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Application of mechanical thrombectomy in the patients with wake-up stroke

HU Yue
, HE Xin-wei, LIU Yi-sheng, ZHAO Rong, LIU Jian-ren

- , 2018, DOI: 10.3969/j.issn.1674-8115.2018.09.021
Abstract: 起病时间不明、短期治疗结局不佳的醒后卒中( wake-up stroke,WUS)约占所有卒中的 25%;且由于以上 2个特点,如何选择 WUS治疗方案仍在探索中。机械取栓是急性缺血性脑卒中( acute ischemic stroke,AIS)的一线治疗, DAWN和 DEFUSE-3研究证明其治疗时间窗可扩大至 24 h;且研究发现通过 CT灌注成像等影像学检查,选择具有“临床评分和影像学上梗死核心体积不匹配”的 WUS患者行血管内治疗仍安全而有效。该文就近年来机械取栓在 WUS治疗中的应用做一总结。
:Wake-up stroke (WUS), which is characterizedthe uncertain onset time and poor short-term outcome, accounts for 25% of stroke. Due to the above two points, how to choose the treatment methods remains to be researched. The mechanical thrombectomy is the first-line treatment of acute ischemic stroke (AIS). DAWN and DEFUSE-3 studies have recently demonstrated that the treatment window can be expanded to 24 hours, so the endovascular treatment may be effective and safe in some WUS patients according to the existence of “the mismatch of clinical score and imaging infart core”CT perfusion imaging and other modern imaging methods. This article summarized the application of mechanical thrombectomy in WUS treatment in recent years
To tube or not to tube? The role of intubation during stroke thrombectomy  [PDF]
Courtney Takahashi,Conrad W. Liang,David S. Liebeskind,Jason D. Hinman
Frontiers in Neurology , 2014, DOI: 10.3389/fneur.2014.00170
Abstract: In the 10 years since the FDA first cleared the use of endovascular devices for the treatment of acute stroke, definitive evidence that such therapy improves outcomes remains lacking. The decision to intubate patients undergoing stroke thrombectomy impacts multiple variables that may influence outcomes after stroke. Three main areas where intubation may deleteriously affect acute stroke management include the introduction of delays in revascularization, fluctuations in peri-procedural blood pressure, and hypocapnia resulting in cerebral vasoconstriction. In this mini-review, we discuss the evidence supporting these limitations of intubation during stroke thrombectomy and encourage neurohospitalists, neurocritical care specialists and neurointerventionalists to carefully consider the decision to intubate during thrombectomy and provide strategies to avoid potential complications associated with its use in acute stroke.
Admission Motor Strength Grade Predicts Mortality in Patients with Acute Ischemic Stroke Undergoing Mechanical Thrombectomy  [PDF]
Vishnumurthy Shushrutha Hedna, Aakash N. Bodhit, Saeed Ansari, Adam D Falchook, Latha G. Stead, Sharathchandra Bidari, Brian L Hoh, Kenneth M Heilman, Michael F Waters
Neuroscience & Medicine (NM) , 2013, DOI: 10.4236/nm.2013.41001

Background: The mortality due to mechanical thrombectomy (MT) in the acute treatment of intracranial arterial occlu- sions can be up to 45%. The SWIFT (Solitaire FR with the Intention for Thrombectomy) and Multi MERCI (mechani- cal embolus removal in cerebral ischemia) trials have evaluated the safety and efficacy of MT. It may be important to determine pre-procedural factors that help predict post-intervention prognosis. We sought to determine if admission medical research council (MRC) motor strength grade along with other factors can be used as predictor of mortality after MT for acute ischemic stroke. Methods: Retrospective analysis of stroke database assessing outcomes in all 62 patients who underwent MT as an intervention for acute ischemic stroke, with or without concurrent intravenous thrombolysis was done. Five baseline variables were included in univariate and multivariate analyses to define the in- dependent predictors of mortality during current hospitalization. The medical research council (MRC) motor grade (0 - 5); modified collateral flow (CS) grading (0 - 3); age; acute and chronic co-morbidities were used as the baseline vari- ables. If motor strength grade were different in upper and lower extremities, then the lower grade was used. Age was analyzed independently as well as dichotomized using 80 as cut-off value. Relevant stroke related acute and chronic co-morbidities were given 1 point each and mean calculated.

