Endovascular Recanalization in the Treatment of Acute Occlusion of the Brain Arteries

Česká verzia

Authors: A. Krajina ¹; D. Krajíčková ²; Miroslav Lojík ¹ ; V. Chovanec ¹; J. Raupach ¹; M. Kubíková ²; M. Vališ ²; Z. Špriňar ¹; R. Taláb ²; P. Ryška ¹; J. Schreiberová ³; J. Holubová ²; J. Šimko ²; O. Renc ¹; Eva Čermáková ⁴ ; S. Řehák ⁵
Authors place of work: LF UK a FN Hradec Králové Radiologická klinika ¹; LF UK a FN Hradec Králové Neurologická klinika ²; LF UK a FN Hradec Králové Klinika anesteziologie, resuscitace a intenzivní medicíny ³; LF UK a FN Hradec Králové Ústav lékařské biofyziky ⁴; LF UK a FN Hradec Králové Neurochirurgická klinika ⁵
Published in the journal: Cesk Slov Neurol N 2010; 73/106(6): 678-684
Category: Original Paper

Summary

Purpose:
The purpose of this study was to assess the role of mechanical endovascular recanalization techniques in the treatment of acute occlusions of the brain arteries in a single-centre group of consecutive patients treated between September 2006 and September 2009. Methods: This is a retrospective analysis of 33 patients (18 women, 15 men) of average age 58.2 years (range 31–80) suffering from acute ischemic stroke (mean NIHSS 16.3; range 7–25). The main inclusion criterion was proven penumbra on perfusion CT. Occlusion in the anterior circulation appeared in 22 patients (67%), and occlusion in the vertebrobasilar circulation in 11 patients (33%). The procedure started within 5.3 hours on average. The following therapies were used: mechanical clot retrieval alone (12 cases), and combined with intra-arterial thrombolysis (17 cases). Angioplasty aspiration and intravascular stents were used in the remaining non-embolic cases. A subgroup analysis comparing functionally good and poor patients and anterior and posterior stroke was performed. Results: Eighteen patients (54.5%) had a mRS of 2 or less at 3 months. The TIMI 3 and 2 recanalization rate was 66%. Three patients (9%) had symptomatic intracranial hemorrhage, and the 90-day mortality was 18%. Conclusion: Using a dedicated mechanical recanalization device has become a primary approach to the treatment of acute embolic ischemic stroke.

Key words:
stroke – mechanical thrombectomy – cerebral revascularization – thrombolytic therapy

Zdroje

1. Widimsky P, Budesinsky T, Vorác D, Groch L, Zelízko M, Aschermann M et al. Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction. Final results of randomized national multicentre trial – Prague-2. Eur Heart J 2003; 24(1): 94–104.

2. Tomycz ND, Holm MB, Horowitz MB, Wechsler LR, Raina K, Gusta R et al. Extensive brainstem ischemia on neuroimaging does not preclude meaningful recovery from locked-in syndrome: two cases of endovascularly managed basilar thrombosis. J Neuroimaging 2008; 18(1): 15–17.

3. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome. Stroke 2007; 38(3): 967–973.

4. Nogueira RG, Schvamm LH, Hirsch JA. Endovascular approaches to acute stroke, part 1: drugs, device, and data. Am J Neuroradiol 2009; 30(4): 649–661.

5. Liebig T, Reinartz J, Cannes R, Miloslavski E, Henkes H. Comparative in vitro study of five mechanical embolectomy systems: effectiveness of clot removal and risk of distal embolization. Neuroradiology 2008; 50(1): 43–52.

6. National Institute of Neurological Disorders and Stroke: rt-PA Stroke Study Group (NINDS). Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333(23): 1581–1587.

7. Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. JAMA 1999; 282(21): 2003–2011.

8. Chopko BW, Kerber CH, Wong W, Georgy B. Transcatheter snare removal of acute middle cerebral artery thromboembolism: technical case report. Neurosurgery 2000; 46(6): 1529–1531.

9. Krajina A, Krajíčková D, Špriňar Z, Nikolov DH, Pařízková R, Lojík M et al. Mechanická perkutánní extrakce embolu při akutní cévní mozkové příhodě: kasuistika a přehled literatury. Cesk Slov Neurol N 2005; 68/101(1): 51–57.

10. Charvát F, Lacman J, Mašková J, Elis J, Beneš V. Mechanická embolektomie pomocí MERCI katétru u nemocných s akutním uzávěrem mozkových tepen. Cesk Slov Neurol N 2008; 68/103(1): 69–75.

11. Levy EI, Ecker RD, Horowitz MB, Gupta R, Hanel RA, Sauvageau E et al. Stent-assisted intracranial recanalization for acute stroke: early results. Neurosurgery 2006; 58(3): 458–463.

12. Nakano S, Iseda T, Yoneyama T, Kawano H, Wakisaka S. Direct percutaneous transluminal angioplasty for acute middle cerebral artery trunk occlusion: an alternative option to intra-arterial thrombolysis. Stroke 2002; 33(12): 2872–2876.

