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Endovascular Management of Stroke

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Introduction to Vascular Neurosurgery

Abstract

The management of ischemic stroke has been marked by three major advances that transformed the approach to its diagnosis and treatment: (1) creation of stroke units, (2) IV thrombolytic (IVT) use, and (3) mechanical thrombectomy.

Intravenous alteplase remained the only approved treatment for acute ischemic stroke for over 20 years, until 2015 when five successful trials were published demonstrating safety and efficacy of mechanical thrombectomy (MT) in patients with anterior circulation large vessel occlusion. These trials included patients within 6 hours of symptom onset with the exception of REVASCAT (up to 8 hours). In 2017, two landmark trials (DAWN and DEFUSE) demonstrated the safety and efficacy of MT in an extended treatment time window beyond 6 hours and up to 24 hours in properly selected patients.

Endovascular techniques and devices have continued to evolve, providing neuroendovascular surgeons the ability to adopt a preferred “bed-rock” technique as also additional options and alternatives in difficult cases. Yet, challenges continue with regard to achieving pervasive awareness in both medical and lay communities, rapid diagnosis and patient access to high level care across the entire socio-economic spectrum both nationally and internationally. Current areas of research focus include application of robotics to perform remote thrombectomy, artificial intelligence in predicting success of therapy, neuro-protection, and avenues for treating patients with unsuccessful thrombectomy.

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References

  1. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581–7.

    Article  Google Scholar 

  2. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D. Et al; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317–29.

    Article  CAS  Google Scholar 

  3. 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;368:914–23. (MR RESCUE).

    Google Scholar 

  4. Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368:904–13. (SYNTHESIS).

    Google Scholar 

  5. Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Endovascular therapy after intravenous t-pa versus t-pa alone for stroke. N Engl J Med. 2013;368:893–903. (IMS 3).

    Google Scholar 

  6. Bekhemer O, Beumer F, Berg V, Lingsma H, Schonewile Y, Nederkoom V. The Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke (Mr. CLEAN). N Engl J Med. 2015;372

    Google Scholar 

  7. Goyal M, Demchuk A, Menon B, Eesa M, Rempel J, Thornton J, Roy D. Randomized assay of rapid endovascular treatment of ischemic stroke (ESCAPE). N Engl J Med. 2015;

    Google Scholar 

  8. Campbell B, Mitchell P, Kleinig T, Dewey H, Churilov L, Yassi N. Endovascular therapy for ischemic stroke with perfusion-imaging selection (EXTEND -IA). N Engl J Med. 2015;

    Google Scholar 

  9. Saver J, Mayank M, Bonafe A, Diener M, Elad P, Levy I. Thrombectomy Stent-Retriever alter Intravenous t-PA vs. t-PA Alone in Stroke (SWIFT PRIME). N Engl J Med. 2015.

    Google Scholar 

  10. Jovin T, Chamorro A, Cobo E, Miquel M, Molina C, Rovira A. Thrombectomy within 8 hours after symptom onset in ischemic stroke (REVASCAT). N Engl J Med. 2015.

    Google Scholar 

  11. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018.

    Google Scholar 

  12. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;

    Google Scholar 

  13. Lapergue B, RaphaelBlanc BG, Labreuche J, Duhamel A, GautierMarnat, et al. Effect of endovascular contact aspiration vs stent retriever on revascularization in patients with acute ischemic stroke and large vessel occlusion. The ASTER Randomized Clinical Trial JAMA. 2017;318(5):443–52. https://doi.org/10.1001/jama.2017.9644.

    Article  PubMed  Google Scholar 

  14. Turk AS, Siddiqui A, Fifi JT, De Leacy RA, Fiorella DJ, Spiotta AM, et al. Aspiration Thrombectomy Versus Stent Retriever Thrombectomy as First-Line Approach for Large Vessel Occlusion (COMPASS): A Multicentre, Randomised, Open Label, Blinded Outcome, Non-Inferiority Trial. Lancet. 2019;393(10175):998–1008. https://doi.org/10.1016/S0140-6736(19)30297-1.