Efficacy and Safety of Endovascular Treatment versus Intravenous Thrombolysis for Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials  [PDF]
Chao Lin, Nan Li, Kang Wang, Xin Zhao, Bai-Qiang Li, Lei Sun, Yi-Xing Lin, Jie-Mei Fan, Miao Zhang, Hai-Chen Sun
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0077849
Abstract: Background and Purpose Although endovascular therapy (ET) is increasingly used in patients with moderate to severe acute ischemic stroke, its efficacy and safety remains controversial. We performed a meta-analysis aiming to compare the benefits and safety of endovascular treatment and intravenous thrombolysis in the treatment of acute ischemic stroke. Methods We systematically searched PubMed, Embase, Science direct and Springer unitil July, 2013. The primary outcomes included good outcome (mRS ≤ 2) and excellent outcome (mRS ≤ 1) at 90 days or at trial end point. Secondary outcomes were occurrence of symptomatic hemorrhage and all-cause mortality. Results Using a prespecified search strategy, 5 RCTs with 1106 patients comparing ET and intravenous thrombolysis (IVT) were included in the meta-analysis. ET and IVT were associated with similar good (43.06% vs 41.78%; OR=1.14; 95% CI, 0.77 to 1.69; P=0.52;) and excellent (30.43% vs 30.42%; OR=1.05; 95% CI, 0.80 to 1.38; P=0.72;) outcome. For additional end points, ET was not associated with increased occurrence of symptomatic hemorrhage (6.25% vs. 6.22%; OR=1.03; 95% CI, 0.62 to 1.69; P=0.91;), or all-cause mortality (18.45% vs. 17.35%; OR=1.00; 95% CI, 0.73 to 1.39; P=0.99;). Conclusions Formal meta-analysis indicates that there are similar safety outcomes and functional independence with endovascular therapy and intravenous thrombolysis for acute ischemic stroke.
The Goldilocks Dilemma in Acute Ischemic Stroke  [PDF]
Aaron P. Tansy,David S. Liebeskind
Frontiers in Neurology , 2013, DOI: 10.3389/fneur.2013.00164
Abstract: Despite the advent of and exciting advances in novel endovascular therapies, t-PA remains the only proven treatment for acute ischemic stroke to date. Although a variety of reasons likely underlie why past trials of endovascular strategies have been unsuccessful, we address in this perspective piece one critical unknown for which a solution is undoubtedly necessary if future ones are to meet with success: determination and selection of patients that are “just right” for endovascular treatments, or the Goldilocks dilemma. Key clinical criteria highlighted in past trials may help provide a solution to this critical problem. However, for them to do so, we propose that they must be applied in service of a model that accounts for the nuanced, dynamic nature of acute ischemic stroke better than the prevailing “time is brain” model. We provide and examine three clinical cases to illustrate this proposal towards solving the Goldilocks dilemma and advancing treatment in acute ischemic stroke. Further, we address our field’s ongoing challenge and mission in the meantime to best care for the “not-so-right” patients, by far the majority of the affected stroke population.
Mechanical Thrombectomy for Ischaemic Stroke: The First UK Case Series  [PDF]
Nasar Ahmad, Sanjeev Nayak, Changez Jadun, Indira Natarajan, Palbha Jain, Christine Roffe
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0082218
Abstract: Background and Purpose Endovascular treatments have the potential to accelerate reperfusion in acute ischaemic stroke with large vessel occlusion. In the UK only a few stroke centres offer this interventional option. The University Hospital of North Staffordshire (UHNS) has treated the largest number of cases in the UK. Results of the first 106 endovascular treatments (EVT) are presented here. Methods All patients treated with EVT (intra-arterial thrombolysis (IAT), mechanical thrombectomy (MT) or both, or an attempt at intervention) for acute stroke at UHNS, Stoke-on-Trent, UK, were entered into a prospective register. Baseline demographic and clinical data, the National Institutes for Health Stroke Scale (NIHSS), imaging results including Thrombolysis in Cerebral Infarction (TICI) score, and complications were recorded. Mortality, and modified Rankin score (mRS) were assessed at 90 days. Results From December 2009 to January 2013 106 patients (mean age 64 years, median baseline NIHSS 18) were treated with EVT (thrombectomy ± IAT 83%, IAT alone 13%, neither 4%). Seventy-eight per cent of occlusions were in the anterior circulation. Intravenous bridging thrombolysis was performed in 81%. Revascularization was successful (TICI 2b/3) in 84%. The median time from stroke onset to the end of the procedure was 6 h 03 min. A good outcome (mRS≤2) at 90 days was achieved in 48% with a mortality of 15%. Fatal or nonfatal symptomatic intracranial haemorrhage (sICH) within 10 days occurred in 9%. The median length of stay was 14 days (31% discharged home ≤7 days). Conclusions EVT led to good clinical outcomes in almost 50% of patients with severe strokes.
