Recanalization Of Large Vessel Occlusions Research Articles

Single-center experience with the Tigertriever device for the recanalization of large vessel occlusions in acute ischemic stroke

BackgroundTigertriever (Rapid Medical, Yoqneam, Israel) is a new design of stent retriever.PurposeTo evaluate the feasibility, safety, and efficacy of the Tigertriever in patients with acute ischemic stroke who have undergone...

Cerebral Ischemic Reperfusion Injury Following Recanalization of Large Vessel Occlusions.

Although stroke has recently dropped to become the nation's fifth leading cause of mortality, it remains the top leading cause of morbidity and disability in the US. Recent advances in stroke treatment, including intravenous fibrinolysis and mechanical thromboembolectomy, allow treatment of a greater proportion of stroke patients than ever before. While intra-arterial fibrinolysis with recombinant tissue plasminogen is an effective for treatment of a broad range of acute ischemic strokes, endovascular mechanical thromboembolectomy procedures treat severe strokes due to large artery occlusions, often resistant to intravenous drug. Together, these procedures result in a greater proportion of revascularized stroke patients than ever before, up to 88% in 1 recent trial (EXTEND-IA). Subsequently, there is a growing need for neurointensivists to develop more effective strategies to manage stroke patients following successful reperfusion. Cerebral ischemic reperfusion injury (CIRI) is defined as deterioration of brain tissue suffered from ischemia that concomitantly reverses the benefits of re-establishing cerebral blood flow following mechanical or chemical therapies for acute ischemic stroke. Herein, we examine the pathophysiology of CIRI, imaging modalities, and potential neuroprotective strategies. Additionally, we sought to lay down a potential treatment approach for patients with CIRI following emergent endovascular recanalization for acute ischemic stroke.

A comparison of direct aspiration versus stent retriever as a first approach (‘COMPASS’): protocol

Background and objectiveAcute ischemic stroke is a potentially devastating condition and leading cause of morbidity and mortality, affecting an estimated 800 000 people per year in the USA. The natural...

Thrombolysis in Real Time: Demonstration of Revascularization with Intravenous Thrombolysis Therapy in the CT Scanner

Administration of intravenous tissue plasminogen activator (tPA) in the computed tomography (CT) scanner has been recently implemented at our institution, as a means to decrease door-to-needle time. This change in protocol provided us a unique opportunity to visualize imaging signs of early recanalization. We evaluated patients who presented with acute ischemic stroke both before and after a change in protocol for intravenous tPA administration. We identified 10 patients who received tPA on the CT scanner and 22 patients who received tPA after CT imaging was complete. Early recanalization was defined as distal migration of thrombus or disappearance of thrombus between initial phases of imaging, large territory of diminished mean transit time on initial perfusion CT, large territory of increased cerebral blood flow on initial perfusion CT, and/or large territory of increased cerebral blood volume on initial perfusion CT. Late recanalization was defined as distal migration of thrombus or disappearance of thrombus between initial and follow-up imaging, decreased attenuation of thrombus between initial and follow-up imaging, or infarcted territory on follow-up imaging smaller than the cerebral blood volume defect on initial perfusion CT. In the patients who received tPA on the CT scanner, 20% demonstrated imaging evidence of early recanalization and 30% demonstrated imaging evidence of late recanalization. In the patients who received tPA after CT imaging, 57% demonstrated imaging evidence of late recanalization. Early recanalization of large-vessel occlusion after intravenous thrombolysis results in unique imaging findings.

ARTS (Aspiration-Retriever Technique for Stroke): Initial clinical experience.

