Past, Present, and Future Perspectives on the Endovascular Treatment of Acute Ischemic Stroke

doi:10.1053/j.tvir.2011.12.001

Techniques in Vascular and Interventional Radiology

Volume 15, Issue 1, March 2012, Pages 87-92

https://doi.org/10.1053/j.tvir.2011.12.001 Get rights and content

Interventional neuroradiology plays a continuously expanding and exciting role in the treatment of acute stroke, as evidenced by the development of several important advances, including the advent of multiple new devices and therapies. Furthermore, guidelines regarding endovascular interventions in the setting of acute stroke have been developed and used. In addition to technological advances, the field of pharmacology in the setting of acute stroke is constantly evolving. In a rapidly expanding field, we aim to review significant recent advances related to the endovascular treatment of stroke as well as provide perspective for future directions.

Section snippets

Prolyse in Acute Cerebral Thromboembolism I (1998, N = 46)

The prolyse in acute cerebral thromboembolism (PROACT) trial was a multicenter, prospective, randomized controlled trial that compared the efficacy of direct IA infusion of pro-urokinase (pro-UK) versus placebo for the treatment of symptomatic middle cerebral artery (MCA) occlusion within 6 hours of stroke onset.¹⁴ Pro-UK is a proenzyme that is locally converted to urokinase by fibrin-associated plasmin at the thrombus surface, and whose effects are augmented by the presence of heparin. It is

Ongoing Trials

To avoid the need for antiplatelet agents following stent deployment, hybrid devices are now being introduced that combine removable intracranial stenting and thrombectomy: the “Solitaire FR With the Intention for Thrombectomy”²⁴ (Fig. 3) and the “Thrombectomy Revascularization of Large Vessel Occlusion in Acute Ischemic Stroke” (TREVO),²⁵ and the trials are underway on similar devices.

Logistics of Care

Improved stroke care begins at the pre-hospital stage; The California Acute Stroke Prototype Registry investigators estimate >10-fold increase in the number of patients receiving appropriate treatment if the hospital arrival time is within 1 hour of symptom onset,²⁶ highlighting the importance of public education and emergency medical services response time. Future first responders to the scene of a suspected stroke may be able to perform real-time neuroimaging rapidly with subsequent

Conclusions

Neurointerventional surgery for the treatment of ischemic stroke is a rapidly expanding field with constantly improving tools and ever evolving indications. Recanalization rates appear to be on the rise in more recent studies compared to early studies. As data continues to accumulate regarding new treatment modalities and technologies, neurosurgeons, radiologists and neurologists should come together to design new treatment paradigms. Much work remains to streamline the care of stroke patients

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Cited by (12)

