Neurothrombectomy for the treatment of acute ischemic stroke in 1530 patients
ABSTRACT Neurothrombectomy is being used increasingly for the treatment of acute ischemic stroke. To assess the recanalization rates and clinical outcomes of patients treated with neurothrombectomy, we searched the CNKI (China National Knowledge Infrastructure), CBM (Chinese Biomedical Literature), MEDLINE and EMBASE databases to 2011 and summarized the outcome data of patients with acute ischemic stroke treated with neurothrombectomy. Forty-six studies (1530 patients) that reported recanalization rates were included in this analysis. Recanalization rates were recorded for the following neurothrombectomy techniques: endovascular thrombectomy (43-100%, median 86%), endovascular thromboaspiration (67-100%, median 83%), laser thrombolysis (41-50%, median 45.5%), and ultrasonification (62-71%, median 66.5%); the respective rates of symptomatic and asymptomatic intracranial hemorrhage were 20%, 22.5%, 12%, and 19% for each of the four types of neurothrombectomy. Clinical outcome data categorized by success or failure in achieving recanalization were available from 12 articles pertaining to 443 patients. At three months, patients in whom recanalization was achieved had better functional outcomes compared to non-recanalized patients (odds ratio [OR], 5.58; 95% confidence interval [CI], 2.98-10.45). In addition, the three-month mortality was lower in recanalized patients (OR, 0.37; 95% CI, 0.24-0.57). Among the various treatments for acute ischemic stroke, neurothrombectomy appears the most promising. Neurothrombectomy devices show great potential in improving functional outcomes and reducing mortality in patients with acute ischemic stroke, and meta-analysis confirms that successful recanalization was the most important indicator of predicting clinical benefit.
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ABSTRACT: An uncontrolled clinical study of the Penumbra(™) system showed high rates of recanalisation and relatively poor functional outcomes that were inadequately compared with historic controls. We aimed to compare the findings in Penumbra with intravenous tissue plasminogen activator trials that determined recanalisation (Combined Lysis Of Thrombus in Brain ischaemia using transcranial Ultrasound and Systemic tissue plasminogen activator and Transcranial Ultrasound in Clinical Sonothrombolysis). Control patients treated with intravenous tissue plasminogen activator and intermittent ultrasound surveillance had National Institutes of Health Stroke Scale scores >7. The Penumbra trial definition of symptomatic intracranial haemorrhage was used. Revascularisation was defined using thrombolysis in brain ischaemia scores predictive of thrombolysis in myocardial infarction flow grades and compared with thrombolysis in myocardial infarction data from Penumbra. Favourable functional outcomes was defined as a modified Rankin Scale of 0-2. Pretreatment stroke severity (National Institutes of Health Stroke Scale score) was 17.6 ± 5.2 points in Penumbra patients (n = 125) and 16.3 ± 5.3 in controls (n = 68; P = 0.101). The control group was older compared with Penumbra (68.8 ± 13.4 vs. 63.5 ± 13.5-years; P = 0.010). Time-to-treatment initiation was on average 2 h later (2.3 ± 0.6 vs. 4.3 ± 1.5 h; P < 0.001) in Penumbra. The rate of any revascularisation after treatment with Penumbra was higher than that following intravenous thrombolysis: 82% (54% thrombolysis in myocardial infarction II and 27% thrombolysis in myocardial infarction III) vs. 40% (25% partial, 15% complete revascularisation), P < 0.001. Symptomatic intracranial haemorrhage tended to be higher with Penumbra (11.2% vs. 4.4%; P = 0.182, Fisher's exact test). At three-months, mortality with Penumbra was higher (32.8%) than controls (14.1%; P = 0.006). Favourable functional outcomes were higher in historic controls (39% vs. 25%; P = 0.046). Despite lower revascularisation rates, patients treated with systemic thrombolysis achieved better functional outcomes likely due to earlier treatment initiation. These data indicate that it is unrealistic to expect primary intraarterial revascularisation to be any better than systemic plasminogen activator within the 3-h time window. Improvements in the speed of delivery and performance of intraarterial reperfusion are needed.International Journal of Stroke 04/2011; 6(2):118-22. DOI:10.1111/j.1747-4949.2010.00559.x · 4.03 Impact Factor
