Skip to main content

Role for Intra-arterial Therapy for Acute Ischemic Stroke

  • Chapter
  • First Online:
Management of Cerebrovascular Disorders
  • 1023 Accesses

Abstract

Endovascular approach has established itself as a cornerstone in the acute and subacute management of strokes related to large vessel disease. The recent strides achieved in the field of hyperacute interventions have impacted the systems of stroke care and provision. Networks are realigning their triaging protocols, and primary stroke centers are increasingly affiliating with tertiary, thrombectomy-capable centers. There is ongoing debate in the field about the value of systemic thrombolysis in patients with suspected Large Vessel Occlusion (LVO) and an inclination to bypass primary stroke centers in favor of thrombectomy-capable hospitals in these cases. While thrombectomy benefits have been elucidated in large populations, refining patient selection, advancement of procedural techniques, and the prevention of procedural complications continue to be targets of ongoing research. New clot retrieval devices, catheters, Embolic Protection Devices (EPD)s, and implantable stents are being developed and produced at higher rates than ever in the history of this field.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 169.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 219.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, et al. Global and regional burden of stroke during 1990–2010: findings from the global burden of disease study 2010. Lancet. 2014;383(9913):245–54.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29–322.

    PubMed  Google Scholar 

  3. Bhatia R, Hill MD, Shobha N, Menon B, Bal S, Kochar P, et al. Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke. 2010;41(10):2254–8.

    Article  CAS  PubMed  Google Scholar 

  4. Beumer D, Saiedie G, Fonvile S. Intra-arterial occlusion in acute ischemic stroke: relative frequency in an unselected population. Cerebrovasc Dis. 2013;35(Suppl):66.

    Google Scholar 

  5. Rai AT, Seldon AE, Boo S, Link PS, Domico JR, Tarabishy AR, et al. A population-based incidence of acute large vessel occlusions and thrombectomy eligible patients indicates significant potential for growth of endovascular stroke therapy in the USA. J Neurointerv Surg. BMJ Publishing Group Ltd; 2016 Jul 15;neurintsurg–2016–012515.

    Google Scholar 

  6. del Zoppo GJ, Higashida RT, Furlan AJ, Pessin MS, Rowley HA, Gent M. PROACT: a phase II randomized trial of recombinant pro-Urokinase by direct arterial delivery in acute middle cerebral artery stroke. Stroke. American Heart Association, Inc. 1998;29(1):4–11.

    Article  PubMed  Google Scholar 

  7. Smith WS, Sung G, Starkman S, Saver JL, Kidwell CS, Gobin YP, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke. American Heart Association, Inc. 2005;36(7):1432–8.

    Article  PubMed  Google Scholar 

  8. Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the multi MERCI trial. Stroke. American Heart Association, Inc. 2008;39(4):1205–12.

    Article  PubMed  Google Scholar 

  9. The Penumbra Pivotal Stroke Trial Investigators. The Penumbra pivotal stroke trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke. American Heart Association, Inc. 2009;40(8):2761–8.

    Article  Google Scholar 

  10. Hussain SI, Zaidat OO, Fitzsimmons BFM. The Penumbra system for mechanical thrombectomy in endovascular acute ischemic stroke therapy. Neurology. Lippincott Williams & Wilkins. 2012;79(13, Suppl. 1):S135–41.

    Article  PubMed  Google Scholar 

  11. Tarr R, Hsu D, Kulcsar Z, Bonvin C, Rufenacht D, Alfke K, et al. The POST trial: initial post-market experience of the Penumbra system: revascularization of large vessel occlusion in acute ischemic stroke in the United States and Europe. J Neurointerv Surg. British Medical Journal Publishing Group. 2010;2(4):341–4.

    Article  PubMed  Google Scholar 

  12. Berkhemer OA, Fransen PSS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of Intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11–20.

    Article  PubMed  Google Scholar 

  13. Kidwell CS, Jahan R, Gornbein J, Alger JR, Nenov V, Ajani Z, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013;368(10):914–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Saver JL, Goyal M, Bonafe A, Diener H-C, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285–95.

    Article  CAS  PubMed  Google Scholar 

  15. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):2296–306.

    Article  CAS  PubMed  Google Scholar 

  16. Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009–18.

    Article  CAS  PubMed  Google Scholar 

  17. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019–30.