A new generation of highly navigable large-bore aspiration catheters and retriever devices for intracranial mechanical thrombectomy has markedly improved recanalization rates, time and clinical outcomes. We report collected clinical data utilizing a new technique based on combined large lumen aspiration catheter and partially resheathed stent retriever (ARTS: Aspiration (catheter)-(stent) Retriever Technique for Stroke). This technique is applied, especially in presence of bulky/rubbery emboli, when resistance is felt while retracting the stent retriever; at that point the entire assembly is locked and removed in-toto under continuous aspiration with additional flow arrest. A retrospective data analysis was performed to identify patients with large cerebral artery acute ischemic stroke treated with ARTS. The study was conducted between August 2013 and February 2015 at a single high volume stroke center. Procedural and clinical data were captured for analysis. Forty-two patients (median age 66 years) met inclusion criteria for this study. The ARTS was successful in achieving Thrombolysis in Cerebral Infarction (TICI) ≥2b revascularization in 97.6% of cases (TICI 2b = 18 patients, TICI 3 = 23 patients). Patients' median National Institutes of Health Stroke Scale score at admission was 18 (6-40). A 3-month follow-up modified Rankin Scale value of 0-2 was achieved in 65.7% of the successfully treated patients (average 2.4). Two patients (4.8%) developed symptomatic intraparenchymal hemorrhages. Six procedure unrelated deaths were observed. We found that ARTS is a fast, safe and effective method for endovascular recanalization of large vessel occlusions presenting within the context of acute ischemic stroke.

Pre and intrahospital workflow for acute stroke treatment.

With the recent demonstration of the effectiveness of rapid recanalization of large vessel occlusions in acute ischemic stroke, it is important to assess the current status of pre and intrahospital workflow for acute stroke. We will review trends in the evaluation and treatment of acute stroke and offer suggestions for how best to advance the workflow for acute stroke care in the coming years. Future research is needed for: field use of clinical scores for predicting large vessel occlusions, telemedicine to facilitate prehospital triage, and pre and intrahospital processes for optimizing stroke care delivery.

Abstract TP68: Recanalization of Large Vessel Occlusion in the Golden Hour of IV tPA Administration for Ischemic Stroke

Introduction: Intracranial large vessel occlusions (LVO) are responsible for approximately 45% of ischemic strokes and the cause of detrimental ischemic strokes associated with poor outcome and high mortality. Little data exist about rates of LVO recanalization with ultra-early administration of IV tPA. Hypothesis: IV tPA given within the first, so called "golden hour", of symptom onset increases recanalization rates in LVO. Methods: Retrospective chart review of all patients who received tPA and were subsequently treated in our health system in 2014. We identified patients that had occlusion of internal carotid artery (ICA) , M1 middle cerebral artery (MCA), A1 segment anterior cerebral artery (ACA), or basilar artery on CTA, MRA, or angiography and compared recanalization rates within 6 hours after administration of IV tPA between those that received tPA ultra-early (≤ 1 hour after symptom onset) versus those that received tPA beyond 1 hour. Results: In 2014, 168 patient received IV tPA of which 35 had LVO. Of these, 9 patients received tPA within one hour of symptom onset while the remaining 26 patients were treated after one hour. Both groups did not differ in regards to age, gender, initial NIHSS, and occluded vessel. Table 1 summarizes the results. Conclusions: Ultra-early IV tPA administration within the "golden hour" appears to have higher LVO recanalization rates as compared to later treatment. Further studies of reperfusion rates in LVO strokes with ultra-early thrombolysis are warranted.

Impact of the Implementation of Thrombectomy with Stent Retrievers on the Frequency of Hemicraniectomy in Patients with Acute Ischemic Stroke.

The increasing use of endovascular treatments has led to higher recanalization rates and better clinical outcomes compared with intravenous thrombolysis alone. Stent retrievers represent the latest development for recanalization of large vessel occlusions. Decompressive hemicraniectomy has proved beneficial in patients suffering from rising intracranial pressure after malignant stroke. We investigated the effect of the implementation of stent retriever treatment on the frequency of hemicraniectomy as a surrogate marker for infarct size and thus for poor neurological outcome. Patients with acute ischemic stroke were retrospectively studied. We compared the frequency of hemicraniectomy following proximal artery occlusion of the internal carotid artery and middle cerebral artery main stem in the years before (2009 and 2010) and after (2012 and 2013) introducing stent retrievers. Overall, 497 patients with proximal arterial occlusion were included in the study. Of 253 patients admitted in the years 2009 and 2010 44 (17.4 %) and of 244 patients admitted in 2012 and 2013, 20 (8.2 %) received a hemicraniectomy. This decrease in the proportion of hemicraniectomies was statistically significant (p < 0.01). The findings in this study illustrate a significantly reduced rate of hemicraniectomies in patients with proximal artery occlusions after implementation of thrombectomy with stent retriever. Hereby, we could show a significant reduction of malignant infarctions after thrombectomy with stent retriever.

