机械取栓装置在缺血性卒中患者治疗中的应用

目前,在发病4．5h内进行静脉溶栓仍然是治疗急性缺血性卒中患者的最有效方法。对于不符合静脉溶栓治疗标准、静脉溶栓后症状无明显改善甚至恶化的患者,血管内介入治疗是一种安全的替代治疗方法。经动脉机械取栓装置能实现迅速和完全的血管再通,为急性缺血性卒中患者提供了更多的治疗选择。文章对近年来机械取栓装置相关的技术演变和临床试验进行了综述。     

静脉溶栓桥接治疗急性缺血性卒中

静脉溶栓是治疗急性缺血性卒中的首选方法,但在大血管闭塞性卒中患者中的血管再通率较低.以血管内机械血栓切除术为代表的血管内治疗能有效使缺血性卒中患者闭塞血管再通和改善转归.文章对静脉溶栓桥接治疗的现状和发展方向进行了综述.     

No space left for intravenous thrombolysis in acute stroke: PROS

Five recently published RCTs (MR CLEAN, EXTEND-IA, SWIFT PRIME, REVASCAT and ESCAPE) employing mechanical thrombectomy with modern stent retriever devices clearly demonstrated the superiority of endovascular treatment compared to thrombolysis alone, which is now considered standard first-line therapy for selected patients with acute severe ischemic stroke and large vessel in the anterior circulation. RCT results led to recommendations outlined in “Mechanical thrombectomy in acute ischemic stroke by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN”. Moreover, endovascular procedures in the 5 RCTs to date were performed at high-volume referral centers with, in some trials, rigid requirements for the interventionalist to participate, which may have contributed substantially to the excellent results, supporting the concept of centralization of intra-arterial thrombolysis resources and expertise. Therefore, patients with suspected large-artery occlusion and deemed candidates for thrombectomy, should be treated at a Comprehensive Stroke Centre with 24/7 endovascular treatment services. There seems to be limited space left for intravenous thrombolysis alone in acute stroke patients with large-vessel occlusions as thrombectomy plus thrombolysis continues to be reported as being superior with regard to outcome.     

Treatment of acute stroke: an update

Stroke is the second leading cause of global mortality after coronary heart disease, and a major cause of neurological disability. About 17 million strokes occur worldwide each year. Patients with stroke often require long‐term rehabilitation following the acute phase, with ongoing support from the community and nursing home care. Thus, stroke is a devastating disease and a major economic burden on society. In this overview, we discuss current strategies for specific treatment of stroke in the acute phase, focusing on intravenous thrombolysis and mechanical thrombectomy. We will consider two important issues related to intravenous thrombolysis treatments: (i) how to shorten the delay between stroke onset and treatment and (ii) how to reduce the risk of symptomatic intracerebral haemorrhage. Intravenous thrombolysis has been approved treatment for acute ischaemic stroke in most countries for more than 10 years, with rapid development towards new treatment strategies during that time. Mechanical thrombectomy using a new generation of endovascular tools, stent retrievers, is found to improve functional outcome in combination with pharmacological thrombolysis when indicated. There is an urgent need to increase public awareness of how to recognize a stroke and seek immediate attention from the healthcare system, as well as shorten delays in prehospital and within‐hospital settings.     

急性缺血性卒中再灌注治疗后血管再闭塞

急性缺血性卒中是最常见的卒中类型,在发病4.5 h内进行静脉溶栓仍是目前最有效的治疗方法.其他再灌注治疗,如血管内血栓切除术也显示出其安全性和有效性.然而,部分接受再灌注治疗的患者会出现血管再闭塞,且与转归不良相关.文章对再灌注后血管再闭塞的发生机制和可能防治措施进行了综述.     

