Thrombectomy in Acute Ischemic Stroke: Challenges to Procedural Success

Yoo, Albert J.; Andersson, Tommy

doi:10.5853/jos.2017.00752

Cited by 182 publications

(177 citation statements)

References 46 publications

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“…As well as permanent stent deployment, other rescue techniques that have been described include catheter delivery of thrombolytics and glycoprotein IIb/IIIa inhibitors, angioplasty,17 or use of double or Y stent retriever approaches, the latter for bifurcation lesions 40. Data regarding the efficacy of these approaches are sparse and limited to case reports or small series.…”

Section: Discussionmentioning

confidence: 99%

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A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy

Wareham

Flood

Phan³

et al. 2018

J NeuroIntervent Surg

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BackgroundThe crucial role of thrombectomy in the management of emergent large vessel occlusive stroke is not disputed but there is a technical failure rate in a significant minority of patients whose outcomes are often poor. Our objective was to perform a systematic review and meta-analysis to assess the safety and efficacy of permanent self-expandable stent deployment as a bailout procedure in cases of failed anterior circulation thrombectomy.MethodsTwo independent reviewers searched the Pubmed (Medline) database for studies reporting outcomes following failed endovascular thrombectomy with subsequent rescue therapy employing self-expandable stents.ResultsEight studies (one prospective, seven retrospective) originating from Europe, Asia, and America comprising 160 patients met the inclusion criteria. Estimated baseline National Institutes of Health Stroke Scale score was 17.1 (95% CI 15.7 to 18.4). Following failed thrombetcomy and stent deployment, the rate of favorable outcome (modified Rankin Scale score 0–2) was 43% (95% CI 34% to 53%). Pooled mortality was 21% (95% CI 13% to 33%). Successful recanalization (Thrombolysis in Cerebral Infarction (TICI) 2b–3 or Thrombolysis in Myocardial Infarction (TIMI) 2–3) was 71% (95% CI 63% to 77%). Symptomatic intracerebral hemorrhage was seen in 12% (95% CI 7% to 18%). The Solitaire stent (Medtronic) was the most commonly deployed stent following failed thrombectomy attempts (66%; 95% CI 31% to 89%). Pre- or post-stent angioplasty was performed in 39%of patients (95% CI 29% to 48%). Glycoprotein IIb/IIIa inhibitors were used in 89% (95% CI 71% to 97%). 95% of patients received postprocedural antiplatelet therapy.ConclusionA rescue stent procedure seems reasonable as a last resort following failed thrombectomy but currently the level of evidence is limited. Prospective registries may aid in guiding future recommendations.

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Section: Discussionmentioning

confidence: 99%

“…The latter has been shown to be responsible for nearly half of unsuccessful procedures 16. Multiple variables are likely to govern device–thrombus interaction17 but patient factors associated with thrombectomy failure include fibrin rich18 or calcific emboli,19 intracranial atherosclerotic disease (ICAD),20 and vessel morphology 21…”

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confidence: 99%

A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy

Wareham

Flood

Phan³

et al. 2018

J NeuroIntervent Surg

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“…Indeed, mechanical thrombectomy is unsuccessful in removing the thrombus in up to 20% of the patients. 10 Beside vascular access, thrombus composition is considered an important factor responsible for thrombectomy failure. 10,11 Notwithstanding the fact that the occluding thrombus is the primary target in both pharmacological and mechanical recanalization therapy, very little is known about the general composition and structural organization of stroke thrombi and about the interplay between their cellular and molecular components.…”

Section: Introductionmentioning

confidence: 99%

Structural analysis of ischemic stroke thrombi: histological indications for therapy resistance

et al. 2019

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Ischemic stroke is caused by a thromboembolic occlusion of cerebral arteries. Treatment is focused on fast and efficient removal of the occluding thrombus, either via intravenous thrombolysis or via endovascular thrombectomy. Recanalization, however, is not always successful and factors contributing to failure are not completely understood. Although the occluding thrombus is the primary target of acute treatment, little is known about its internal organization and composition. The aim of this study, therefore, was to better understand the internal organization of ischemic stroke thrombi on a molecular and cellular level. A total of 188 thrombi were collected from endovascularly treated ischemic stroke patients and analyzed histologically for fibrin, red blood cells, von Willebrand factor , platelets, leukocytes and DNA, using bright field and fluorescence microscopy. Our results show that stroke thrombi are composed of two main types of areas: red blood cell-rich areas and platelet-rich areas. Red blood cell-rich areas have limited complexity as they consist of red blood cells that are entangled in a meshwork of thin fibrin. In contrast, platelet-rich areas are characterized by dense fibrin structures aligned with von Willebrand factor and abundant amounts of leukocytes and DNA that accumulate around and in these platelet-rich areas. These findings are important to better understand why platelet-rich thrombi are resistant to thrombolysis and difficult to retrieve via thrombectomy and can guide further improvements of acute ischemic stroke therapy.

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“…7 The overwhelming clinical benefit of intra-arterial stroke therapy has been mainly due to advances made in revascularization brought on by the current generation of thrombectomy devices, nevertheless, there still a remains a large percentage of cases in which, substantial reperfusion is achieved either too late or cannot be achieved at all. 8 In spite of rigorous and extensive research, therapeutic methods remain limited. At present there is still no generally accepted, routinely effective, specific approach in regards to IS treatment.…”

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confidence: 99%

Retracted: Inhibition of SNK‐SPAR signaling pathway promotes the restoration of motor function in a rat model of ischemic stroke

Fan

Liu

Zhang

et al. 2017

J of Cellular Biochemistry

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This study aimed to investigate the effects of SPAR signaling pathway on the restoration of motor function in ischemic stroke (IS). Sprague-Dawley male rats were separated into the control and sham groups, as well as the group for middle cerebral artery occlusion (MCAO) model establishment. Successfully established rat ischemic models were randomly divided into model, SNK MCAO-del and pcDNA3.1-SNK groups. The evaluation of motor function among the rats in each group was assessed using a balance beam, a screen test and the Garcia scoring method. CatWalk gait analysis was employed to evaluate the effect of the SNK signaling pathway on rat motor function. Triphenyltetrazolium chloride (TTC) and TUNEL staining were techniques were utilized for cerebral infarction (CI) area as well for hippocampal neuron apoptosis. The quantitative real-time polymerase chain reaction (qRT-PCR) and western blotting methods were performed to detect mRNA and protein expressions of SNK and SPAR. When compared with the model group, the SNK MCAO-del group displayed decreased motor function score and CI area, while contrasting results were observed in the pcDNA3.1-SNK group. According to the results obtained from the CatWalk gait analysis, the SNK MCAO-del group showed a clear improvement compared to the model group whereas the pcDNA3.1-SNK group exhibited poorer results than the model group in the objective parameters of the study, such as movement, speed, running duration, print area, maximal contact area, maximal, mean intensity, and stride length. These findings suggested that SNK gene silencing promotes motor function by inhibiting the SNK-SPAR signaling pathway in rats with ischemic stroke.

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Thrombectomy in Acute Ischemic Stroke: Challenges to Procedural Success

Cited by 182 publications

References 46 publications

A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy

A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy

Structural analysis of ischemic stroke thrombi: histological indications for therapy resistance

Retracted: Inhibition of SNK‐SPAR signaling pathway promotes the restoration of motor function in a rat model of ischemic stroke

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