A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke

Berkhemer, Olvert A.; Fransen, Puck S.S.; Beumer, Debbie; Berg, Lucie A. van den; Lingsma, Hester F.; Yoo, Albert J.; Schonewille, Wouter J.; Vos, Jan Albert; Nederkoorn, Paul J.; Wermer, Marieke J.H.; Walderveen, Marianne A.A. van; Staals, Julie; Hofmeijer, Jeannette; Oostayen, Jacques A. van; Nijeholt, Geert J. Lycklama à; Boiten, Jelis; Brouwer, Patrick A.; Emmer, Bart J.; Bruijn, Sebastiaan F. de; Dijk, Lukas C. van; Kappelle, L. Jaap; Lo, Rob H.; Dijk, Ewoud J. van; Vries, Joost de; Kort, Paul L.M. de; Rooij, W. J. J. van; Berg, Jan S.P. van den; Hasselt, Boudewijn A.A.M. van; Aerden, Leo A.M.; Dallinga, René J.; Visser, Marieke C.; Bot, Joseph C.J.; Vroomen, Patrick; Eshghi, Omid; Schreuder, Tobien H.C.M.L.; Heijboer, Roel J.J.; Keizer, Koos; Tielbeek, Alexander V.; Hertog, Heleen M. den; Gerrits, Dick; Berg-Vos, Renske M. van den; Karas, Giorgos B.; Steyerberg, Ewout W.; Flach, H. Zwenneke; Marquering, Henk A.; Sprengers, Marieke E.S.; Jenniskens, Sjoerd F.M.; Beenen, Ludo F. M.; Berg, René van den; Koudstaal, Peter J.; Zwam, Wim H. van; Roos, Yvo B.W.E.M.; Lugt, Aad van der; Oostenbrugge, Robert J. van; Majoie, Charles B. L. M.; Dippel, Diederik W.J.

doi:10.1056/nejmoa1411587

Cited by 5,701 publications

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“…Recently it was shown that intra‐arterial treatment (IAT) is highly effective in patients with acute ischemic stroke caused by a proximal intracranial arterial occlusion, and it has revolutionized stroke treatment 1, 2, 3, 4, 5, 6…”

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High‐Resolution Imaging of Interaction Between Thrombus and Stent‐Retriever in Patients With Acute Ischemic Stroke

Autar

Hund

Ramlal

et al. 2018

JAHA

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BackgroundCurrently, acute ischemic stroke is still a leading cause of mortality and morbidity. Approximately 2 years ago, mechanical thrombectomy was proven beneficial as a revolutionary new therapy for stroke in the MR‐CLEAN trial (A Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands). However, the mechanisms by which the thrombectomy device, or stent‐retriever, interacts with the thrombus are largely unknown. A better understanding could lead to improved efficacy of mechanical thrombectomy devices.Methods and ResultsSeven stent‐retrievers with thrombi still entrapped were collected directly after thrombectomy. The stent‐retrievers were studied using micro computed tomography, followed by scanning electron microscopy and light microscopy. Two independent observers rated interaction type and thrombus surface structure (porous filamentous or dense) at the interaction sites.A total of 79 interaction sites between thrombus and stent‐retriever were categorized. Thrombus‐stent‐retriever interaction was found to be adhesive (n=44; 56%) or mechanical (n=35; 44%). Adhesive interaction was most frequently observed at interaction sites with a dense surface, compared with interaction sites with a porous filamentous fibrin surface (38/58; 66% versus 6/21; 29%, P=0.011).ConclusionsThe interaction between thrombus and stent‐retriever was predominantly adhesive, not mechanical. Adhesive interaction was strongly associated with the presence of a dense thrombus surface without a porous filamentous fibrin network.

