Impact of introducing endovascular treatment on acute ischemic stroke outcomes: A shift from an era of medical management to thrombectomy in Japan

Abstract

Background: Endovascular treatment (EVT) has increasingly become the standard treatment of acute cerebral large vessel occlusion (LVO). We evaluated the impact of introducing EVT on LVO therapy in a single center where intravenous thrombolysis (IVT) had been the only recanalization therapy. Materials and methods: Between April 2013 and March 2017, 354 consecutive patients with LVO admitted to our institution were analyzed. We compared outcomes between two chronological groups before (Pre-EVT group) and after (Post-EVT group) introducing EVT in April 2015. We assessed prognostic factors for favorable outcomes (modified Rankin scale score 2 at 90 days). Results: In the Pre-EVT group, all 140 patients were treated medically, including 30 patients (21%) undergoing IVT. In the Post-EVT group, 118 patients (55%) underwent EVT, and the remaining 96 patients treated medically, including six patients (3%) undergoing IVT. The proportion undergoing recanalization therapy with IVT or EVT significantly increased after introducing EVT (21% versus 58%, p < 0.001). The rate of patients achieving favorable outcomes also significantly increased (14% versus 31%, p < 0.001). In multivariate regression analysis, introducing EVT was an independent predictive factor after adjusting for age, stroke severity and extent, and time (p ¼ 0.005). The arrival time in patients with helicopter transport was significantly shorter than that with ground ambulance for a distance of more than 10 km (p < 0.001). Conclusions: This study demonstrated that the introduction of EVT improved outcomes of acute LVO patients, increasing the opportunity to receive recanalization therapy. Further efforts to establish medical systems to provide EVT are required throughout the country.

Acute internal carotid artery occlusion due to dissection of the paraclinoid segment: Diagnostic usefulness of angiographic findings during stent retriever deployment

“…Among those 13 cases with intracranial dissection, ICA was involved in only 3 cases with terminal ICA dissection. In our experience of approximately 280 mechanical thrombectomy procedures over the past 6 years, intracranial ICA dissection was identified in only this single case (0.4%) [11] , [12] , [13] , [14] . The present case demonstrated that acute cerebral artery occlusion, although rare, can occur with a dissection more proximal to the supraclinoid lesion.…”

Iatrogenic intracranial vessel dissection during mechanical thrombectomy rescued by emergent stenting: 2 case reports

“…Among these cases, extracranial dissection was more common, whereas intracranial vessel dissection was precisely described in only a small number [11 , 17] . Among approximately 250 cases of mechanical thrombectomy at our institute over the past 5 years, only these 2 patients were definitively diagnosed with iatrogenic intracranial dissection (0.8%) [20] , [21] , [22] , [23] . However, there is a current concern that instances of intracranial dissection may increase because more peripheral lesions are being treated with a variety of interventions other than the simple SR technique.…”

“…Two patients (0.8%), out of approximately 250 cases of mechanical thrombectomy over the past 5 years at our institution, were definitively diagnosed with iatrogenic intracranial dissection caused by the thrombectomy procedure [20] , [21] , [22] , [23] . In this report, we provide the details of these 2 cases of refractory iatrogenic intracranial artery dissection that occurred during mechanical thrombectomy performed with the combined use of an SR and an aspiration catheter.…”

Endovascular Treatment of Tandem Atherosclerotic Cervical Internal Carotid Artery Occlusion in the Setting of Acute Ischemic Stroke

“…Our detailed protocol for acute ischemic stroke intervention has been previously reported. [15][16][17][18][19] Based on angiography findings, ACICAO was defined as cervical internal carotid artery (ICA) occlusion due to an atherosclerotic plaque, in which blood flow to the distal artery was completely stopped. Our main EVT indications for tandem ACICAO were as follows: (1) <8 hours from symptom onset or <24 hours from the time the patient was last seen to be well in cases where the time of symptom onset was unknown; (2) presence of intracranial LVO; (3) lack of sufficient collateral blood flow; (4) mismatch between neurological symptoms on admission and findings on imaging; (5) a score of ≥6 on the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) or ASPECTS-diffusion weighted imaging.…”

“…Endovascular procedures for LVO at our institute have been previously reported. [15][16][17][18][19] The concept of our treatment strategy for tandem ACICAO is shown in Figure 1. Earlier in this cohort, percutaneous transluminal angioplasty (PTA) and carotid artery stenting (CAS) were performed before treating the intracranial lesion (CAS first-antegrade approach), while, towards the end, only PTA was performed before intracranial lesion treatment (PTA first-antegrade approach without emergent CAS).…”