Evolving role of endovascular treatment of acute ischemic stroke.
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ABSTRACT:
SUBMITTER: Ciccone A
PROVIDER: S-EPMC4066631 | biostudies-literature | 2014 Jan
REPOSITORIES: biostudies-literature
Publications
Evolving role of endovascular treatment of acute ischemic stroke.
Ciccone Alfonso A del Zoppo Gregory J GJ
Current neurology and neuroscience reports 20140101 1
The perceived advantages of endovascular treatment for acute ischemic stroke in terms of recanalization, the multimodal and targeted approaches, and perhaps the more permissive rules on devices than on medications for their licensing favored the assumption that endovascular treatment is superior to intravenous thrombolysis for acute treatment of ischemic stroke, and its adoption in more advanced stroke centers. However, this assumption has been questioned by recent clinical trial experience show ...[more]
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Project description:BackgroundIn patients with ischemic stroke, endovascular treatment results in a higher rate of recanalization of the affected cerebral artery than systemic intravenous thrombolytic therapy. However, comparison of the clinical efficacy of the two approaches is needed.MethodsWe randomly assigned 362 patients with acute ischemic stroke, within 4.5 hours after onset, to endovascular therapy (intraarterial thrombolysis with recombinant tissue plasminogen activator [t-PA], mechanical clot disruption or retrieval, or a combination of these approaches) or intravenous t-PA. Treatments were to be given as soon as possible after randomization. The primary outcome was survival free of disability (defined as a modified Rankin score of 0 or 1 on a scale of 0 to 6, with 0 indicating no symptoms, 1 no clinically significant disability despite symptoms, and 6 death) at 3 months.ResultsA total of 181 patients were assigned to receive endovascular therapy, and 181 intravenous t-PA. The median time from stroke onset to the start of treatment was 3.75 hours for endovascular therapy and 2.75 hours for intravenous t-PA (P<0.001). At 3 months, 55 patients in the endovascular-therapy group (30.4%) and 63 in the intravenous t-PA group (34.8%) were alive without disability (odds ratio adjusted for age, sex, stroke severity, and atrial fibrillation status at baseline, 0.71; 95% confidence interval, 0.44 to 1.14; P=0.16). Fatal or nonfatal symptomatic intracranial hemorrhage within 7 days occurred in 6% of the patients in each group, and there were no significant differences between groups in the rates of other serious adverse events or the case fatality rate.ConclusionsThe results of this trial in patients with acute ischemic stroke indicate that endovascular therapy is not superior to standard treatment with intravenous t-PA. (Funded by the Italian Medicines Agency, ClinicalTrials.gov number, NCT00640367.).
| S-EPMC3708480 | biostudies-literature
Project description:PURPOSE:Knowledge about the localization and outcome of iatrogenic dissection (ID) during endovascular treatment of acute ischemic stroke (AIS) is limited. We aimed to determine the frequency, clinical aspects and morphology of ID in endovascular AIS treatment and to identify predictors of this complication. METHODS:Digital subtraction angiography (DSA) of ID carried out during endovascular treatment between January 2000 and March 2012 have been re-evaluated. The ID localization and morphology were analyzed and related to the interventional techniques. Baseline clinical and radiological findings, treatment modality and outcome were compared with patients without ID. RESULTS:Out of 866 patients 18 (2%) suffered an ID (44% female, median age 64 years). Localization was extracranial in 15 (83%, 14 internal carotid artery and 1 vertebral artery) and intracranial in 3 (17%; 1 vertebrobasilar dissection and 2 in the anterior circulation). Of the IDs 5 (28%) resulted in a high-degree, 3 (17%) in a moderate, 5 (28%) in a mild and 5 (28%) in no stenosis and 8 IDs were stented in the acute phase. At 3 months 7 (42%) patients had a favorable outcome (modified Rankin score mRS ≤ 2) and 6 (33%) patients had died. Patients with ID had a different stroke etiology (p = 0.041), were more likely to be smokers (44% versus 19%, p = 0.015) and were more likely to be treated with mechanical thrombectomy (100% versus 60%, p < 0.001). Although two ID patients had relevant complications, the outcome did not differ between the groups. CONCLUSION:The occurrence of ID is a rare complication of endovascular AIS treatment associated with smoking and mechanical thrombectomy.
