The document discusses the evolution of treatments for acute ischemic stroke (AIS), including intravenous thrombolysis and mechanical thrombectomy. It summarizes key randomized trials that established the benefits of mechanical thrombectomy. The first-generation trials using early thrombectomy devices did not show benefit, but recent trials using stent retrievers demonstrated significantly improved recanalization rates and superior outcomes for mechanical thrombectomy combined with intravenous thrombolysis compared to intravenous thrombolysis alone in eligible patients presenting within 6 hours of stroke onset. The document concludes that mechanical thrombectomy is now a standard treatment for AIS but remains underutilized.
Mechanical thrombectomy for acute ischemic stroke (temporary stroke) is a minimally invasive endovascular procedure to remove blood clots from larger vessels in the brain.
Who is it recommended for?
Mechanical thrombectomy is indicated for patients who:
1. Had an Acute ischemic stroke due to LAO
2. Has failed intravenous thrombolysis
3. Have temporarily or permanent disabilities with the the below mentioned.
Complications:
a. Paralysis or loss of movement in muscles
b. Difficulty when talking or swallowing
c. Memory loss or difficulty in processing thoughts, reasoning or making decisions/judgements
d. Pain or numbness in affected parts
e. Change in moods, behaviour and self-care ability.
However, consulting physicians and surgeons decide if Mechanical thrombectomy for Acute Ischemic (temporary) Stroke is a suitable option for the patient. The decision is made based on various factors, such as age, severity of the stroke, time and test results. Eligible patients should receive intravenous alteplase without delay even if mechanical thrombectomy is being considered.
Recovery after Mechanical thrombectomy:
Recovery of the patient depends on:
1. Overall condition
2. Severity of the stroke
3. Severity of the symptoms
Patients are seen usually walking within 24 hours.of the procedure, but if the injury is severe then doctors recommend a couple of days rest with physiotherapy and rehabilitation.
Benefits of Mechanical thrombectomy for acute ischemic stroke are:
1. Greater Efficacy
2. Cost Effective
3. Larger Treatment window (up to 24 hours)
4. Short Hospital stay and rehabilitation
Mechanical thrombectomy for acute ischemic stroke (temporary stroke) is a minimally invasive endovascular procedure to remove blood clots from larger vessels in the brain.
Mechanical thrombectomy for acute ischemic stroke (temporary stroke) is a minimally invasive endovascular procedure to remove blood clots from larger vessels in the brain.
Who is it recommended for?
Mechanical thrombectomy is indicated for patients who:
1. Had an Acute ischemic stroke due to LAO
2. Has failed intravenous thrombolysis
3. Have temporarily or permanent disabilities with the the below mentioned.
Complications:
a. Paralysis or loss of movement in muscles
b. Difficulty when talking or swallowing
c. Memory loss or difficulty in processing thoughts, reasoning or making decisions/judgements
d. Pain or numbness in affected parts
e. Change in moods, behaviour and self-care ability.
However, consulting physicians and surgeons decide if Mechanical thrombectomy for Acute Ischemic (temporary) Stroke is a suitable option for the patient. The decision is made based on various factors, such as age, severity of the stroke, time and test results. Eligible patients should receive intravenous alteplase without delay even if mechanical thrombectomy is being considered.
Recovery after Mechanical thrombectomy:
Recovery of the patient depends on:
1. Overall condition
2. Severity of the stroke
3. Severity of the symptoms
Patients are seen usually walking within 24 hours.of the procedure, but if the injury is severe then doctors recommend a couple of days rest with physiotherapy and rehabilitation.
Benefits of Mechanical thrombectomy for acute ischemic stroke are:
1. Greater Efficacy
2. Cost Effective
3. Larger Treatment window (up to 24 hours)
4. Short Hospital stay and rehabilitation
Mechanical thrombectomy for acute ischemic stroke (temporary stroke) is a minimally invasive endovascular procedure to remove blood clots from larger vessels in the brain.
Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods
Int J Stroke. 2017 Aug;12(6):641-652.
Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct
N Engl J Med. 2018 Jan 4;378(1):11-21.
A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3)
Int J Stroke. 2017 Oct;12(8):896-905.
Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging
N Engl J Med. 2018 Feb 22;378(8):708-718.
Acute stroke management
IV thrombolysis guidelines
IV thrombolysis side effects
Early CT changes in stroke
ASPECTS scoring
AHA stroke guidelines
Thrombolysis controversies
Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods
Int J Stroke. 2017 Aug;12(6):641-652.
Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct
N Engl J Med. 2018 Jan 4;378(1):11-21.
A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3)
Int J Stroke. 2017 Oct;12(8):896-905.
Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging
N Engl J Med. 2018 Feb 22;378(8):708-718.
Acute stroke management
IV thrombolysis guidelines
IV thrombolysis side effects
Early CT changes in stroke
ASPECTS scoring
AHA stroke guidelines
Thrombolysis controversies
2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment
Stroke. 2015;46:3020-3035.
"Revolutionizing Stroke Care: Endovascular Therapy and Neuro Intervention in Acute Ischemic Stroke with Dr. Ganesh"
đ Greetings, everyone! Dr. Ganesh here, and today, we're exploring a groundbreaking topic that's transforming the landscape of stroke care: Endovascular Therapy and Neuro Intervention in Acute Ischemic Stroke (AIS). Whether you're a healthcare professional, a patient, or simply intrigued by medical advancements, this discussion is tailored for you.
Terapi Endovaskuler, Standar Baru Manajemen Stroke Iskemik Akut? Ersifa Fatimah
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Konon, plenary pertama International Stroke Conference (ISC) 2015 yang digelar di Nashville, Tennessee bulan Februari lalu merupakan sesi ISC terseru selama beberapa tahun terakhir. Sebagaimana diberitakan dalam Medscape (Hughes, 2015), para presenter terpaksa memberi jeda beberapa saat untuk menyambut applause dari audiens. Suatu kejadian langka dalam partemuan saintifik. Adalah MR CLEAN, ESCAPE, EXTEND-IA, dan SWIFT PRIME yang menjadi topik hangat lantaran keempat studi ini dirilis dengan hasil yang positif dramatis hingga diprediksi bakal menjadikan terapi endovascular sebagai standar baru dalam manajemen stroke iskemik akut. Sehebat apakah 4 studi yang âmenyejarahâ dalam tatalaksana stroke iskemik akut ini? Bagaimana bila studi-studi ini diadopsi dan diaplikasikan dalam praktik sehari-hari di sentra kita?
Note: Esai ini ditulis saat SWIFT PRIME fulltext belum published (akhir Maret-awal April 2015). Update & beberapa revisi dibuat menjelang presentasi tanggal 18 Mei 2015.
Can read freely here
https://sethiortho.blogspot.com/
A COMPARISON OF RECOMBINANT UROKINASE WITH VASCULAR SURGERY AS INITIAL TREATMENT FOR ACUTE ARTERIAL OCCLUSION OF THE LEGS
For the thrombolysis or peripheral arterial surgery (TOPAS) investigators RCT
The Rochester study -1994
Surgery Vs Thrombolysis for Ischemia of the Lower Extremity (STILE) - 1996
endovascular surgery
Primary PCI with stenting immediately after coronary reperfusion salvage procedures jeopardizes myocardium, improves prognosis, and is the current standard of care for acute STEMI .
No-reflow is defined as an acute reduction in myocardial blood flow despite a patent epicardial coronary artery .
The pathophysiology of no-reflow involves microvascular obstruction secondary to distal embolization of clot, microvascular spasm, and thrombosis .
No-reflow occurs in ~10% of cases of primary PCI and is associated with patient characteristics such as advanced age and delayed presentation and coronary characteristics such as a completely occluded culprit artery and heavy thrombus burden .
Similar to acute ischemic Stroke interventions (20)
Report Back from SGO 2024: Whatâs the Latest in Cervical Cancer?bkling
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Are you curious about whatâs new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Womenâs Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
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Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
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Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
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Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
Itâs work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Tom Selleck Health: A Comprehensive Look at the Iconic Actorâs Wellness Journeygreendigital
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Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
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1. Acute Ischemic Stroke Intervention &
Recent Endovascular Stroke Trials and
Their Impact on Stroke Systems of Care
Dr.G.Abishek
2. OUTLINE
⢠Introduction
⢠Present Status Of Intravenous Thrombolytic Therapy
⢠Evolution Of AIS Treatment
⢠1st
generation mechanical thrombectomy devices
⢠2nd
generation mechanical thrombectomy devices
⢠Endovascular treatment trails
⢠Present status and future direction of endovascular treatment
⢠Conclusions
3. INTRODUCTION
⢠Acute ischemic stroke (AIS) occurs when there is a sudden occlusion of the arterial blood supply
to part of the brain, and is most commonly manifested by focal neurological deficits.
⢠The mechanisms of ischemic stroke can be divided into embolic (artery to artery or
cardioembolic), lipohyalinotic occlusion of small arteries, or in situ thrombosis over an
atherostenotic plaque (atherothrombosis).
⢠Thrombolysis to recanalize the occlusion and reperfuse the brain, through either pharmacological
or mechanical means, is the mainstay of treatment options for patients with AIS.