Acute myocardial infarction and acute stroke: What are the differences? Focus on reperfusion therapy

This review compares acute myocardial infarction and acute stroke— their similarities and differences. The focus is given on reperfusion therapy: pharmacologic, mechanical or combined. The key trials and metaanalyses are described.The published data on iv. thrombolysis show, that even among a subgroup of patients treated within 90 min from stroke onset the trend to lower mortality is not significant and in all other subgroups (i.e. treated after >90 min) there is a trend towards increased mortality with thrombolytic treatment.The data on combined therapy demonstrate, that there is no benefit from facilitated intervention (iv. thrombolysis followed by ia. thrombolysis ± catheter intervention) over iv. thrombolysis alone in acute stroke. This is very similar to the situation in acute myocardial infarction 25 years ago (intracoronary thrombolysis was not superior to intravenous thrombolysis) or more recently (facilitated PCI was not shown to be superior in several trials).The latest generation of stent retrievers is able to recanalize >70% of occluded intracranial arteries—approximately twice more compared to thrombolysis. However, it is not yet known whether this translates to better clinical outcomes. The sufficient data on clinical outcomes after primary catheter-based thrombectomy (without thrombolysis) are still missing and trials comparing iv. thrombolysis versus primary catheter-based thrombectomy are urgently needed.The future trials in acute stroke may follow the way paved by acute myocardial infarction trials. If such trials would demonstrate superiority of catheter-based thrombectomy, we can face in future similar revolution in acute stroke treatment as we have been facing in acute MI treatment in the past years.     

Stroke intervention: catheter-based therapy for acute ischemic stroke

The majority (>80%) of the three-quarters of a million strokes that will occur in the United States this year are ischemic in nature. The treatment of acute ischemic stroke is very similar to acute myocardial infarction, which requires timely reperfusion therapy for optimal results. The majority of patients with acute ischemic stroke do not receive any form of reperfusion therapy, unlike patients with acute myocardial infarction. Improving outcomes for acute stroke will require patient education to encourage early presentation, an aggressive expansion of qualified hospitals, and willing providers and early imaging strategies to match patients with their best options for reperfusion therapy to minimize complications.     

Management of Acute Ischemic Stroke

The treatment of acute ischemic stroke includes both intravenous (IV) thrombolysis and mechanical thrombectomy. Important advances regarding both treatment modalities have occurred recently that all physicians who see patients at risk for or who have had a stroke should be aware of. This review will focus on recent clinical trials of IV thrombolysis both positive and negative. Additionally, the results of a large number of early and late time window thrombectomy trials will be presented that demonstrate the remarkable efficacy of this treatment for appropriately selected patients.     

No space left for intravenous thrombolysis in acute stroke: CONS

Recent successful clinical trials of endovascular thrombectomy for large artery ischaemic stroke have established the value of this treatment modality as an adjunct to intravenous thrombolysis, not as an alternative: thrombectomy delivery was undertaken in the context of highly efficient networks for acute thrombolysis delivery and the great majority of patients received IV thrombolytic drug treatment. Even for the minority of acute stroke patients for whom thrombectomy is potentially relevant, access will be limited by geography and service infrastructure. Developments in intravenous thrombolysis in the near future will likely produce safer and more effective intravenous treatments. Intravenous thrombolysis will remain the first line of treatment for the great majority of acute stroke patients.     

Characteristic and prognosis of acute large vessel occlusion in anterior and posterior circulation after endovascular treatment: the ANGEL registry real world experience

There were limited studies comparing the anterior (AC) and posterior (PC) circulation acute ischemic strokes (AIS). Our study aimed to evaluate distinct features of AC and PC strokes regarding clinical, vascular risk, pathogenesis and outcome factors after endovascular procedures. This multicenter prospective study registered 873 patients with acute large occlusion of anterior circulation stroke (ACS) and posterior circulation stroke (PCS). Patients who underwent endovascular procedures were included in this study. The differences in ACS and PCS regarding baseline characteristics, post-operative intracranial hemorrhage and outcomes were evaluated. A total of 741 patients were included in the data analysis. Intravenous thrombolysis (31.5%), atrial fibrillation (22.7%) and stent thrombectomy (82.4%) were more frequently observed in ACS patients. While higher NIHSS score, hypertension (67.6%) and balloon angioplasty (20.7%) were more prevalent in PCS patients. Symptomatic intracranial hemorrhage was more common in ACS (7.4% vs 2.8%). However, a 3-month follow-up outcomes were better in ACS with higher functional independence and low mortality rate than PCS (46.8% vs 30.3% and 16.4% vs 33.8%, respectively, P?<?0.01). In this large prospective study, there were significant differences in the pathogenesis of stroke and treatment procedure between ACS and PCS which influence the clinical outcome. These findings could lead to a tailored clinical procedures and treatment strategies to improve the prognosis in both groups.

