treatment

Robert W. Regenhardt, MD, PhD

Gory B, Piotin M, Haussen DC, Steglich-Arnholm H, Holtmannspötter M, Labreuche J, et al. Thrombectomy in Acute Stroke With Tandem Occlusions From Dissection Versus Atherosclerotic Cause. Stroke. 2017

The revolution of acute stroke care, with the 2015 trials demonstrating superiority of endovascular thrombectomy (ET) compared to tPA alone and the subsequent DAWN and DEFUSE 3 trials extending its time window, has raised many questions about which patients will experience net benefit from this powerful therapy. Certainly, some vessel occlusions are more amenable to ET than others, but should the presence of technically difficult occlusions, with perhaps higher procedural risks, limit eligibility? Though poorly represented, patients with anterior circulation tandem lesions, involving both the cervical internal carotid artery (ICA) and an intracranial artery, experienced similar benefits as those with isolated intracranial occlusions in the HERMES meta-analysis. It is unclear if the etiology of tandem lesions predicts outcomes, if etiology should influence the decision to undergo ET, or if it should influence the procedural approach.

The two most common etiologies of tandem lesions are carotid atherosclerosis and carotid dissection. Treatment typically occurs in two phases: management of the cervical ICA lesion by stenting, angioplasty, both, or medical treatment alone, and management of the intracranial occluded vessel by stent retriever or direct aspiration first pass technique. The order of these phases remains controversial, with some centers starting with the intracranial lesion as stent retrievers only require a small microcatheter for deployment. Stenting versus angioplasty of the cervical ICA can be debated based on adequacy of collaterals, risk of reperfusion injury, risk of immediate dual antiplatelet therapy, and other individualized factors.

Shashank Shekhar, MD, MS
@Artofstroke

Smith CJ, Hulme S, Vail A, Heal C, Parry-Jones AR, Scarth S, et al. SCIL-STROKE (Subcutaneous Interleukin-1 Receptor Antagonist in Ischemic Stroke): A Randomized Controlled Phase 2 Trial. Stroke. 2018

Multiple preclinical and clinical research is suggesting the definite role of inflammation in the brain after ischemic stroke. The inflammation could be both detrimental and helpful based on the stages of the post-stroke pathogenesis. I always explain this to my stroke patients by giving an example of injury to, e.g., a finger. I ask them, When you hurt your finger, what happens to it? It starts hurting, swells and turns colors due to inflammation. Similarly, in the brain after stroke, the brain goes through the similar process; unlike pain medicine for fingers, we don’t have medicine which helps with inflammation in the brain, but with time, the body tends to heal most of the inflammation. Explaining to them in lay terms helps them understand the process better. In this study, investigators from the SCIL-Stroke phase II trial are investigating if blocking interleukin IL-1 results in the lowering IL-6 levels and if this could be associated with a better clinical outcome. This project is in line with the previously published work by Dr. Albers’ group, where they addressed a similar question but without a placebo control arm.

Sami Al Kasab, MD

Taschner CA, Chapot R, Costalat V, Machi P, Courthéoux P, Barreau X, et al. Second-Generation Hydrogel Coils for the Endovascular Treatment of Intracranial Aneurysms: A Randomized Controlled Trial. Stroke. 2018

Following the results of the ISAT trial (International Subarachnoid Aneurysm Trial), which showed better functional with endovascular treatment compared to surgical clipping, endovascular therapy became the preferred method for treating most intracranial aneurysms. Incomplete aneurysm occlusion or aneurysm recurrence, however, are among the main limitations of the endovascular approach. The use of detachable coils with or without balloon and/or stent is the most common endovascular approach treating intracranial aneurysms. Bare platinum coils are commonly used to treat intracranial aneurysms; however, given the relatively high recurrence rate, efforts have been made to evaluate the efficacy of newer generation detachable coils. Few new generation coils that aim at providing better packing and aneurysm embolization have been evaluated. Platinum coils coated with polyglycolic acid/polylactic acid polymers that provide inflammatory response at the aneurysm neck failed to prove efficacy. The use of platinum coils coated with hydrogel, which expands once in contact with liquids, leading to increased packing density, was studied in a previous trial and proved to be effective with lower rate of major recurrence; however, its use has been limited by technical limitation. In this trial (German-French Randomized Endovascular Aneurysm Trial), the authors evaluate the use of softer, second generation hydrogel coils for the treatment of intracranial aneurysms.

Mark R. Etherton, MD PhD

Bellwald S, Weber R, Dobrocky T, Nordmeyer H, Jung S, Hadisurya J, et al. Direct Mechanical Intervention Versus Bridging Therapy in Stroke patients Eligible for Intravenous Thrombolysis. Stroke. 2017

In this entry, I discuss the matched pairs analysis of IV tPA eligible patients with large-vessel occlusion (LVO) of the anterior circulation that underwent endovascular thrombectomy (EVT) with or without pre-treatment with IV tPA.

The clinical importance of understanding the role of bridging therapy in patients with LVO is critical for efficaciously triaging this population to stroke centers. The hypothetical scenario is, how should emergency medical services appropriately triage a patient with suspicion for LVO with regards to transfer to a primary stroke center with tPA capabilities or a comprehensive stroke center with EVT capabilities that is further away? This scenario epitomizes why there is great interest in understanding the contribution that bridging therapy with tPA has on outcomes in patients with LVO of the anterior circulation.

Kaustubh Limaye, MD
@kaustubhslimaye

Mueller-Kronast NH, Zaidat OO, Froehler MT, Jahan R, Aziz-Sultan MA, Klucznik RP, et al. Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke: Primary Results of the STRATIS Registry. