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Current Status of Endovascular Therapy for Acute Ischemic Stroke

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Clinical Neurology".

Deadline for manuscript submissions: closed (20 April 2024) | Viewed by 9224

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Prof. Dr. Iris Quasar Grunwald

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Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, UK
Interests: endovascular stroke; acute stroke; stroke imaging; interventional neuroradiology; carotid arteries; aneurysm; neuroscience
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Special Issue Information

Dear Colleagues,

Endovascular therapy (EVT) is now broadly recognized as one of the most powerful treatments for acute stroke caused by large-vessel occlusion. Recent advancements in acute ischemic stroke management via EVT have led to significant reductions in the morbidity and mortality rates in selected patients with large vessel, occlusions. Despite these developments, post-stroke disability remains pervasive and further studies are warranted to establish the role of EVT in posterior circulation and distal vessel occlusions, with the need for the development of new and effective techniques for the revascularization of small vessels.

Many of these questions are the subject of current or upcoming clinical trials. This Special Issue aims to gather up-to-date publications regarding endovascular therapy for ischemic stroke and updates in pre-peri and post-procedural management. This information will help improve acute stroke management and provide new perspectives for current clinical practice.

We are looking forward to your contributions to this Special Issue.

Prof. Dr. Iris Quasar Grunwald
Guest Editor

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Keywords

endovascular therapy (EVT)
cerebrovascular disease
thrombectomy
thrombolysis
ischemic stroke
interventional stroke therapy

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Published Papers (6 papers)

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12 pages, 269 KiB

Open AccessArticle

Predictors of Outcome after Direct Aspiration of Basilar Artery Occlusion

by Miroslav Mako, Georgi Krastev, Vladimír Nosáľ, Jozef Haring, Denisa Jakubcová, Martin Daniš, Andrej Klepanec, Ján Haršány, Štefan Sivák and Egon Kurča

J. Clin. Med. 2024, 13(6), 1576; https://doi.org/10.3390/jcm13061576 - 9 Mar 2024

Viewed by 1270

Abstract

Background: Basilar artery occlusion (BAO) is a serious disease with a poor prognosis if left untreated. Endovascular therapy (EVT) is the most effective treatment that is able to reduce mortality and disability. Treatment results are influenced by a wide range of factors that have not been clearly identified. In the present study, direct aspiration was chosen as a first-line treatment. The safety and effectiveness of direct aspiration in BAO were determined, and factors affecting patient outcomes were identified. Methodology: Data for patients with BAO treated between November 2013 and December 2021 were evaluated using a database. The association between clinical and procedural parameters and functional outcome was assessed. Results: A total of 89 patients with BAO were identified. Full recanalization was achieved in 69.7% of cases and partial recanalization in 19.1%. Intracranial hemorrhage was detected in 11 (12.4%) patients, of which, eight (9.0%) patients experienced symptomatic intracranial hemorrhage. Patients with good outcomes presented with milder strokes (mean NIHSS score of 12.58 vs. 24.00, p < 0.001), had higher collateral scores (6.79 vs. 5.88, p = 0.016), more often achieved complete recanalization (87.9% vs. 58.9%, p = 0.009), and more often experienced early neurological improvement (66.7% vs. 26.8%, p < 0.001). On the contrary, patients with worse outcomes had higher serum glucose levels (p = 0.05), occlusion of the middle portion of the basilar artery (MAB) (30.3% vs. 53.6%, p = 0.033), longer thrombus lengths (10.51 vs. 16.48 mm, p = 0.046), and intracranial hemorrhage (p = 0.035). Conclusions: The present study results suggest that direct aspiration is a safe and effective treatment for patients with BAO. We identified several factors affecting the patients’ outcome. Full article

(This article belongs to the Special Issue Current Status of Endovascular Therapy for Acute Ischemic Stroke)

