New developments in clinical ischemic stroke prevention and treatment and their imaging implications

Heit, Jeremy J; Wintermark, Max

doi:10.1177/0271678x17694046

Cited by 11 publications

(8 citation statements)

References 149 publications

(237 reference statements)

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“…These limitations have led to a widespread adoption of CT-based techniques in acute stroke imaging. 78 The presence or absence of a robust collateral circulation, a prognostic factor in patients with acute ischemic stroke, is relatively quickly and simply assessed using CT angiography. The ability to quickly recruit blood flow via a collateral network to the affected brain area is crucial to delay and, in some cases, even prevent permanent injury.…”

Section: Hemodynamics and Mechanical Thrombectomymentioning

confidence: 99%

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Biomechanics and hemodynamics of stent-retrievers

Kühn

Vardar

Kraitem

et al. 2020

J Cereb Blood Flow Metab

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In 2015, multiple randomized clinical trials showed an unparalleled treatment benefit of stent-retriever thrombectomy as compared to standard medical therapy for the treatment of a large artery occlusion causing acute ischemic stroke. A short time later, the HERMES collaborators presented the patient-level pooled analysis of five randomized clinical trials, establishing class 1, level of evidence A for stent-retriever thrombectomy, in combination with intravenous thrombolysis when indicated to treat ischemic stroke. In the years following, evidence continues to mount for expanded use of this therapy for a broader category of patients. The enabling technology that changed the tide to support endovascular treatment of acute ischemic stroke is the stent-retriever. This review summarizes the history of intra-arterial treatment of stroke, introduces the biomechanics of embolus extraction with stent-retrievers, describes technical aspects of the intervention, provides a description of hemodynamic implications of stent-retriever embolectomy, and proposes future directions for a more comprehensive, multi-modal endovascular approach for the treatment of acute ischemic stroke.

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Section: Hemodynamics and Mechanical Thrombectomymentioning

confidence: 99%

“…These limitations have led to a widespread adoption of CT-based techniques in acute stroke imaging. 78…”

Section: Hemodynamics and Mechanical Thrombectomymentioning

confidence: 99%

Biomechanics and hemodynamics of stent-retrievers

Kühn

Vardar

Kraitem

et al. 2020

J Cereb Blood Flow Metab

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“…Acute ischemic stroke is usually caused by an embolic or thromboembolic occlusion of a cerebral artery, which results in reduced cerebral blood flow (CBF) in the brain. This leads to brain ischemia, which can be divided into two distinct components, 1. the irreversibly damaged "core" infarction and 2. the ischemic, but viable surrounding tissue called penumbra [1][2][3]. Mechanical endovascular treatment (EVT) of large vessel occlusion (LVO) has been proven effective treatment in acute stroke care and the time-window for EVT has increased up to 24 h [4][5][6][7][8][9][10][11].…”

Section: Introductionmentioning

confidence: 99%

Comparison of automated infarct core volume measures between non-contrast computed tomography and perfusion imaging in acute stroke code patients evaluated for potential endovascular treatment

Suomalainen

Elseoud

Martinez‐Majander

et al. 2021

Journal of the Neurological Sciences

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Patients with small core infarction and salvageable penumbra are likely to benefit from endovascular treatment (EVT). As computed tomography perfusion imaging (CTP) is not always available 24/7 for patient selection, many patients are transferred to stroke centers for CTP. We compared automatically measured infarct core volume (NCCT core ) from the non-contrast computed tomography (NCCT) with ischemic core volume (CTP core ) from CTP and the outcome of EVT to clarify if NCCT core measurement alone is sufficient to identify patients that benefit from transfer to stroke centers for EVT. Patients and methods: We included all consecutive stroke-code patients imaged with both NCCT and CTP at Helsinki University Hospital during 9/2016-01/2018. NCCT core and CTP core volumes were automatically calculated from the acute NCCT images. Follow-up infarct volume (FIV) was measured from 24 h follow-up NCCT to evaluate efficacy of EVT. To study whether NCCT core could be used to identify patients eligible to EVT, we subgrouped patients based on NCCT core volumes (>50 mL and ≥ 70 mL). Results: Out of 1743 patients, baseline NCCT core , CTP core and follow-up NCCT was available for 288 patients. Median time from symptom onset to baseline imaging was 74 min (IQR 52-118), and time to follow-up imaging 24.15 h (22.25-26.33). Baseline NCCT core was 20 mL (10-42), CTP core 4 mL (0-16), and FIV 5 mL (1-49). Out of 288 patients, 23 had NCCT core ≥ 70 mL and 26 had CTP core ≥ 70 mL. NCCT core and CTP core performed similarly well in predicting large FIV (≥70 ml). Conclusion: NCCT core is a promising tool to identify patients that are not eligible to EVT due to large ischemic cores at baseline imaging.

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“…Initially, ICAS is treated with non-invasive medical therapy that seeks to reduce the risk of cerebral infarction (Qureshi and Caplan, 2014;Heit and Wintermark, 2018). However, patients who develop recurrent cerebral infarction or recurrent transient ischemic attacks (TIAs) despite optimal medical therapy may be considered for more aggressive treatment, including cerebral arterial angioplasty and/or stent placement (Qureshi and Caplan, 2014;Heit and Wintermark, 2018). Optimal visibility of the intracranial stent is limited using digital subtraction angiography (DSA) applications (Kato et al, 2020).…”

Section: Introductionmentioning

confidence: 99%

Application of High-Resolution Flat Detector Computed Tomography in Stent Implantation for Intracranial Atherosclerotic Stenosis

Wang

et al. 2021

Front. Neurosci.

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ObjectiveTo evaluate the utility of high-resolution flat-detector computed tomography (HR-FDCT) compared with conventional flat-detector computed tomography (FDCT) for stent placement in symptomatic intracranial atherosclerotic stenosis (ICAS).MethodsWe retrospectively reviewed the clinical data of 116 patients with symptomatic ICAS who underwent stent implantation. Images were acquired using conventional FDCT [voxel size = 0.43 mm (isotropic)] and HR-FDCT [voxel size = 0.15 mm (isotropic)]. Immediately after stent deployment, dual-volume three-dimensional (3D) fusion images were obtained from 3D digital subtraction angiography (DSA) and HR-FDCT. The image quality for stent visualization was graded from 0 to 2 (0: not able to assess; 1: limited, but able to assess; 2: clear visualization), and the stent-expansion status (“full,” “under-expanded” or “poor apposition”) was recorded.ResultsA total of 116 patients with symptomatic ICAS were treated successfully using 116 stents (58 NeuroformTM EZ, 42 EnterpriseTM, and 16 ApolloTM). The mean pre-stent stenosis was 80.5 ± 6.4%, which improved to 20.8 ± 6.9% after stenting. Compared with FDCT, HR-FDCT improved visualization of the fine structures of the stent to improve the image quality that significantly (mean score: 1.63 ± 0.60 vs. 0.41 ± 0.59, P < 0.001). In 19 patients, stent under-expansion (n = 11) or poor apposition (n = 8) was identified by HR-FDCT but not by conventional FDCT. After balloon dilatation, stent malapposition was shown to have improved on HR-FDCT. None of the 19 patients with stent malapposition experienced short-term complications during hospitalization or had in-stent stenosis at 6-month follow-up.ConclusionHigh-resolution flat-detector computed tomography (HR-FDCT) improves visualization of the fine structures of intracranial stents deployed for symptomatic ICAS compared with that visualized using conventional FDCT. High-resolution flat-detector computed tomography improves assessment of stent deployment and could reduce the risk of complications.

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New developments in clinical ischemic stroke prevention and treatment and their imaging implications

Cited by 11 publications

References 149 publications

Biomechanics and hemodynamics of stent-retrievers

Biomechanics and hemodynamics of stent-retrievers

Comparison of automated infarct core volume measures between non-contrast computed tomography and perfusion imaging in acute stroke code patients evaluated for potential endovascular treatment

Application of High-Resolution Flat Detector Computed Tomography in Stent Implantation for Intracranial Atherosclerotic Stenosis

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