Endovascular treatment strategies for acute ischemic stroke

Department of Neurological Surgery, Columbia University Medical Center, New York, NY 10032, USA.
International Journal of Stroke (Impact Factor: 4.03). 12/2011; 6(6):511-22. DOI: 10.1111/j.1747-4949.2011.00670.x
Source: PubMed

ABSTRACT The limitations of intravenous thrombolysis therapy have paved the way for the development of novel endovascular technologies for use in the setting of acute stroke. These technologies range from direct intraarterial thrombolysis to various thrombus disruption or retrieval devices to angioplasty and stenting. The tools in the armamentarium of the neuroendovascular interventionalist enable fast, effective revascularization to be offered to a wider population of patients that may otherwise have few therapeutic options available to them. In this paper, we review the current state-of-the-art in neuroendovascular intervention for acute ischemic stroke. Particular emphasis is placed on delineating the indications and outcomes for use of these various technologies.

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    • "Apart from the s-TPI, these predictive instruments, however, have been developed and validated in patients treated with intravenous recombinant tissue plasminogen activator (IV rtPA) according to restrictive criteria. In daily practice, patients are being treated according to local institutional guidelines, which may involve off-license use of IV rtPA and intra-arterial thrombolytic therapy [16] [17]. "
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    ABSTRACT: Objective: We evaluated the reliability of eight clinical prediction models for symptomatic intracerebral hemorrhage (sICH) and long-term functional outcome in stroke patients treated with thrombolytics according to clinical practice. Methods: In a cohort of 169 patients, 60 patients (35.5%) received IV rtPA according to the European license criteria. The remaining patients received off-label IV rtPA and/or were treated with intra-arterial thrombolysis. We used receiver operator characteristic curves to analyze the discriminative capacity of the MSS score, the HAT score, the SITS SICH score, the SEDAN score and the GRASPS score for sICH according to the NINDS and the ECASSII criteria. Similarly, the discriminative capacity of the s-TPI, the iScore and the DRAGON score were assessed for the modified Rankin Scale (mRS) score at 3 months poststroke. An area under the curve (c-statistic) >0.8 was considered to reflect good discriminative capacity. The reliability of the best performing prediction model was further examined with calibration curves. Separate analyses were performed for patients meeting the European license criteria for IV rtPA and patients outside these criteria. Results: For prediction of sICH c-statistics were 0.66-0.86 and the MMS yielded the best results. For functional outcome c-statistics ranged from 0.72 to 0.86 with s-TPI as best performer. The s-TPI had the lowest absolute error on the calibration curve for predicting excellent outcome (mRS 0-1) and catastrophic outcome (mRS 5-6). Conclusions: All eight clinical models for outcome prediction after thrombolysis for acute ischemic stroke showed fair predictive value in patients treated according daily practice. The s-TPI had the best discriminatory ability and was well calibrated in our study population.
    Clinical Neurology and Neurosurgery 08/2014; 125C:189-193. DOI:10.1016/j.clineuro.2014.08.011 · 1.25 Impact Factor
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    ABSTRACT: BACKGROUND AND PURPOSE:Acute vertebrobasilar occlusion is an ominous disease with few proved effective treatments. Experience with stent retrievers is scarce and limited to combined therapies (stent retrievers associated with previous intravenous fibrinolysis, intra-arterial thrombolysis, or other mechanical devices). We present our experience with 18 patients treated with direct thrombectomy by using stent retrievers.MATERIALS AND METHODS:Eighteen patients with vertebrobasilar occlusion were treated with direct thrombectomy by using stent retrievers at our hospital. The mean age was 67.5 years. Clinical presentation was sudden deterioration in consciousness level in 61.2% and progressive or fluctuating brain stem symptoms in 38.8%. Stroke subtype (TOAST) was atherothrombotic (33.3%), undetermined (33.3%), cardioembolic (27.7%), and of unusual etiology (5.5%).RESULTS:The occlusion site was the vertebral artery in 1 case, proximal basilar artery in 4, middle basilar artery in 6, distal basilar artery in 5, and unilateral posterior cerebral artery in 2 cases. SRs included the Solitaire AB in 8 cases, Solitaire FR in 5 cases, and Trevo Pro in 5 cases. An 8F Merci balloon guide catheter was used in 15 patients, and a Neuron 6F, in 3 patients. Post-clot retrieval definitive intracranial stents were used in 5 patients (27.7%). Postprocedural TICI ≥ 2b was achieved in 17 patients (94.4%). Clinically, 72.2% of patients experienced an improved NIHSS score at discharge, 22.2% died, and in 5.5% the NIHSS scores did not change. The mRS score at 3 months was 0-2 in 9 patients (50%) and 3-5 in 5 patients (27.7%).CONCLUSIONS:Thrombectomy with stent retrievers is feasible in the treatment of vertebrobasilar occlusion. These initial results must be confirmed by further prospective studies with a larger number of cases.
    American Journal of Neuroradiology 11/2012; 34(5). DOI:10.3174/ajnr.A3329 · 3.68 Impact Factor
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    ABSTRACT: Acute ischemic stroke (AIS) due to thrombo-embolic occlusion in the cerebral vasculature is a major cause of morbidity and mortality in the United States and throughout the world. Although the prognosis is poor for many patients with AIS, a variety of strategies and devices are now available for achieving recanalization in patients with this disease. Here, we review the treatment options for cerebrovascular thromboembolic occlusion with a focus on the evolution of strategies and devices that are utilized for achieving endovascular clot extraction. In order to demonstrate the progression of this treatment strategy over the past decade, we will also present a single-center case series of AIS patients treated with endovascular thrombectomy.
    06/2013; 3(2):521-39. DOI:10.3390/brainsci3020521
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