Standards of practice in acute ischemic stroke intervention: international recommendations

Piérot, Laurent; Jayaraman, Mahesh; Szikora, István; Hirsch, Joshua A; Baxter, Blaise; Miyachi, Shigeru; Mahadevan, Jeyaledchumy; Chong, Winston; Mitchell, Peter; Coulthard, Alan; Rowley, Howard A.; Sanelli, Pina C.; Tampieri, Donatella; Brouwer, Patrick A.; Fiehler, Jens; Koçer, Naci; Vilela, Pedro; Rovira, Àlex; Fischer, Urs; Caso, Valeria; Worp, Bart van der; Sakai, Nobuyuki; Matsumaru, Yuji; Yoshimura, Shin; Anxionnat, René; Desal, Hubert; Biscoito, Luísa; Pumar, José Manuel; Diaz, Orlando M.; Fraser, Justin F.; Linfante, Italo; Liebeskind, David S; Nogueira, Raul G; Hacke, Werner; Brainin, Michael; Yan, Bernard; Soderman, McHael; Taylor, Allan; Pongpech, Sirintara; Tanaka, Michihiro; Karel, Terbrugge

doi:10.1136/neurintsurg-2018-014287

Cited by 41 publications

(15 citation statements)

References 19 publications

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“…Hospitals have differing capabilities in terms of treatment of AIS, and an international consensus exists on levels of care 1 through 3 11. Level 1 stroke centers have the full spectrum of endovascular care, do a minimum number of mechanical thrombectomies, have dedicated neurointensive care and stroke units, and have full neurosurgical services.…”

Section: Pre-hospital Managementmentioning

confidence: 99%

Management of acute ischemic stroke

Phipps

Cronin

2020

BMJ

408

315

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Stroke is the leading cause of long term disability in developed countries and one of the top causes of mortality worldwide. The past decade has seen substantial advances in the diagnostic and treatment options available to minimize the impact of acute ischemic stroke. The key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible. Here, we review the data supporting pre-hospital and emergency stroke care, including use of emergency medical services protocols for identification of patients with stroke, intravenous thrombolysis in acute ischemic stroke including updates to recommended patient eligibility criteria and treatment time windows, and advanced imaging techniques with automated interpretation to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy in extended time windows from symptom onset. We also review protocols for management of patient physiologic parameters to minimize infarct volumes and recent updates in secondary prevention recommendations including short term use of dual antiplatelet therapy to prevent recurrent stroke in the high risk period immediately after stroke. Finally, we discuss emerging therapies and questions for future research.

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Section: Pre-hospital Managementmentioning

confidence: 99%

Management of acute ischemic stroke

Phipps

Cronin

2020

BMJ

408

315

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“…13 All 7 participating comprehensive stroke centers are highvolume facilities and offer interventional stroke treatment 24/7 with long-time experience in endovascular thrombectomy. 14…”

Section: Patient Demographicsmentioning

confidence: 99%

Endovascular Thrombectomy of Calcified Emboli in Acute Ischemic Stroke: A Multicenter Study

Maurer¹,

Dobrocky

Joachimski³

et al. 2020

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: Large intracranial vessel occlusion due to calcified emboli is a rare cause of major stroke. We assessed the prevalence, imaging appearance, the effectiveness of mechanical thrombectomy, and clinical outcome of patients with large-vessel occlusion due to calcified emboli. MATERIALS AND METHODS:We performed a retrospective analysis of clinical and procedural data of consecutive patients who underwent mechanical thrombectomy due to calcified emboli in 7 European stroke centers. RESULTS:We screened 2969 patients, and 40 patients matched the inclusion criteria, accounting for a prevalence of 1.3%. The mean maximal density of the thrombus was 327 HU (range, 150-1200 HU), and the mean thrombus length was 9.2 mm (range, 4-20 mm). Four patients had multiple calcified emboli, and 2 patients had an embolic event during an endovascular intervention. A modified TICI score of $2b was achieved in 57.5% (23/40), with minimal-to-no reperfusion (modified TICI 0-1) in 32.5% (13/40) and incomplete reperfusion (modified TICI 2a) in 10% (4/40). Excellent outcome (mRS 0-1) was achieved in only 20.6%, functional independence (mRS 0-2) in 26.5% and 90-day mortality was 55.9%. CONCLUSIONS:Acute ischemic stroke with large-vessel occlusion due to calcified emboli is a rare entity in patients undergoing thrombectomy, with considerably worse angiographic outcome and a higher mortality compared with patients with noncalcified thrombi. Good functional recovery at 3 months can still be achieved in about a quarter of patients. ABBREVIATIONS: CLASS ¼ calcium load assessment; MT ¼ mechanical thrombectomy; mTICI ¼ modified TICI C alcified emboli are a rare, underreported cause of ischemic stroke. 1 Their prevalence has been estimated as between 2.7% and 5.9% of all patients presenting with acute ischemic stroke. 1,2 Intravenous rtPA seems to be an ineffective treatment, probably due to the thrombus composition. 3 Endovascular

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“…Acute ischemic stroke (AIS) is a major cause of mortality and long-term disability world-wide that lacks curative therapies [ 1 , 2 ]. Recent key advancements in pharmacological thrombolysis and mechanical endovascular thrombectomy remain limited by a narrow therapeutic window and restrictive eligibility [ 3 , 4 ]. Additionally, the spectrum of rehabilitation paradigms implores evidence base [ 5 ], while efforts targeting neuroprotection largely fail to translate to human therapies [ 6 ].…”

Section: Introductionmentioning

confidence: 99%

Beyond the Brain: The Systemic Pathophysiological Response to Acute Ischemic Stroke

et al. 2020

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Stroke research has traditionally focused on the cerebral processes following ischemic brain injury, where oxygen and glucose deprivation incite prolonged activation of excitatory neurotransmitter receptors, intracellular calcium accumulation, inflammation, reactive oxygen species proliferation, and ultimately neuronal death. A recent growing body of evidence, however, points to far-reaching pathophysiological consequences of acute ischemic stroke. Shortly after stroke onset, peripheral immunodepression in conjunction with hyperstimulation of autonomic and neuroendocrine pathways and motor pathway impairment result in dysfunction of the respiratory, urinary, cardiovascular, gastrointestinal, musculoskeletal, and endocrine systems. These end organ abnormalities play a major role in the morbidity and mortality of acute ischemic stroke. Using a pathophysiology-based approach, this current review discusses the pathophysiological mechanisms following ischemic brain insult that result in end organ dysfunction. By characterizing stroke as a systemic disease, future research must consider bidirectional interactions between the brain and peripheral organs to inform treatment paradigms and develop effective, comprehensive therapeutics for acute ischemic stroke.

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Standards of practice in acute ischemic stroke intervention: international recommendations

Cited by 41 publications

References 19 publications

Management of acute ischemic stroke

Management of acute ischemic stroke

Endovascular Thrombectomy of Calcified Emboli in Acute Ischemic Stroke: A Multicenter Study

Beyond the Brain: The Systemic Pathophysiological Response to Acute Ischemic Stroke

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