New mechanical thrombectomy model in the rabbit: A feasibility study
2016, Journal of Neuroscience Methods
Citation Excerpt :
Its reported complications include cerebral hemorrhage, thrombus dislocation and vessel rupture (Campbell et al., 2015; Goyal et al., 2015). To minimize complications and to further improve clinical outcome many research groups focus on the development of new and improved devices (Arnaout et al., 2012). The most important precondition for reliable results of experimental studies is the use of an adequate animal model mimicking human conditions.
Thrombolytic therapy represented the gold standard for the treatment of ischemic stroke. Its drawbacks include increased bleeding risk and low recanalization rates. Mechanical thrombectomy is a new promising therapy option. Devices used for this procedure were substantially improved during recent years. New devices require extensive preclinical invivo testing. We therefore sought to translate the commonly used pig model to a simplified and cheaper rabbit model.
We performed thromboembolisation in eight intubated and sedated adult female New Zealand white rabbits. The thrombus was created by careful rotation of autologous blood in a silicone tube and addition of barium sulfate for radiopacity. We injected the artificial thrombus via a catheter through the cannulated femoral artery. After thromboembolisation, 2D-DSA was performed to evaluate location and thrombus dimensions.
None.
No complications or mortality were observed in our series. In seven cases (87.5%) the location of the thromboembolism was the maxillary artery and in one case (12.5%) the thrombus reached the occipital artery. The radiopaque thrombus had a length of 7.0 ± 4.55 mm invivo. Vessel diameters in angiographic evaluation were 2.44 ± 0.21 mm for the common carotid artery and 2.1 ± 0.16 mm for the maxillary artery.
The novel small animal model for mechanical thrombectomy in rabbit is technically feasible and cheap. It offers comparable vessel diameters to cranial arteries and closely mimics human coagulation system.
L-NAME combats excitotoxicity and recuperates neurological deficits in MCAO/R rats
2015, Pharmacology Biochemistry and Behavior
Citation Excerpt :
Treatment of cerebral ischaemia still remains a daunting due to its complex pathophysiological cascade and lack of time dependent therapeutic intervention (Trent et al., 2012). Though treatments such as thrombolytic agents (tissue plasminogen activator and pro-urokinase) and other endovascular procedures are currently available, pitfall like long and poor recanalisation rates, vascular rupture (haemorrhagic) and vasospasm restricts their use (Paramdeep et al., 2013; Kurre et al., 2013; Arnaout et al., 2012; Davalos et al., 2005). Extensive investigations over the past few decades revealed generation of nitric oxide, as one of the primary ground for the devastating effects of cerebral ischaemia.
Since, transient focal cerebral ischaemia exhibits detrimental effect not only during the course of ischaemia but also after the onset of reperfusion, the current study is focussed on identifying the appropriate therapeutic time point at which NG-nitro-l-arginine methyl ester (l-NAME) exerts better neuroprotection.
Pre-ischaemic administration of l-NAME ameliorated neurological deficits much better than the during ischaemic and post-ischaemic groups. Pre-ischaemic l-NAME has also mitigated glutamate excitotoxicity, increased glutamine synthetase activity, ATP and NAD levels, decreased nitrate/nitrite content, down regulated TNF-α and upregulated IL-10 expressions and reduced the cerebral infarction significantly than the during ischaemic and post-ischaemic groups.
Current study revealed that l-NAME improved neurological deficit at the pre-ischaemic state in transient focal cerebral ischaemia and has also significantly ameliorated glutamate excitotoxicity. Though l-NAME showed neuroprotective effects when administered at during and post-ischaemia (during reperfusion), it exerts considerable neuroprotection when administered pre-ischaemically.
Advantages and limitations of anesthesia and sedation practices used during endovascular revascularization therapy among acute ischemic stroke patients
2013, Journal of Radiology Nursing
Citation Excerpt :
Endovascular revascularization procedures for AIS, especially off-label use of endovascular thrombolysis with tPA, continues to be rare and controversial because of the potential risk of intracranial hemorrhage and other procedure-related complications. At the same time, the logistics of the procedure delivery have not been established yet (Arnaout et al., 2012). The choice of conscious sedation versus general anesthesia must be considered carefully based on the knowledge of the procedure, patient history, and limitations of each of the anesthesia techniques.
The purpose of this article is to establish what would be the safest type of anesthesia management that should be used during endovascular revascularization procedures among acute ischemic stroke (AIS) patients. Although still rare, endovascular treatment options are evolving; however, their efficacy has not been fully validated yet. The number of AIS patients, who would potentially benefit from endovascular revascularization procedures, is unclear because of its multiple predictors and limited scientific evidence supporting it. To safely perform endovascular interventions, these patients often require general anesthesia or sedation; however, the anesthesia management used during intra-arterial revascularization procedures varies significantly between institutions, and there are no standard protocols available.
Exploration, Development and Optimization of Eco-friendly Novel Dosage Form – Pastilles
2023, Current Drug Therapy
Cerebral ischemic reperfusion injury following recanalization of large vessel occlusions
2018, Neurosurgery
Neuroendovascular management of emergent large vessel occlusion: Update on the technical aspects and standards of practice by the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery
2018, Journal of NeuroInterventional Surgery

View all citing articles on Scopus

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Past, Present, and Future Perspectives on the Endovascular Treatment of Acute Ischemic Stroke

Section snippets

Prolyse in Acute Cerebral Thromboembolism I (1998, N = 46)

Ongoing Trials

Logistics of Care

Conclusions

Acute vertebral-basilar thrombosisAngiologic-clinical comparison and therapeutic implications

Acta Radio Suppl

Thrombolytic therapy of acute basilar artery occlusionVariables affecting recanalization and outcome

Stroke

‘Malignant’ middle cerebral artery territory infarction: Clinical course and prognostic signs

Arch Neurol

Thrombolytic therapy in acute occlusion of the intracranial internal carotid artery bifurcation

Am J Neuroradiol

Association of outcome with early stroke treatment: Pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials

Lancet

Intra-arterial thrombolytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease

Stroke

Predictors of clinical improvement, angiographic recanalization, and intracranial hemorrhage after intra-arterial thrombolysis for acute ischemic stroke

Stroke

New magnetic resonance techniques for acute ischemic stroke

JAMA

Correlations between MR diffusion perfusion studies and MRA in acute stroke

Neurology

Tissue plasminogen activator for acute ischemic strokeThe National Institute of Neurological Disorders and Stroke rt-pa stroke study group

N Engl J Med

Intravenous tissue plasminogen activator ameliorates the outcome of hyperacute embolic stroke

Cerebrovasc Dis

Combined intravenous and intra-arterial recanalization for acute ischemic stroke: The interventional management of stroke study

Stroke

The interventional management of stroke (IMS) II study

Stroke

PROACT: A phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery strokePROACT investigators. Prolyse in acute cerebral thromboembolism

Stroke

Intra-arterial prourokinase for acute ischemic strokeThe PROACT II study: A randomized controlled trial. Prolyse in acute cerebral thromboembolism

JAMA

Quality improvement and tissue-type plasminogen activator for acute ischemic stroke: A cleveland update

Stroke

Adult stroke: part 9

Circulation

Intra-arterial stroke therapy: An assessment of demand and available work force

Am J Neuroradiol

Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke emergency management of stroke (EMS) bridging trial

Stroke

Safety and efficacy of mechanical embolectomy in acute ischemic stroke results of the MERCI trial

Stroke