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Endovascular treatment for acute ischemic stroke

In 2015, the American Heart Association (AHA) made major changes to the guidelines for the endovascular treatment of acute ischemic stroke. The Class IA indications for endovascular therapy of stroke patients include symptom onset within 6 hours, proven large vessel occlusion of an artery in the anterior circulation, and the use of a stent retriever as part of the mechanical thrombectomy. Advanced perfusion imaging helps identify patients with a low ratio of ischemic core to salvageable penumbra. Equally important to overall clinical outcome is the organization of comprehensive stroke centers and the recent advent of the mobile stroke unit. Future clinical endovascular stroke trials will help us to better understand the role of endovascular interventions 1).

Endovascular treatment (ET) of acute ischemic stroke (AIS) in the setting of carotid artery dissection (CAD) is a feasible, safe, and promising strategy 2).

The treatment has been revolutionized by the introduction of several interventions supported by class I evidence-care on a stroke unit:

Thrombolysis with recombinant tissue plasminogen activator within 4.5 hours of stroke onset, aspirin commenced within 48 hours of stroke onset, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction. There is new class I evidence also demonstrating benefits of endovascular therapy on functional outcomes in those with anterior circulation stroke. In addition, the importance of the careful management of key systemic physiological variables, including oxygenation, blood pressure, temperature, and serum glucose, has been appreciated. In line with this, the role of anesthesiologists and intensivists in managing AIS has increased 3).

Anesthetic management

Debate continues about the optimal anesthetic management for patients undergoing endovascular treatment (ET) of acute ischemic stroke due to emergent large vessel occlusion.

Goyal et al., performed a systematic review and meta-analysis of all available studies that involved the use of stent retrievers for ET (stentriever group). Additionally, we included studies that were published in 2015 and later, and compared the clinical outcomes among the studies using stentrievers or no stentrievers (pre-stentriever group). Outcome variables included functional independence (FI; modified Rankin Scale scores of 0-2), symptomatic hemorrhage, mortality, procedure duration, and vascular and respiratory complications. We calculated pooled odds ratios and 95% CIs using random-effects models.

Sixteen studies (three randomized controlled clinical trials (RCTs) and 13 non-randomized studies) were identified comprising 5836 patients. Although non-GA was associated with higher odds of 3-month FI (OR=1.57; 95% CI 1.17 to 2.10; P=0.003) and lower odds of 3-month mortality (OR=0.62; 95% CI 0.47 to 0.82; P=0.0006, substantial heterogeneity was noted across included trials. Sensitivity analyses of RCTs showed that non-GA was inversely associated with FI (OR=0.55; 95% CI 0.34 to 0.89; P=0.01; I2=15%), while no association was noted with mortality (OR=1.36; 95% CI 0.79 to 2.34; P=0.27; I2=0%).

The updated meta-analysis demonstrates favorable results with non-GA, probably owing to inclusion of non-randomized studies. Recent single-center RCTs indicate that GA is associated with higher odds of FI at 3 months, while other outcomes are similar between the two groups 4).

Case series

A matched case-control study of patients with proximal occlusion after stroke (intracranial internal carotid artery and/or middle cerebral artery M1 and/or M2) on computed tomography angiography and baseline ischemic core greater than 50 mL on CT Perfusion (CTP) at a tertiary care center from May 1, 2011, through October 31, 2015. Patients receiving ET and controls receiving medical treatment alone were matched for age, baseline ischemic core volume on CTP, and glucose levels. Baseline characteristics and outcomes were compared.

The primary outcome measure was the shift in the degree of disability among the treatment and control groups as measured by the modified Rankin Scale (mRS) (with scores ranging from 0 [fully independent] to 6 [dead]) at 90 days.

Fifty-six patients were matched across 2 equally distributed groups (mean [SD] age, 62.25 [13.92] years for cases and 58.32 [14.79] years for controls; male, 13 cases [46%] and 14 controls [50%]). Endovascular therapy was significantly associated with a favorable shift in the overall distribution of 90-day mRS scores (odds ratio, 2.56; 95% CI, 2.50-8.47; P = .04), higher rates of independent outcomes (90-day mRS scores of 0-2, 25% vs 0%; P = .04), and smaller final infarct volumes (mean [SD], 87 [77] vs 242 [120] mL; P < .001). One control (4%) and 2 treatment patients (7%) developed a parenchymal hematoma type 2 (P > .99). The rates of hemicraniectomy (2 [7%] vs 6 [21%]; P = .10) and 90-day mortality (7 [29%] vs 11 [48%]; P = .75) were numerically lower in the intervention arm. Sensitivity analysis for patients with a baseline ischemic core greater than 70 mL (12 pairs) revealed a significant reduction in final infarct volumes (mean [SD], 110 [65] vs 319 [147] mL; P < .001) but only a nonsignificant improvement in the overall distribution of mRS scores favoring the treatment group (P = .18). All 11 patients older than 75 years had poor outcomes (mRS score >3) at 90 days.

In properly selected patients, ET appears to benefit patients with large core and large mismatch profiles. Future prospective studies are warranted 5).

Wang A, Schmidt MH. Neuroendovascular Surgery for the Treatment of Ischemic Stroke. Cardiol Rev. 2017 Jun 22. doi: 10.1097/CRD.0000000000000155. [Epub ahead of print] PubMed PMID: 28767503.
Haussen DC, Jadhav A, Jovin T, Grossberg J, Grigoryan M, Nahab F, Obideen M, Lima A, Aghaebrahim A, Gulati D, Nogueira RG. Endovascular Management vs Intravenous Thrombolysis for Acute Stroke Secondary to Carotid Artery Dissection: Local Experience and Systematic Review. Neurosurgery. 2015 Oct 21. [Epub ahead of print] PubMed PMID: 26492430.
Kirkman MA, Lambden S, Smith M. Challenges in the Anesthetic and Intensive Care Management of Acute Ischemic Stroke. J Neurosurg Anesthesiol. 2015 Sep 11. [Epub ahead of print] PubMed PMID: 26368664.
Goyal N, Malhotra K, Ishfaq MF, Tsivgoulis G, Nickele C, Hoit D, Arthur AS, Alexandrov AV, Elijovich L. Current evidence for anesthesia management during endovascular stroke therapy: updated systematic review and meta-analysis. J Neurointerv Surg. 2018 Jun 15. pii: neurintsurg-2018-013916. doi: 10.1136/neurintsurg-2018-013916. [Epub ahead of print] PubMed PMID: 29907575.
Rebello LC, Bouslama M, Haussen DC, Dehkharghani S, Grossberg JA, Belagaje S, Frankel MR, Nogueira RG. Endovascular Treatment for Patients With Acute Stroke Who Have a Large Ischemic Core and Large Mismatch Imaging Profile. JAMA Neurol. 2016 Nov 7. doi: 10.1001/jamaneurol.2016.3954. [Epub ahead of print] PubMed PMID: 27820620.
endovascular_treatment_for_acute_ischemic_stroke.txt · Last modified: 2018/06/17 12:48 by administrador