     

Nouveautés dans la prise en charge de l’infarctus cérébral en 2014 : ce que le cardiologue doit savoir

Introduction

Interventional cardiology procedures are regularly exposed to ischemic neurological complications. IV fibrinolysis is the only approved treatment in ischemic stroke but is very often contraindicated in these situations. Many techniques of interventional neuroradiology (mechanical thrombectomy) have been developed over the past years and are used to treat these patients.

Observation

We report the case of two patients who were admitted in emergency for ischemic stroke with contraindication to IV fibrinolysis (cardioversion for atrial fibrillation under anticoagulation; 24 hours after carotid surgery). These patients were treated by endovascular thrombectomy procedure.

Discussion

After validation of IV fibrinolysis within 4.5 hours after stroke onset, techniques of mechanical thrombectomy have gradually been developed, either as a complementary treatment or as an alternative in the case of CI to fibrinolysis. These endovascular thrombectomy devices currently allow recanalization of proximal cerebral occlusions, which correlates with a favorable clinical prognosis. A review of the literature is provided, along with a discussion about the techniques currently being improved, their advantages and disadvantages and the selection of patients that can benefit from endovascular procedures.

Conclusion

In the case of a sudden occurrence of a neurological deficit during a cardiovascular procedure, a “thrombolysis alert” should be triggered. This will permit the rapid establishment of a clinico-radiological report for selecting stroke patients eligible for a procedure of recanalization by thrombolysis and/or mechanical thrombectomy.     

Effect of thrombolysis in a mobile stroke unit versus in hospital for patients with ischemic stroke: A protocol for systematic review and meta-analysis of randomized controlled trials

Introduction:Ischemic stroke caused by arterial occlusion is the cause of most strokes. The focus of treatment is rapid reperfusion through intravenous thrombolysis and intravascular thrombectomy. Two acute stroke management including prehospital thrombolysis and in hospital have been widely used clinically to treat ischemic stroke with satisfied efficacy. However, there is no systematic review comparing the effectiveness of these 2 therapies. The aim of this study is to compare the effect of prehospital thrombolysis versus in hospital for patients with ischemic stroke.Methods and analysis:The following electronic databases will be searched: Web of Science, PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBM), Wanfang Database, and Chinese Scientific Journal Database.The randomized controlled trials of prehospital thrombolysis versus in hospital for ischemic stroke will be searched in the databases from their inception to December 2020 by 2 researchers independently. Onset to therapy (OTT) duration and National Institute Health Stroke Scale (NIHSS) scores will be assessed as the primary outcomes; safety assessment including intracerebral hemorrhage (ICH) and mortality will be assessed as the secondary outcomes. The Review Manager 5.3 will be used for meta-analysis and the evidence level will be assessed by using the method for Grading of Recommendations Assessment, Development and evaluation Continuous outcomes will be presented as the weighted mean difference or standardized mean difference with 95% confidence interval (CI), whereas dichotomous data will be expressed as relative risk with 95% CI. If heterogeneity existed (P < .05), the random effect model was used. Otherwise, we will use the fixed effect model for calculation.Ethics and dissemination:Ethical approval is not required because no primary data are collected. This review will be published in a peer-reviewed journal.PROSPERO registration number:CRD42020200708     

New Cerebral Microbleeds After Mechanical Thrombectomy for Large-Vessel Occlusion Strokes