4. ⢠Acute ischemic stroke (AIS) is the leading cause of disability worldwide and among the leading
causes of mortality.
⢠Although intravenous tissue plasminogen activator (IV-rtPA) was approved nearly 2 decades ago
for treatment of AIS, only a minority of patients receive it due to a narrow time window for
administration and several contraindications to its use.
⢠Endovascular approaches to recanalization in AIS developed in the 1980s, and recently, 5 major
randomized trials showed an overwhelming superior benefit of combining endovascular
mechanical thrombectomy with IV-rtPA over IV-rtPA alone
6. THROMBOLYSIS
⢠IV-rtPA treatment was shown to benefit patients with AIS in the 1995 NINDS (National Institute
of Neurological Disorders and Stroke) study.
⢠IV-rtPA was a major milestone in stroke treatment, as the first disease-modifying therapy for AIS.
⢠1996, FDA approved the use of IV-rtPA for patients with AIS presenting within 3 h of symptom
onset.
⢠2008, ECASS (European Cooperative Acute Stroke Study) III showed benefit of IV-rtPA over
placebo among those treated within 3 to 4.5 h of symptom onset
⢠2015, stroke guidelines from AHA recommended using it up to 4.5 h from onset of symptoms in
eligible patients.
7. Whatâs wrong with IV thrombolysis?
⢠Intravenous recombinant tissue plasminogen activator (IV-rtPA) is the approved therapy for
patients with AIS presenting within 0 to 4.5 h.
⢠50% of patients receiving IV-rtPA were still either severely disabled or dead.
⢠The absolute reduction in chance of poor outcome in patients treated with IV-rtPA within 3 h is
10% (NNT-10).
⢠In a 3- to 4.5-h time window, the effect is reduced further, to 7% (NNT-14).
⢠Inadequately complete recanalization(13% to 50)
⢠Hemorrhagic transformation.
11. MECHANICAL THROMBECTOMY
⢠âMechanical Embolus Removal In Cerebral Ischemiaâ (MERCI) device.
⢠The device is made of a corkscrew-shaped nitinol wire that is deployed into the thrombus in the
occluded intracranial artery.
16. IMS (Interventional Management of Stroke) III trial
⢠The IMS III trial was an international RCT comparing standard-dose IV-rtPA with a combination
IV-rtPA and mechanical thrombectomy.
⢠No pre-procedure vascular imaging was required before enrolling patients for the study, which led
to 89 (21%) patients enrolled in the endovascular arm without LVO.
⢠The first-generation MERCI device was the only FDA-approved device at the time of the study,
and was used in the majority of patients.
⢠In 2012, the study was stopped due to futility and showing no significant difference in long-term
functional outcome between groups
18. SYNTHESIS EXP TRAIL
⢠Randomized patients into IV-rtPA or endovascular arms (MT with or without IA thrombolysis)
⢠Vascular imaging was not mandatory to randomize patients in the endovascular arm.
⢠Second-generation devices were used in only 13% of patients undergoing endovascular treatment.
⢠No functional benefit of endovascular therapy was observed in this trial (30.4% for endovascular
therapy vs. 34.8% for IV-rtPA therapy; p 0.37).
20. MR RESCUE trial
⢠RCT of first- generation device MT in the anterior circulation in patients randomized by magnetic
resonance imaging (MRI) perfusion imaging, in addition to randomization of embolectomy versus
medical therapy.
⢠There were no significant differences between the MT and medical therapy groups , regardless of
recanalization status.
⢠There was also no significant benefit with MT seen in either of the subgroups with penumbral
versus non penumbral patterns.
⢠Thus, the 3 trials using mainly first-generation MT devices and done within acute stroke systems
of care between 2004 and 2012 did not show functional
22. MECHANISM OF THE STENT RETRIEVERS
⢠Designed for purpose of stent-assisted coiling and for retracting errant coils dislodged during
endovascular procedures.
⢠Effective in capturing naturally occurring thrombus and could effect early vessel recanalization.
⢠Self-expanding stents that are delivered across the thrombus with the help of a microcatheter.
⢠Their design, with multiple crisscrossing struts, ensures capture of the thrombus within the stent
wall, followed by withdrawal of the unfolded stent into the guide catheter under constant
aspiration.
23. Why are Retrievable stents better that self expanding stents?
Disadvangates of SES:-
1.Dual antiplatelet therapy,
2.IV glycoprotein IIb/IIIa inhibitors
3.Additional risk of hemorrhagic
4.Long-term risk of restenosis and reocclusion @ 25% and 32.3% respectively
Advantages of RSS:-
1.Immediate flow restoration after deployment.
