Intraarterial Therapy for Acute Ischemic Strokes

doi:10.1016/j.jvir.2008.11.021

Journal of Vascular and Interventional Radiology

Volume 20, Issue 3, March 2009, Pages 327-333

https://doi.org/10.1016/j.jvir.2008.11.021 Get rights and content

Purpose

To determine the safety and feasibility of intraarterial stroke therapy for acute ischemic strokes at a community-based medical center.

Materials and Methods

This is a retrospective analysis of data gathered from consecutive stroke patients treated between June 2004 and April 2007. The following therapies were used to treat acute ischemic stroke within 6 hours of symptom onset: intraarterial thrombolytic drugs, intraarterial vasodilators, mechanical clot retrieval, intravascular stents, and angioplasty. The outcomes measured included posttherapy National Institutes of Health Stroke Score (NIHSS), neurologic function at 90 days graded according to the modified Rankin Scale (mRS), recanalization, symptomatic intracranial hemorrhage, and 90-day mortality.

Results

Eighty-three patients with a median baseline NIHSS of 17 (range, 3–30) were treated with intraarterial therapy. The median posttherapy NIHSS was 5 (range, 0–33). Forty-two patients (76%) had an mRS score of 2 or less at 90 days. The recanalization rate was 76%. Five patients (6%) had symptomatic intracranial hemorrhage, and the 90-day mortality was 22%.

Conclusions

The results of this review showed that an intraarterial therapeutic approach to acute ischemic stroke was feasible at a community-based heath center and demonstrated encouraging data for outcome and safety.

Section snippets

Materials and Methods

An institutional review board approved and evaluated retrospective analysis of prospectively gathered data from stroke patients treated between June 2004 and April 2007 at a single institution. The institutional review board initially approved all protocol and procedures in 2001, with revisions as new technology and terminology were available. Operative physicians received informed consent from all patients before treatment.

After initial presentation to the emergency department, all patients

Results

During this review, 98 patients met the inclusion criteria and underwent diagnostic cerebral angiography within 5 hours of symptom onset. The median time that it took stroke patients to arrive at the emergency department after the onset of symptoms was 115 minutes. Of the patients who underwent diagnostic angiography, 87 underwent intraarterial therapy; complete data were collected in 83 patients. The mean patient age was 69 years (range, 32–86 years); 43 of the 83 patients (52%) were men. The

Discussion

This review indicates that a combination intraarterial therapeutic approach to acute ischemic stroke based on the time of symptom onset, past medical history, and angiographic findings led to favorable outcomes with respect to published trials. The primary outcome with an mRS score of less than or equal to 2 at 90 days showed the overall percentage of treated patients with a favorable outcome was 11%–12% higher in this review than in the PROACT II study (P = .15) and the NINDS recombinant tPA

Acknowledgments

All patient care was performed at Mercy Health Center, Oklahoma City, Oklahoma. The authors wish to thank Heloisa Pearson, RN, Kelli Dutton, BSN, RN, and Marvin Mullin, RT, for data collection, data input, and statistical analysis.

