Rapid endovascular treatment for stroke

CardioVascular and Interventional Radiology, 2003

Cardiac embolism accounts for a large proportion of ischemic stroke. Revascularization using systemic or intra-arterial thrombolysis is associated with increasing risks of cerebral hemorrhage as time passes from stroke onset. We report successful mechanical thrombectomy from a distal branch of the middle cerebral artery (MCA) using a novel technique. A 72-year old man suffered an acute ischemic stroke from an echocardiographically proven ventricular thrombus due to a recent myocardial infarction. Intraarterial administration of 4 mg rt-PA initiated at 5.7 hours post-ictus failed to recanalize an occluded superior division branch of the left MCA. At 6 hours, symptomatic embolic occlusion persisted. Mechanical extraction of the clot using an Attracter-18 device (Target Therapeutics, Freemont, CA) resulted in immediate recanalization of the MCA branch. Attracter-18 for acute occlusion of MCA branches may be considered in selected patients who fail conventional thrombolysis or are nearing closure of the therapeutic window for use of thrombolytic agents.

The American Journal of Emergency Medicine, 2013

A 65-year-old man improved significantly during intravenous thrombolysis with recombinant tissue plasminogen activator (tPA) for acute stroke due to thrombotic occlusion of the basilar artery apex. However, 5 minutes after the end of tPA infusion, he developed anterior circulation clinical symptoms. Angiography showed signs of left middle cerebral artery and anterior cerebral artery occlusion. Endovascular recanalization by mechanical thrombus aspiration, and intra-arterial infusion of tPA (20 mg) was followed by complete left middle cerebral artery recanalization. The patient showed an improvement of 11 points of the National Institutes of Health Stroke Scale score at hospital discharge and a 3month modified Rankin scale score of 3. In patients with early recurrent ischemic stroke involving an initially unaffected vascular territory after intravenous thrombolysis, endovascular recanalization can be considered safe and effective. j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / a j e m

Expert Review of Cardiovascular Therapy, 2010

Acute ischaemic stroke is a devastating postoperative complication that significantly impacts upon a patient's quality of life. Endovascular retrieval of thromboembolic material from proximal cerebral arteries by mechanical thrombectomy is the new standard of care for patients presenting with a proximal artery occlusion. We report the case of a patient developing an acute ischaemic stroke following pulmonary lobectomy, who was transferred to the regional neurosciences unit, despite the absence of an established referral pathway, to undergo mechanical thrombectomy, with significant prognostic neurological benefit. We would advocate all cardiothoracic centres identify their regional neurosciences unit and initiate discussion to establish a referral pathway.

Neurology, 2012

A large number of patients presenting with acute ischemic stroke have large artery intracranial occlusions, and timely recanalization of these occlusions often leads to improved neurologic outcome. Starting with the widespread use of IV tissue plasminogen activator, a wide variety of pharmacologic and mechanical methods have been introduced to improve vessel recanalization and clinical outcome of patients with acute ischemic stroke, which include endovascular therapies such as intra-arterial thrombolytics and mechanical thrombectomy devices. One of the potential therapies is angioplasty and stenting, and this has been evaluated in multiple case reports and small series published by various centers regarding its use in this setting. In this article, we review the current literature on stenting with and without angioplasty, used alone or as a part of multimodal therapy for recanalization for acute cerebrovascular occlusions. Neurology ® 2012;79 (Suppl 1):S142-S147 GLOSSARY AIS ϭ acute ischemic stroke; IA ϭ intra-arterial; IMS ϭ Interventional Management of Stroke; MERCI ϭ Mechanical Embolus Removal in Cerebral Ischemia; mRS ϭ modified Rankin Scale; NIHSS ϭ NIH Stroke Scale; NINDS ϭ National Institute of Neurological Disorders and Stroke; PROACT ϭ Prolyse in Acute Cerebral Thromboembolism; TIMI ϭ thrombolysis in myocardial ischemia; tPA ϭ tissue plasminogen activator.

