J Vasc Interv Radiol. 2013 Sep;24(9):1273-9.

Acute combined revascularization in acute ischemic stroke with intracranial arterial occlusion: self-expanding solitaire stent during intravenous thrombolysis.

Šaňák D, Köcher M, Veverka T, Černá M, Král M, Buřval S, Školoudík D, Prášil V, Zapletalová J, Herzig R, Kaňovský P.

Department of Neurology, Comprehensive Stroke Center, University Hospital Olomouc, I. P. Pavlova 6, 77520 Olomouc, Czech Republic. daniel.sanak@centrum.cz

 

Abstract

Purpose: To investigate the safety and efficacy of the self-expanding Solitaire stent used during intravenous thrombolysis (IVT) for intracranial arterial occlusion (IAO) in acute ischemic stroke (AIS). Materials and Methods: Consecutive non-selected patients with AIS with IAO documented on computed tomographic angiography or magnetic resonance angiography and treated with IVT were included in this prospective study. Stent intervention was initiated and performed during administration of IVT without waiting for any clinical or radiologic signs of potential recanalization. Stroke severity was assessed by National Institutes of Health Stroke Scale (NIHSS), and 90-day clinical outcome was assessed by modified Rankin scale (mRS), with a good outcome defined as a mRS score of 0–2. Recanalization was rated by thrombolysis in cerebral infarction (TICI) scale. Results: Fifty patients (mean age, 66.8 y ± 14.6) had a baseline median NIHSS score of 18.0. Overall recanalisation was achieved in 94% of patients, and complete recanalisation (ie, TICI 3 flow) was achieved in72% of patients. The mean time from stroke onset to maximal recanalisation was 244.2 minutes ± 87.9, with a median of 232.5 minutes. The average number of device passes was 1.5, with a mean procedure time to maximal recanalisation of 49.5 minutes ± 13.0. Symptomatic intracerebral hemorrhage occurred in 6% of patients. The median mRS score at 90 days was 1, and 60% of patients had a good outcome (ie, mRS score 0–2). The overall 3-month mortality rate was 14%. Conclusions: Combined revascularization with the Solitaire stent during IVT appeal to be safe and effective in the treatment of acute IAO.

PMID: 23973019

 

Additional information

The early recanalization of an occluded cerebral artery is crucial for clinical improvement and good outcome in patients with acute ischemic stroke (AIS). 1 Although intravenous thrombolysis (IVT) is a safe and effective therapy for acute stroke, it has a relatively low recanalisation rate for large vessel occlusions, and therefore is associated with poor outcomes. 2-4

 In the past decade, several small series 5-8 showed promising data with respect to the use of mechanical devices in the treatment of AIS. In last years, stent retrievers, which allow simple trombus extraction, have been introduced and tested in several small pilot studies. 911 Our center began to use the self-expanding stent retriever (Solitaire AB; ev3, Irvine, California) because of its unique ability to achieve immediate flow restoration when deployed and its easy retrieval if not detached.

Waiting for the effect of IVT may significantly delay endovascular treatment and decrease the chance to reach good clinical outcome. With the target of reaching the shortest possible interval from stroke onset to successful recanalization, and respecting the guidelines for IVT administration, the concept of combined therapy was implemented in our center as a standard treatment app- roach, which included initial IVT followed directly by endovascular treatment with the use of the stent retriever without a period of waiting for clinical improvement or radiologic signs of early recanalisation during intravenous infusion of recombinant tissue plasminogen activator (rt-PA)

The results of our study demonstrate that mechanical treatment of occluded cerebral arteries with the use of stent is safe and highly effective during the continuous administration of rt-PA.

 

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Fig 01Figure 1. Digital subtraction angiography: occluded middle cerebral artery in M1 segment

Fig 02Figure 2. Guiding microcatheter is passing through the site of occlusion into distal part of occluded middle cerebral artery. 

Fig 03Figure 3. Stent retriever (Solitaire AB, ev3) is deployed in the middle cerebral artery.

Fig 04Figure 4. Stent retriever is being pulled off.

Fig 05Figure 5. Complete recanalisation of middle cerebral artery.

Fig 06Figure 6. Extracted clots.

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