The interval appearance of cerebral microbleeds (CMBs) after endovascular treatment has never been described. We investigated the frequency and predictors of new CMBs that developed shortly after mechanical thrombectomy for acute ischemic stroke, and its impact on clinical outcome.We retrospectively analyzed patients with large-vessel occlusion strokes treated with Merci Retriever, Penumbra System, or stent-retriever devices. Serial T2∗-weighted gradient-recall echo (GRE) magnetic resonance imaging (MRI) before and 48 h after endovascular thrombectomy were assessed to identify new CMBs. We examined independent factors associated with new CMBs after mechanical thrombectomy. We analyzed the association of the presence, burden, and distribution of new CMBs with clinical outcome.A total of 187 consecutive patients with serial GRE were enrolled in this study. CMBs were evident in 36 (19.3%) patients before mechanical thrombectomy. New CMBs occurred in 41 (21.9%) patients after mechanical thrombectomy. Of the 68 new CMBs, 45 appeared in the lobar location, 18 in the deep location and 5 in the infratentorial location. The presence of baseline CMBs was associated with new CMBs after mechanical thrombectomy (OR 5.38; 95% CI 2.13–13.59; P < 0.001), no matter whether the patients were treated primarily with mechanical thrombectomy or with intravenous thrombolysis followed by mechanical thrombectomy. Patients with new CMBs did not have increased rates of hemorrhagic transformation, in-hospital mortality, and modified Rankin Scale score 4 to 6 at discharge.New CMBs are common after mechanical thrombectomy in one-fifth of patients with acute ischemic stroke. Baseline CMBs before mechanical thrombectomy predicts the development of new CMBs. New CMBs after mechanical thrombectomy do not influence clinical outcome.     

高血糖与缺血性卒中患者再灌注治疗后转归

高血糖被认为是急性缺血性卒中患者死亡、功能转归不良、有症状脑出血和梗死体积增大的预测因素。许多研究通过使用标准差、变异系数、血糖水平、应激性高血糖比和葡萄糖/糖化血红蛋白比等参数来表示高血糖,进而研究高血糖与卒中转归的关系。在接受静脉溶栓治疗的卒中患者中,高血糖与有症状脑出血、神经功能转归不良以及血管再通率较低密切相关...     

Periprocedural antithrombotic medication in acute ischemic stroke treated by catheter-based thrombectomy. A review

This review summarized limited information known about periprocedural antithrombotic therapy before, during and immediately after percutaneous catheter-based thrombectomy for acute ischemic stroke. Very few data on this topic were published so far. In general, rtPA should be used upfront whenever clinically clearly indicated (0–3 h from stroke onset, absence of contraindications) irrespective of subsequent mechanical thrombectomy. If mechanical treatment follows after thrombolysis, neither anticoagulation, nor antiplatelet agents should be used in the acute phase. No data exist about the periprocedural use of anticoagulation or antiplatelet therapy in patients who cannot receive fibrinolysis and undergo direct mechanical thrombectomy alone. Most centers use no or very low dose heparin and a single dose of aspirin.     

Fibrinolytic therapy in acute stroke

Acute ischemic stroke is a major cause of morbidity and mortality in Europe, North America, and Asia. Its treatment has completely changed over the past decade with different interventional approaches, such as intravenous trials, intra-arterial trials, combined intravenous/intra-arterial trials, and newer devices to mechanically remove the clot from intracranial arteries. Intravenous thrombolysis with tissue plaminogen activator (tPA) within 4.5 hours of symptoms onset significantly improved clinical outcomes in patients with acute ischemic stroke. Pharmacological intra-arterial thrombolysis has been shown effective until 6 hours after middle cerebral artery occlusion and offers a higher rate of recanalization compared with intravenous thrombolysis, whereas combined intravenous/ intra-arterial thrombolysis seems to be as safe as isolated intravenous thrombolysis. The more recent advances in reperfusion therapies have been done in mechanical embolus disruption or removal. Merci Retriever and Penumbra System have been approved for clot removal in brain arteries, but not as a therapeutic modality for acute ischemic stroke since it is no clear whether mechanical thrombectomy improves clinical outcome in acute stroke. However, mechanical devices are being used in clinical practice for patients who are ineligible for tPA or who have failed to respond to intravenous tPA. We summarize the results of the major thrombolytic trials and the latest neurointerventional approaches to ischemic stroke.     