2.Ability to retrieve the stent after mechanical embolectomy.
3.Negate the long term need for dual antiplatelet therapy and IV glycoprotein IIb/IIIa inhibitors
in the acute setting.
26. When paired with the Solitaire FR Revascularization Device, the Cello Balloon Guide Catheter can help
prevent distal embolization during a revascularization procedure and improve patient outcomes
33. MR CLEAN TRAIL
⢠(Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in
the Netherlands) randomized acute stroke patients presenting within 6 h of stroke onset to standard
medical management alone or standard medical management followed by MT.
⢠Noninvasive vascular imaging before enrolling a patient into MT was mandatory, and as long as
there was clear vessel occlusion.
⢠Patients with AIS who were older than 18 years of age and with anterior circulation LVO
confirmed on noninvasive vascular imaging were eligible to be enrolled in the trial.
⢠Good FIO was superior among those treated with the combination of MT and standard medical
management
⢠There were no significant differences in mortality or occurrence of sICH.
34.
35.
36.
37.
38.
39. COMPARISON OF FIRST GENERATION
AND CURRENT ENDOVASCULAR TRIALS: KEY FACTORS THAT
MADE THE DIFFERENCE
40. CT NEUROIMAGING IN PATIENT SELECTION
⢠ASPECTS is a 10-point scoring system that reliably predicts the extent of early ischemic changes
from CT scans.
⢠Earlier RCTs using first-generation devices did not adequately assess the extent of early ischemic
changes on the initial CT scan for selectively enrolling the patient into the trial.
⢠first-generation trials, enrolled and randomized acute stroke patients on the clinically assessed
NIHSS score rather than confirmed LVO on noninvasive vascular imaging.
⢠Recent RCTs have mandated confirmation of LVO on CT angiography or MR angiography prior
to randomization.
⢠This change was likely one of the critical factors in showing clear benefit of MT in patients with
AIS.
41. FASTER AND IMPROVED RECANALIZATION
⢠Faster treatment from stroke onset to IV-rtPA is associated with better clinical outcomes.
⢠The mean time from symptom onset to IA in the MR-RESCUE study was 381 min. In
SYNTHESIS EXP and IMS III, the median times from symptom onset to start of endovascular
treatment were 225 and 240 min, respectively, indicating significant time delays.
⢠Learning from the time delays in previous trials, the recent endovascular trials all emphasized the
importance of faster door-to-recanalization times.
⢠Another significant difference in the recent trials was the tremendously improved rate of
substantial recanalization, primarily through the use of stent retriever devices.
42. RECANALIZATION
⢠Clot lysis resulting in recanalization and restoration of cerebral blood flow is the desired
immediate result of thrombolytic therapy.
⢠Recanalization is associated with improved outcome and reduced mortality in acute ischemic
stroke.
⢠Symptomatic intracranial hemorrhagic transformation rates were similar for recanalization
compared with no recanalization.
⢠Recanalization rates:-
⢠Spontaneous, 24.1 percent
⢠Intravenous thrombolysis, 46.2 percent
⢠Intra-arterial thrombolysis, 63.2 percent
⢠Combined intravenous and intra-arterial thrombolysis, 67.5 percent
⢠Mechanical, 83.6 percent
⢠Early recanalization from thrombolysis can lead to dramatic early clinical recovery in some but not
all patients other patients with recanalization have delayed recovery due to ischemic stunning.
43.
44.
45.
46.
47.
48.
49.
50. LIMITATIONS OF CURRENT ENDOVASCULAR TRIALS
⢠Limited numbers of patients will benefit from intervention, and clinicians must be selective when
choosing patients for endovascular therapy.
Ex:-EXTEND-IA screen to enrollment ratio was 100:1 (70 patients were enrolled after screening 7,000 patients),
⢠Centers participating in the trials were high-volume centers with very experienced
interventionalists.
⢠These centers also had streamlined workflow protocols for rapid triage of the stroke patients with
incredibly fast door-to-treatment times.
⢠4 of 5 trials that were stopped early (except MR CLEAN, the only completed study) may have
overestimated the treatment effect.
51. Issues Likely To Limit The Widespread Clinical Use Of Intra-arterial
Mechanical Thrombectomy?
⢠Only An Estimated 10 Percent Of Patients With Acute Ischemic Stroke Have A Proximal Large
Artery Occlusion In The Anterior Circulation And Present Early Enough To Qualify For
Mechanical Thrombectomy
⢠A Few Stroke Centers Have Sufficient Resources And Expertise To Deliver This Therapy.