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High‐Resolution Imaging of Interaction Between Thrombus and Stent‐Retriever in Patients With Acute Ischemic Stroke

Autar

Hund

Ramlal

et al. 2018

JAHA

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“…2015). Three months after the procedure, one additional patient reached functional independence (modified Rankin scale 0–2) for every seven patients with thrombectomy.…”

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Mechanical thrombectomy for emergent large vessel occlusion: a critical appraisal of recent randomized controlled clinical trials

et al. 2016

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Background and PurposeAfter numerous attempts to prove efficacy for endovascular treatment of ischemic stroke, a series of recent randomized controlled clinical trials (RCTs) established fast mechanical thrombectomy (MT) as a safe and effective novel treatment for emergent large vessel occlusion (ELVO) in the anterior cerebral circulation.MethodsWe reviewed five recent RCTs that evaluated the safety and efficacy of MT in ELVO patients and captured available information on recanalization/reperfusion, symptomatic intracranial hemorrhage (sICH), clinical outcome, and mortality. MT was performed with stent retrievers, aspiration techniques, or a combination of these endovascular approaches. We applied meta‐analytical methodology to evaluate the pooled effect of MT on recanalization/reperfusion, sICH, functional independence (modified Rankin scale score of 0–2) and 3‐month mortality rates in comparison to best medical therapy (BMT).Results MT was associated with increased likelihood of complete recanalization/reperfusion (RR: 2.22; 95%CI: 1.89–2.62; P < 0.00001) and 3‐month functional independence (RR: 1.72; 95%CI: 1.48–1.99; P < 0.00001) without any heterogeneity across trials (I 2 = 0%). The absolute benefit increase in MT for complete recanalization/reperfusion and functional independence was 44 (NNT = 2) and 16 (NNT = 6), respectively. MT was not associated with increased risk of 3‐month mortality (15% with MT vs. 19% with BMT) and sICH (4.6% with MT vs. 4.3% with BMT), while small heterogeneity was detected across the included trials (I 2 < 25%).Conclusions MT is a safe and highly effective treatment for patients with ELVO in the anterior circulation. For every six ELVO patients treated with MT three more will achieve complete recanalization at 24 h following symptom onset and one more will be functionally independent at 3 months in comparison to BMT.

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“…2014; Berkhemer et al. 2015). Merely, a minority of stroke patients has access to and even fewer eventually benefit from acute stroke therapies (Adeoye et al.…”

Section: Discussionmentioning

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The stroke east Saxony pilot project for organized post‐stroke care: a case–control study

et al. 2016

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BackgroundLow adherence to secondary prevention guidelines in stroke survivors may increase the risk for recurrent stroke and adversely impact quality of life. We aimed to determine the feasibility of a self‐developed standardized post‐stroke pathway and its impact on secondary stroke prevention and long‐term outcome in patients with acute stroke.MethodsConsecutive patients with acute stroke were prospectively included in a standardized post‐stroke pathway accomplished through a single certified CM (case manager), which comprised educational discussions and quarterly checkups for vascular risk factors and adherence to antithrombotic/anticoagulant medication in addition to usual care. At 12 months, we compared achieved target goals for secondary prevention, functional outcome, stroke recurrence, and vascular death with age‐ and gender‐matched controls that received only usual care after stroke.ResultsWe included 45 cases and 45 controls. The following target goals were more frequently achieved in CM‐patients than in controls: blood pressure (100% vs. 46.2%, P < 0.001), cholesterol (100% vs. 74.4%, P < 0.001), and body mass index (67.4% vs. 46.2%, P = 0.052). The CM‐intervention emerged as an independent predictor of favorable functional outcome (mRS ≤ 2) at 12 months after adjusting for stroke severity and systemic thrombolysis (OR: 4.27; 95%CI:1.2–15.21; P = 0.025). Quality of life was rated significantly higher in CM‐patients than in controls (P = 0.049). As opposed to controls, none of the cases experienced a recurrent stroke (0% vs. 13.3%; P = 0.026) or suffered from vascular death (0% vs. 6.7%; P = 0.242).ConclusionsOur pilot data suggest that organized post‐stroke care enhances achievement of secondary prevention goals. Its possible effect on stroke recurrence, long‐term disability, and quality of life is currently investigated in a prospective cohort study.

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A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke

Cited by 5,701 publications

References 27 publications

High‐Resolution Imaging of Interaction Between Thrombus and Stent‐Retriever in Patients With Acute Ischemic Stroke

High‐Resolution Imaging of Interaction Between Thrombus and Stent‐Retriever in Patients With Acute Ischemic Stroke

Mechanical thrombectomy for emergent large vessel occlusion: a critical appraisal of recent randomized controlled clinical trials

The stroke east Saxony pilot project for organized post‐stroke care: a case–control study

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