P-014 arts (ace-retriever technique for stroke): initial clinical experience

Background The development of a new generation of highly navigable large bore aspiration catheters and retriever devices, dedicated to the revascularization of large intracranial vessel occlusions in the context of acute ischemic stroke (AIS), has improved recanalization rates and time, with significant impact on clinical outcomes. We report a retrospectively collected clinical data utilizing a new recanalization technique based on combined large lumen aspiration catheter and partially resheathed stent retrievers for thrombectomy (ARTS: ACE-Retriever Technique for Stroke). Methods A retrospective data analysis was performed to identify patients with acute ischemic stroke treated at our institution with ARTS for occluded large cerebral vessels recanalization. The study was conducted between July 2013 and October 2014 at a single high volume stroke center. Procedural and clinical data were captured for analysis, including recanalization rate, post-treatment National Institutes of Health Stroke Scale (NIHSS) score, symptomatic intracranial hemorrhage, discharge 90 day modified Rankin Scale (mRS) score, and mortality. Results 40 patients (average age of 64.5 years, range 90–20 years; 24 F:16 M) were found that met the inclusion criteria for this retrospective study. The ARTS was successful in achieving Thrombolysis in Cerebral Infarction (TICI) 2b or 3 revascularization in 97.5% of cases (TICI 2b = 18 pts, TICI 3 = 21 pts). The average time from groin puncture to at least TICI 2b recanalization was 62 min. In patients with successful recanalization, admitted with median National Institutes of Health Stroke Scale (NIHSS) score of 16.7 (6.0–29.0), was observed a value improvement to a median NIHSS score at discharge of 3.4 (0–13.0). In eight patients (20%), the association of a carotid bifurcation severe stenosis/occlusion and intracranial large vessel occlusion (tandem lesions), required a carotid stent deployment along the cervical segment of the internal carotid artery. A 3 month follow-up Modified Rankin Scale (mRS) value of 0–2 was observed in 48.5% of the successfully treated patients (average 2.6). Two patients were lost to follow-up. No procedure related deaths were observed. Conclusions Mechanical thrombectomy utilizing combined 5 MAX ACE aspiration catheter and Stent Retrievers Technique for Stroke treatment (ARTS) is a fast, safe and effective method for endovascular recanalization of large vessel occlusions presenting within the context of AIS. Disclosures F. Massari: None. N. Henninger: None. J. Lozano: None. M. Howk: None. M. Perras: None. C. Brooks: None. M. Gounis: 1; C; NIH, Philips Healthcare, Covidien, Codman, Stryker, Wyss Institute, Tay Sachs Foundation. 2; C; Stryker (fee per hour). A. Wakhloo: 1; C; Philips Medical. 2; C; Stryker. 3; C; Harvard Postgraduate Course, Miami Baptist Vascular Institute. A. Puri: 1; C; Stryker. 2; C; Codman, Covidien.

Distal aspiration with retrievable stent assisted thrombectomy for the treatment of acute ischemic stroke

ObjectiveFlexible large lumen aspiration catheters and stent retrievers have recently become available in the USA for the revascularization of large vessel occlusions presenting within the context of acute ischemic stroke...

Self-Expandable Stents in the Treatment of Acute Ischemic Stroke Refractory to Current Thrombectomy Devices: Single Center Experience (P06.212)