    Article  PubMed  Google Scholar 

  15. Spiotta AM, Chaudry MI, Hui FK, Turner RD, Kellogg RT, Turk AS. Evolution of thrombectomy approaches and devices for acute stroke: a technical review. J NeuroIntervent Surg. 2015;7:2–7. https://doi.org/10.1136/neurintsurg-2013-011022.

    Article  Google Scholar 

  16. Munich SA, Vakharia K, Levy EI. Overview of mechanical thrombectomy techniques. Neurosurgery. 2019;85(suppl_1):S60–7. https://doi.org/10.1093/neuros/nyz071.

    Article  PubMed  Google Scholar 

  17. Kang D-H, Park J. Endovascular stroke therapy focused on stent retriever thrombectomy and direct clot aspiration: historical review and modern application. J Korean Neurosurg Soc. 2017;60(3):335–47. https://doi.org/10.3340/jkns.2016.0809.005.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Mocco J, Zaidat OO, von Kummer R, et al. Aspiration thrombectomy after intravenous alteplase versus intravenous alteplase alone. Stroke. 2016;47(9):2331–8.

    Article  CAS  Google Scholar 

  19. Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Spiotta A. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J NeuroIntervent Surg. 2014;6:252–3.

    Article  Google Scholar 

  20. Spiotta A, Alawieh A, Chatterjee AR, Vargas J, Chaudry MI, Lena J. Lessons learned over more than 500 stroke thrombectomies using ADAPT with increasing aspiration catheter size. Neurosurgery. 2020;86(1):61–70. https://doi.org/10.1093/neuros/nyy444.

    Article  PubMed  Google Scholar 

  21. Holmstedt CA, Turan TN, Chimowitz MI. Atherosclerotic intracranial arterial stenosis: risk factors, diagnosis, and treatment. Lancet Neurol. 2013;12:1106–14.

    Article  Google Scholar 

  22. Sivan-Hoffmann R, Gory B, Armoiry X, Goyal M, Riva R, Labeyrie PE. Stent-retriever thrombectomy for acute anterior ischemic stroke with tandem occlusion: a systematic review and meta-analysis. Eur Soc Radiol. 2016; https://doi.org/10.1007/s00330-016-4338-y.

  23. Grigoryan M, Haussen DC, Hassan AE, Lima A, Grossberg J, Rebello LC. Endovascular treatment of acute ischemic stroke due to tandem occlusions: large Multicenter series and systematic review. Cerebrovasc Diseases. 2016;41:306–12.

    Article  CAS  Google Scholar 

  24. Anadani M, Spiotta A, Alawieh A, Turjman F, Piotin M, Steglich-Arnholm H. Effect of extracranial lesion severity on outcome of endovascular thrombectomy in patients with anterior circulation tandem occlusion: analysis of the TITAN registry. J NeuroIntervent Surg. 2019;0:1–5. https://doi.org/10.1136/neurintsurg-2018-014629.

    Article  Google Scholar 

  25. Zhu F, Bracard S, Anxionnat R, Derelle A-L, Tonnelet R, Liang L. Impact of emergent cervical carotid stenting in tandem occlusion strokes treated by thrombectomy: a review of the TITAN collaboration. Front Neurol. 2019;10:206. https://doi.org/10.3389/fneur.2019.00206.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Wilson MP, Murad MH, Krings T, Pereira VM, O’Kelly C, Rempel J. Management of tandem occlusions in acute ischemic stroke – intracranial versus extracranial first and extracranial stenting versus angioplasty alone: a systematic review and meta-analysis. J NeuroIntervent Surg. 2018;0:1–9. https://doi.org/10.1136/neurintsurg-2017-013707.