    Article  CAS  PubMed  Google Scholar 

  18. Goyal M, Menon BK, van Zwam WH, Dippel DWJ, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723–31.

    Article  PubMed  Google Scholar 

  19. Hacke W, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363(9411):768–74.

    Article  PubMed  Google Scholar 

  20. Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CBLM, Dippel DW, et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA. 2016;316(12):1279–89.

    Article  PubMed  Google Scholar 

  21. Khatri P, Yeatts SD, Mazighi M, Broderick JP, Liebeskind DS, Demchuk AM, et al. Time to angiographic reperfusion and clinical outcome after acute ischaemic stroke: an analysis of data from the interventional management of stroke (IMS III) phase 3 trial. Lancet Neurol. 2014;13(6):567–74.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Pierot L, Soize S, Benaissa A, Wakhloo AK. Techniques for endovascular treatment of acute ischemic stroke. Stroke. 2015;46(3):909–14.

    Article  PubMed  Google Scholar 

  23. Jadhav AP, Aghaebrahim A, Horev A, Giurgiutiu DV, Ducruet AF, Jankowitz B, et al. Stent retriever-mediated manual aspiration thrombectomy for acute ischemic stroke. Intervent Neurol Karger Publishers. 2016;6(1–2):16–24.

    Google Scholar 

  24. Lapergue B. ASTER: contact aspiration versus stent retriever front line for recanalization in acute cerebral infarction. Houston; 2017. http://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@scon/documents/downloadable/ucm_492110.pdf

  25. Rubiera M, Ribo M, Delgado-Mederos R, Santamarina E, Delgado P, Montaner J, et al. Tandem internal carotid artery/middle cerebral artery occlusion: an independent predictor of poor outcome after systemic thrombolysis. Stroke. 2006;37(9):2301–5.

    Article  PubMed  Google Scholar 

  26. Endo S, Kuwayama N, Hirashima Y, Akai T, Nishijima M, Takaku A. Results of urgent thrombolysis in patients with major stroke and atherothrombotic occlusion of the cervical internal carotid artery. AJNR Am J Neuroradiol. 1998;19:1169–75.

    Google Scholar 

  27. Meyer FB, Sundt TMJ, Piepgras DG, Sandok BA, Forbes G. Emergency carotid endarterectomy for patients with acute carotid occlusion and profound neurological deficits. Ann Surg. 1986;203(1):82–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Heck DV, Brown MD. Carotid stenting and intracranial thrombectomy for treatment of acute stroke due to tandem occlusions with aggressive antiplatelet therapy may be associated with a high incidence of intracranial hemorrhage. J Neurointerv Surg. 2015;7(3):170–5.

    Article  PubMed  Google Scholar 

  29. Froehler MT, Fifi JT, Majid A, Bhatt A, Ouyang M, McDonagh DL. Anesthesia for endovascular treatment of acute ischemic stroke. Neurology. Lippincott Williams & Wilkins. 2012;79(13, suppl. 1):S167–73.

    Article  CAS  PubMed  Google Scholar 

  30. Anastasian ZH. Anaesthetic management of the patient with acute ischaemic stroke. Br J Anaesth. Oxford University Press. 2014;113(suppl 2):ii9–ii16.

    Article  PubMed  Google Scholar 

  31. Abou-Chebl A, Yeatts SD, Yan B, Cockroft K, Goyal M, Jovin T, et al. Impact of general anesthesia on safety and outcomes in the endovascular arm of interventional management of stroke (IMS) III trial. Stroke. American Heart Association, Inc. 2015;46(8):2142–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Schönenberger S, Uhlmann L, Hacke W, Schieber S, Mundiyanapurath S, Purrucker JC, et al. Effect of conscious sedation vs general anesthesia on early neurological improvement among patients with ischemic stroke undergoing endovascular thrombectomy. JAMA. 2016;316(19):1986–96.

    Article  PubMed  Google Scholar 

  33. Flaherty ML, Kissela B, Khoury JC, Alwell K, Moomaw CJ, Woo D, et al. Carotid artery stenosis as a cause of stroke. Neuroepidemiology. 2013;40(1):36–41.

    Article  PubMed  Google Scholar 

  34. Lovett JK, Coull AJ, Rothwell PM. Early risk of recurrence by subtype of ischemic stroke in population-based incidence studies. Neurology. 2004;62(4):569–73.

    Article  CAS  PubMed  Google Scholar 

  35. Conrad MF, Michalczyk MJ, Opalacz A, Patel VI, LaMuraglia GM, Cambria RP. The natural history of asymptomatic severe carotid artery stenosis. J Vasc Surg. 2014;60(5):1218–26.

