Subacute Recanalization and Reocclusion in Patients with Acute Ischemic Stroke Following Endovascular Treatment

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Background and Purpose-The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. Methods-Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. Results-The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. Guidelines for the Early Management of PatientsThis statement was approved by the American Heart Association Science Advisory and Coordinating Committee on December 12, 2012. A copy of the document is available at http://my.americanheart.org/statements by selecting either the "By Topic" link or the "By Publication Date" link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.The Executive Summary is available as an online-only Data Supplement with this article at http://stroke.ahajournals.org/lookup/suppl/ doi:10.1161/STR.0b013e318284056a/-/DC1.The American Heart Association requests that this document be cited as follows: Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; on behalf of the American Heart Association Stroke Council, Council on Cardio...

Section: Anticoagulants As An Adjunctive Therapymentioning

confidence: 99%

Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Jauch¹,

Saver²,

Adams³

et al. 2013

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“…Patients in the thrombectomy group with an absence of revascularization (mAOL grade 0) at 24 hours showed a nonsignificant higher infarct volume than nonrecanalizers in the medical group, finding that has also been observed in the SWIFT-PRIME study. 11 Little is known about the incidence of arterial reocclusion after successful endovascular revascularization and its effect on clinical outcome, [19][20][21] and no data are available to date from the recent large endovascular clinical trials. [1][2][3][4][5][6] In REVASCAT, arterial reocclusion was infrequent (3.1%) in patients with complete postprocedural revascularization (mTICI 2b/3), whereas reocclusion rate was significantly higher (26%) in those patients who only achieved partial revascularization (mTICI 2a).…”

Section: April 2017mentioning

confidence: 99%

Vessel Patency at 24 Hours and Its Relationship With Clinical Outcomes and Infarct Volume in REVASCAT Trial (Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset)

Millán

Remollo

Quesada

et al. 2017

Background and Purpose-Higher rates of target vessel patency at 24 hours were noted in the thrombectomy group compared with control group in recent randomized trials. As a prespecified secondary end point, we aimed to assess 24-hour revascularization rates by treatment groups and occlusion site as they related to clinical outcome and 24-hour infarct volume in REVASCAT (Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset). Methods-Independent core laboratory adjudicated vessel status according to modified arterial occlusive lesion classification at 24 hours on computed tomographic/magnetic resonance (94.2%/5.8%) angiography and 24-hour infarct volume on computed tomography were studied (95/103 patients in the thrombectomy group versus 94/103 in the control group, respectively). Complete revascularization was defined as modified arterial occlusive lesion grade 3. Its effect on clinical outcome was analyzed by ordinal logistic regression. Results-Complete revascularization was achieved in 70.5% of the solitaire group and in 22.3% of the control group (P<0.001). Significant differences in complete revascularization rates were found for terminus internal carotid artery, M1, and tandem occlusions (all P<0.001) but not for M2 occlusions. In the thrombectomy group, 2 out of 63 patients (3.1%) with modified Thrombolysis in Cerebral Infarction 2b/3 after thrombectomy showed arterial reocclusion (modified arterial occlusive lesion grade 0/1) at 24 hours. Complete revascularization was associated with improved outcome in both thrombectomy (adjusted odds ratio, 4.5; 95% confidence interval, 1.9-10.9) and control groups (adjusted odds ratio, 2.7; 95% confidence interval, 1.0-6.7). Revascularization (modified arterial occlusive lesion grade 2/3) was associated with smaller infarct volumes in either treatment arm. Conclusions-Complete revascularization at 24 hours is a powerful predictor of favorable clinical outcome, whereas revascularization of any type results in reduced infarct volume in both thrombectomy and control groups. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01692379.

“…The clinical significance of delayed recanalization for 3-month outcome is supported by the present data in correspondence with previous reports. 30,31 Based on SITS data, we have no information of timing of recanalization before the follow-up report (22-36 hour) and, hence, cannot distinguish whether the final benefit of recanalization without improvement is based on early Not improved at 2 h, recanalized at 22-36 h (RWI)…”

Section: Strokementioning

confidence: 99%

Importance of Cerebral Artery Recanalization in Patients With Stroke With and Without Neurological Improvement After Intravenous Thrombolysis

Харитонова¹,

Melo²,

Andersen³

et al. 2013

P atients with major cerebral artery occlusion represent the most severe cases of ischemic stroke, 1 for whom prompt recanalization would offer an alternative to a very unfavorable outcome. 2 We have previously demonstrated that hyperdense middle cerebral artery sign, which indicates proximal middle cerebral artery occlusion, disappears after intravenous thrombolysis (IVT) in approximately half of cases, and this disappearance, implying vessel recanalization (although not verified as its marker), is associated with lower mortality and better functional outcome.3 Nevertheless, a large proportion of patients (45% in our previous study) 3 does not achieve vessel recanalization by IVT only. The need for additional recanalizing interventions in this group has been discussed 4-8 because their 3-month survival and independence are unsatisfactory with IVT only. 3,9,10 Several newer combined methods have been suggested for rescue reperfusion in patients with stroke with large vessel occlusion after unsuccessful IVT treatment, such as intra-arterial thrombolysis and mechanical retrieval of the clot.11-15 Combination of IVT and endovascular treatment of major vessel occlusion (intra-arterial thrombolysis and Background and Purpose-Recanalization status after intravenous thrombolysis (IVT) in patients with ischemic stroke is a reference point to proceed with a rescue reperfusion intervention, although early neurological improvement (NI) may preclude endovascular procedures. We aimed to evaluate the importance of restoration of blood flow at the arterial occlusion site in subgroups of patients with stroke stratified by early NI after IVT. Methods-The following patients were recruited from the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register: (1) with baseline vessel occlusion documented by computed tomographic (CT) or magnetic resonance (MR) angiography and follow-up angioimaging between 22 and 36 hours after IVT available; and (2) with dense cerebral artery sign on admission CT scan and results of follow-up CT reported. Recanalization at 24 hours was defined as absence of vessel occlusion or as resolution of dense cerebral artery sign on follow-up 22-to 36-hour imaging. NI was assessed at 2 hours and 24 hours after IVT and was defined as improvement by 20% from baseline National Institute of Health Stroke scale score. Primary outcome measure was independence, defined as modified Rankin scale score 0 to 2 after 3 months. Results-Of 28136 cases registered between December 2003 and November 2009, 5324 cases (19%) met the inclusion criteria. Patients with both NI at 2 hours post-treatment and vessel recanalization had the best chances to achieve independence at 3 months (adjusted odds ratio, 15.8; 95% confidence interval, 12.5-20.0), followed by those who had NI despite persistent occlusion (adjusted odds ratio, 4.7; 95% confidence interval, 3.6-6.1); and those without NI despite recanalization (adjusted odds ratio, 2.7; 95% confidence interval, 2.2-3.3). Conclusions-Recanalization of an occ...