Therapeutic Decision Making in Acute Stroke due to Carotid Artery Dissection: A Potential Role for Percutaneous Vascular Intervention following Intravenous Thrombolysis  [PDF]
J. B. Lewis,á. Merwick,R. ó. Laoide,A. O'Hare,C. McGuigan
Case Reports in Vascular Medicine , 2013, DOI: 10.1155/2013/121696
Abstract: Internal carotid artery dissection (ICAD) is an important cause of acute ischemic stroke in younger patients. Potential acute treatments include anticoagulation, intravenous thrombolysis (IVT), and endovascular thrombectomy (ET). We report a case where the use of IVT followed by ET resulted in a good clinical outcome in a patient with tandem internal carotid and middle cerebral artery occlusion following ICAD. 1. Introduction A 31-year-old right-handed woman, who was 4-month postpartum, presented to the emergency department with a thirty-five-minute history of left-sided face, arm and leg weakness, along with slurred speech. She reported right-sided neck pain for the preceding three days, with no history of trauma or neck manipulation. Two days prior to presentation, she had experienced transient loss of vision in her right eye. On examination, she had left upper motor neuron pattern facial weakness, left upper and lower limb MRC grade 0/5 power, sensory inattention, and cumulative NIH Stroke Scale (NIHSS) score of 14. Horner’s syndrome was absent. CT brain imaging performed 1 hour after symptom onset showed a hyperdense middle cerebral artery (MCA) sign (Figure 1(a)), and CT angiogram showed a right internal carotid artery dissection (ICAD). MRI confirmed the internal carotid artery dissection and demonstrated restricted diffusion limited to the lenticulostriate distribution of the MCA. Figure 1: (a) Prethrombolysis CT showing hyperdense vessel sign in right MCA. (b) Angiogram after right ICA stenting and before Solitaire AB deployment showing pseudoaneurysm at the dissection site (white arrowhead) and thrombus within the ACA and M1 (black arrowheads). (c) Solitaire AB deployment with stent in situ. (d) Angiogram after clot retrieval from right MCA showing recanalization and reperfusion. The intravenous thrombolysis (IVT) was initiated 2 hours 20 minutes following symptom onset, but following IV tPA administration the patient continued to display persistent left hemiparesis, dysarthria, and sensory inattention. NIHSS score was 10. The patient was transferred to a hospital with interventional neuroradiology expertise in view of the persisting disability and presumed persistent proximal artery occlusion. Informed consent was obtained and the patient was placed under general anaesthesia. The initial angiogram via a 5?Fr catheter showed a normal left carotid, left anterior circulation, vertebral artery, and posterior circulation. Absence of cross-flow via the anterior communicating artery precluded the assessment of the right anterior circulation from the
Tratamiento endovascular y trombólisis intraarterial en el ictus isquémico agudo Endovascular treatment and intra-arterial thrombolysis in acute ischemic stroke
D. Escudero,R. Molina,L. Vi?a,P. Rodríguez
Medicina Intensiva , 2010,
Abstract: Objetivo: Analizar la eficacia y la seguridad de la trombólisis intraarterial y el tratamiento endovascular en pacientes con ictus isquémico agudo. Dise o y ámbito: Estudio prospectivo observacional en una unidad de cuidados intensivos. Pacientes: Dieciséis pacientes recibieron tratamiento endovascular. Se recogieron datos epidemiológicos, localización de la oclusión arterial, tiempo desde el ictus al tratamiento, indicación del tratamiento, National Institutes of Health Stroke Scale al ingreso y al alta hospitalaria, y complicaciones y evolución funcional por escala de Rankin modificada realizada mediante una encuesta telefónica. Resultados: Diez varones, con una edad media de 59 a os (29-74) y una estancia media en la unidad de cuidados intensivos de 6 días (1-33). Siete pacientes requirieron ventilación mecánica. Indicación del tratamiento: 4 casos por fracaso de la trombólisis intravenosa, 5 por oclusión de gran vaso, 2 por estar fuera de la ventana terapéutica, 3 por oclusión de la circulación posterior, uno por estar fuera de la ventana terapéutica y tener, además, una oclusión de gran vaso y uno por contraindicación para la