Recanalization and Outcome After Intra-Arterial Thrombolysis in Middle Cerebral Artery and Internal Carotid Artery Occlusion

Arnold, Marcel; Kappeler, Liliane; Nedeltchev, Krassen; Brekenfeld, Caspar; Fischer, Urs; Keserue, Borbala; Remonda, Luca; Schroth, Gerhard; Mattle, Heinrich

doi:10.1161/01.str.0000259711.13490.23

Cited by 55 publications

(44 citation statements)

References 22 publications

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“…Our study is based on the Bernese stroke registry, a prospective database on patients with AIS [18][19][20]. Baseline and 3-month outcome data on consecutive AIS patients admitted to the Neurological Department of the University Hospital of Bern are collected.…”

Section: Methodsmentioning

confidence: 99%

Iatrogenic Vessel Dissection in Endovascular Treatment of Acute Ischemic Stroke

et al. 2017

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Purpose Knowledge about the localization and outcome of iatrogenic dissection (ID) during endovascular treatment of acute ischemic stroke (AIS) is limited. We aimed to determine the frequency, clinical aspects and morphology of ID in endovascular AIS treatment and to identify predictors of this complication. Methods Digital subtraction angiography (DSA) of ID carried out during endovascular treatment between January 2000 and March 2012 have been re-evaluated. The ID localization and morphology were analyzed and related to the interventional techniques. Baseline clinical and radiological findings, treatment modality and outcome were compared with patients without ID. Results Out of 866 patients 18 (2%) suffered an ID (44% female, median age 64 years). Localization was extracranial in 15 (83%, 14 internal carotid artery and 1 vertebral artery) and intracranial in 3 (17%; 1 vertebrobasilar dissecThese authors jointly directed the study: J. Slotboom, J. Gralla, M. Arnold. tion and 2 in the anterior circulation). Of the IDs 5 (28%) resulted in a high-degree, 3 (17%) in a moderate, 5 (28%) in a mild and 5 (28%) in no stenosis and 8 IDs were stented in the acute phase. At 3 months 7 (42%) patients had a favorable outcome (modified Rankin score mRS Ä 2) and 6 (33%) patients had died. Patients with ID had a different stroke etiology (p = 0.041), were more likely to be smokers (44% versus 19%, p = 0.015) and were more likely to be treated with mechanical thrombectomy (100% versus 60%, p < 0.001). Although two ID patients had relevant complications, the outcome did not differ between the groups. Conclusion The occurrence of ID is a rare complication of endovascular AIS treatment associated with smoking and mechanical thrombectomy. Electronic supplementary material

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Section: Methodsmentioning

confidence: 99%

Iatrogenic Vessel Dissection in Endovascular Treatment of Acute Ischemic Stroke

et al. 2017

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“…On the other hand, the presence of complete internal carotid artery (ICA) occlusion from the bulb to the terminus with MCA occlusion and no pial collateral flow from the anterior cerebral artery is a predictor of poor response to IV thrombolysis, even in patients treated in <3 h [12,24]. Even IAT has a relatively low probability of complete recanalization (compared to MCA branch occlusion, for example) in such patients, and when taken into consideration with other mitigating factors, such as advanced age, hypertension, and prolonged duration of ischemia, ICA terminus occlusion portends a poor prognosis regardless of recanalization method [25][26][27]. By comparison, patients with cervical ICA occlusion, with or without tandem MCA occlusion have a better prognosis than those with ICA terminus occlusion [28,29].…”

Section: Indicationsmentioning

confidence: 99%

Intra-arterial Therapy for Acute Ischemic Stroke

Aböu-Chebl

2011

Neurotherapeutics

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Intra-arterial therapy (IAT) for acute ischemic stroke refers to endovascular catheter-based approaches to achieve recanalization using mechanical clot disruption, locally injected thrombolytic agents or both. IAT may be used in addition to intravenous tissue plasminogen activator (tPA) or in patients who do not qualify for tPA, usually because they are outside the approved 3-h timeframe window or have contraindications, such as elevated international normalized ratio or partial thromboplastin time. Recanalization rates correlate with clinical improvement, and with the newest catheters it is possible to achieve recanalization in roughly 80% of patients treated. However, while the catheters are approved by the Food and Drug Administration, there are still no randomized trial data demonstrating the role of current IAT therapy vs either tPA or standard management. IAT is reserved for patients with large artery occlusions in the basilar, distal carotid, or proximal middle cerebral arteries. Imaging the penumbra using magnetic resonance imaging or computed tomographic perfusion is currently the most frequently used way to identify patients who might benefit. However, the imaging and clinical criteria for identifying which patients benefit, and perhaps more importantly those who will do poorly despite IAT, remain unclear.

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“…Further studies reported that milder baseline stroke deficits, elevated systolic blood pressures, normal glucose values, smoking history, absence of atrial fibrillation, distal vessel occlusion, and thrombus length positively predicts post-thrombolytic recanalisation. Considering these risk factors in individual cases, perhaps patients with smaller chance for reperfusion/recanalisation could benefit from more aggressive interventions, such as intra-arterial fibrinolysis [12][13][14][15][16][17][18]. …”

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confidence: 99%

Hemorrhagic transformation of ischemic stroke

J¹,

Hortobágyi²

2017

Vascul Dis Ther

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The better understanding of the diverse mechanisms leading to the hemorrhagic transformation of an ischemic stroke is the crucial point in the prevention of this altogether common phenomenon. The different individual risk factors include the anatomical variability of collateral blood supply, age, genetics, body weight, etiology of the occlusion, side of the occluded vessel, renal status, stroke severity, history of high serum glucose or hypertension and hypertension or hyperglycemia at the onset of the stroke, ferritin level, INR, antiplatelet usage or the platelet count etc. All these might contribute to the process of hemorrhagic transformation. These risk factors have been identified by retrospective epidemiological studies and are useful to identify patients who are at high risk for hemorrhagic conversion and help the decision between conservative, thrombolytic or more advanced treatments such as thrombectomy. The modulations of potential molecular targets participating in the process seem to be promising in animal models, but human trials are lacking the breakthrough success so far, both in extending the time frame of the thrombolysis and in replacing the recombinant tissue plasminogen activator (rtPA) as thrombolytic agent.So far, the careful preselection of patients eligible for thrombolytic therapy is the best way to prevent hemorrhagic transformation. The intensive research in the field revealing small but important molecular details are continuously contributing to the better understanding of hemorrhagic transformation with the intention of finding new agents that co-administrated to the rtPA or completely replacing that could decrease the risk of secondary bleeding.The aim of this review is to give comprehensive insight into the process of hemorrhagic transformation of ischemic stroke, starting with basic overview of the penumbra concept and the collateral supply followed by discussion of the recanalisation-reperfusion-hemorrhagic transformation process after vessel occlusion also highlighting the importance of timing and ratio of recanalisation spontaneously and in case of thrombolytic agent administration. We overview the risk factors of hemorrhagic transformation, which may be helpful to physicians to identify high risk patients before rtPA administration. The last part of the work is dealing with future therapeutic possibilities based on the so far revealed molecular mechanisms of hemorrhagic transformation. With the aim to assess the rate and influencing factors on the recanalisation and reperfusion rate 381 patients with large-vessel occlusion was investigated. The patient group involved ones treated with rtPA or treated conservatively. Partial or complete recanalisation was achieved in 121 out of 210 (58%) patients after intravenous rtPA administration. The recanalisation success was more likely if the patient had atrial fibrillation [4] -maybe because cardioembolic clots consists more fibrin and are more likely to reopen by plasmin proteolysis than thrombosis of an atherosclerotic plaq...

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Recanalization and Outcome After Intra-Arterial Thrombolysis in Middle Cerebral Artery and Internal Carotid Artery Occlusion

Cited by 55 publications

References 22 publications

Iatrogenic Vessel Dissection in Endovascular Treatment of Acute Ischemic Stroke

Iatrogenic Vessel Dissection in Endovascular Treatment of Acute Ischemic Stroke

Intra-arterial Therapy for Acute Ischemic Stroke

Hemorrhagic transformation of ischemic stroke

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