13. Tomsick T, Brott T, Barsan W, Broderic J, Haley EC, Spilker J et al. Prognostic value of the hyperdense middle cerebral artery sign and stroke scale score before ultraearly thrombolytic therapy. Am J Neuroradiol 1996; 17(1): 79–85.

14. Saqqur M, Uchimo K, Demchuk AM, Molina CA, Garami Z, Calleja S et al. Site of arterial occlusion identified by transcranial doppler predicts the response to intravenous thrombolysis for stroke. Stroke 2007; 38(3): 948–954.

15. Ribo M, Alvarez-Sabín J, Montaner J, Romero F, Delgado P, Rubiera M et al. Temporal profile of recanalization after intravenous tissue plasminogen activator. Selecting patients for rescue reperfusion techniques. Stroke 2006; 37(4): 1000–1004.

16. Smith WS, Sung G, Starkman S, Saver JL, Kidwell CS, Gobin YP et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 2005; 36(7): 1432–1440.

17. Cloft HJ, Rabinstein A, Lanzino G, Kallmes DF. Intra-arterial stroke therapy: an assessment of demand and available work force. Am J Neuroradiol 2009; 30(3): 453–458.

18. Heuschmann PU, Berger K, Misselwitz B, Hermanek P, Leffmann C, Adelmann M et al. Frequency of thrombolytic therapy in patiens with acute ischemic stroke and the risk of in-hospital mortality. Stroke 2003; 34(5): 1106–1113.

19. Meyer BC, Hemmen TM, Jackson CM, Lyden PD. Modified National Institutes of Health Stroke Scale for use in stroke clinical trials. Stroke 2002; 33(5): 1261–1266.

20. The TIMI Study Group. Special Report. The thrombolysis in myocardial infarction (TIMI) trial. N Engl J Med 1985; 312: 932–936.

21. Rankin J. Cerebral vascular accidents in patiens over the age of 60. II. Prognosis. Scot Med J 1957; 2(6): 200–215.

22. Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. JAMA 1995; 274(13): 1017–1025.

23. Hill MD, Kent DM, Hinchey J, Rowley H, Buchan AM, Wechsler LR et al. Sex-based differences in the effect of intra-arterial treatment of stroke. Analysis of the PROACT-2 study. Stroke 2006; 37(9): 2322–2325.

24. Meseguer E, Mazighi M, Labreuche J, Arnaiz C, Cabrejo L, Slaoui T et al. Outcomes of intravenous recombinant tissue plasminogen activator therapy according to gender. A clinical registry study and systematic review. Stroke 2009; 40(6): 2104–2110.

25. Smith WS, Sung G, Saver J, Budzi R, Duckwiler G, Liebeskind DS et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke 2008; 39(4): 1205–1212.

26. Nogueira RG, Liebeskind DS, Sung G, Duckwiler G, Smith WS. Predictors of good clinical outcomes, mortality, and successful revascularization in patients with acute ischemic stroke undergoing thrombectomy. Pooled analysis of the mechanical embolus removal in cerebral ischemia (MERCI) and Multi MERCI Trials. Stroke 2009; 40(12): 3777–3783.

27. Nogueira RG, Smith WD. Safety and efficacy of endovascular thrombectomy in patients with abnormal hemostasis. Pooled analysis of the MERCI and Multi MERCI trials. Stroke 2009; 40(2): 516–522.

28. Brekenfeld C, Schroth G, El-Koussy M, Nedeltchev K, Reinert M, Slotboom J et al. Mechanical thromboembolectomy for acute ischemic stroke. Comparison of the Catch thromboectomy device and the Merci Retriever in vivo. Stroke 2008; 39(4): 1213–1219.

29. Gralla J, Burkhardt M, Schroth G, El-Koussy M, Reinert M, Nedeltchev K et al. Occlusion length is a crucial determinant of efficiency and complication rate in thrombectomy for acute ischemic stroke. Am J Neuroradiol 2008; 29(2) 247–252.

30. The Penumbra Pivotal Stroke Trial Investigators. The Penumbra pivotal stroke trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke 2009; 40(8): 2761–2768.

31. Školoudík D, Fadrná T, Bar M, Zapletalová O, Zapletal O, Blatný et al. Ovlivnění fibrinolytického systému pomocí kontinuálního dopplerovského monitoringu u zdravých dobrovolníků. Cesk Slov Neurol N 2009; 72/105(5): 446–452.

32. Lin DD, Gailloud P, Beauchamp NJ, Aldrich EM, Wityk RJ, Murphy KJ. Combined stent placement and thrombolysis in acute vertebrobasilar ischemic stroke. Am J Neuroradiol 2003; 24(9): 1827–1833.

33. Hauck EF, Mocco J, Snyder KV, Levy EI. Temporary endovascular bypass: a novel treatment for acute stroke. Am J Neuroradiol 2009; 30(8): 1532–1533.

34. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D et al. Thrombolysis with alteplase 3 to 4,5 hours after acute ischemic stroke. N Engl J Med 2008; 359(13): 1317–1329.

35. Imai K, Mori T, Izumoto H, Takabatake N, Kunieda T, Shimizu H et al. Clot removal therapy by aspiration and extraction for acute embolic carotid occlusion. Am J Neuroradiol 2006; 27(7): 1521–1527.