http://www.springerlink.com/content/64rr0h3827k1g5p7/

Patients with acute stroke with large vessel occlusion and carotid stenosis have been stented and then thrombolysed, or the stenosis simply left as it is, in the past. However, a problem arises if a visible clot sticks in the lumen at the stenotic site. No need to worry. You can stent this as well and then perform thrombolysis, as done by the authors of this paper. Of course one needs to use a distal filter device!

Abstract

Introduction 

Carotid stenosis with intraluminal thrombus is associated with a high risk of early recurrent stroke. We evaluated the feasibility and outcome of carotid stenting in acute ischemic stroke patients with carotid stenosis and intraluminal thrombus.

Methods 

Among 295 consecutive acute ischemic stroke patients who were referred for intra-arterial thrombolytic (IAT) therapy, six patients with carotid stenosis and intraluminal thrombus were treated by stent assisted angioplasty. The clinical characteristics, feasibility, and clinical outcomes were assessed.

Results 

All patients had severe stenosis of the underlying carotid bulb (mean, 86.8%; range, 71–99%) with adjacent intraluminal thrombus. Stent assisted angioplasty resulted in successful recanalization in all six patients. Thrombus was captured with the filter device in four patients. Three patients with tandem occlusion of the ipsilateral proximal middle cerebral artery were successfully recanalized with intra-arterial urokinase. No patients suffered procedure related complications or symptomatic hemorrhage. Four patients showed good long-term outcome (3 month mRS; 0–2).

Conclusions 

Stent assisted angioplasty is a feasible treatment option for acute ischemic stroke patients caused by carotid stenosis with intraluminal thrombus and may be effective in preventing early recurrent stroke.

Keywords  Carotid stenosis – Angioplasty – Stent – Thrombolytic therapy

http://www.springerlink.com/content/u315778702g1jj86/

Jee-Hyun Kwon, Shang Hun Shin, Young Cheol Weon, Jae Cheol Hwang and Seung Kug Baik. Intra-arterial adjuvant tirofiban after unsuccessful intra-arterial thrombolysis of acute ischemic stroke: preliminary experience in 16 patients. NeuroradiologyVolume 53, Number 10, 779-785, DOI: 10.1007/s00234-011-0939-y

Intra-arterial chemical thrombolytic therapy of acute stroke is rapidly gaining strides. However, the drugs and their dosage to be used is far from clear, with ever neurointerventionist using a different protocol. Even then, few points are becoming lucid;

1. Fibrin busting drugs e.g tPA or urokinase is not effective in a substantial number of patients

2. Antiplatelets are vey handy in intra-arterial thrombolysis

3. Intra-arterial heparin also can be handy in many instances

Reports of  groups using antiplatelets have been published.

A recent one studied 16 patients with failed thrombolysis after IA urokinase, in whom tirofiban was used. They achieved good recanalisation rates. However, 6 patients had ICH, which to my mind does not really augur well for this idea, even though the authors themselves say that it is a good result.

Probably we need to design a chemical IA thrombolysis dosage using both Urokinase/tPA and antiplatelets rather than using one after the other has failed.

Abstract

Introduction 

Intra-arterial (IA) thrombolysis with plasminogen activator is well-known, but the use of IA tirofiban as an adjuvant for IA thrombolysis is not well-known. We investigated the feasibility of IA tirofiban as an adjuvant after unsuccessful IA recanalization with urokinase (UK) for acute ischemic stroke.

Methods 

We retrospectively analyzed all 16 consecutive patients (11 men and five women; mean age, 61.3 years; range, 36–85 years) who were treated with IA tirofiban after isolated IA thrombolysis with UK or bridging therapy with systemic recombinant tissue plasminogen activator (rt-PA; 0.6 mg/Kg) and IA UK for acute ischemic stroke. Outcome measures included angiographic recanalization (thrombolysis in cerebral infarction, TICI), symptomatic and asymptomatic intracerebral hemorrhage (ICH), mortality, and functional independence at 3 months (modified Rankin Scale, 0–2).

