Imaging as a Selection Tool for Thrombectomy in Acute Ischemic Stroke

Abstract

Large vessel occlusion (LVO) stroke represents a stroke subset associated with the highest morbidity and mortality. Multiple prospective randomized trials have shown that thrombectomy, alone or in conjunction with IV thrombolysis, is highly effective in reestablishing cerebral perfusion and improving clinical outcomes. In unselected patients and especially in patients with poor collaterals, the benefit of reperfusion therapy is exquisitely time sensitive; the earlier thrombectomy is started, the lower the likelihood of disability or death. Understanding both the pathophysiologic underpinnings and the modifying factors of this strong time-to-treatment effect demonstrated in numerous randomized clinical trials is important for implementation of intrahospital workflow measures to maximize time efficiency of thrombectomy. Reducing delays in reperfusion therapy initiation has become a priority in acute stroke care, and therefore a thorough understanding of the main systems-based factors responsible for these delays is critical. Because the time spent evaluating the patient in the emergency department, which typically includes neuroimaging studies performed in scanners remote from the angiography suite, represents the main source of delays in thrombectomy initiation, the direct to angiography (DTA) model has emerged as a means to substantially reduce treatment times and is being instituted at an increasing number of thrombectomy centers across the world. The aim of this report is to introduce DTA as an emerging stroke care paradigm for patients with suspicion of LVO stroke, review results from studies evaluating its feasibility and impact on outcomes, describe current barriers to its more widespread adoption, and propose potential solutions to overcoming these barriers.

Three Dimensional-Arterial Spin Labeling Evaluation of Improved Cerebral Perfusion After Limb Remote Ischemic Preconditioning in a Rat Model of Focal Ischemic Stroke

“…Acute ischemic stroke is a pathological process involving multiple mechanisms. Vascular wall lesions and hemodynamic changes are the main factors in the pathogenesis of ischemic stroke (Thon and Jovin, 2021;Zhang et al, 2021), which is consistent with our results. On the basis of atherosclerosis, hemodynamic changes, cerebral perfusion, decreased embolus clearance and decreased establishment of collateral circulation in the ischemic area, brain cells become hypoxic and apoptotic, forming a central necrotic area and a surrounding ischemic penumbra (Yousefi-Manesh et al, 2021); this process is accompanied by excessive release of free radicals, intracellular calcium overload, and excitatory amino acid toxicity, resulting in neuronal damage (Catanese et al, 2017;Uzdensky, 2019).…”

Predictive value of clot imaging in acute ischemic stroke: A systematic review of artificial intelligence and conventional studies

“…The model intends to reduce the delays in initiating treatment when they are associated with additional and unnecessary neuroimaging investigations. Most likely, benefitting from this model are predominantly the patients with severe stroke (NIHSS > 9) in early time window (0-6 h hours from symptoms onset) [90]. Several studies published up to date demonstrate the feasibility of automatic hyperdense sign detection and its translational potential.…”

What You Always Wanted to Know about Endovascular Therapy in Acute Ischemic Stroke but Never Dared to Ask: A Comprehensive Review

“…1 ) [ 29 ]. Overall, a beneficial effect of MT can be expected in patients with ASPECTS 6 [ 30 ]. MRI can rule out intracranial hemorrhage as reliably as NCCT using gradient recalled echo sequences (GRE) [ 31 ].…”