Recanalization In Acute Stroke Research Articles

The relationship of laboratory values with prognosis in acute stroke recanalization treatment applied patients

Objectives: Many factors affect the results of acute recanalization treatment and prognosis of ischemic stroke patients. Some markers which has a role in inflammation process cause atherosclerosis that leads to ischemic stroke. We aimed to evaluate the relationship between admission laboratory findings and prognosis in patients to whom acute recanalization therapy were applied. Methods: In our study, we evaluated 139 acute stroke patients to whom acute recanalization therapies had been applied. Demographic data, glomerular filtration rate, uric acid, albumin, lipid profile, C-reactive protein, fibrinogen values were evaluated. Admission and discharge National Institutes of Health Stroke Scale and modified Rankin Scale scores were recorded. The effect of laboratory parameters on prognosis was examined. P <0.05 was considered significant. Results: Tissue plasminogen activator therapy was applied to 53 (38.1%) patients, thrombectomy to 62 (44.6%) patients, tPA bolus+thrombectomy to 3 (2.2%) patients, tPA full dose+thrombectomy to 19 (13.7%), and thrombectomy+stent to 2 (1.4%) patients. None of the laboratory were statistically related to prognosis except for lymphocytes count (p = 0.012) and albumin (p = 0.01). There was no relationship between laboratory findings with hemorrhagic transformation and acute recanalization treatment outcome. Conclusions: In the etiology of ischemic stroke, there are many inflammatory processes that cause atherosclerosis such as hypertension, hyperlipidemia, diabetes mellitus. The effect of admission laboratory values on prognosis has not been clarified. In patients with acute recanalization therapies, admission laboratory findings has no effect on patient management. Consequently, laboratory parameters provide limited information about the prognosis of patients who underwent acute recanalization therapies.

Cerebral Circulation Time After Thrombectomy: A Potential Predictor of Outcome After Recanalization in Acute Stroke

BackgroundDespite successful recanalization, up to half of patients with acute ischemic stroke caused by large‐vessel occlusion treated with endovascular treatment (EVT) do not recover to functional independence. We aim to evaluate the role of cerebral circulation time (CCT) as outcome predictor after EVT.Methods and ResultsWe retrospectively enrolled consecutive patients with acute ischemic stroke–large‐vessel occlusion undergoing EVT. Three categories of CCT based on digital subtraction angiography were studied: CCT of the stroke side, CCT of the healthy side), and change of CCT of the stroke side versus CCT of the healthy side. Dramatic clinical recovery was defined as a 24‐hour National Institutes of Health Stroke Scale score ≤2 or ≥8 points drop. A modified Rankin Scale score ≤2 at 3 months was considered a favorable outcome. Logistic regression analysis was performed to evaluate the prediction of CCT on prognosis. One hundred patients were enrolled, of which 38 (38.0%) experienced a dramatic clinical recovery and 43 (43.0%) achieved a favorable outcome. Logistic regression analysis found that shorter change of CCT of the stroke side versus CCT of the healthy side and CCT of the stroke side were independent positive prognostic factors for dramatic clinical recovery (odds ratio [OR], 0.189; P=0.033; OR, 0.581; P=0.035) and favorable outcomes (OR, 0.142; P=0.020; OR, 0.581; P=0.046) after adjustment for potential confounders. A model including the change of CCT of the stroke side versus CCT of the healthy side also had significantly higher area under the curve values compared with the baseline model in patients with dramatic clinical recovery (0.780 versus 0.742) or favorable outcome (0.759 versus 0.713).ConclusionsTo our knowledge, this is the first report that CCT based on digital subtraction angiography data exhibits an independent predictive performance for clinical outcome in patients with acute ischemic stroke–large‐vessel occlusion after EVT. Given that this readily available CCT can provide alternative perfusion information during EVT, a prospective, multicenter trial is warranted.