11 pages, 253 KiB

Open AccessArticle

Mechanical Thrombectomy in Stroke—Retrospective Comparison of Methods: Aspiration vs. Stent Retrievers vs. Combined Method—Is Aspiration the Best Starting Point?

by Grzegorz Meder, Paweł Żuchowski, Wojciech Skura, Piotr Płeszka, Marta Dura, Piotr Rajewski, Magdalena Nowaczewska, Magdalena Meder, Andrea M Alexandre and Alessandro Pedicelli

J. Clin. Med. 2024, 13(5), 1477; https://doi.org/10.3390/jcm13051477 - 4 Mar 2024

Viewed by 1859

Abstract

Background: There are three main methods of mechanical thrombectomy (MT): using a stent retriever (SR) only (SO), aspiration catheter (AC) only (AO) and the combined method (CM) using both the SR and AC. This paper describes a real-life, single-center experience using SO, AO and CM during 276 consecutive MTs. Methods: The primary endpoint was the frequency of first-pass complete (FPE TICI3). The secondary endpoints were final mTICI 2b-3, procedure duration, clinical outcome and the total number of device passes. The third aim of this study was to test the association between the clinical outcomes in patients treated with each method and various factors. Results: There was a significant difference (p = 0.016) between the groups’ FPE TICI3 rates with 46% mTICI 3 in the AO group, 41% in the CM group and 21% in the SO group. AO resulted in procedure time shortening to a mean duration of 43 min, and the scores were 56 min for CM and 63 min for SO (p < 0.0001). There were no significant differences in clinical outcomes or in-hospital mortality. The analysis showed a correlation between good clinical outcomes and the administration of IVT: OR 1.71 (1.03–2.84) p = 0.039. Patients ≥66 years old had higher odds of a bad outcome compared to younger patients in general (OR, 1.99 95% CI, 1.17–3.38; p = 0.011). FPE TICI3 was associated with good functional outcomes in the whole treated cohort (OR, 1.98; 95% CI, 1.21–3.25; p = 0.006). Conclusions: In our series, AO proved to be the best starting point in most cases. It demonstrates good technical efficacy regarding FPE, it is fast and clinical outcomes seem to be the least age- and FPE TICI3-dependent. It can be easily converted into the combined method, which had the second-best outcomes in our cohort. Full article

(This article belongs to the Special Issue Current Status of Endovascular Therapy for Acute Ischemic Stroke)

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12 pages, 1035 KiB

Open AccessArticle

Preprocedural D-Dimer Level as a Predictor of First-Pass Recanalization and Functional Outcome in Endovascular Treatment of Acute Ischemic Stroke

by Jang-Hyun Baek, Ji Hoe Heo, Hyo Suk Nam, Byung Moon Kim, Dong Joon Kim and Young Dae Kim

J. Clin. Med. 2023, 12(19), 6289; https://doi.org/10.3390/jcm12196289 - 29 Sep 2023

Cited by 2 | Viewed by 1225

Abstract

We aimed to evaluate the association between preprocedural D-dimer levels and endovascular and clinical outcomes. We retrospectively reviewed patients with acute intracranial large-vessel occlusion who underwent mechanical thrombectomy. Plasma D-dimer levels were measured immediately before the endovascular procedure. Endovascular outcomes included successful recanalization, first-pass recanalization (first-pass effect (FPE) and modified FPE (mFPE)), thrombus fragmentation, and the number of passes of the thrombectomy device. Clinical outcomes were assessed at 3 months using the modified Rankin Scale. A total of 215 patients were included. Preprocedural D-dimer levels were lower in patients with FPE (606.0 ng/mL [interquartile range, 268.0–1062.0]) than in those without (879.0 ng/mL [437.0–2748.0]; p = 0.002). Preprocedural D-dimer level was the only factor affecting FPE (odds ratio, 0.92 [95% confidence interval, 0.85–0.98] per 500 ng/mL; p = 0.022). D-dimer levels did not differ significantly based on successful recanalization and thrombus fragmentation. The number of passes of the thrombectomy device was higher (p = 0.002 for trend) and the puncture-to-recanalization time was longer (p = 0.044 for trend) as the D-dimer levels increased. Patients with favorable outcome had significantly lower D-dimer levels (495.0 ng/mL [290.0–856.0]) than those without (1189.0 ng/mL [526.0–3208.0]; p < 0.001). Preprocedural D-dimer level was an independent factor for favorable outcome (adjusted odds ratio, 0.88 [0.81–0.97] per 500 ng/mL; p = 0.008). In conclusion, higher preprocedural D-dimer levels were significantly associated with poor endovascular and unfavorable functional outcomes. Full article