| S-EPMC6394531 | biostudies-other
Project description:Background and purpose Recent randomized clinical trials have proved the efficacy of endovascular treatment of acute ischemic stroke in the anterior circulation. However, the benefit of endovascular treatment of ischemic stroke in the posterior circulation remains to be proven since it was excluded from these trials. We evaluate the benefit of endovascular treatment in posterior circulation strokes. Methods A total of 110 consecutive patients with posterior circulation stroke who underwent endovascular treatment in our institute in the period 1991-2015 were included. Recanalization rate according to modified Treatment in Cerebral Ischemia score and neurological outcome at three months according to modified Rankin Scale were the main outcomes. Collateral circulation, procedural complications and radiological outcome were evaluated in the radiological examinations. Results The median National Institutes of Health Stroke Scale was 31 (IQR: 13-31) and median time from symptom onset to groin puncture was 300 (IQR: 175-463) minutes. Successful recanalization was seen in 80 of 110 patients (73%). Favorable outcome (modified Rankin Scale ≤2) was seen in 38 patients (35%) while moderate favorable outcome (≤3) was seen in 48 patients (44%). Symptomatic intracerebral hemorrhage occurred in 10 patients (9%). An association between collateral circulation, recanalization rate and outcome was seen. Conclusion Endovascular treatment for posterior circulation stroke in this single-center cohort is relatively safe and effective with decreased mortality and increased favorable outcome compared to natural history.
| S-EPMC6050892 | biostudies-other
Project description:Acute kidney injury (AKI) is often associated with the use of contrast agents. We evaluated the frequency of AKI, factors associated with AKI after endovascular treatment (EVT), and associations with AKI and clinical outcomes. We retrospectively analyzed consecutively enrolled patients with acute ischemic stroke who underwent EVT at three stroke centers in Korea. We compared the characteristics of patients with and without AKI and independent factors associated with AKI after EVT. We also investigated the effects of AKI on functional outcomes and mortality at 3 months. Of the 601 patients analyzed, 59 patients (9.8%) developed AKI and five patients (0.8%) started renal replacement therapy after EVT. In the multivariate analysis, diabetes mellitus (odds ratio (OR), 2.341; 95% CI, 1.283-4.269; p = 0.005), the contrast agent dose (OR, 1.107 per 10 mL; 95% CI, 1.032-1.187; p = 0.004), and unsuccessful reperfusion (OR, 1.909; 95% CI, 1.019-3.520; p = 0.040) were independently associated with AKI. The presence of AKI was associated with a poor functional outcome (OR, 5.145; 95% CI, 2.177-13.850; p < 0.001) and mortality (OR, 8.164; 95% CI, 4.046-16.709; p < 0.001) at 3 months. AKI may also affect the outcomes of ischemic stroke patients undergoing EVT. When implementing EVT, practitioners should be aware of these risk factors.
| S-EPMC7291207 | biostudies-literature
Project description:PurposeAs endovascular therapy (EVT) has been approved as a treatment guideline for acute ischemic stroke (AIS), it has been increasing in Korea. We conducted a nationwide survey to evaluate the current status of EVT for patients with AIS in Korea.Materials and methodsAn electronic survey was sent to a representative clinician at each hospital where EVT was available in Korea. A Google survey was used to distribute the questionnaires and receive responses from October 2017 to December 2017.ResultsAmong 120 hospitals in our society, 76 participated in this survey. In 26% of the hospitals, more than 50 annual cases of EVT were performed, and 25-50 annual cases in 37%. Fifty-six hospitals (73.7%) achieved successful recanalization (thrombolysis in cerebral infarction ?2b) in more than 80% of patients. Computed tomography (CT) angiography was the most common imaging modality for AIS treatment, and magnetic resonance (MR) diffusion, MR-perfusion/diffusion, and perfusion CT were frequently used in order. Non-eligibility criteria for EVT included a National Institutes of Health Stroke Scale <4 (64.5%), the absence of MR perfusion/diffusion mismatch (52.6%), and a low Alberta Stroke Program Early CT Score (42.1%). For anterior circulation stroke, 60% of Korean hospitals adopted a wider time range of "8 hours" from symptom onset, while 70% of hospitals had a time limitation of 12-24 hours for posterior circulation stroke. The most preferred EVT device was a stentriever (89.4%). In the failed cases due to underlying stenosis, 79% of Korean hospitals performed angioplasty or stenting for revascularization.ConclusionThis first nationwide survey showed that most Korean hospitals conducted EVT for AIS patients according to the present guideline in the era of mechanical thrombectomy by integrating the clinical experiences of many medical institutions and specialists.
