Endovascular Therapy in Hyperacute Ischaemic Stroke: History and Current Status

Abstract

<jats:p> This is a literature review on to the use of endovascular therapy in hyperacute ischaemic stroke secondary to large vessel occlusion (LVO). The prognosis for LVO is generally poor and the efficacy of intravenous tissue plasminogen activator (IV TPA) in the treatment of this subtype of stroke is questionable. It is well documented that recanalisation is associated with improved outcomes but IV TPA has limited efficacy in LVO recanalisation and the complication rates are higher for IV TPA in this stroke subset. </jats:p><jats:p> Improved recanalisation rates have been demonstrated with intra-arterial TPA and first and second generation mechanical techniques but the rate of favourable outcome has not overtly mirrored this improvement. </jats:p><jats:p> Several controversial trials using these early techniques have recently been published but fail to reflect modern practice which centres on the use of stent-retriever technology. This has been proven to be superior to older techniques. Not only are recanalisation rates higher, but the speed of recanalisation is greater and clinical results are improved. </jats:p><jats:p> Multiple observational studies demonstrate consistently high rates of LVO recanalisation; TICI 2b/3 in the order of 65–95% and, rates of favourable outcome (mRS 0–2) in the order of 55% (42.5–77%) in clinically moderate to severe stroke with complicating symptomatic haemorrhage in the order of 1.5–15%. </jats:p><jats:p> A major factor determining outcome is time to treatment but success has been demonstrated using these devices with bridging therapy, after IV TPA failure or as a stand-alone treatment. </jats:p>

Prior Cancer in Patients with Ischemic Stroke: The Bergen NORSTROKE Study

“…represents a mean to radiologically determine the severity of the stroke in the acute phase, as large vessel occlusion seen on CTA has a worse prognosis than small vessel occlusion. 178,179 Cerebral CT was repeated throughout the acute phase if indicated by clinical worsening of the stroke patient; noticed either by an increase in the NIHSS score or reductions of the GCS score.…”

A Mobile Stroke Treatment Unit for Field Triage of Patients for Intraarterial Revascularization Therapy

“…16 Initial trials studying clinical outcomes, such as IMS III, were not able to show the efficacy of endovascular therapy, due to use of older devices and also due to prolonged times to groin puncture and recanalization. More recently, five clinical trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, and REVASCAT) have established the clinical effectiveness of IAT for ELVO.…”

“…14,15 The number of options for endovascular treatment of AIS has increased substantially over the past decade and with the advent of stent-retrievers, recanalization rates have improved significantly (TICI 2b/3 rates of 80-90%). 16 Initial trials studying clinical outcomes, such as IMS III, were not able to show the efficacy of endovascular therapy, due to use of older devices and also due to prolonged times to groin puncture and recanalization. More recently, five clinical trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, and REVASCAT) have established the clinical effectiveness of IAT for ELVO.…”

Experiencia en el tratamiento endovascular del accidente cerebrovascular isquémico agudo en un centro chileno

“…En el año 2015 una serie de estudios demostraron la eficacia y seguridad del tratamiento endovascular principalmente con stent retrievers precedido o no de terapia endovenosa en territorio carotídeo [4][5][6][7][8] . Seleccionar la mejor terapia para cada paciente es fundamental para lograr una óptima reperfusión del tejido isquémico, en cuanto la probabilidad de recanalización de un vaso de gran calibre, como ACI terminal y segmento M1 de la ACM mediante TEV es baja (4-18% y 22-33% respectivamente) 17 , llegando a tasas de recanalización superiores al 70% con terapias mixtas y sólo endovasculares 5,6,[18][19][20] .…”