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Appireddy RMR, Demchuk AM, Goyal M, Menon BK, Eesa M, Choi P, Hill MD. Endovascular therapy for ischemic stroke. J Clin Neurol 2015; 11:1-8. [PMID: 25628731 PMCID: PMC4302170 DOI: 10.3988/jcn.2015.11.1.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 10/23/2014] [Accepted: 10/23/2014] [Indexed: 01/19/2023] Open
Abstract
The utility of intravenous tissue plasminogen activator (IV t-PA) in improving the clinical outcomes after acute ischemic stroke has been well demonstrated in past clinical trials. Though multiple initial small series of endovascular stroke therapy had shown good outcomes as compared to IV t-PA, a similar beneficial effect had not been translated in multiple randomized clinical trials of endovascular stroke therapy. Over the same time, there have been parallel advances in imaging technology and better understanding and utility of the imaging in therapy of acute stroke. In this review, we will discuss the evolution of endovascular stroke therapy followed by a discussion of the key factors that have to be considered during endovascular stroke therapy and directions for future endovascular stroke trials.
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Affiliation(s)
- Ramana M R Appireddy
- Department of Clinical Neurosciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew M Demchuk
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Departments of Clinical Neurosciences and Radiology, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Muneer Eesa
- Department of Radiology, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Philip Choi
- Department of Clinical Neurosciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Departments of Clinical Neurosciences, Medicine, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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Sheth SA, Sanossian N, Hao Q, Starkman S, Ali LK, Kim D, Gonzalez NR, Tateshima S, Jahan R, Duckwiler GR, Saver JL, Vinuela F, Liebeskind DS. Collateral flow as causative of good outcomes in endovascular stroke therapy. J Neurointerv Surg 2014; 8:2-7. [PMID: 25378639 DOI: 10.1136/neurintsurg-2014-011438] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 10/20/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Endovascular reperfusion techniques are a promising intervention for acute ischemic stroke (AIS). Prior studies have identified markers of initial injury (arrival NIH stroke scale (NIHSS) or infarct volume) as predictive of outcome after these procedures. We sought to define the role of collateral flow at the time of presentation in determining the extent of initial ischemic injury and its influence on final outcome. METHODS Demographic, clinical, laboratory, and radiographic data were prospectively collected on a consecutive cohort of patients who received endovascular therapy for acute cerebral ischemia at a single tertiary referral center from September 2004 to August 2010. RESULTS Higher collateral grade as assessed by the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) grading scheme on angiography at the time of presentation was associated with improved reperfusion rates after endovascular intervention, decreased post-procedural hemorrhage, smaller infarcts on presentation and discharge, as well as improved neurological function on arrival to the hospital, discharge, and 90 days later. Patients matched by vessel occlusion, age, and time of onset demonstrated smaller strokes on presentation and better functional and radiographic outcome if found to have superior collateral flow. In multivariate analysis, lower collateral grade independently predicted higher NIHSS on arrival. CONCLUSIONS Improved collateral flow in patients with AIS undergoing endovascular therapy was associated with improved radiographic and clinical outcomes. Independent of age, vessel occlusion and time, in patients with comparable ischemic burdens, changes in collateral grade alone led to significant differences in initial stroke severity as well as ultimate clinical outcome.
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Affiliation(s)
- Sunil A Sheth
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
| | - Nerses Sanossian
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Qing Hao
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
| | - Sidney Starkman
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Latisha K Ali
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
| | - Doojin Kim
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
| | - Nestor R Gonzalez
- Division of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, California, USA Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, California, USA
| | - Reza Jahan
- Division of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, California, USA
| | - Gary R Duckwiler
- Division of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, California, USA
| | - Jeffrey L Saver
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
| | - Fernando Vinuela
- Division of Interventional Neuroradiology, University of California Los Angeles, Los Angeles, California, USA
| | - David S Liebeskind
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
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154
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Abstract
Several landmark clinical trials of endovascular therapy for acute ischemic stroke have recently jolted the concerted multidisciplinary efforts to develop effective revascularization strategies. Further consideration of these four endovascular stroke trials published in the last year suggests a more fundamental question: are these trials of specific treatments or have the results simply reflected the importance of underlying pathophysiology? Data from IMS III, MR RESCUE, SWIFT and TREVO2 consistently demonstrate the dramatic impact of collateral perfusion in acute ischemic stroke. Such collateral, or parallel, trials of the underlying pathophysiology in stroke reveal that diagnosis or selection of optimal candidates may be paramount to the specific drug or device therapy. Future trials of endovascular therapies may harness the influential role of collaterals as critical selection criteria for intervention, with triage based on imaging rather than time alone. Treating the optimal patient may be more important than chasing an elusive magical therapy.
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