(This article belongs to the Special Issue Current Status of Endovascular Therapy for Acute Ischemic Stroke)

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13 pages, 2612 KiB

Open AccessArticle

Piecing Arterial Branching Pattern Together from Non-Contrast and Angiographic Brain Computed Tomography before Endovascular Thrombectomy for Acute Ischemic Stroke

by Horyul Lee, Woojin Shim, Dongjun Jeong, Younghoon Kwon and Sung Won Youn

J. Clin. Med. 2023, 12(12), 4051; https://doi.org/10.3390/jcm12124051 - 14 Jun 2023

Viewed by 1199

Abstract

Predicting the unseen arterial course and branching pattern distal to vessel occlusion is crucial for endovascular thrombectomy in acute stroke patients. We investigated whether a comprehensive interpretation of NCT and CTA would enhance arterial course prediction more than either NCT or CTA interpretation alone. Among 150 patients who achieved post-thrombectomy TICI grades ≥ IIb for anterior circulation occlusions, we assessed visualization grade on both NCT and CTA by five scales at the thrombosed and the distal-to-thrombus segment, using DSA as the reference standard. The visualization grades were compared and related to various subgroups. The mean visualization grade of the distal-to-thrombus segment on NCT was significantly larger than that of CTA (mean ± SD, 3.62 ± 0.87 versus 3.31 ± 1.20; p < 0.05). On CTA, visualization grade of distal-to-thrombus segment in the good collateral flow subgroup was higher than that in the poor collateral flow subgroup (mean ± SD, 4.01 ± 0.93 versus 2.56 ± 0.99; p < 0.001). After the comprehensive interpretation of NCT and CTA, seventeen cases (11%) showed visualization grade of distal-to-thrombus segment upgrading. Tracing arterial course and piecing branching patterns together in distal-to-occlusion of stroke patients was feasible on the routine pre-interventional NCT and CTA, which may provide timely guidance during thrombectomy. Full article

(This article belongs to the Special Issue Current Status of Endovascular Therapy for Acute Ischemic Stroke)

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12 pages, 751 KiB

Open AccessArticle

Alternative Arterial Access Routes for Endovascular Thrombectomy in Patients with Acute Ischemic Stroke: A Study from the MR CLEAN Registry

by Sabine L. Collette, Elke A. van de Ven, Gert-Jan R. Luijckx, Hester F. Lingsma, Pieter Jan van Doormaal, Adriaan C. G. M. van Es, Ido R. van den Wijngaard, Robert-Jan B. Goldhoorn, Jan Cees de Groot, Wim H. van Zwam, Charles B. L. M. Majoie, Diederik W. J. Dippel, Reinoud P. H. Bokkers, Maarten Uyttenboogaart and on behalf of the MR CLEAN Registry Investigators