Mechanical Thrombectomy in Distal Residual Occlusions of the Middle Cerebral Artery after Large Vessel Recanalization in Acute Stroke: 2b or not 2b? A Pragmatic Approach in Real-Life Scenarios

Recent studies have suggested that a recanalization grade of modified Thrombolysis in Cerebral Infarction (mTICI) score ≥2c is strongly related with good clinical outcome rather than the current therapeutic angiography target ≥2b. To achieve better recanalization, additional further maneuvers on distal residual vessel occlusion (RVO) may be required. The aim of this study was to evaluate the safety and efficacy of rescue treatment in RVOs after recanalization of large vessel occlusions in the anterior circulation. A single-center retrospective review of a prospectively maintained stroke databank was performed. Patients presenting with RVOs after mechanical thrombectomy on the M1/internal carotid artery terminus were included and further divided into treated and untreated groups: the former underwent additional maneuvers on RVOs, whereas the latter did not. Baseline and posttreatment clinical, radiologic, and angiographic data were compared between the 2 groups. End points included good functional outcome (modified Rankin Scale [mRS] score ≤2) rates of hemorrhagic transformations, neurologic deterioration and mortality. RVOs were observed in 183/488 patients (37.5%). 74/183 (40.4%) underwent rescue treatment, showing a better outcome in terms of median 24 hours National Institutes of Health Stroke Scale score (13 vs. 18; P < 0001), 24 hours Alberta Stroke Programme Early CT Score (6 vs. 5; P < 0.001) and 3 months mRS score 0-2 (47.3% vs. 33.1%; P= 0.06). Recanalization of the superior (frontal) branch of the middle cerebral artery was particularly critical in terms of outcome. Hemorrhagic transformation was higher in the untreated group (53.6% vs. 66.6%; P= 0.1) as well as symptomatic intracranial hemorrhage (13.1% vs. 29.4%; P= 0.01). Neurologic deterioration occurred more often among untreated patients (16.2% vs. 25.7%; P= 0.1). Three complications (1.3%) occurred during rescue treatment. When feasible, improving mTICI score 2a-2b recanalization to mTICI 2c/3 is safe and associated with a better clinical outcome, particularly for residual occlusions involving the superior branch of bifurcation.

Hemorrhage After Endovascular Recanalization in Acute Stroke: Lesion Extent, Collaterals and Degree of Ischemic Water Uptake Mediate Tissue Vulnerability.

Background and Purpose: Intracranial hemorrhage (ICH) remains a major complication of endovascular treatment (ET) in acute stroke. The aim of this study was to identify clinical and imaging predictors for ICH in patients with acute ischemic stroke undergoing successful ET.Methods: We performed a retrospective analysis of patients with large vessel occlusion in the anterior circulation who underwent successful ET at our university medical center between 2015 and 2018. ICH was diagnosed on non-enhanced CT and a binary outcome was defined: ICH occurrence in the immediate post-interventional phase within 12–36 h (yes/no). The impacts of clinical, radiological, and interventional parameters on outcome were assessed in logistic regression models.Results: One hundred and seven patients fulfilled the inclusion criteria. 37 (34.6%) showed an ICH of which 7 (6.5%) patients were diagnosed as symptomatic and 30 (28.04%) as asymptomatic. Multivariable regression analyses identified a lower ASPECTS (adjusted odds ratio (OR) 1.95, 95%CI: 1.4–3.63, P = 0.037), low collateral score (adjusted OR 0.12, 95%CI: 0.03–0.49, P = 0.003) and high Net Water Uptake (NWU) (adjusted OR 1.56, 95%CI: 2.34–1.03, P = 0.007) as independent predictors of ICH after successful ET.Conclusions: CT-based quantitative NWU, ASPECTS, and collateral score mediate tissue vulnerability and are reliable independent predictors of a bleeding event after successful ET. This imaging-based prediction model might be useful for early stratification of patients at high risk of a bleeding event after ET, especially with low ASPECTS.

Number of Stent Retriever Passes Associated With Futile Recanalization in Acute Stroke.