| S-EPMC6132038 | biostudies-literature
Project description:ObjectiveThe effect of anesthetic management (general anesthesia [GA], conscious sedation, or local anesthesia) on functional outcome and the role of blood pressure management during endovascular treatment (EVT) for acute ischemic stroke is under debate. We aimed to determine whether hypotension during EVT under GA is associated with functional outcome at 90 days.MethodsWe retrospectively collected data from patients with a proximal intracranial occlusion of the anterior circulation treated with EVT under GA. The primary outcome was the distribution on the modified Rankin Scale at 90 days. Hypotension was defined using two thresholds: a mean arterial pressure (MAP) of 70 mm Hg and a MAP 30% below baseline MAP. To quantify the extent and duration of hypotension, the area under the threshold (AUT) was calculated using both thresholds.ResultsOf the 366 patients included, procedural hypotension was observed in approximately half of them. The occurrence of hypotension was associated with poor functional outcome (MAP <70 mm Hg: adjusted common odds ratio [acOR], 0.57; 95% confidence interval [CI], 0.35-0.94; MAP decrease ≥30%: acOR, 0.76; 95% CI, 0.48-1.21). In addition, an association was found between the number of hypotensive periods and poor functional outcome (MAP <70 mm Hg: acOR, 0.85 per period increase; 95% CI, 0.73-0.99; MAP decrease ≥30%: acOR, 0.90 per period; 95% CI, 0.78-1.04). No association existed between AUT and functional outcome (MAP <70 mm Hg: acOR, 1.000 per 10 mm Hg*min increase; 95% CI, 0.998-1.001; MAP decrease ≥30%: acOR, 1.000 per 10 mm Hg*min; 95% CI, 0.999-1.000).ConclusionsOccurrence of procedural hypotension and an increase in number of procedural hypotensive periods were associated with poor functional outcome, whereas the extent and duration of hypotension were not. Randomized clinical trials are needed to confirm our hypothesis that hypotension during EVT under GA has detrimental effects.
| S-EPMC8221480 | biostudies-literature
Project description:Background: Although endovascular treatment (EVT) has greatly improved outcomes in acute ischemic stroke, still one third of patients die or remain severely disabled after stroke. If we could select patients with poor clinical outcome despite EVT, we could prevent futile treatment, avoid treatment complications, and further improve stroke care. We aimed to determine the accuracy of poor functional outcome prediction, defined as 90-day modified Rankin Scale (mRS) score ≥5, despite EVT treatment. Methods: We included 1,526 patients from the MR CLEAN Registry, a prospective, observational, multicenter registry of ischemic stroke patients treated with EVT. We developed machine learning prediction models using all variables available at baseline before treatment. We optimized the models for both maximizing the area under the curve (AUC), reducing the number of false positives. Results: From 1,526 patients included, 480 (31%) of patients showed poor outcome. The highest AUC was 0.81 for random forest. The highest area under the precision recall curve was 0.69 for the support vector machine. The highest achieved specificity was 95% with a sensitivity of 34% for neural networks, indicating that all models contained false positives in their predictions. From 921 mRS 0-4 patients, 27-61 (3-6%) were incorrectly classified as poor outcome. From 480 poor outcome patients in the registry, 99-163 (21-34%) were correctly identified by the models. Conclusions: All prediction models showed a high AUC. The best-performing models correctly identified 34% of the poor outcome patients at a cost of misclassifying 4% of non-poor outcome patients. Further studies are necessary to determine whether these accuracies are reproducible before implementation in clinical practice.