Results 

Among the 16 patients treated with IA tirofiban as an adjuvant, 10 patients had conventional dose (<25 ug/kg, bolus) and six patients had high dose (≥25 ug/kg, bolus) of IA tirofiban after unsuccessful IA thrombolysis whether systemic rt-PA used or not. Successful angiographic recanalization (TICI grade 2b or 3) was achieved in 13 patients (13/16) and a functional independence at 3 months in eight patients (8/16). Three months after therapy, three patients had died. There were two patients of symptomatic ICH and four asymptomatic ICH.

Conclusion 

Conventional dose of IA tirofiban as an adjuvant during IA thrombolysis for acute ischemic stroke seems feasible. However, further dose escalation studies should be performed regarding the IA use of tirofiban for acute ischemic stroke.

Keywords  Acute ischemic stroke – Intra-arterial – Tirofiban – Thrombolysis

    Click to open the article in the journal website

Charlotte Rosso, Olivier Colliot, Romain Valabrègue, Sophie Crozier, Didier Dormont, Stéphane Lehéricy and Yves Samson. Tissue at risk in the deep middle cerebral artery territory is critical to stroke outcome. Neuroradiology Volume 53, Number 10, 763-771, DOI: 10.1007/s00234-011-0916-5

We have often seen that patients with predominant cortical ischemia do well over time however, the ones with large deep white matter infarcts have poor outcomes. A growing body of evidence has been accumulating the same. In this recent article, the authors have used voxel based ADC mapping and diffusion tensor imaging to establish this fact.

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Abstract

Introduction 

The clinical efficacy of thrombolysis in stroke patients is explained by the increased rate of recanalization, which limits infarct growth. However, the efficacy could also be explained by the protection of specific sites of the brain. Here, we investigate where is this outcome-related tissue at risk using voxel-based analysis.

Methods 

We included 68 acute stroke patients with middle cerebral artery (MCA) occlusion on the admission MRI performed within 6 h of symptoms onset (H6) and 16 controls. MCA recanalization was assessed using the magnetic resonance angiography performed at day 1 (D1). Apparent diffusion coefficient (ADC) changes were analyzed using a voxel-based method between patients vs. controls group at admission (H6) in non-recanalized vs. recanalized and in 3-month poor vs. good outcome patients at D1.

Results 

Complete or partial MCA recanalization was observed in 52 of 68 patients. Good outcome at 3 months occurred in 40 patients (59%). In non-recanalized patients, ADC was decreased in the deep MCA and watershed arterial territory (the lenticular nucleus, internal capsule, and the overlying periventricular white matter). This decrease was not observed in recanalized patients at D1 or patients at H6. Fiber tracking suggested that the area is crossed by the cortico-spinal, cerebellar, and intra-hemispheric association tracts. Finally, this area almost co-localized with the area associated with poor outcome.

Conclusions 

A clinically relevant area of tissue at risk may occur in patients with MCA infarcts at the level of deep white matter fiber tracts. These findings suggest that neuroprotection research should be refocused on white matter.

Keywords  Stroke – Recanalization – Outcome – MRI – DWI

• We all know that intravenous thrombolysis has to become widespread to achieve any kind of success in our fight against stroke. However our efforts had been marred by the shortage of trained and certified neurologists who could thrombolyse. This new paper must be considered a landmark as it proves that IV thombolysis can be done 
• ​
• Click to see the article abstract in the journal site​

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Telestroke-Guided Intravenous Tissue-Type Plasminogen Activator Treatment Achieves a Similar Clinical Outcome as Thrombolysis at a Comprehensive Stroke Center

1. Syed F. Zaidi, MD; 
2. Mouhammad A. Jumma, MD; 
3. Xabier N. Urra, MD;
4. Maxim Hammer, MD; 
5. Lori Massaro, CRNP; 
6. Vivek Reddy, MD; 
7. Tudor Jovin, MD; 
8. Ridwan Lin, MD, PhD; 
9. Lawrence R. Wechsler, MD

Correspondence to Lawrence R. Wechsler, MD, Professor and Chair, Department of Neurology, University of Pittsburgh, 3471 Fifth Avenue, 811 LK Building, Pittsburgh, PA 15213. E-mail wechslerlr@upmc.edu​

Abstract

Background and Purpose—

Telestroke networks offer an opportunity to increase tissue-type plasminogen activator use in community hospitals.