Interventional Neuroradiology, 2008

We report a case of a 59-year-old man who presented with an acute stroke involving the territory of his left middle cerebral artery, and who was treated with combined systemic and intraarterial thrombolysis. After these treatments, the segment remained stenotic. An urgent intracranial angioplasty was performed, resulting in satisfactory recanalization of the stenotic segment, and significant improvement of his National Institutes of Health Stroke Scale (NIHSS) from 14 to 5. This case report suggests an effective alternate protocol for treatment of acute stroke with arterial occlusion: immediate smaller dose of IV tissue plasminogen activator (tPA), followed by angiogram, intra-arterial thrombolysis, and angioplasty if indicated.

ARC Journal of Surgery, 2018

Journal of Stroke and Cerebrovascular Diseases, 2009

Thrombolysis with recombinant tissue plasminogen activator is the only established treatment for acute ischemic stroke. Recurrent ischemic stroke involving an initially unaffected arterial territory during the course of thrombolysis has been reported but remains exceptionally rare. Here we report a 75-year-old woman with acute left middle cerebral artery occlusion who developed right internal carotid artery occlusion during the last minutes of recombinant tissue plasminogen activator infusion. Although the transthoracic echocardiography did not reveal an intra-atrial thrombus, cardioembolism due to disintegration of a pre-existing thrombus was thought to be the underlying mechanism because the patient had atrial fibrillation. Arterial occlusion due to intraplaque hemorrhage and de novo thrombosis caused by thrombin-mediated platelet aggregation are also discussed as potential mechanisms of arterial occlusion.

Therapeutic Advances in Neurological Disorders

The treatment of stroke caused by intracranial vessel occlusion with intravenous recombinant tissue plasminogen activator (rt-PA) was the only evidence-based treatment option for a long time. Nevertheless the response rate was disappointing in large vessel occlusions. Five studies that evaluated the efficacy of mechanical thrombectomy published in 2015 proved a significant clinical benefit for selected patients suffering from acute ischemic stroke. These results are the basis for extensive technical, institutional, and personal structural changes in the neurovascular field of stroke treatment. This review gives an overview of the current status of mechanical thrombectomy and future expectations and challenges are discussed.

Case reports in neurology

Many recent trials show the benefit of mechanical thrombectomy in acute ischemic stroke caused by thrombi lodged in large arteries. We report the case of a 55-year-old patient who developed sudden-onset right-sided hemiplegia and aphasia. Computed tomography angiography showed a thrombus in the M1 segment of the left middle cerebral artery. The thrombus was removed by mechanical thrombectomy 85 min after the onset of symptoms. A magnetic resonance imaging (MRI) scan showed no infarct, and the patient was discharged symptom free. To the best of our knowledge, this is the first report of thrombectomy of a symptomatic proximal middle cerebral artery occlusion leading to complete rescue, both clinically and radiologically assessed by MRI. Our case report shows that an early thrombectomy can provide an excellent outcome.

Neuroradiology, 2014

Introduction There is only very limited data about complications in mechanical thrombectomy for acute ischemic stroke. The purpose of this study was to evaluate the frequency and the clinical relevance of procedure-related complications in mechanical thrombectomy. Methods We conducted a retrospective analysis of 176 consecutive acute ischemic stroke cases that were treated with mechanical thrombectomy. Primary outcome measures included the following: symptomatic intracranial hemorrhage (sICH), vessel dissection, emboli to new vascular territories, vasospasm, and stent dislocation/occlusion whenever appropriate. Secondary outcome measures included mTICI score, time from symptom onset to revascularization, and time from groin puncture to revascularization as well as the early clinical outcome at discharge. Results Complications occurred in 20/176 patients (11 %) comprising 23 adverse events at the following rates: sICH 8/176 (5 %), emboli to new vascular territories 4/176 (2 %); vessel dissection 3/176 (2 %); vasospasm of the access vessel 5/176 (3 %); stent dislocation in 1/42 (2 %); and stent occlusion in 2/42 (5 %). Two out of 20 (10 %) suffered from two or more procedure-related complications. There was a statistically significant correlation of complications with time from groin puncture to revascularization, unfavorable revascularization results, and unfavorable clinical outcome. Conclusion Overall, the frequency of procedure-related complications lies within acceptable limits for an emergency procedure. The endovascular treatment does not seem to add significantly to the stroke patients' risk of sICH but implies an innate risk of stroke in an initially uninvolved territory. Furthermore, a prolonged endovascular procedure beyond an hour is correlated with higher complication rates, which underlines the importance of a swift and complete revascularization.