.
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Affiliation(s)
- Heinrich P Mattle
- Department of Neurology, Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.
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Mordasini P, Brekenfeld C, Byrne JV, Fischer U, Arnold M, Jung S, Schroth G, Gralla J. Experimental evaluation of immediate recanalization effect and recanalization efficacy of a new thrombus retriever for acute stroke treatment in vivo. AJNR Am J Neuroradiol 2012; 34:153-8. [PMID: 22837308 DOI: 10.3174/ajnr.a3275] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Currently, several new stent retriever devices for acute stroke treatment are under development and early clinical evaluation. Preclinical testing under standardized conditions is an important first step to evaluate the technical performance and potential of these devices. The aim of this study was to evaluate the immediate recanalization effect, recanalization efficacy, thrombus-device interaction, and safety of a new stent retriever intended for thrombectomy in patients with acute stroke. MATERIAL AND METHODS The pREset thrombectomy device (4 × 20 mm) was evaluated in 16 vessel occlusions in an established swine model. Radiopaque thrombi (10-mm length) were used for visualization of thrombus-device interaction during application and retrieval. Flow-restoration effect immediately after deployment and after 5-minute embedding time before retrieval, recanalization rate after retrieval, thromboembolic events, and complications were assessed. High-resolution FPCT was performed to illustrate thrombus-device interaction during the embedding time. RESULTS Immediate flow restoration was achieved in 75% of occlusions. An increase or stable percentage of recanalizations during embedding time before retrieval was seen in 56.3%; a decrease, in 12.5%; reocclusion of a previously recanalized vessel, in 18.8%; and no recanalization effect at all, in 12.5%. Complete recanalization (TICI 3) after retrieval was achieved in 93.8%; partial recanalization (TICI 2b), in 6.2%. No distal thromboembolic events were observed. High-resolution FPCT illustrated entrapment of the thrombus between the stent struts and compression against the contralateral vessel wall, leading to partial flow restoration. During retrieval, the thrombus was retained in a straight position within the stent struts. CONCLUSIONS In this experimental study, the pREset thrombus retriever showed a high recanalization rate in vivo. High-resolution FPCT allows detailed illustration of the thrombus-device interaction during embedding time and is advocated as an add-on tool to the animal model used in this study.
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Affiliation(s)
- P Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland.
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Jeromel M, Milosevic ZV, Kocijancic IJ, Lovric D, Svigelj V, Zvan B. Mechanical revascularization for acute ischemic stroke: a single-center, retrospective analysis. Cardiovasc Intervent Radiol 2012; 36:338-45. [PMID: 22806246 DOI: 10.1007/s00270-012-0441-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 06/09/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Endovascular mechanical revascularization (thrombectomy) is an increasingly used method for intracranial large vessel recanalization in acute stroke. The purpose of the study was to analyze the recanalization rate, clinical outcome, and complication rate in our stroke patients treated with mechanical revascularization. METHODS A total of 57 patients with large vessel stroke (within 3 h for anterior and 12 h for posterior circulation) were treated with mechanical revascularization at a single center during 24 months. The primary goal of endovascular treatment using different mechanical devices was recanalization of the occluded vessel. Recanalization rate (reported as thrombolysis in cerebral infarction [TICI] score), clinical outcome (reported as National Institutes of Health Stroke Scale [NIHSS] score and modified Rankin scale [mRS] score), as well as periprocedural complications were analyzed. RESULTS The mean age of the patients was 63.1 ± 12.9 years, with baseline median NIHSS score of 14 (interquartile range, 9.5-19). Successful recanalization (TICI 2b or 3) was achieved in 41 (72 %) patients. Twenty patients (35 %) presented with favorable outcome (mRS ≤2) 30 days after stroke. Overall, significant neurological improvement (≥4 NIHSS point reduction) occurred in 36 (63 %) patients. A clinically significant procedure-related adverse events (vessel disruption, peri/postprocedural intracranial bleeding) defined with decline in NIHSS of ≥4 or death occurred in three (5 %) patients. CONCLUSIONS The study showed a high recanalization rate with improved clinical outcome and a low rate of periprocedural complications in our stroke patients treated with mechanical revascularization. Therefore, we could conclude that endovascular revascularization (primary or in combination with a bridging thrombolysis) was an effective and safe procedure for intracranial large vessel recanalization in acute stroke.