Background and Purpose- Stent retriever (SR) thrombectomy has become the mainstay of treatment of acute intracranial large artery occlusion. However, it is still not much known about the optimal limit of SR attempts for favorable outcome. We evaluated whether a specific number of SR passes for futile recanalization can be determined. Methods- Patients who were treated with a SR as the first endovascular modality for their intracranial large artery occlusion in anterior circulation were retrospectively reviewed. The recanalization rate for each SR pass was calculated. The association between the number of SR passes and a patient's functional outcome was analyzed. Results- A total of 467 patients were included. Successful recanalization by SR alone was achieved in 82.2% of patients. Recanalization rates got sequentially lower as the number of passes increased, and the recanalization rate achievable by ≥5 passes of the SR was 5.5%. In a multivariable analysis, functional outcomes were more favorable in patients with 1 to 4 passes of the SR than in patients without recanalization (odds ratio [OR] was 8.06 for 1 pass; OR 7.78 for 2 passes; OR 6.10 for 3 passes; OR 6.57 for 4 passes; all P<0.001). However, the functional outcomes of patients with ≥5 passes were not significantly more favorable than found among patients without recanalization (OR 1.70 with 95% CI, 0.42-6.90 for 5 passes, P=0.455; OR 0.33 with 0.02-5.70, P=0.445 for ≥6 passes). Conclusions- The likelihood of successful recanalization got sequentially lower as the number of SR passes increased. Five or more passes of the SR became futile in terms of the recanalization rate and functional outcomes.

Prehospital care for stroke patients

The effectiveness of thrombolysis or mechanical recanalization for acute stroke is higher, the sooner these therapies are started. Therefore, acute stroke patients need to be evaluated by qualified staff for these therapies as soon as possible. Lay persons need to identify the typical symptoms of stroke as an emergency and act accordingly by calling the emergency medical system (EMS). The EMS team reassesses the symptoms and prompts cerebral imaging. Cerebral imaging is performed ideally in hospitals with a stroke unit where subsequent (stroke) treatments occur. On the way, the emergency team will measure and stabilize vital functions and obtain further important clinical information. Telemedicine allows communicating exact time of onset and severity of symptoms, as well as comorbidities and medication of the patient to the respective hospital. Thereby, the intrahospital workload will be disencumbered and accelerated. Some EMS vehicles now carry point-of-care laboratories and may measure lab values en route (glucose and INR [International Normalized Ratio] for example). Some ambulances are not only equipped with qualified staff, telemedicine technique, and point-of-care labs but even computer tomography (CT) to perform imaging. Such mobile stroke emergency mobiles (STEMO) or mobile stroke units may perform thrombolysis prehospitally. Prehospital thrombolysis has been proven to be initiated faster and is safe. Preliminary results even suggest superiority to intrahospital thrombolysis with respect to clinical outcome. Moreover, STEMO may perform CT-angiography and assess intracranial large-vessel status. If intracranial large-vessel occlusion is present, patients will be brought directly to hospitals able to perform mechanical recanalization. Thus, secondary transports are no longer required.

ERic Acute StrokE Recanalization: A study using predictive analytics to assess a new device for mechanical thrombectomy.

Aim and hypothesis Using a new study design, we investigate whether next-generation mechanical thrombectomy devices improve clinical outcomes in ischemic stroke patients. We hypothesize that this new methodology is superior to intravenous tissue plasminogen activator therapy alone. Methods and design ERic Acute StrokE Recanalization is an investigator-initiated prospective single-arm, multicenter, controlled, open label study to compare the safety and effectiveness of a new recanalization device and distal access catheter in acute ischemic stroke patients with symptoms attributable to acute ischemic stroke and vessel occlusion of the internal cerebral artery or middle cerebral artery. Study outcome The primary effectiveness endpoint is the volume of saved tissue. Volume of saved tissue is defined as difference of the actual infarct volume and the brain volume that is predicted to develop infarction by using an optimized high-level machine learning model that is trained on data from a historical cohort treated with IV tissue plasminogen activator. Sample size estimates Based on own preliminary data, 45 patients fulfilling all inclusion criteria need to complete the study to show an efficacy >38% with a power of 80% and a one-sided alpha error risk of 0.05 (based on a one sample t-test). Discussion ERic Acute StrokE Recanalization is the first prospective study in interventional stroke therapy to use predictive analytics as primary and secondary endpoint. Such trial design cannot replace randomized controlled trials with clinical endpoints. However, ERic Acute StrokE Recanalization could serve as an exemplary trial design for evaluating nonpivotal neurovascular interventions.