Objective: This study examines the outcomes of recanalization of large vessel occlusions in acute ischemic stroke. The interventions compared are the Mechanical Embolus Removal in Cerebral Ischemia, the Penumbra System, and self-expandable stents. Background Recanalization of occluded large vessels is a sign of good prognosis in ischemic stroke. With FDA approved thrombectomy devices such as the Concentric Thrombus Retriever (Concentric Medical; Mountain View, CA, USA) and the Penumbra System (Penumbra Inc.; Alameda, CA, USA), recanalization rates have been reported to range between 40-81%. Recent research, however, has shown self-expandable stents (SES) to be a safe option for flow restoration in cases of acute ischemic stroke (AIS), with higher recanalization rates than other treatments at 92-100%. Design/Methods: All cases of self-expandable stent deployment as a acute ischemic stroke (AIS) intervention from August 2008 to the current time at Baptist Cardiac & Vascular Institute are included in this study. Stent intervention was used during AIS according to a National Institute of Health Stroke Scale (NIHSS)≥ 4, due to large vessel occlusion where thrombolysis and mechanical thrombectomy failed to restore flow. A good outcome was defined as a modified Rankin Scale (mRS) ≤2 one month after hospital discharge. This was assessed at follow-up visits or by a structured telephone interview. Recanalization of the vessel was assessed using the Thrombolysis in Myocardial Infarction (TIMI) grading system by a physician not involved with the procedure and blinded from the clinical outcome. Results: Twenty-four stented patients have been included in the study at this point. Forty-one percent of patients had a good outcomes (mRS ≤2) and 95% of patients were reperfused with SES. Symptomatic intracerebral hemorrhage (sICH) occurred in 13% of patients and overall mortality was 21%. Conclusions: SES is a safe and effective alternative when thrombolysis and mechanical thrombectomy fail. Disclosure: Dr. Garland has nothing to disclose. Dr. Linfante has received personal compensation for activities with Micrus Corporation and Codman Neurovascular as a consultant.Dr. Linfante has received research support from Surpass Medical Inc. Dr. Samaniego has nothing to disclose.

Treatment with tPA Predicts Better Outcome Even if MCA Occlusion Persists

Functional improvement after middle cerebral artery ischaemia seems to depend on recanalization of large-vessel occlusion as early as possible. The only approved medical treatment for acute stroke is early IV tissue plasminogen activator administration. However, while some patients do not benefit from quick recanalization, others recover despite persistent middle cerebral artery occlusion. We wondered whether there are different effects of tissue plasminogen activator treatment on large artery and small artery reopening. We enrolled 55 acute stroke patients who showed persisting middle cerebral artery occlusion evidenced by transcranial colour-coded duplex ultrasonography in follow-up examination within 48 h postonset of middle cerebral artery stroke syndromes (mean 30·8 ± 5·4 h after admission). Twenty-two of 55 had been treated with tissue plasminogen activator and 33/55 had been treated without tissue plasminogen activator. We compared neurological (National Institutes of Health Stroke Scale) and functional (modified Rankin Scale) scores at baseline, after seven-days, and then after two-months. Risk factors, previous stroke prophylaxis, as well as clinical baseline characteristics were analysed to exclude significant differences between both groups. Despite later admission to hospital (tissue plasminogen activator patients 1·6 ± 0·66 h vs. non-tissue plasminogen activator patients 7·4 ± 5·84 h; P < 0·001), there was no significant difference between both groups concerning demographic data, severity of symptoms on admission, risk factors, stroke prophylaxis, as well as basic laboratory values (international normalized ratio, leucocyte count, C-reactive protein) blood pressure and body temperature on admission. Irrespective of Doppler findings demonstrating persistent middle cerebral artery occlusion in all 55 patients, there was a significant neurological and functional improvement in tissue plasminogen activator patients compared to non-tissue plasminogen activator patients. Tissue plasminogen activator patients had a mean improvement on National Institutes of Health Stroke Scale within the first seven-days of 2·8 points, while non-tissue plasminogen activator patients deteriorated by 2·2 points (P < 0·001). Concerning modified Rankin Scale tissue plasminogen activator-treated patients showed a mean improvement within the first seven-days of 0·5 points, while non-tissue plasminogen activator patients deteriorated by 0·3 points (P = 0·019). A favourable overall short-term clinical course (i.e. improvement on National Institutes of Health Stroke Scale >3 points and/or modified Rankin Scale >1 point) was found in 36·4% of tissue plasminogen activator patients and in 6·1% of non-tissue plasminogen activator patients (P = 0·0047). At two-months follow-up, patients still showed a median modified Rankin Scale of 4 points after tissue plasminogen activator treatment and 5 points after non-tissue plasminogen activator treatment (P = 0·023). Although the prognosis of patients with persisting middle cerebral artery occlusion after tissue plasminogen activator administration is known to be poor, patients do better if treated with tissue plasminogen activator vs. those who could not be treated - mainly for late presentation. This may be due to sufficient small vascular territory recanalization despite persistence of large artery occlusion after tissue plasminogen activator treatment.