| S-EPMC7593486 | biostudies-literature
Project description:Background Patients aged ≥90 were excluded or under-represented in past thrombectomy trials; thus, uncertainty remains whether treatment benefits can be expected regardless of age. This study investigates outcome and safety of thrombectomy in nonagenarians to improve decision making in a real-world setting. Methods and Results All currently available data of patients aged ≥90 enrolled in the GSR-ET (German Stroke Registry-Endovascular Treatment) were combined with a smaller cohort from 3 tertiary stroke centers. Baseline characteristics, procedural (Thrombolysis in Cerebral Infarction scale) and functional outcomes (modified Rankin Scale; mRS), as well as complications (symptomatic intracranial hemorrhage, serious adverse events; SAEs) were analyzed. Good functional outcome was defined as mRS ≤3 at 90-days. 203 patients with anterior circulation stroke and prestroke mRS ≤3 were included. The rate of successful recanalization (Thrombolysis in Cerebral Infarction scale ≥2b) was 75.9% (154/203). Good functional outcome (mRS ≤3) was observed in 21.6% (41 of 193) at 90-days. In-hospital mortality was 27.1% (55 of 203) and increased significantly at 90 days to 48.9% (93 of 190; P<0.001). Symptomatic intracranial hemorrhage occurred in 3% (6 of 203) of patients. Logistic regression analysis identified Alberta Stroke Program Early CT Score (adjusted odds ratio, 1.93; 95% CI, 1.01-3.70; P=0.046) and initial National Institute of Health Stroke Scale (adjusted odds ratio, 0.85; 95% CI, 0.76-0.97; P=0.014) as independent predictors for good outcome. Patients with successful recanalization had a significant (P=0.001) shift of mRS distribution with higher rates of good functional outcomes (23.8% [34 of 143] versus 14.9% [7 of 47]) and lower mortality at 90-days (46.8% [67 of 143] versus 55.3% [26 of 47]). Conclusions Despite high mortality and less frequent favorable outcome, our data suggest that thrombectomy is still effective and safe for nonagenarians. Decision making for thrombectomy in patients aged ≥90 should be based on a case-by-case basis with regard to initial National Institute of Health Stroke Scale and Alberta Stroke Program Early CT Score.
| S-EPMC7335589 | biostudies-literature
Project description:ObjectiveTo compare the outcomes between endovascular and medical management of acute ischemic stroke in recent randomized controlled trials (RCT).MethodsA systematic literature review was performed, and multicenter, prospective RCTs published from January 1, 2013, to May 1, 2015, directly comparing endovascular therapy to medical management for patients with acute ischemic stroke were included. Meta-analyses of modified Rankin Scale (mRS) and mortality at 90 days and symptomatic intracranial hemorrhage (sICH) for endovascular therapy and medical management were performed.ResultsEight multicenter, prospective RCTs (Interventional Management of Stroke [IMS] III, Local Versus Systemic Thrombolysis for Acute Ischemic Stroke [SYNTHESIS] Expansion, Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy [MR RESCUE], Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands [MR CLEAN], Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness [ESCAPE], Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial [EXTEND-IA], Solitaire With the Intention For Thrombectomy as Primary Endovascular Treatment [SWIFT PRIME], and Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours [REVASCAT]) comprising 2,423 patients were included. Meta-analysis of pooled data demonstrated functional independence (mRS 0-2) at 90 days in favor of endovascular therapy (odds ratio [OR] = 1.71; p = 0.005). Subgroup analysis of the 6 trials with large vessel occlusion (LVO) criteria also demonstrated functional independence at 90 days in favor of endovascular therapy (OR = 2.23; p < 0.00001). Subgroup analysis of the 5 trials that primarily utilized stent retriever devices (≥70%) in the intervention arm demonstrated functional independence at 90 days in favor of endovascular therapy (OR = 2.39; p < 0.00001). No difference was found for mortality at 90 days and sICH between endovascular therapy and medical management in all analyses and subgroup analyses.ConclusionsThis meta-analysis provides strong evidence that endovascular intervention combined with medical management, including IV tissue plasminogen activator for eligible patients, improves the outcomes of appropriately selected patients with acute ischemic stroke in the setting of LVO.
| S-EPMC4664128 | biostudies-literature
Project description:Although randomized control trials about endovascular treatment (EVT) of emergent large vessel occlusion (LVO) have demonstrated the success of mechanical thrombectomy as the choice of treatment, a wide range of caveats remain unaddressed. Asian patients were rarely included in the trials, thereby raising the question of whether the treatment could be generalized. In addition, there remains a concern on the feasibility of the method with respect to its application against intracranial atherosclerosis (ICAS)-related LVO, frequently observed in the Asian population. It is important to include evidence on ICAS LVO from Asian countries in the future for a comprehensive understanding of LVO etiology. Besides the issues with EVT, prognostic concerns in diabetes patients, acute kidney injury following EVT, neuroprotective management against reperfusion injury, and other peri-EVT issues should be considered in clinical practice. In the current article, we present an in-depth review of the literature that revises information pertaining to such concerns.
| S-EPMC8261106 | biostudies-literature