Methods—

We compared 83 patients treated with intravenous tissue-type plasminogen activator by telestroke to 59 patients treated after in-person evaluation by the same neurologists at a tertiary care stroke center. Onset and door-to-treatment times and functional outcome at 90 days were obtained prospectively. Favorable outcome was defined as modified Rankin Scale score ≤2.

Results—

Favorable outcome rates were comparable between the groups (42.1% versus 37.5%, P=0.7). There was no significant difference in the rate of symptomatic hemorrhage.

Conclusions—

Telestroke is a viable alternative to in-person evaluation when stroke expertise is not readily available.

​

• An interesting article
• All this time we have been following the dictum 'time is brain' although in practice a lot of patients have been benefited by thrombolysis after 6 hours. No the MERCI collaboratos have come out with with data to prove the same. A big thumbs up for them...It not only ahall pave the path for more patient oriented work, but also alter our thinking of the pathophysiology of stroke and the path our research should take.
• ​
• Original Contributions

Effect of Time to Reperfusion on Clinical Outcome of Anterior Circulation Strokes Treated With Thrombectomy

Pooled Analysis of the MERCI and Multi MERCI Trials

1. Raul G. Nogueira, MD; 
2. Wade S. Smith, MD, PhD; 
3. Gene Sung, MD;
4. Gary Duckwiler, MD; 
5. Gary Walker, PhD; 
6. Robin Roberts, BSc, MSc;
7. Jeffrey L. Saver, MD; 
8. David S. Liebeskind, MD 
9. on Behalf of the MERCIMulti MERCI Writing Committee

+Author Affiliations

1. From the Departments of Neurology, Neurosurgery, and Radiology (R.G.N.),
2. Emory University School of Medicine, Marcus Stroke & Neuroscience Center,
3. Grady Memorial Hospital, Atlanta, GA; Department of Neurology (W.S.S.), University of California,
4. San Francisco, CA; Department of Neurology (G.S.), University of Southern California, Los Angeles,
5. CA; Department of Interventional Neuroradiology (G.D.), University of California, Los Angeles,
6. CA; Division of Clinical Research (G.W.), Concentric Medical Inc, Mountain View, CA;
7. Department of Clinical Epidemiology & Biostatistics (R.R.), McMaster University, Hamilton,
8. ON, Canada; Department of Neurology (J.L.S., D.S.L.), University of California, Los Angeles, CA.

1. Correspondence to Raul G. Nogueira, MD, Emory Faculty Office Building 80 Jesse Hill Dr. SE, Room 398, Atlanta, GA 30303. E-mail rnoguei@emory.edu

Abstract

Background and Purpose—Previous studies have demonstrated a strong correlation between treatment time and outcomes after intravenous recombinant tissue-type plasminogen activator. However, the temporal profile of ischemia may vary according to the level of occlusion, and it is likely that more proximal occlusions have a more variable temporal course than their distal counterparts. We sought to establish how time influences outcomes in anterior circulation proximal arterial occlusions.

Methods—All patients from the MERCI/Multi MERCI trials with intracranial internal carotid artery and/or middle cerebral artery (M1-M2 segments) occlusions who were successfully revascularized were included in univariate/multivariate analyses to define the predictors of independent functional outcomes (modified Rankin Scale score ≤2) and mortality at 90 days. The effect of time to reperfusion on outcomes was calculated after adjustment for age, baseline National Institutes of Health Stroke Scale, and glucose levels.

Results—A total of 175 patients presenting with internal carotid artery/M1/M2 occlusions were revascularized. There was no definite association between time (to treatment or reperfusion) and outcomes in the unadjusted analysis. Baseline National Institutes of Health Stroke Scale score and age were independent predictors of independent outcome and mortality. High glucose demonstrated a strong trend toward worse outcomes. After adjustment for age, baseline National Institutes of Health Stroke Scale score, and glucose, there was a strong trend toward fewer independent outcomes with later reperfusion times. Notably, 40% of the patients reperfused at ≥6.9 hours achieved independent functional outcomes.

Conclusions—Time (to treatment or reperfusion) is only one of the many variables that may impact outcome in proximal arterial occlusions strokes. Reperfusion therapies should be started promptly, but our findings also suggest that stroke patients presenting at later time points may still benefit.

Key Words:

• stroke outcomes
• thrombectomy