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Society of Interventional Radiology Training Guidelines for Endovascular Stroke Treatment
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Interventional radiologists have been partners with neurointerventional radiologists, endovascular neurosurgeons, and interventional neurologists in acute intervention for stroke (AIS) since the inception of EVT. Vascular/IR physicians who were not trained in formal neurointerventional fellowships have historically provided and continue to provide EVT in substantial numbers with good outcomes, comparable to those achieved by neurointerventional physicians during similar years (29–35). A recent survey of the Joint Commission (JC) PSCs found that 60% of the responding PSCs performed EVT, and, of these, 41% relied on IR physicians to provide this care (26).
The Role of Interventional Radiologists in Acute Stroke Interventions: A Joint Statement from the Australia and New Zealand Society of Neuroradiology (ANZSNR), the Society of Neurointerventional Surgery (SNIS), the United Kingdom Neurointerventional Group (UKNG), the British Society of Neuroradiology (BSNR), and the European Society for Minimally Invasive, Neurological Therapy (ESMINT)
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Efficacy of peripheral interventional radiologists performing endovascular stroke therapy guided by CT perfusion triage of patients
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The reason for the decreased rate of asymptomatic ICH is not likely related to the technique of the thrombectomy procedures but rather to improved patient selection for intervention with the use of CT perfusion imaging and/or the shorter time from stroke onset to treatment with the thrombectomy device in the present study. Other peripheral interventional radiologists have also shown good safety and efficacy in the endovascular treatment of stroke (15). Interventional radiologists in the present study who used CT perfusion imaging for patient selection achieved efficacy with endovascular stroke therapy, demonstrating low mortality rate and good neurologic outcome (mRS score ≤ 2 at 90 d), equal or in many cases exceeding those published in large trials of procedures performed by fellowship-trained neurointerventionalists (1–3).
To assess safety and efficacy of intraarterial mechanical thrombectomy for treatment of ischemic stroke in a community hospital by peripheral interventional radiologists employing computed tomography (CT) perfusion imaging for patient selection.
Forty patients, 11 men (27.5%) and 29 women (72.5%), were treated between February 2008 and October 2011. Eligible patients had a National Institutes of Health Stroke Scale (NIHSS) score greater than 8 and diagnosis of large-vessel ischemic stroke by head CT angiogram, and met previously reported CT perfusion imaging triage criteria.
The baseline NIHSS score was 18.0 ± 7.9 (range, 8–35). Sixteen patients (40%) had a baseline NIHSS score greater than 20. Symptom onset was unknown in five patients. Symptom onset to device time in the remaining 35 patients was 254.8 minutes ± 150.9 (range, 75–775 min). A total of 65% of patients showed thrombolysis in cerebral infarction (TICI) 2a, 2b, or 3 flow following the procedure. Symptomatic intracranial hemorrhage was seen in four patients (10.0%). At 90 days, 32 patients (80%) were alive and eight (20%) had died. The modified Rankin scale (mRS) score at 90 days was no more than 2 in 20 patients (50.0%). The mean mRS score at 90 days was 2.9 ± 2.0 (range, 0–6). NIHSS score at 90 days was 5.1 ± 6.1 (range, 0–24). In patients with successful recanalization (ie, TICI 2 or 3 flow), a good clinical outcome (ie, mRS score ≤ 2) was achieved in 65.3% of patients (mean, 2.4 ± 1.9; range, 0–6), and 90-day mortality rate was 15.4%, compared with 28.6% in patients with TICI 0/1 flow.
Peripheral interventional radiologists who use CT perfusion imaging for patient triage can have good neurologic outcomes and provide sustainable, safe, and complete around-the-clock coverage for endovascular stroke treatment.
Multisociety consensus quality improvement guidelines for intraarterial catheter-directed treatment of acute ischemic stroke, from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, ..
2013, Journal of Vascular and Interventional Radiology
Citation Excerpt :
The evidence for efficacy of endovascular therapy is less robust, but data for endovascular stroke procedures using fibrinolytic drugs or mechanical devices show promise. Evidence evaluating endovascular treatment of acute ischemic stroke now includes randomized trials subjected to metaanalysis (1–4), as well as registry data and case series (5–14). Techniques for revascularization use pharmacologic lysis, mechanical clot extraction, and clot displacement.
In this international multispecialty document, quality benchmarks for processes of care and clinical outcomes are defined. It is intended that these benchmarks be used in a quality assurance program to assess and improve processes and outcomes in acute stroke revascularization.
Members of the writing group were appointed by the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society of Cardiac Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology. The writing group reviewed the relevant literature from 1986 through February 2012 to create an evidence table summarizing processes and outcomes of care. Performance metrics and thresholds were then created by consensus. The guideline was approved by the sponsoring societies. It is intended that this guideline be fully updated in 3 years.
In this international multispecialty document, quality benchmarks for processes of care and clinical outcomes are defined. These include process measures of time to imaging, arterial puncture, and revascularization and measures of clinical outcome up to 90 days.
Quality improvement guidelines are provided for endovascular acute ischemic stroke revascularization procedures.

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: None of the authors have identified a conflict of interest.

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Clinical studyIntraarterial Therapy for Acute Ischemic Strokes

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

J Vasc Interv Radiol

Tissue plasminogen activator for acute ischemic stroke

N Engl J Med

MERCI 1: a phase 1 study of Mechanical Embolus Removal in Cerebral Ischemia

Stroke

The PROACT II study: a randomized controlled trial–-prolyse in acute cerebral thromboembolism

JAMA

Emergency interventional stroke therapy: a statement from the American Society of Interventional and Therapeutic Neuroradiology Stroke Task Force of the American Society of Neuroradiology and the Society of Cardiovascular and Interventional Radiology

AJNR Am J Neuroradiol

Guidelines for the early management of adults with ischemic stroke

Stroke

Prehospital and in-hospital delays in acute stroke care

Neuroepidemiology

Acute stroke care in the US: results from 4 pilot prototypes of the Paul Coverdell National Acute Stroke Registry

Stroke

Clinical study
Intraarterial Therapy for Acute Ischemic Strokes