trombólisis intravenosa. Localización de la oclusión: 3 en la circulación posterior y 13 en el territorio carotídeo y sus ramas. El fibrinolítico utilizado fue uroquinasa en dosis de 100.000-600.000 UI. Cuatro pacientes requirieron embolectomía mecánica y 10, implantación de stent. Se obtuvo recanalización completa en 11 pacientes (69%) y parcial en 4 (25%). Tres pacientes evolucionaron a muerte encefálica. Seis pacientes (46%) tuvieron una buena recuperación (escala de Rankin modificada <2). Como complicación técnica destacó un seudoaneurisma de la arteria femoral. Conclusiones: El tratamiento intraarterial obtiene altas tasas de recanalización y buenos resultados funcionales con escasas complicaciones. Su uso estaría indicado en pacientes con afectación neurológica importante (National Institutes of Health Stroke Scale >10) -tiempo de evolución de 3-6h-, y contraindicacio'n para la trombólisis intravenosa y la oclusión arterial proximal. Objective: Analysis of the safety and efficacy of intra-arterial thrombolysis therapy and endovascular treatment in acute ischemic stroke. Design and area: An observational prospective study in the Intensive Care Unit. Patients and methods: 16 patients had endovascular treatment. Epidemiological data, arterial occlusion site, time between stroke onset and treatment, treatment indication, NIHSS scale at admission and discharge from hospital, complications and functional outcome measured by mod
Abdominal wall hemorrhage after intravenous thrombolysis for acute ischemic stroke  [cached]
An Se-A,Kim Jinkwon,Kim Sang Heum,Kim Won Chan
BMC Neurology , 2013, DOI: 10.1186/1471-2377-13-6
Abstract: Background Thrombolysis is strongly recommended for patients with significant neurologic deficits secondary to acute ischemic stroke. Extracranial bleeding is a rare but major complication of thrombolysis. Case presentation A 78-year-old woman presented with acute ischemic stroke caused by occlusion of the basilar artery. Clinical recovery was observed after successful recanalization by intravenous thrombolysis and intraarterial thrombectomy. However, the patient complained of sudden abdominal pain following the intervention and a newly developed abdominal wall mass was found. CT scan and selective angiography confirmed active bleeding from the left epigastric artery into the abdominal muscle layer and the bleeding was successfully managed by selective embolization of the bleeding artery. Conclusions We report a rare case of abdominal wall hemorrhage after thrombolysis for acute ischemic stroke. The findings indicate that abdominal wall hemorrhage should be considered as a differential diagnosis in the presence of abdominal discomfort after thrombolysis for acute ischemic stroke.
The Role of Citicoline in Neuroprotection and Neurorepair in Ischemic Stroke  [PDF]
José álvarez-Sabín,Gustavo C. Román
Brain Sciences , 2013, DOI: 10.3390/brainsci3031395
Abstract: Advances in acute stroke therapy resulting from thrombolytic treatment, endovascular procedures, and stroke units have improved significantly stroke survival and prognosis; however, for the large majority of patients lacking access to advanced therapies stroke mortality and residual morbidity remain high and many patients become incapacitated by motor and cognitive deficits, with loss of independence in activities of daily living. Therefore, over the past several years, research has been directed to limit the brain lesions produced by acute ischemia (neuroprotection) and to increase the recovery, plasticity and neuroregenerative processes that complement rehabilitation and enhance the possibility of recovery and return to normal functions (neurorepair). Citicoline has therapeutic effects at several stages of the ischemic cascade in acute ischemic stroke and has demonstrated efficiency in a multiplicity of animal models of acute stroke. Long-term treatment with citicoline is safe and effective, improving post-stroke cognitive decline and enhancing patients’ functional recovery. Prolonged citicoline administration at optimal doses has been demonstrated to be remarkably well tolerated and to enhance endogenous mechanisms of neurogenesis and neurorepair contributing to physical therapy and rehabilitation.
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