    Article  Google Scholar 

  27. Sheng K, Tong M. Aspiration thrombectomy for posterior circulation stroke: A systematic review and meta-analysis. Asian J Neurosurg. [serial online] 2020 [cited 2020 Aug 25];15:251–61.

    Google Scholar 

  28. Schonewille WJ, Wijman CAC, Michel P, Rueckert CM, Weimar C, Mattle HP, Engelter ST, Tanne D, Muir KW, Molina CA, Thijs V, Audebert H, Pfefferkorn T, Szabo K, Lindsberg PJ, de Freitas G, Kappelle LJ, Algra A, BASICS study group. On behalf of the BASICS study group. Treatment and outcomes of acute basilar artery occlusion in the basilar artery international cooperation study (BASICS): a prospective registry study. Lancet Neurol. 2009;8:724–30.

    Article  Google Scholar 

  29. Van der Hoeven EJ, Dankbaar JW, Algra A, Vos JA, Niesten JM, van Seeters T, van der Schaaf I, Schonewille WJ, Kappelle LJ, Velthuis BK, Investigators DUST. Additional diagnostic value of computed tomography perfusion for detection of acute ischemic stroke in the posterior circulation. Stroke. 2015;46:1113–5.

    Article  Google Scholar 

  30. Alawieh AM, Eid M, Anadani M, Sattur M, Maier IL, Spiotta AM, et al. Thrombectomy technique predicts outcome in posterior circulation stroke—insights from the STAR collaboration. Neurosurgery. 2020:nyaa179. https://doi.org/10.1093/neuros/nyaa179.

  31. Gory B, Eldesouky I, Sivan-Hoffmann R, et al. Outcomes of stent retriever thrombectomy in basilar artery occlusion: an observational study and systematic review. J Neurol Neurosurg Psychiatry. 2016;87(5):520–5.

    Article  Google Scholar 

  32. Chaudry I, Feng W, Holmstedt C, Turner R, Adams R, Turk AS. Delayed basilar artery recanalization 100 hours after symptom onset. J Neurointervent Surg. 2010;2(4):345–7.

    Google Scholar 

  33. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early Management of Patients with Acute Ischemic Stroke: 2019 update to the 2018 guidelines for the early Management of Acute Ischemic Stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–418.

    Article  Google Scholar 

  34. Sarraj A, Sangha N, Hussain MS, Wisco D, Vora N, Elijovich L, et al. Endovascular therapy for acute ischemic stroke with occlusion of the middle cerebral artery M2 segment. JAMA Neurol. 2016;73:1291–6. https://doi.org/10.1001/jamaneurol.2016.2773.

    Article  PubMed  Google Scholar 

  35. Saber H, Narayanan S, Palla M, Saver JL, Nogueira RG, Yoo AJ, et al. Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: a meta-analysis [published online ahead of print November 10, 2017]. J Neurointerv Surg. https://doi.org/10.1136/neurintsurg-2017-013515.

  36. Anadani M, Alawieh A, Arthur AS, Kim J-T, Leacy RD, Spiotta A. Abstract 148: Mechanical Thrombectomy for Distal Occlusions: Efficacy, Functional and Safety Outcomes. Insights From the STAR Collaboration. Stroke. 51:A148.

    Google Scholar 

  37. Barchetti G, Cagnazzo F, Raz E, Barbagallo G, Toccaceli G, Peschillo S. Mechanical thrombectomy of distal occlusions using ADAPT compared to new generation of mini – 017 microcatheter compatible – stent retrievers: a meta-analysis. World Neurosurg. 2019; https://doi.org/10.1016/j.wneu.2019.10.030.

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Negrotto, M., Sattur, M.G., Spiotta, A.M. (2022). Endovascular Management of Stroke. In: Mascitelli, J.R., Binning, M.J. (eds) Introduction to Vascular Neurosurgery. Springer, Cham. https://doi.org/10.1007/978-3-030-88196-2_11

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  • DOI: https://doi.org/10.1007/978-3-030-88196-2_11

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