A numerical framework to investigate hemodynamics during endovascular mechanical recanalization in acute stroke.

Ischemic stroke, caused by embolism of cerebral vessels, inflicts high morbidity and mortality. Endovascular aspiration of the blood clot is an interventional technique for the recanalization of the occluded arteries. However, the hemodynamics in the Circle of Willis (CoW) are not completely understood, which results in medical misjudgment and complications during surgeries. In this study we establish a multiscale description of cerebral hemodynamics during aspiration thrombectomy. First, the CoW is modeled as a 1D pipe network on the basis of computed tomography angiography (CTA) scans. Afterwards, a vascular occlusion is placed in the middle cerebral artery and the relevant section of the CoW is transferred to a 3D computational fluid dynamic (CFD) domain. A suction catheter in different positions is included in the CFD simulations. The boundary conditions of the 3D domain are taken from the 1D domain to ensure system coupling. A Eulerian-Eulerian multiphase simulation describes the process of thrombus aspiration. The physiological blood flow in the 1D and 3D domains is validated with literature data. Further on, it is proved that domain reduction and pressure coupling at the boundaries are an appropriate method to reduce computational costs. Future work will apply the developed framework to various clinical questions.

Endovascular Treatment of Acute Stroke: Evolution and Selection of Techniques and Instruments Based on Thrombus Imaging.

Mechanical thrombectomy provides higher recanalization rates than intravenous or intra-arterial thrombolysis. Finally this has been shown to translate into improved clinical outcome in six multicentric randomized controlled trials. However, within cohorts the clinical outcomes may vary, depending on the endovascular techniques applied. Systems aiming mainly for thrombus fragmentation and lacking a protection against distal embolization have shown disappointing results when compared to recent stent-retriever studies or even to historical data on local arterial fibrinolysis. Procedure-related embolic events are usually graded as adverse events in interventional neuroradiology. In stroke, however, the clinical consequences of secondary emboli have so far mostly been neglected and attributed to progression of the stroke itself. We summarize the evolution of instruments and techniques for endovascular, image-guided, microneurosurgical recanalization in acute stroke, and discuss how to avoid procedure-related embolic complications.

Leaving the black box approach: individualized prediction of recanalization benefit by advanced imaging in acute stroke.

The enthusiasm about mechanical recanalization in acute stroke has experienced a ‘state of hibernation' due to inconclusive studies several years ago but has now been ‘reperfused' by overwhelming evidence from recent randomized trials.1, 2, 3 On the one hand, the short message delivered by these studies is the following: recanalization is beneficial if early and complete. This is not a surprising finding for the stroke community but it is well embedded in a clinical setting. On the other hand, these studies open the door to treatment efforts in a late time window (that still awaits clear definitions),4 and to the use of advanced imaging biomarkers as for example collateral flow assessment or imaging of the tissue at risk.5

Trends in the Effectiveness of Endovascular Recanalization for Acute Stroke: Is a Change Taking Place?

