To bridge or not to bridge: summary of the new evidence in endovascular stroke treatment

Podlasek, Anna; Dhillon, Permesh Singh; Butt, Waleed; Grunwald, Iris Q.; England, Timothy J.

doi:10.1136/svn-2021-001465

Cited by 8 publications

(6 citation statements)

References 12 publications

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“…This led to clinical equipoise for RCTs, some of which are ongoing, while others are complete. A recent meta-analysis of 6 RCTs suggests direct MT is non-inferior, but perhaps has lower recanalization rates ( 86 ). Understanding the influence of thrombolytics on the mechanical properties of clots is limited ( 87 ).…”

Section: Discussion and Recommendations For Future Advancementsmentioning

confidence: 99%

A Review of the Advancements in the in-vitro Modelling of Acute Ischemic Stroke and Its Treatment

Johnson

Dwivedi

Mirza

et al. 2022

Front. Med. Technol.

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In-vitro neurovascular models of large vessel occlusions (LVOs) causing acute ischemic stroke (AIS) are used extensively for pre-clinical testing of new treatment devices. They enable physicians and engineers to examine device performance and the response of the occlusion to further advance design solutions for current unmet clinical needs. These models also enable physicians to train on basic skills, to try out new devices and new procedural approaches, and for the stroke team to practice workflows together in the comfort of a controlled environment in a non-clinical setting. Removal of the occlusive clot in its entirety is the primary goal of the endovascular treatment of LVOs via mechanical thrombectomy (MT) and the medical treatment via thrombolysis. In MT, recanalization after just one pass is associated with better clinical outcomes than procedures that take multiple passes to achieve the same level of recanalization, commonly known as first pass effect (FPE). To achieve this, physicians and engineers are continually investigating new devices and treatment approaches. To distinguish between treatment devices in the pre-clinical setting, test models must also be optimized and expanded become more nuanced and to represent challenging patient cohorts that could be improved through new technology or better techniques. The aim of this paper is to provide a perspective review of the recent advancements in the in-vitro modeling of stroke and to outline how these models need to advance further in future. This review provides an overview of the various in-vitro models used for the modeling of AIS and compares the advantages and limitations of each. In-vitro models remain an extremely useful tool in the evaluation and design of treatment devices, and great strides have been made to improve replication of physiological conditions. However, further advancement is still required to represent the expanding indications for thrombectomy and thrombolysis, and the generation of new thrombectomy devices, to ensure that smaller treatment effects are captured.

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Section: Discussion and Recommendations For Future Advancementsmentioning

confidence: 99%

A Review of the Advancements in the in-vitro Modelling of Acute Ischemic Stroke and Its Treatment

Johnson

Dwivedi

Mirza

et al. 2022

Front. Med. Technol.

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“…Recently, there are several randomized controlled trials questioning this approach and first results show a non-inferiority of EVT alone vs. a combination therapy [16][17][18]. Podlasek et al concisely summarized the combined trial data of six studies including SWIFT-DIRECT and DIRECT-SAFE, showing a clinical non-inferiority of direct mechanical thrombectomy to bridging therapy [19] but significantly better technical success rates in the MT/IVT groups; however, there is still a paucity of evidence concerning the concomitant use of IVT and MT with overlapping lysis activity during the MT procedure. As there are no guidelines on the temporal orchestration of IVT and MT, a certain insecurity has spread among neurointerventionalists and neurologists whether to stop or to continue alteplase administration before initiation or after completion of the thrombectomy procedure [10].…”

Section: Discussionmentioning

confidence: 99%

Start, Stop, Continue? The Benefit of Overlapping Intravenous Thrombolysis and Mechanical Thrombectomy

Burian

Sepp²,

Lehm³

et al. 2022

Clin Neuroradiol

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Objective Here we compare the procedural and clinical outcome of patients undergoing thrombectomy with running thrombolysis to matched controls with completed intravenous therapy and an only marginally overlapping activity. Methods Patients from 25 sites in Germany were included, who presented with an acute ischemic stroke. Patients’ baseline characteristics (including ASPECTS, NIHSS and mRS), grade of reperfusion, and functional outcome 24 h and at day 90 after intervention were extracted from the German Stroke Registry (n = 2566). In a case-control design we stepwise matched the groups due to age, sex and time to groin puncture and time to flow restoration. Results In the initial cohort (overlap group n = 864, control group n = 1702) reperfusion status (median TICI in overlap group vs. control group: 3 vs. 2b), NIHSS after 24 h, early neurological improvement parameters, mRS at 24 h and at day 90 were significantly better in the overlap group (p < 0.001) with a similar risk of bleeding (2.9% vs. 2.4%) and death (18% vs. 22%). After adjustment mRS at day 90 still showed a trend for lower disability scores in the overlap group (3 IQR 1-5 vs. 3 IQR 1-6, p = 0.09). While comparable bleeding risk could be maintained (4% in both groups), there were significantly more deaths in the control group (18% vs. 30%, p = 0.006). Conclusion The presented results support the approach of continuing and completing a simultaneous administration of intravenous thrombolysis during mechanical thrombectomy procedures.