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Affiliation(s)
- Miran Jeromel
- Clinical Institute of Radiology, Department for Diagnostic and Interventional Neuroradiology, University Medical Centre Ljubljana, Zaloska cesta 2, 1000, Ljubljana, Slovenia.
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Ghobrial GM, Chalouhi N, Rivers L, Witte S, Davanzo J, Dalyai R, Gardecki ML, Jabbour P, Gonzalez F, Dumont AS, Rosenwasser RH, Tjoumakaris S. Multimodal endovascular management of acute ischemic stroke in patients over 75 years old is safe and effective. J Neurointerv Surg 2012; 5 Suppl 1:i33-7. [PMID: 22791182 PMCID: PMC3623029 DOI: 10.1136/neurintsurg-2012-010422] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Greater attention has been directed to endovascular recanalization of acute ischemic stroke in septuagenarians and above. Technique A retrospective chart review was conducted to include patients treated for acute ischemic stroke from 2006 to 2012. All patients underwent initial neurological assessment and non-contrast head CT. Patients treated from 2009 to 2012 additionally received emergent CT angiogram and CT perfusion. 51 patients met the clinical and radiographic criteria and underwent multimodal endovascular revascularization for acute ischemic events. Results All patients underwent cerebral angiography and met angiographic criteria for endovascular thrombolysis. 34 patients (67%) were older than 80 years of age. 23 patients (45%) received intravenous tissue plasminogen activator prior to admission. Eight (16%) patients underwent stent placement after intra-arterial thrombolysis, 10 (20%) underwent balloon angioplasty and seven (14%) underwent both angioplasty and stent placement. 21 (41%) required only intra-arterial thrombolytics. An improvement in Thrombolysis in Myocardial Infarction score was noted in 34 patients (67%). The average modified Rankin Scale score on discharge was 3.9. Symptomatic intracranial hemorrhage occurred in three patients (6%); none required surgery. One patient (1.9%) had a postoperative retroperitoneal hematoma, which was managed conservatively. Two fatalities resulted from intraoperative vessel rupture (3.9%), with a combined morbidity and mortality of 27.5%. Conclusions Multimodal endovascular recanalization of acute ischemic stroke is a relatively safe treatment option in patients older than 75 years of age. Careful patient selection by clinical and radiographic inclusion criteria is necessary for the successful management of stroke in this age group.
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Affiliation(s)
- George M Ghobrial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA
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Mordasini P, Brekenfeld C, Byrne JV, Fischer U, Arnold M, Heldner MR, Lüdi R, Mattle HP, Schroth G, Gralla J. Technical feasibility and application of mechanical thrombectomy with the Solitaire FR Revascularization Device in acute basilar artery occlusion. AJNR Am J Neuroradiol 2012; 34:159-63. [PMID: 22723058 DOI: 10.3174/ajnr.a3168] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Acute BAO is a devastating neurological condition associated with a poor clinical outcome and a high mortality rate. Recanalization has been identified as a major prognostic factor for good outcome in BAO. Mechanical thrombectomy using retrievable stents is an emerging treatment option for acute stroke. First clinical trials using stent retrievers have shown promising high recanalization rates. However, these studies mainly included large artery occlusions in the anterior circulation with only a few or single cases of BAO. Therefore, the purpose of this study was to evaluate technical feasibility, safety, and efficacy of mechanical thrombectomy using retrievable stent in the treatment of acute BAO. MATERIALS AND METHODS Fourteen consecutive patients with BAO undergoing endovascular therapy using retrievable stents (Solitaire FR Revascularization Device) were included. Additional multimodal treatment approaches included thromboaspiration, intravenous and/or intra-arterial thrombolysis, and PTA/ permanent stent placement. Recanalization rates after multimodal therapy and stent retrieval were determined. Clinical outcome and mortality were assessed 3 months after treatment. RESULTS Median patient age was 64.5 years (range 55-85). Median NIHSS score at presentation was 21 (range 5-36). Overall, successful recanalization (TICI 3 or 2b) was achieved in all patients (TICI 3 in 78.6%, 11/14). In 4 patients (28.6%), insufficient recanalization after stent retrieval was due to an underlying atherosclerotic stenosis. Additional deployment of a permanent intracranial stent was performed in 3 patients (21.4%) and PTA alone in 1 patient (7.1%), resulting in final TICI 3 in 1 patient and TICI 2b in 3 patients. Stent retrieval alone was performed in 4 patients (28.6%). Average number of device passes was 1.3 (range 1-3). Median procedure time to maximal recanalization was 47 minutes (range 10-252). No device-related complications or thromboembolic occlusion of a previously unaffected artery occurred. There was no symptomatic intracranial hemorrhage. At 3 months, good functional outcome (mRS 0-2) was observed in 28.6% (4/14); overall mortality was 35.7% (5/14). CONCLUSIONS A multimodal endovascular approach using retrievable stents in BAO has high recanalization rates, with very low complication rates. Underlying atherothrombotic stenotic lesions of the basilar artery may still necessitate additional permanent stent placement to achieve complete recanalization.
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Affiliation(s)
- P Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Switzerland.
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Eesa M, Almekhlafi MA, Mitha AP, Wong JH, Goyal M. Manual aspiration thrombectomy through balloon-tipped guide catheter for rapid clot burden reduction in endovascular therapy for ICA L/T occlusion. Neuroradiology 2012; 54:1261-5. [PMID: 22552837 DOI: 10.1007/s00234-012-1039-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 04/04/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Timely recanalization during endovascular procedures for acute ischemic stroke can be challenging in cases with large clot burden, such as those encountered in the terminal internal carotid T- or L-type occlusion. METHODS A novel but simple technique to achieve fast reduction in clot burden in stroke patients with occlusion of the internal carotid artery termination is described where manual suction using a 60-ml syringe applied through an 8-F balloon guide catheter positioned in the cervical carotid vasculature with proximal flow arrest allows subsequent revascularization of the residual middle cerebral artery clot. RESULTS The use of manual suction through a balloon-tipped guide catheter in internal carotid artery L- or T-type occlusion is illustrated. This resulted in a significant reduction of the clot burden and facilitated further interventions leading to full recanalization. CONCLUSION Manual suction using a 60-ml syringe through a balloon guide catheter is a useful and feasible technique that facilitates thrombectomy of large burden cerebral clots.
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Affiliation(s)
- Muneer Eesa
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
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Koh JS, Lee SJ, Ryu CW, Kim HS. Safety and efficacy of mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke: a systematic review. Neurointervention 2012; 7:1-9. [PMID: 22454778 PMCID: PMC3299943 DOI: 10.5469/neuroint.2012.7.1.1] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 01/18/2012] [Indexed: 11/24/2022] Open
Abstract
Purpose In recent years, mechanical thrombectomy using Solitaire stent retrieval has been tried for treating acute ischemic stroke with a large artery occlusion. We systematically reviewed published articles to appraise the evidence that supports the safety and efficacy of the mechanical thrombectomy in acute strokes with Solitaire stent. Materials and Methods Systematic searches using Medline and Scopus were performed for studies evaluating mechanical thrombectomy using a Solitaire stent in acute ischemic stroke. Articles were included if they were published since 2008, contained at least 5 subjects, and provided clinical results. Results Thirteen articles (262 cases) were included in this review. The mean time of the procedures ranged from 37 to 95.6 minutes in 10 studies. The success of recanalization was achieved in 89.7% and the recanalization rate varied from 66.7% to 100% in all 13 studies. The overall rates of the symptomatic hemorrhagic complications and mortality were 6.8% and 11.1%, respectively. A favorable outcome of mRS 2 or under was 47.3%. Procedure-induced complications developed in 3.4%. Conclusion The present review suggested that mechanical thrombectomy using a Solitaire stent in acute ischemic stroke was effective in recanalizing the occluded artery. The rate of procedural complications was small.
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Affiliation(s)
- Jun Seok Koh
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
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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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Mattle HP, Arnold M, Lindsberg PJ, Schonewille WJ, Schroth G. Basilar artery occlusion. Lancet Neurol 2011; 10:1002-14. [DOI: 10.1016/s1474-4422(11)70229-0] [Citation(s) in RCA: 255] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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