Despite recent technical advances in endovascular recanalization, there is skepticism regarding its clinical effectiveness compared with intravenous thrombolysis for treating acute ischemic stroke. We aimed to delineate its effectiveness and safety and their change over time. Using a prospective, multicenter stroke registry database, we identified 872 patients with ischemic stroke who underwent recanalization therapy with intravenous thrombolysis alone (IVT; n=533) or endovascular recanalization with or without intravenous thrombolysis (EVT; n=339) between April 2008 and January 2012. All subjects had National Institute of Health Stroke Scale score of 10 or more and arrived at the hospital within 4.5hours of onset. Propensity score was used to address baseline imbalances between treatment groups, but balance adjustment was not performed for subgroup analyses. The primary outcome was modified Rankin Scale score of 0-2 at discharge. The year-by-year effectiveness and safety of EVT and IVT were compared. Before 2010, the primary outcome was not associated with the recanalization method. However, in 2011, EVT increased the odds of having a primary outcome compared with IVT (adjusted odds ratio [OR], 1.87; 95% confidence interval [CI], 1.08-3.23). In 2011, EVT was superior to IVT regarding the achievement of a favorable outcome at 3months after stroke (OR, 1.99; 95% CI, 1.10-3.59). The odds of in-hospital mortality and 3-month mortality were not different over 4years. There might have been achange in the effectiveness of endovascular recanalization compared with intravenous thrombolysis, but the results remain tentative until prospectively evaluated.

Abstract T P2: A Clinical Score to Predict Major Arterial Occlusions Eligible for Endovascular Recanalization in Acute Stroke based on the ASTRAL registry

Aims: Endovascular treatment (EVT) for acute ischemic stroke (AIS) has the potential to improve clinical outcome in well selected patients with a major intracranial occlusion. This study aimed to identify easily available pre-hospital predictors and to develop a clinical score to detect AIS patients with such occlusions potentially eligible for acute EVT. Methods: Consecutive AIS enrolled in the ASTRAL registry with good quality CT-angiography within 12h after onset were selected (1’645 patients, Lausanne) and categorized according to occlusion site. Easily accessible demographic and clinical information were used in a logistic regression analysis to derive predictors of major intracranial occlusions (intracranial carotid, basilar and M1-artery). A The score was created developed using the beta-logistic regression coefficients of the logistic regression analysis, and was validated internally and externally (848 patients, Bern). Results: Major intracranial occlusions were present in 316 (21%) acute stroke patients in the derivation and 566 (28%) in the internal validation cohort. From all 12 significant predictors of major intracranial occlusions, a 7- item score was developed to obtain the best diagnostic performance; it was termed ASTRAL-O score according to its constituents: Admission NIHSS (A): (NIHSS 0-4: 0 points; 5-9: 4; 10-14: 8; ≥15: 12), absence of pre-STroke handicap (mRS≤2) (ST: 2 points), absence of previous STroke (ST: 1 point), Right-sided stroke (R: 3 points), Atrial fibrillation (A: 1 point), Level of consciousness decreased (L: 1 point) and wOmen (O:2 points). Diagnostic accuracy of the score in both the internal and external validation cohort was good at different cut-off levels (AUC 0.84 and 0.76 respectively). A Wilcoxon signed rank test showed that the ASTRAL-0 score performed better than NIHSS alone in term of predicted probabilities. Conclusions: The ASTRAL-O score accurately predicts the major intracranial occlusions eligible for EVT. It improves predicted probabilities over the NIHSS alone. This tool could help to rapidly triage stroke patients in the hyper-acute phase

Hyperattenuated Intracerebral Lesions after Mechanical Recanalization in Acute Stroke: Contrast and Compare

Lummel et al[1][1] herein report their observations regarding hyperdense cerebral lesions (HCL) identified after mechanical revascularization in acute ischemic stroke. They construct a nexus between HCL and iodinated radiographic contrast material (IRCM) deposition, which may either disappear within

Hyperattenuated Intracerebral Lesions after Mechanical Recanalization in Acute Stroke

Following mechanical recanalization of an acute intracranial vessel occlusion, hyperattenuated lesions are frequently found on postinterventional cranial CT. They represent either blood or-more frequently-enhancement of contrast agent. Here, we aimed to evaluate the prognostic value of these hyperattenuated intracerebral lesions. One hundred one consecutive patients with acute stroke in the anterior circulation who underwent mechanical recanalization were included. Risk factors for hyperattenuated intracerebral lesions were assessed, and lesion volume was compared with the volume of final infarction. Clinical outcome and relative risk of secondary hemorrhage were determined in patients with and without any hyperattenuated lesions and compared. The frequency of hyperattenuated lesions was 84.2%. Risk factors for hyperattenuated lesions were female sex, higher NIHSS score on admission, and higher amount of contrast agent applied. On follow-up, 3 patients showed no infarction; 53 patients, an ischemic infarction; and 45 patients, a hemorrhagic infarction. In all except 1 case, final volume of infarction (median = 92.4 mL) exceeded the volume of hyperattenuated intracerebral lesions (median = 5.6 mL). Patients with hyperattenuated lesions were at a 4 times higher relative risk for hemorrhagic transformation but had no significantly worse clinical outcome. Our data show that the extent of postinterventional hyperattenuated intracerebral lesions underestimates the volume of final infarction. Although hyperattenuated lesions indicate a higher risk of secondary hemorrhagic transformation, their presence seems not to be of any prognostic value regarding clinical outcome.

Periprocedural aspects in mechanical recanalization for acute stroke: data from the ENDOSTROKE registry

The ENDOSTROKE registry aims to accompany the spreading use of endovascular stroke treatment (EVT) in academic and non-academic hospitals. This analysis focuses on preprocedural imaging, patient handling and referral, as well as on different treatment modalities in mechanical recanalization. Data for this study were from observational registry study in 12 stroke centers in Germany and Austria with online assessment of prespecified variables concerning endovascular stroke therapy. Data from 734 patients undergoing EVT were analyzed. Preferred imaging modality prior to EVT was CT (83 %) and CTA (78 %). In 95 %, EVT was performed under general anesthesia. In 55 % of patients, a combination of intravenous (IV) thrombolysis and EVT was used, followed by pure EVT (25 %), intra-arterial (IA) thrombolysis plus EVT (13 %) and IV + IA thrombolysis plus EVT (7 %). Intrahospital time delay until start of EVT was 91 and 99 min in anterior and vertebrobasilar circulation stroke, respectively. Average duration of EVT was 60 min. Overall thrombolysis in myocardial infarction grade 2/3 recanalization rate was 85 %. Stent retrievers were used in 75 %, being associated with higher recanalization rates than non-stent retrievers. Hemorrhagic complications (symptomatic and asymptomatic) occurred in 12 %. Overall vessel occlusion time was approximately 60 min longer in patients being referred from a primary care hospital for EVT. This study gives an overview of procedure-related factors in current EVT practice. It gives estimates on preprocedural imaging modalities, periprocedural handling, and treatment combinations used for EVT. Patient referral for EVT from primary care hospitals is associated with longer vessel occlusion times.

Clot Burden Score on Admission T2*-MRI Predicts Recanalization in Acute Stroke

To propose a T2*-MR adaptation of the computed tomography angiography-clot burden score (CBS), and assess its value as predictor of 24-hour recanalization and clinical outcome in anterior circulation stroke treated by intravenous thrombolysis ≤4.5 hours from onset. Two independent observers retrospectively analyzed pretreatment T2* images for evaluation of clot burden, using a 10-point scale T2*-CBS. Three points are subtracted for susceptibility vessel sign in the supraclinoid internal carotid artery, 2 points each for susceptibility vessel sign in the proximal and distal part of middle cerebral artery, and 1 point each for susceptibility vessel sign in middle cerebral artery branches (with a maximum of 2 points) and for susceptibility vessel sign in anterior cerebral artery. Associations with 24-hour recanalization and favorable outcome (3-month modified Rankin Scale score, ≤2) were assessed in multivariate analyses. We analyzed 184 consecutive patients (mean age, 67 years) with median (interquartile range) admission National Institutes of Health Stroke Scale score and onset-to-treatment time of 15 (9-19) and 151 (120-185) minutes, respectively. The intraclass correlation for T2*-CBS between observers was 0.97 (95% confidence interval, 0.97-0.98). In multivariate analyses, T2*-CBS >6 was significantly associated with 24-hour recanalization (adjusted odds ratio, 5.1 [1.9-13.5]; P=0.001) or with favorable outcome (adjusted odds ratio, 4.2 [1.7-10.8]; P=0.003). T2*-CBS, a new reproducible semiquantitative score adapted from the computed tomography angiography-CBS, is associated with 24-hour recanalization and 3-month outcome after intravenous thrombolysis. This score needs external validation and could be useful to identify poor responders to intravenous thrombolysis.