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“…Acute ischemic stroke of extracranial carotid artery origin (AIS-CA) has an unfavorable clinical prognosis due to the large volume of affected brain tissue and the typically large thrombus load, with recanalization rates below 10% using systemic intravenous thrombolysis (IVT) [9][10][11]. IVT is an established part of stroke reperfusion therapy that, in the setting of large vessel occlusions (LVO), should be combined with mechanical reperfusion [10][11][12][13][14][15][16]. There is some evidence in intracranial LVO strokes that IVT administration prior to emergency mechanical reperfusion (EMR) may be associated with increased early recanalization rate [14][15][16]; but this may be less applicable to AIS-CA due to the typically large thrombus burden in AIS-CA [6,9,17].…”

Section: Introductionmentioning

confidence: 99%

“…IVT is an established part of stroke reperfusion therapy that, in the setting of large vessel occlusions (LVO), should be combined with mechanical reperfusion [10][11][12][13][14][15][16]. There is some evidence in intracranial LVO strokes that IVT administration prior to emergency mechanical reperfusion (EMR) may be associated with increased early recanalization rate [14][15][16]; but this may be less applicable to AIS-CA due to the typically large thrombus burden in AIS-CA [6,9,17]. Some authors suggest that the bleeding risk with mechanical recanalization may be increased if IVT precedes mechanical thrombectomy (MT) [13,18].…”

Section: Introductionmentioning

confidence: 99%

Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers

et al. 2022

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Background:Systemic intravenous thrombolysis and mechanical thrombectomy (MT) are guideline-recommended reperfusion therapies in large-vessel-occlusion ischemic stroke. However, for acute ischemic stroke of extracranial carotid artery origin (AIS-CA) there have been no specific trials, resulting in a data gap. Material/Methods:We evaluated referral/treatment pathways, serial imaging, and neurologic 90-day outcomes in consecutive patients, presenting in a real-life series in 2 stroke centers over a period of 6 months, with AIS-CA eligible for emergency mechanical reperfusion (EMR) on top of thrombolysis as per guideline criteria. Results:Of 30 EMR-eligible patients (33.3% in-window for thrombolysis and thrombolysed, 73.3% male, age 39-87 years, median Alberta Stroke Program Early Computed Tomography Score (ASPECTS) 10, pre-stroke mRS 0-1 in all, tandem lesions 26.7%), 20 (66.7%) were EMR-referred (60% -endovascular, 6.7% -surgery referrals). Only 40% received EMR, nearly exclusively in stroke centers with carotid artery stenting (CAS) expertise (100% eligible patient acceptance rate, 100% treatment delivery involving CAS±MT with culprit lesion sequestration using micronet-covered stents). The emergency surgery rate was 0%. Baseline clinical and imaging characteristics did not differ between EMR-treated and EMR-untreated patients. Ninety-day neurologic status was profoundly better in EMR-treated patients: mRS 0-2 (91.7% vs 0%; P<0.001); mRS 3-5 (8.3% vs 88.9%; P<0.001), mRS 6 (0% vs 11.1%; P<0.001). Conclusions:In a real-life AIS-CA setting, the referral rate of EMR-eligible patients for EMR was low, and the treatment rate was even lower. AIS-CA revascularization was delivered predominantly in stroke thrombectomy-capable cardioangiology centers, resulting in overwhelmingly superior patient outcome. Large vessel occlusion stroke referral and management pathways should involve centers with proximal-protected CAS expertise. AIS-CA, irrespective of any thrombolysis administration, is a hyperacute cerebral emergency and EMR-eligible patients should be immediately referred for mechanical reperfusion.

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To bridge or not to bridge: summary of the new evidence in endovascular stroke treatment

Cited by 8 publications

References 12 publications

A Review of the Advancements in the in-vitro Modelling of Acute Ischemic Stroke and Its Treatment

A Review of the Advancements in the in-vitro Modelling of Acute Ischemic Stroke and Its Treatment

Start, Stop, Continue? The Benefit of Overlapping Intravenous Thrombolysis and Mechanical Thrombectomy

Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers

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