J. Clin. Med. 2023, 12(9), 3257; https://doi.org/10.3390/jcm12093257 - 2 May 2023

Cited by 1 | Viewed by 1616

Abstract

Background: Endovascular thrombectomy (EVT) through femoral access is difficult to perform in some patients with acute ischemic stroke due to challenging vasculature. We compared outcomes of EVT through femoral versus alternative arterial access. Methods: In this observational study, we included patients from the MR CLEAN Registry who underwent EVT for acute ischemic stroke in the anterior circulation between 2014 and 2019 in the Netherlands. Patients who underwent EVT through alternative and femoral access were matched on propensity scores in a 1:3 ratio. The primary endpoint was favorable functional outcome (modified Rankin Scale score ≤ 2) at 90 days. Secondary endpoints were early neurologic recovery, mortality, successful intracranial reperfusion and puncture related complications. Results: Of the 5197 included patients, 17 patients underwent EVT through alternative access and were matched to 48 patients who underwent EVT through femoral access. Alternative access was obtained through the common carotid artery (n = 15/17) and brachial artery (n = 2/17). Favorable functional outcome was less often observed after EVT through alternative than femoral access (18% versus 27%; aOR, 0.36; 95% CI, 0.05–2.74). The rate of successful intracranial reperfusion was higher for alternative than femoral access (88% versus 58%), although mortality (59% versus 31%) and puncture related complications (29% versus 0%) were more common after alternative access. Conclusions: EVT through alternative arterial access is rarely performed in the Netherlands and seems to be associated with worse outcomes than standard femoral access. A next step would be to compare the additional value of EVT through alternative arterial access after failure of femoral access. Full article

(This article belongs to the Special Issue Current Status of Endovascular Therapy for Acute Ischemic Stroke)

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14 pages, 1393 KiB

Open AccessSystematic Review

Outcomes of Endovascular Treatment versus Standard Medical Treatment for Acute Ischemic Stroke with Basilar Artery Occlusion: A Systematic Review and Meta-Analysis

by Jia-Hung Chen, Sheng-Chieh Lin, Chien-Tai Hong and Lung Chan

J. Clin. Med. 2023, 12(20), 6444; https://doi.org/10.3390/jcm12206444 - 10 Oct 2023

Viewed by 1461

Abstract

Background: Although endovascular treatment (EVT) is beneficial for large vessel occlusion in anterior circulation stroke, whether these benefits exist for basilar artery occlusion (BAO) remains unclear. This systematic review and meta-analysis compared the outcomes of patients with BAO undergoing EVT and standard medical treatment (SMT). Methods: The PubMed, Embase, and Cochrane Library databases were searched for eligible randomized control trials (RCTs) and non-RCTs involving patients with acute ischemic stroke and BAO undergoing EVT or SMT. The following outcomes were assessed: 90-day functional outcomes (favorable outcome and functional independence: modified Rankin scale [mRS] score of 0–3 or 0–2, respectively), mortality, and symptomatic intracranial hemorrhage (sICH) incidence. The summary effect sizes were determined as risk ratios (RRs) through the Mantel–Haenszel method with a random-effects model. Results: Four RCTs and four non-RCTs were included. Compared with SMT, EVT resulted in a higher proportion of patients with 90-day mRS scores of 0–3 (RR: 1.54 [1.16–2.06] in RCTs and 1.88 [1.11–3.19] in non-RCTs), a higher proportion of patients achieving functional independence (90-day mRS score of 0–2; RR: 1.83 [1.07–3.12] and 1.84 [0.97–3.48], respectively), a lower risk of mortality (RR: 0.76 [0.65–0.89] and 0.72 [0.62–0.83], respectively), and a higher sICH risk (RR: 5.98 [2.11–16.97] and 4.95 [2.40–10.23], respectively). Severe neurological deficits, intravenous thrombolysis, and higher posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) were associated with EVT benefits. Conclusion: In patients with BAO, EVT results in superior functional outcomes, lower mortality risk, and higher sICH risk than does SMT, independent of age and sex. Higher National Institutes of Health Stroke Scale scores, intravenous thrombolysis, and higher pc-ASPECTSs before treatment are associated with greater benefits from EVT. Full article

(This article belongs to the Special Issue Current Status of Endovascular Therapy for Acute Ischemic Stroke)

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