Abstract WP52: A Novel CT-angiogram Based Recanalization Grading System (TICI-CTA) Correlates With Early Neurologic Response After Intravenous tPA Therapy

Introduction: Noninvasive imaging tools to assess the degree of recanalization are limited. CT-angiography (CTA) may be ideal for assessment of recanalization in view of excellent visualization of thrombus and distal vasculature; however no scoring system is available to evaluate extent of recanalization. We sought to derive a score and test it’s correlation to early neurologic response (24 hours NIHSS) within a research study having a post tPA CTA. Method: The TICI-CTA score was defined by debulking of thrombus of proximal intracranial arterial occlusive lesion (PIAOL) and forward filling of distal arterial tree.(see graphic) Data is from INTERRSeCT, an ongoing multi-center study evaluating thrombus characteristics and recanalization in acute stroke. Results: From 166, 78 patients treated with IV tPA were evaluated. The cohort had 48% males. The median time from symptom onset to baseline CTA was 114 min, and onset to IV tPA bolus was 148 min. Proximal intracranial sites of occlusions were: carotid-T 6.4%, M1-MCA 26.9%, distal MCA 58.9%, PCA 6.4%, and vertebral 1.3%. The symptom onset to follow-up post treatment CTA was 373 min. The recanalization grading TICI-CTA in post iv tPA CTA was: TICI-CTA 0 in 30 (38.4%), TICI-CTA 1A/1B in 3 (3.8%); TICI-CTA 2A/2B/2C in 17 (21.7%); and TICI-CTA 3 in 28 (35.8%). We noted a significant positive correlation between TICI-CTA score and absolute change in NIHSS from baseline to 24 hours (r=0.26, p=0.02). A positive correlation was also noted between TICI-CTA score and proportional change in NIHSS from baseline to 24 hrs (r=0.34, p&lt;0.01). Conclusion: The TICI-CTA score based on comparison of pre and post treatment CTA correlates with early neurologic response, thus showing content validity. Further validation is needed. This grading score could be used to evaluate the recanalization efficacy of novel lytics and combination therapies in phase 2 proof of concept or as a predefined CTA sub-study in a pivotal Phase 3 clinical trial.

Angioplasty as an Adjuvant Therapy for the Treatment of Acute Ischemic Stroke

Different endovascular techniques can be employed to achieve vessel recanalization in acute stroke. We assessed whether an endovascular strategy that included angioplasty was safe and effectively recanalized acutely occluded intracranial vessels. We retrospectively reviewed 70 patients that received intra-arterial therapy for acute stroke. Patients were divided into two groups depending on whether they had received angioplasty as part of their endovascular treatment. Angioplasty was used in the treatment of 35/70 patients (50%). Median baseline NIHSS was 15. The site of occlusion was at the M1 in 11 patients, M1/M2 in 3, ICA/M1 in 13 and vertebrobasilar in 8 patients. Intravenous thrombolysis was administered to 16/35 patients (46%). Angioplasty was used alone in 4 patients, in combination with intra-arterial thrombolysis in 27 and with a mechanical retrieval device or stent in 13 patients. Recanalization (TICI 2-3) was achieved in 23/35 patients (66%). Median time from symptom onset to recanalization was six hours. In patients where angioplasty was employed, symptomatic intracranial hemorrhage occurred in 2/35 (6%), which was similar to patients that were not treated with angioplasty. A favorable functional outcome (mRS=2) was achieved in 20% (7/35) at 24 hour and 34% (12/35) at one month. All patients that had a favorable outcome had recanalized. In this small cohort, an endovascular treatment strategy that employed angioplasty was safe and effectively recanalized acutely occluded intracranial vessels. Angioplasty should be considered as a potential treatment option in interventional acute stroke trials.

