Article

Complications of endovascular therapy for acute ischemic stroke and proposed management approach

Correspondence & reprint requests to Dr. Linfante: .
Neurology (Impact Factor: 8.29). 09/2012; 79(13 Suppl 1):S192-8. DOI: 10.1212/WNL.0b013e31826958e3
Source: PubMed

ABSTRACT

Over the past decade, endovascular therapy has emerged as a promising therapeutic approach for select patients with acute ischemic stroke. However, the morbidity, mortality, and complication rates in intra-arterial recanalization trials are higher than in the National Institute of Neurological Disorders and Stroke trial of IV tissue plasminogen activator. This review discusses common complications associated with endovascular therapy for acute ischemic stroke, avoidance of complications, and management of some of the common complications.

0 Followers
 · 
3 Reads
  • Source
    • "In contrast, the advent of intra-arterial thrombolysis and the introduction of endovascular clot retrieval devices (e.g., MERCI, Penumbra, and Solitaire) have shown great potential in improving the efficacy of vascular recanalization, which in turn may further extend the therapeutic window [8] [9]. While promising results in extending the tPA time window and utilizing new endovascular clot retrieval devices have been reported, both methods carry additional risks of mortality, morbidity, and serious complications, underscoring the critical role of careful patient selection [10]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Extensive efforts have recently been devoted to developing noninvasive imaging tools capable of delineating brain tissue viability (penumbra) during acute ischemic stroke. These efforts could have profound clinical implications for identifying patients who may benefit from tPA beyond the currently approved therapeutic time window and/or patients undergoing neuroendovascular treatments. To date, the DWI/PWI MRI and perfusion CT have received the most attention for identifying ischemic penumbra. However, their routine use in clinical settings remains limited. Preclinical and clinical PET studies with [(18)F]-fluoro-2-deoxy-D-glucose ((18)F-FDG) have consistently revealed a decreased (18)F-FDG uptake in regions of presumed ischemic core. More importantly, an elevated (18)F-FDG uptake in the peri-ischemic regions has been reported, potentially reflecting viable tissues. To this end, this paper provides a comprehensive review of the literature on the utilization of (14)C-2-DG and (18)F-FDG-PET in experimental as well as human stroke studies. Possible cellular mechanisms and physiological underpinnings attributed to the reported temporal and spatial uptake patterns of (18)F-FDG are addressed. Given the wide availability of (18)F-FDG in routine clinical settings, (18)F-FDG PET may serve as an alternative, non-invasive tool to MRI and CT for the management of acute stroke patients.
    Full-text · Article · May 2013
  • [Show abstract] [Hide abstract]
    ABSTRACT: CT hyperattenuation arising from iodinated contrast has a different temporal evolution than that arising due to hemorrhage. This paper presents a method for optimal discrimination between hemorrhage and iodinated contrast in a postintervention CT in stroke patients. We analyzed the brain computed tomography (CT) scans of consecutive patients with intraparenchymal hyperattenuation due to hemorrhage (n= 41), those due to iodinated contrast alone (n= 24), and those due to contrast mixed with hemorrhage after reperfusion therapy (n= 14) in stroke patients. The difference between the maximum enhancement in hyperattenuation in the affected area and the corresponding contralateral area, dubbed Relative Maximum Enhancement (RME), was tracked over time. We fitted regression models to the RME changes due to hemorrhage and contrast to describe their temporal decay, and then derived the optimal discriminant curve that distinguishes the two. A computer algorithm coregistered the baseline and follow-up CT scans and performed pixel-by-pixel comparison to determine hemorrhage and iodinated contrast based on the RME changes with respect to the discriminant curve. For both hemorrhage (k= - 0.004, R (2) = 0.7) and iodinated contrast (k= - 0.064, R (2) = 0.9), the temporal evolution of RMEs were best fitted by exponential decay curves, with respective half-lives of 192.3 and 10.7 h. An exponential decay model (k= - 0.026) for optimal discrimination of hemorrhage vs. contrast was fitted. The computer algorithm implementing this model was successful in predicting the presence of hemorrhage in a hyperdense lesion with sensitivity = 93 % and specificity = 91 %. Intraparenchymal hemorrhage and contrast have markedly different decay half-lives that can be used to assess hemorrhage in a hyperdense lesion on a CT scan after intra-arterial therapy.
    No preview · Article · Jan 2014
  • [Show abstract] [Hide abstract]
    ABSTRACT: Die endovaskuläre Schlaganfalltherapie hat sich seit ihrer Einführung zunehmend, vor allem in den letzten Jahren, weiterentwickelt. In dieser Übersicht wird ein Resümee der bisherigen Möglichkeiten, hauptsächlich der mechanischen Rekanalisierung, gegeben. Diese stellt heute die am weitesten verbreitete und nach aktuellen Studien die erfolgreichste Methode der endovaskulären Therapie dar. Das deutlichste Entwicklungspotential hatte hierbei die Einführung der stentähnlichen Retriever. Auch nach den 2013 erschienenen randomisierten Studien ist das allgemeine Fazit, dass nach Patientenselektion eine endovaskuläre Therapie mit einem modernen Stent-Retriever durchaus das klinische Outcome verbessern kann. In diesen Studien wurden lediglich ältere Geräte oder ein lokal rekombinanter gewebespezifischer Plasminogenaktivator (rtPA, „recombinant tissue-type plasminogen activator“) verwendet, jedoch keine Stent-Retriever. Damit wird u. a. auch dadurch die Dateninterpretation etwas eingeschränkt und die Diskussion durchaus kontrovers. Was kann also als aktueller Konsens angesehen werden? Für die A.-basilaris-Thrombose ist die endovaskuläre Therapie die mittlerweile akzeptierte Methode der Wahl. Im vorderen Kreislauf gelten nach Studienlage die langstreckigen Thromben als Indikationen für das endovaskuläre Vorgehen. Zudem sind für die Patientenauswahl wichtige bildgebungsgestützte Parameter entwickelt worden. Falls notwendig, können in der akuten Phase auch Gefäßdilatationen erfolgen; das Einbringen eines Stents ist möglich, muss aber aufgrund der erforderlichen Thrombozytenfunktionshemmung gut abgewogen werden. Weitere Studien, die randomisiert die i.v.-Thrombolyse und die Thrombektomie mit modernen Geräten vergleichen sollen, sind nun wichtig und derzeit in Planung oder gerade begonnen worden. Patienten, bei denen eine Thrombektomie erwogen wird, sollten in diese Studien eingeschlossen werden.
    No preview · Article · Apr 2014
Show more