    Article  PubMed  Google Scholar 

  36. Spence JD. Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis. Arch Neurol. 2010;67(2):180–6.

    Article  PubMed  Google Scholar 

  37. AbuRahma AF, Metz MJ, Robinson PA. Natural history of ≥60% asymptomatic carotid stenosis in patients with contralateral carotid occlusion. Trans Meet Am Surg Assoc. 2003;121:244–55.

    Google Scholar 

  38. Noiphithak R, Liengudom A. Recent update on carotid endarterectomy versus carotid artery stenting. Cerebrovasc Dis. 2017;43(1–2):68–75.

    Article  PubMed  Google Scholar 

  39. Brott TG, Hobson RW II, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Mantese VA, Timaran CH, Chiu D, Begg RJ, Brott TG, for the CREST Investigators. The carotid revascularization endarterectomy versus stenting trial (CREST): stenting versus carotid endarterectomy for carotid disease. Stroke. American Heart Association, Inc; 2010;41(10, suppl. 1):S31–4.

    Article  PubMed  PubMed Central  Google Scholar 

  41. International Carotid Stenting Study Investigators. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet. 2010;375(9719):985–97.

    Google Scholar 

  42. Bonati LH, Dobson J, Featherstone RL, Ederle J, van der Worp HB, de Borst GJ, et al. Long-term outcomes after stenting versus endarterectomy for treatment of symptomatic carotid stenosis: the international carotid stenting study (ICSS) randomised trial. Lancet. 2015;385(9967):529–38.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Rosenfield K, Matsumura JS, Chaturvedi S, Riles T, Ansel GM, Metzger DC, et al. Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med. 2016;374(11):1011–20.

    Article  CAS  PubMed  Google Scholar 

  44. Brott TG, Howard G, Roubin GS, Meschia JF, Mackey A, Brooks W, et al. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med. 2016;374(11):1021–31.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJM. Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischemic attack and nondisabling stroke. Stroke. American Heart Association, Inc. 2004;35(12):2855–61.

    Article  CAS  PubMed  Google Scholar 

  46. Halliday A, Harrison M, Hayter E, Kong X, Mansfield A, Marro J, et al. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet. 2010;376(9746):1074–84.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, et al. ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation. American Heart Association, Inc; 2011;124(4):489–532.

    Google Scholar 

  48. Garg N, Karagiorgos N, Pisimisis GT, Sohal DPS, Longo GM, Johanning JM, et al. Cerebral protection devices reduce Periprocedural strokes during carotid angioplasty and stenting: a systematic review of the current literature. J Endovasc Ther. 2009;16(4):412–27.

    Article  PubMed  Google Scholar 

  49. Iyer V, de Donato G, Deloose K, Peeters P, Castriota F, Cremonesi A, et al. The type of embolic protection does not influence the outcome in carotid artery stenting. J Vasc Surg. 2007;46(2):251–6.

    Article  PubMed  Google Scholar 

  50. Montorsi P, Caputi L, Galli S, Ciceri E, Ballerini G, Agrifoglio M, et al. Microembolization during carotid artery stenting in patients with high-risk, lipid-rich plaque. J Am Coll Cardiol. 2011;58(16):1656–63.

    Article  PubMed  Google Scholar 

  51. Bijuklic K, Wandler A, Hazizi F, Schofer J. The PROFI study (prevention of cerebral embolization by proximal balloon occlusion compared to filter protection during carotid artery stenting). J Am Coll Cardiol. 2012;59(15):1383–9.

    Article  PubMed  Google Scholar 

  52. Hye RJ, Voeks JH, Malas MB, Tom M, Longson S, Blackshear JL, et al. Anesthetic type and risk of myocardial infarction after carotid endarterectomy in the carotid revascularization endarterectomy versus stenting trial (CREST). J Vasc Endovasc Surg. 2016;64(1):3–8.e1.

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to J. Mocco .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2019 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Shoirah, H., Mocco, J. (2019). Role for Intra-arterial Therapy for Acute Ischemic Stroke. In: Spiotta, A., Turner, R., Chaudry, M., Turk, A. (eds) Management of Cerebrovascular Disorders. Springer, Cham. https://doi.org/10.1007/978-3-319-99016-3_31

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-99016-3_31

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-99015-6

  • Online ISBN: 978-3-319-99016-3

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics