Selecting Endovascular Treatment Strategy according to the Location of Intracranial Occlusion in Acute Stroke

Abstract

Background: Selection of endovascular approaches for acute stroke patients remains unclear. The efficacy of intra-arterial therapy (IAT) has been demonstrated in the past. However, in the last years, the use of mechanical thrombectomy by retrievers (RET) is increasing at the expense of IAT. We aimed to compare several clinical outcomes between patients treated with IAT or RET. Methods: In a 6-year period, acute stroke patients (<8 h) with confirmed internal carotid artery (ICA) occlusion or middle cerebral artery (MCA) occlusion undergoing endovascular therapy were prospectively included in our database. Patients who underwent intra-arterial tissue plasminogen activator (tPA) ± microguidewire mechanical clot disruption (IAT group) were compared with those who underwent thrombectomy with the Solitaire® or Trevo® retrievers (RET group). Recanalization (REC) was considered if at the end of the endovascular procedure thrombolysis in cerebral infarction score was 2a-3. Dramatic clinical improvement (DCI) was defined as a decrease of ≥10 NIHSSS points from baseline to discharge or 7 days. Results: One hundred and eighty patients were included, 100 (55.6%) patients in the IAT group and 80 patients (44.4%) in the RET group. There were no differences in baseline characteristics (age, gender, risk factors profile, previous treatment with i.v. tPA, baseline NIHSS, extracranial ICA angioplasty and time to REC). Rates of REC, DCI and symptomatic intracranial hemorrhage were also similar between groups. Among patients with ICA occlusions (41 IAT, 34 RET), REC was significantly higher with RET (83.9 vs. 61%; p = 0.04).There was a trend towards a higher DCI rate in the RET group (32.3%) compared with the IAT group (14.6%; p = 0.06). According to MCA occlusions, there were no major differences in the main outcome variables. The number needed to treat to achieve one additional DCI with RET compared with IAT was 12 for MCA occlusions, and only 5 for ICA occlusions. Conclusions: Among acute stroke patients undergoing endovascular therapies, the benefits of RET over IAT are greater in ICA occlusions. Retrievers may be considered as the first therapeutic option in these patients.

Acute Ischemic Stroke (AIS) Patient Management in French Stroke Units and Impact Estimation of Thrombolysis on Care Pathways and Associated Costs

“…In particular, this could be the case for combination therapy with intravenous thrombolysis and mechanical thrombectomy. Until recently, intravenous thrombolysis and mechanical thrombectomy have been considered mutually exclusive interventions, with the choice of which to use depending on specific clinical criteria, such as the location of the intracranial occlusion [18]. However, clinical study results providing definitive evidence of the clinical benefit and the health economic impact of the combined treatment strategy are anticipated.…”

Instant Reocclusion following Mechanical Thrombectomy of in situ Thromboocclusion and the Role of Low-Dose Intra-Arterial Tirofiban

“…Although the MT technology and associated outcomes have recently improved [12,15,16], there remain (infrequent but nonnegligible) cases of recanalization failure. Complications can result from heterogeneous etiologies of the occlusion or endothelial damage caused by MT devices.…”

Intra-arterial treatment of patients with acute ischemic stroke and internal carotid artery occlusion: a literature review

“…If one of the two primary outcome measures was missing, the study was excluded. In two studies19 20 the information was incomplete or unclear. In these cases, we tried to contact the corresponding authors by email.…”

“…In these cases, we tried to contact the corresponding authors by email. In one study19 the data were retrieved in this way. The second study was not excluded but the inconsistency is noted in table 1.…”