Ischemic Stroke in Children: New Aspects of Treatment

From the NIHROxford Biomedical Research Centre (I.G.) and Nuffield Department of Surgery (M.K.), University of Oxford, Oxford, United Kingdom; Department of Neurology, Saarland University, Homburg, Germany (S.W., K.F.); Department of arly treatment of stroke in children and infants is essential, but success is not supported by data. Recent studies have demonstrated a mortality rate of up to 3%-11% and persistent neurologic deficit in 68%-74% of affected children. The epidemiology of thrombembolism is vastly different in pediatric patients and adults. In children, the most common underlying conditions are sickle cell disease and heart disease. Other risk factors include head trauma, infections, anemia, leukocytosis, and prothrombotic disorders. Transient cerebral arteriopathy due to unilateral intracranial arterial wall disease is another frequent cause of childhood acute ischemic stroke (AIS), specifically in previously healthy children. Here the focus should be on a rigorous assessment of anti-inflammatory treatment. The treatment of AIS is evolving at a quick pace, and acute mechanical interventions to restore cerebral blood flow are now a reality in the management of acute stroke. We reviewed the available literature and identified 7 published reports on mechanical recanalization in acute stroke in children. Here we review the currently available evidence on acute arterial AIS and highlight recent advances and possible future advances in the use of mechanical devices to treat stroke in this vulnerable population. We identified references for this review through searches of PubMed from 1980 to 2010 with the terms ‘‘acute,’’ ‘‘stroke,’’ ‘‘stroke treatment,’’ ‘‘children,’’ ‘‘childhood,’’ ‘‘child,’’ ‘‘artery occlusion,’’ ‘‘pediatric,’’ ‘‘girl,’’ ‘‘boy,’’ ‘‘endovascular,’’ ‘‘pediatrics,’’ ‘‘mechanical recanalization,’’ and ‘‘stroke trials.’’ We also identified articles through searches of the authors’ personal files. Only articles published in English were reviewed. For ethical reasons, previous and ongoing stroke trials have conventionally excluded children. Thus, current treatment methodologies do not include a uniform treatment approach for the pharmacologic and interventional management of AIS in the pediatric population. Guidelines are scarce, do not involve mechanical recanalization, and are mainly those set forth by the American College of Chest Physicians and the Royal College of Physicians. These guidelines do not provide sufficient recommendations for the acute management of ischemic stroke, and are based mainly on consensus and expert opinion.

Preliminary experience with the use of self-expanding stent as a thrombectomy device in ischemic stroke

Objectives: Stent-based techniques may allow rapid arterial recanalization in acute stroke. We present our experience using a self-expanding stent to achieve transient bypass, and then as a thrombectomy device, with no permanent stent implantation, in acute stroke.Material and methods: Six patients (mean age 55, range 35-71) presented with major ischemic stroke secondary to large vessel occlusion. Patients had a National Institutes of Health stroke scale score >17, no intracerebral hemorrhage or early infarction, and a poor collateral supply to the affected parenchyma. Within 6 hours of symptom onset, a stent (Solitaire; ev3 Inc., Irvine, CA, USA) was deployed across the entire occluded segment. Repeat angiogram was performed to evaluate the reconstituted flow. The balloon of the guide-catheter was inflated for proximal carotid occlusion. The partially deployed stent was slowly pulled back (mechanical thrombectomy step) under continuous aspiration. Suction was repeated to ensure the aspiration of any clot remnants.Results: In all the cases, complete recanalization (Thrombolysis in Myocardial Infarction revascularization and reperfusion score of 3) was achieved in less than 60 minutes after femoral access, and a single thrombectomy attempt was sufficient to achieve clot removal. No stent was permanently implanted. Modified Rankin scores were 0-2 in all patients at a mean follow-up of 1 month.Conclusions: The presented approach allowed three desired effects: rapid endovascular revascularization, clot removal, and no need of leaving a permanent implant. In our preliminary experience this simple and rapid stent-based mechanical thrombectomy technique has had an unprecedented success rate.