Full Answer
How effective is endovascular therapy for large vessel occlusion stroke (lvos)?
Previous versions: Endovascular therapy (ET) for acute ischemic stroke is now broadly recognized as one of the most powerful treatments in our field. Nonetheless, only a highly selected proportion of large vessel occlusion stroke (LVOS) patients are presently being offered treatment.
What is the time window for neuroradiological intervention after stroke?
The time window for neuroradiological intervention is 8 hours after stroke onset in patients not eligible for i.v thrombolysis or in whom intravenous thrombolysis is unsuccessful. The method was approved for AIS treatment in 2007.[13,14,15] The Penumbra System has been examined in many trials.
Does imaging modality influence outcome in endovascular therapy in stroke patients?
Stroke. 2021;52:491-497. Perfusion imaging currently represents a key selection tool for endovascular therapy (EVT) in stroke patients with large vessel occlusions in the extended time window. However, the extent to which imaging modality influences clinical outcome in EVTs remains unclear in this context.
How quickly do stroke codes predict endovascular treatment?
Predictors of endovascular treatment among stroke codes activated within 6 hours from symptom onset. Stroke. 2018; 49:2116–2121. doi: 10.1161/STROKEAHA.118.021316 Link Google Scholar 49. Saver JL, Goyal M, van der Lugt A, Menon BK, Majoie CB, Dippel DW, et al.; HERMES Collaborators.
What is the maximum time for last known normal when endovascular therapy can be performed?
Conclusions. For acute stroke patients, the late and the unknown time window of up to 24 hours after last seen normal is now open for treatment with intravenous as well as with endovascular reperfusion therapies.
What is the ideal timeframe for the administration of endovascular therapy?
Endovascular therapy must be done within six to eight hours of the onset of a stroke, depending on the location. Endovascular treatment can restore blood flow within minutes.
What is endovascular intervention stroke?
Endovascular treatment of stroke is the non-surgical treatment for the sudden loss of brain function due to blood clots. The treatment uses microcatheters (thin tubes visible under X-rays) which are inserted into the blood clot from the groin or the arm.
What is the maximum time from last known normal when intra arterial thrombolysis can be performed?
The time from last seen normal to treatment with intravenous alteplase should be under 3 hours for eligible patients with the use of standard eligibility criteria.
What is window period in stroke?
The full treatment time window for stroke is defined by the stroke onset to successful reperfusion time, and not by an arbitrary 4.5-hour or 6-hour or even 12-hour time window after onset.
Which of the following are indications for endovascular treatment of ischemic stroke?
Endovascular therapy should be considered in patients with a clinical stroke who fulfill the following criteria:Age ≥ 18 years.National Institute of Health Stroke Scale (NIHSS) ≥ 6.Have received intravenous tissue plasminogen activator (IV tPA), alteplase (Activase) within 4.5 hours of onset of symptoms.More items...
How does endovascular clot retrieval work?
Endovascular clot retrieval (ECR) is the removal of large clots occluding a brain vessel through an intra-arterial approach. ECR is a highly effective treatment that reduces the occurrence of disability and death after an ischaemic stroke.
What is EVT in stroke care?
Introduction. Endovascular thrombectomy (EVT) improves clinical outcomes, reduces disability, and saves lives for patients with acute ischemic strokes (AISs) due to anterior circulation large vessel occlusion (LVO).
How do clinical guidelines improve quality of care?
Clinical guidelines may improve the quality of care by offering clear recommendations for clinicians who are unsure about best management, overcoming outdated practices, improving consistency of care, and helping establishing treatment policies. Guidelines are typically based on an expert consensus appraisal of the best available scientific evidence. However, because only a minor subset of medical practice has been properly tested in well conducted trials, evidence is often absent, ambiguous, biased, or misinterpreted. More importantly, evidence-based medicine derives from large populational studies that fail to account for many of the individual nuances we face in clinical practice. Therefore, inflexible guidelines that may be perceived as rigid rules can be harmful for patients by leaving insufficient room for clinicians to tailor care to patients’ personal circumstances. 8 Perhaps, in the setting of grave conditions such as LVOS, the best application of guidelines would be to use them to set the minimal thresholds for what should be offered to patients rather than establishing the upper limit of acceptable clinical practice. Unfortunately, their use has been misguided as guidelines have often served for the purposes of malpractice litigation and economic decisions by hospitals and healthcare insurance carriers, which has further reinforced the despotism of cookbook medicine.