Mechanical thrombectomy for acute ischemic stroke: The road thus far

Early restoration of flow to perfuse the salvageable brain tissue in acute ischemic stroke significantly reduces mortality and morbidity. Recanalization of large vessel occlusions has not been more than 10-20% with intravenous thrombolysis. Use of mechanical devices in acute ischemic stroke has shown promise in greater recanalization rates and hopefully will yield more optimal stroke outcomes. The results of the recent trials appear promising as the devices continue to evolve, become more operator friendly, and patient outcomes improve.

Initial experience with a self-expanding retrievable stent for recanalization of large vessel occlusions in acute ischemic stroke

Quicker recanalization results in better clinical outcomes in patients with acute ischemic strokes. We describe our experience with the use of a self-expanding, fully retrievable stent in acute intracranial occlusions. Patients who underwent intra-arterial procedures with a self-expanding, fully retrievable stent for acute ischemic strokes at our center in 2009 were included in this study. The primary outcome was recanalization [Thrombolysis in Myocardial Infarction (TIMI) grade 2/3] at end of procedure. Secondary endpoints were procedural interval times, incidence of vasospasm, rupture of vessels, device-related complications, groin complications, postprocedural intracerebral hemorrhage (ICH) on noncontrast CT, and all-cause mortality. Fourteen patients (mean age 62.1years, range 34-81years; six males) were included in the study. Sites of occlusion are as follows: M1 middle cerebral artery (MCA, n = 8), M2 MCA (n = 1), proximal basilar artery (n = 1), and distal basilar artery (n = 4). An additional device or technique was used in 9 of 14 patients prior to the use of the retrievable stent. Twelve out of 14 (85.7%) achieved TIMI 2-3 recanalization with 4 of 14 (28.6%) achieving TIMI 3. Eight of 14 (57.1%) patients had modified Rankin Scale (0-2) at 3months or discharge. ICH on follow-up CT was noted in 28.6% (4 of 14) of patients. All-cause mortality was 2 of 14 (14.3%). Use of a novel self-expanding, fully retrievable stent resulted in fast and very high recanalization rates in acute ischemic strokes with intravascular occlusions.

E-002 Initial experience with the Penumbra stroke system for recanalization of large vessel occlusions in acute ischemic stroke

BackgroundThe Penumbra system is a newly approved mechanical device for the treatment of acute stroke designed for better and faster recanalization. We describe our initial experience with the use of...

Initial experience with the Penumbra Stroke System for recanalization of large vessel occlusions in acute ischemic stroke

The Penumbra system is a newly approved mechanical device for the treatment of acute stroke designed for better and faster recanalization. We describe our initial experience with the use of this device. We studied 27 consecutive patients with acute ischemic strokes due to arterial occlusions presenting at our center from January to October 2009. The primary outcome was the degree of recanalization measured by thrombolysis in myocardial infarction (TIMI grade 2/3) at the end of the procedure. Secondary end points were the proportion of patients who achieved a modified Rankin scale (mRS) ≤2 at 3months, all-cause mortality and intracerebral hemorrhage (ICH) on non contrast computed tomography at 24h. Procedural complications were also recorded. Of 27 patients (13 male, mean age 61years) in the study, 22 (81%) patients had anterior circulation strokes and five (18%) had posterior circulation strokes. Twenty-three (85%) patients achieved TIMI grade 2/3 recanalization at completion of the procedure. Excluding five patients who needed use of a second device, the Penumbra system achieved TIMI grade 2/3 recanalization in 67% of patients. Thirteen (48%) patients had mRS ≤2 at 3-month follow-up. Procedural and post-procedural complications included vasospasm (3.7%), distal emboli (48.1%), and ICH (33.3%). The distribution of ICH is as follows: hemorrhagic infarct type 1 (25.9%), parenchymal hemorrhage type 1 (3.7%), and parenchymal hemorrhage type 2 (3.7%). All-cause mortality was 19%. High recanalization rates and good clinical outcomes are achievable with the Penumbra system. Complication rates are comparable to a previously published literature.