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ABSTRACT: We present the results of endovascular photoacoustic recanalization (EPAR) treatment for acute ischemic stroke from the Safety and Performance Study at 6 centers in Europe and North America. The objectives of mechanical thrombolysis are rapid vessel recanalization and minimal use of chemical thrombolysis. This study was a prospective, nonrandomized study. The National Institutes of Health Stroke Scale (NIHSS) score and the modified Rankin Scale (mRS) score were recorded before treatment. The presence of recanalization was assessed by angiography. To measure outcome, follow-up examinations were performed at 24 hours, 7 days, and 30 days after stroke onset. Thirty-four patients (median NIHSS 19) were enrolled. Ten patients had internal carotid artery occlusion, 12 patients had middle cerebral artery occlusion, 11 patients had vertebrobasilar occlusion, and 1 patient had posterior cerebral artery occlusion. The overall recanalization rate was 41.1% (14/34). Complete EPAR treatment was possible in 18 patients (median NIHSS 18), with vessel recanalization in 11 patients (61.1%) after EPAR. The average lasing time was 9.65 minutes. Incomplete EPAR treatment (16/34, median NIHSS 19) was defined as intention to treat with EPAR and that the EPAR microcatheter entered the patient. Additional treatment with intraarterial application of rTPA occurred in 13 patients. An adverse event associated with use of the device occurred in 1 patient. Symptomatic hemorrhages occurred in 2 patients (5.9%). The mortality rate was 38.2%. This study demonstrates the safety and technical feasibility of EPAR. This new technique may provide another treatment option in the therapeutic armamentarium for patients with acute ischemic stroke.Stroke 06/2004; 35(5):1112-6. DOI:10.1161/01.STR.0000124126.17508.d3 · 6.02 Impact Factor
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ABSTRACT: Data from recent reports have indicated that mechanical thrombectomy may have potential as a treatment for acute ischemic stroke. The purpose of this study was to assess the safety and performance of the Penumbra System (PS): a novel mechanical device designed to reduce clot burden in acute stroke due to large-vessel occlusive disease. A prospective, single arm, independently monitored and core laboratory adjudicated trial enrolled subjects with an acute neurologic deficit consistent with acute stroke, presenting within 8 hours of symptom onset and an angiographically verified occlusion (Thrombolysis in Myocardial Infarction [TIMI] grade 0 or 1) of a treatable intracranial vessel. The primary end point was revascularization of the target vessel to TIMI grade 2 or 3. Secondary end points were the proportion of subjects who achieved a modified Rankin Scale (mRS) score of 2 or less or a 4-point improvement on the National Institutes of Health Stroke Scale (NIHSS) score at 30-day follow-up, as well as all-cause mortality. Twenty-three subjects were enrolled, and 21 target vessels were treated in 20 subjects by the PS. At baseline, mean age was 60 years, mean mRS score was 4.6, and mean NIHSS score was 21. Postprocedure, all 21 of the treated vessels (100%) were successfully revascularized by the PS to TIMI 2 or 3. At 30-day follow-up, 9 subjects (45%) had a 4-point or more NIHSS improvement or an mRS of 2 or less. The all-cause mortality rate was 45% (9 of 20), which is lower than expected in this severe stroke cohort, where 70% of the subjects at baseline had either an NIHSS score of more than 20 or a basilar occlusion. Thus, early clinical experience suggests that the PS allows revascularization in certain subjects experiencing acute ischemic stroke.American Journal of Neuroradiology 06/2008; 29(7):1409-13. DOI:10.3174/ajnr.A1110 · 3.68 Impact Factor