⢠A recently published study reported that only 1.6% of patients with ischemic stroke received MT,
⢠Delay in arrival to the hospital is the most common reason seen in exclusion of patients with AIS
for MT
54. INTRA-ARTERIAL THROMBOLYSIS
⢠The dose of thrombolytic drugs can be limited to that needed for recanalization, since the
procedure is done under direct visualization.
⢠The total dose of intra-arterial therapy is about one-third of the intravenous dose.
⢠intra-arterial thrombolysis is a reasonable treatment option for patients with acute ischemic stroke
who have contraindications to intravenous thrombolysis
PROACT II TRAIL
⢠Patients receiving r-proUK (intra-arterial recombinant prourokinase )were more likely to have
recanalization (66 versus 18 percent) and to achieve functional independence at 90 days (40 versus
25 percent).
⢠proUK group had a significantly higher incidence of symptomatic intracranial hemorrhage within
24 hours (10.9 versus 3.1 percent)
55. Ultrasound Enhanced Thrombolysis
⢠Ultrasound energy may have a biologic effect that facilitates the activity of fibrinolytic agents
⢠Employed to enhance thrombolysis in patients with acute stroke treated with intravenous tPA.
⢠CLOTBUST TRAIL:-
⢠The rate of sustained complete recanalization at 2 hours was significantly increased for the
treatment group compared with placebo (38 versus 13 percent).
⢠Ultrasound enhanced thrombolysis holds promise for improving recanalization rates and outcomes
in acute ischemic stroke.
⢠Technique is investigational, and there is risk of symptomatic hemorrhage, particularly with low-
frequency ultrasound.
56. Combined Intravenous And Intra-arterial Thrombolysis
⢠The rationale for combined intravenous and intra-arterial thrombolytic therapy is to unite the
advantages of each:
1. wide availability of early rapid intravenous thrombolysis
2. potentially higher recanalization rates and therefore better outcomes of intra-arterial thrombolysis.
⢠IMS III trial found that this combined approach yielded no additional benefit compared with
intravenous thrombolysis alone.
57. CURRENT RECOMMENDATIONS AND FUTURE
DIRECTIONS
⢠Due to consistent findings across multiple endovascular trials, in the recent (June 2015) revision of
guidelines from the AHA/American Stroke Association,
⢠Class I recommendations were made (Level of Evidence: A) for the use of MT along with IV-rtPA
treatment for AIS for eligible patients.
⢠The guidelines endorsed the use of IV-rtPA in combination with MT in patients with AIS of <6 h
duration who had LVO confirmed with vascular imaging.
58. Selecting Patients For Mechanical Thrombectomy
⢠Mechanical thrombectomy treatment should not be delayed to assess the response to IV tPA.
Inclusion criteria:-
⢠A clinical diagnosis of acute stroke, with a deficit on the NIHSS of âĽ2 points and ASPECTS
score âĽ6 on noncontrast brain CT
1. Brain CT or MRI scan ruling out intracranial hemorrhage
2. Intracranial arterial occlusion of the distal intracranial internal carotid artery, or the middle
(M1/M2) or anterior (A1/A2) cerebral artery, demonstrated with CT angiography, MR
angiography, or digital subtraction angiography
3. Sufficient time to initiate endovascular thrombectomy (ie, groin puncture) within 6 hours of
stroke onset
4. Informed consent given
5. Age âĽ18 years
59. Exclusion criteria
1. Arterial blood pressure >185/110 mmHg
2. Blood glucose <2.7 or >22.2 mmol/L
3. Intravenous treatment with thrombolytic therapy in a dose exceeding 0.9 mg/kg
alteplase or 90 mg
4. Laboratory evidence of coagulation abnormalities (eg, platelet count <40,000/mL [40 x
109/L] or International Normalized Ratio [INR] >3.0)
60.
61.
62. ⢠The evidence for MT is less clear for patients presenting >6 h after symptom onset.
⢠The evidence for MT is also not clear for patients with posterior circulation strokes, as the
majority of present and past trials have excluded these patients.
⢠The guidelines also recommend use of stent retrievers as the first- line device;
⢠recommendations include faster door-to-recanalization time, the angiographic goal of TICI 2b/3
for better clinical outcomes,
63. CONCLUSIONS
⢠Recent endovascular acute stroke trials have compellingly demonstrated the superiority of
combined treatment with MT (with stent retriever) and IV-rtPA over medical therapy alone for
patients with LVO who present within 6 h.
⢠This is a revolutionary advance in our ability to combat the massive disability that results from
stroke.
⢠Perfusion imaging and technical advancements in mechanical thrombectomy expand the number
of candidates for meaningful endovascular intervention.