Acute stroke therapy: A review

This review summarizes the modern early diagnosis and acute phase treatment of acute stroke. The guidelines for treatment of acute ischemic stroke underwent major changes in 2015 and endovascular therapy (catheter-based mechanical thrombectomy with a stent retriever) became the class IA indication for patients presenting within less than 6 h from symptom onset who have proven occlusion of large intracerebral artery in anterior circulation. Acute stroke care organization should enable to perform effective revascularization therapy as soon as possible after the initial brain imaging whenever this examination provides indication for the procedure.     

Stable Clinical Outcomes When a Stroke Thrombectomy Program Is Started in an Experienced Cardiology Cath Lab

ObjectivesThis study analyzed the learning curve effect when a new stroke thrombectomy program was initiated in a cardiac cath lab in close cooperation with neurologists and radiologists.BackgroundMechanical thrombectomy has proven to be the best treatment option for ischemic stroke patients, but this method is not widely available.MethodsAn endovascular treatment program for acute ischemic strokes was established in the cardiac cath lab of a tertiary university hospital in 2012. The decision to perform catheter-based thrombectomy was made by a neurologist and was based on acute stroke clinical symptoms and computed tomography angiographic findings. Patients with a large vessel occlusion of either anterior or posterior circulation were enrolled. The primary endpoint was the functional neurological outcome (Modified Rankin Scale [mRS] score) of the patient at 3 months. A total of 333 patients were enrolled between October 2012 and December 2019.ResultsThe clinical (mRS) outcomes did not vary significantly across years 2012 to 2019 (mRS 0 to 2 was achieved in 47.9% of patients). Symptomatic intracerebral hemorrhage occurred in 19 patients (5.7%). Embolization in a new vascular territory occurred in 6 patients (1.8%).ConclusionsWhen a catheter-based thrombectomy program was initiated in an experienced cardiac cath lab in close cooperation between cardiologists, neurologists, and radiologists, outcomes were comparable to those of neuroradiology centers. The desired clinical results were achieved from the onset of the program, without any signs of a learning curve effect. These findings support the potential role of interventional cardiac cath labs in the treatment of acute stroke in regions where this therapy is not readily available due to the lack of neurointerventionalists.     

Interventionalists beware: the apical thrombus!

Recent myocardial infarction is a recognized risk factor for ischemic stroke. Patients who have a stroke in the peri-infarct period are usually in hospital and therefore well placed to access early cerebral reperfusion therapy. However, due to the risk of myocardial rupture, recent myocardial infarction is considered a contraindication to intravenous thrombolysis, which is usually the first-line therapy for the treatment of ischemic stroke. We report a case in which intravenous thrombolysis was safely and effectively used to treat acute ischemic stroke in a patient who had suffered an acute myocardial infarct within the previous 48 h. We also highlight the lack of evidence-based guidelines for the treatment of stroke in this important subgroup of patients.     

Hyperacute Management of Ischemic Strokes: JACC Focus Seminar

Acute ischemic stroke is the leading cause of disability and among the leading causes of mortality worldwide. Intravenous tissue plasminogen activator has been a cornerstone for treatment of acute ischemic stroke for more than 20 years; however, its use is limited due to a narrow therapeutic window, several contraindications, and low efficacy to recanalize the artery in large vessel occlusion. Recently, the addition of endovascular mechanical thrombectomy of large artery occlusion has revolutionized the stroke treatment for most disabling strokes. The paper reviews updates to the thrombolytic treatment as well as catheter-based treatment, and results from recent trials in the selection of patients in an extended time window using perfusion imaging.