What are the limitations of Aspects and Infarct Volume?
A critical limitation for both ASPECTS and infarct volumes in treatment selection is that they do not account for tissue eloquence. A voxel-based lesion symptom mapping study has shown that injury to corona radiata, internal capsule, postcentral gyrus, putamen, and operculum is more likely to result in poor functional recovery. 41 An ASPECTS-based study demonstrated that involvement of the right parieto-occipital (M6) and left superior frontal (M4) regions affects clinical outcome above other ASPECTS regions after adjustment for infarct volume, 42 whereas another study suggested the use of a weighted ASPECTS assessment as the preservation of the high cortical regions (in particular, the right M6 and M4 and left M6, M5, and M3) had a more robust association with improved outcomes compared with the deep ASPECTS regions. 36 We believe that the mismatch between the topographical assessment of patient’s symptoms and the infarct visualized on imaging is likely the most pragmatic and reliable surrogate for penumbra and the optimal tool for an accurate decision-making. For instance, despite large infarcts, patients may still recover from specific deficits as long as the related areas are not yet infarcted on imaging (Figure II in the online-only Data Supplement ).
How much does Alteplase cost?
The costs of Alteplase in the United States increased by 111% between 2005 and 2014 with a 100-mg vial pricing ≈$6400. 14 Regardless of the increased costs, alteplase treatment remains highly cost-effective. Indeed, treatment with IV tPA (tissue-type plasminogen activator) within the first 3 hours leads to an average per patient gain of 0.39 quality-adjusted life-years (QALYs) and a lifetime cost saving of $25 000 compared with no tPA. 15 In the 3- to 4.5-hour window, the benefit drops to a lifetime gain of 0.28 QALYs for an additional cost of $6050, yielding an incremental cost-effectiveness ratio of $21 978 per QALY. 16 The cost-effectiveness of ET is also well established and at least in a similar range. In contrast to alteplase, the costs of stroke devices seem to be decreasing, likely as the result of expansion in the number of options and manufacturers. At the time of SWIFT PRIME, the Solitaire device costed ≈$6862; however, after considering all the other expenses, the initial hospitalization costs were ≈$17 000 per patient higher for ET+IV tPA versus tPA alone. 17 Despite this, ET+tPA was associated with substantial gains in QALYs (6.79 versus 5.05) and cost savings ($23 203) on lifetime projections as compared with tPA alone. Likewise, 2 other studies have shown that the addition of ET to IV tPA compared IV tPA-alone–yielded lifetime gains in the range of 0.7 to 1.05 QALYs for additional costs in the $9911 to 12 263 range resulting in a cost of $11 651 to 14 137 per QALY. 18, 19 Moreover, it is possible that direct ET for LVOS patients presenting to thrombectomy-capable hospitals may lead to similar (or better) outcomes while mitigating the extra costs and risks associated with IV thrombolysis. In fact, a recent study suggested that IV tPA before ET does not seem to not improve recanalization, ET efficacy, functional outcomes, or length of stay but is associated with significantly higher total ($33 810±13 505 versus 40 743±17 177; P =0.02) and direct (23 034±8786 versus 28 711±11 406; P =0.007) hospital costs as compared with ET alone. 20 The direct ET paradigm has been previously shown to be advantageous for ST-segment–elevation myocardial infarction patients, and direct ET in stroke is currently being tested in 5 different RCTs worldwide.
Why is CTP better than NCCT?
More sophisticated imaging selection paradigms will lead to better outcomes in treated patients but risk excluding patients who may still have a meaningful benefit. A single-center matched analysis comparing NCCT versus CTP selection showed that CTP was significantly associated with a favorable 90-day mRS shift, lower mortality, and higher reperfusion rates. 43 Similarly, the rates of functional independence were remarkably higher in treated patients from the RCTs that primarily utilized CTP (EXTEND-IA, 71%; SWIFT PRIME, 60%) versus those primarily based on NCCT (MR CLEAN, 32.6%; REVASCAT, 43.7%). While at first glance, this may suggest that better imaging leads to better outcomes, that is not really the case for at least 3 distinct reasons: (1) over-selection, (2) longer times to treatment, and (3) at least in the case of CTP, limited accuracy. The denominator effect underlying over-selection can be exemplified by the fact that the rate of independent outcomes for ET in MR CLEAN (32.6%) was actually lower than the controls from EXTEND-IA (40%). In the CTP cohort of MR CLEAN (n=175), infarct volumes predicted functional outcomes, whereas penumbral volumes did not. More importantly, there was no significant interaction between the volumes of infarct, penumbra, or mismatch and treatment effect. 44 Similarly, CTP mismatch volume was not associated with functional outcomes independently of infarct volume and did not modify treatment effect in HERMES. 40 Notably, the authors emphasized that the nonmismatch sample size was small and the few patients with no mismatch did not seem to benefit from treatment. The conclusion is that CTP parameters may predict outcome, but, at least at this point, CTP has not established itself as a treatment effect modifier. Moreover, it is becoming progressively clear that CTP abnormalities should not be a reason for treatment exclusion in face of a favorable NCCT because as many as 16% of patients will have a ghost infarct core defined by >10 mL lesion reversal post-treatment (Figure III in the online-only Data Supplement ). 45 Unlike DWI that relies on bioenergetic failure, perfusion studies are merely a snapshot in time of hemodynamics. Therefore, their relationship with tissue fate is time dependent and often unreliable. 45, 46
Is age a predictor of stroke?
Age is a strong predictor of outcome after stroke . The older the patient is, the lower is the chance of a good outcome. However, the treatment benefit with IV tPA or thrombectomy (eg, the difference between treatment and no treatment) is maintained across age despite age’s negative impact on outcome. Indeed, the HERMES meta-analysis showed no significant heterogeneity in treatment effect (90-day mRS shift) across age ( P =0.07). Interestingly, the treatment benefit was numerically higher in patients ≥80 years of age (n=198; common odds ratio [cOR], 3.68; 95% CI, 1.95–6.92) as compared with their younger counterparts, with the youngest subgroup having the lowest relative benefit (18–49 years, n=158; cOR, 1.36; 95% CI, 0.75–2.46). 10 Analogously, the ESCAPE trial demonstrated a significant benefit of ET in terms of 90-day mortality (adjusted hazard ratio, 0.4; 95% CI, 0.2–0.8) that was primarily driven by the elderly (≤80 years, 6.8% versus 10.2%; >80 years, 19.6% versus 43.6%). 26 Nevertheless, it remains essential to acknowledge that the tolerance to final infarct burden decays as a function of age. Previous studies have shown that the target cutoff final infarct volume that best predicts a good outcome decreases from ≈50 mL in patients <70 years of age to ≈15 mL in those ≥80 years of age with few patients ≥80 years of age achieving good outcome once their FIVs cross the >50-mL margin. 33, 34 Access to the target lesion due to arterial tortuosity represents another important challenge in the elderly. Radial or direct carotid access can almost invariably overcome these difficulties and should be an early consideration to prevent delays in reperfusion. Finally, one must consider that age is a strong surrogate for functional status and comorbidities, factors that cannot be easily considered in large populational studies but can be computed in individual treatment decisions. As such, we need to depart the concept of chronological age and work with biological age instead.
Is endovascular therapy effective for stroke?
Endovascular therapy (ET) for acute ischemic stroke is now broadly recognized as one of the most powerful treatments in our field. Nonetheless, only a highly selected proportion of large vessel occlusion stroke (LVOS) patients are presently being offered treatment. Herein, we discuss some of the scientific and philosophical aspects surrounding the care of LVOS and provide a critical view of the current clinical practice centering our discussions on the concept of personalized medicine.
Should LVOS patients undergo thrombectomy?
Given the robust nature of benefit from thrombectomy, the paradigm shift should be that every patient with acute LVOS should undergo thrombectomy unless the weight of evidence is strongly against treatment. This is a paradigm shift that focuses on rapid and aggressive interventional therapy and withholds treatment as an exception. Such clinical paradigms exist in medicine, even in neurological diseases. Acute MI patients with ST-segment elevation on EKG within the first 12 hours of symptoms are transferred directly to the angio-suite. There is not even a requirement for cardiac enzyme elevation, and it is accepted that ≈15% of the patients will eventually not be treated. Patients with possible bacterial meningitis are treated with antibiotics as an emergent priority well before a definitive diagnosis is made. The reasons for this are obvious as delays in treatment are devastating because bacteria can double in number every 20 to 30 minutes. Time to reperfusion in LVOS is as critical as time to reperfusion in ST-segment–elevation myocardial infarction and time to treatment with antibiotics in bacterial meningitis, so treatment speed should equally prevail over diagnostic accuracy.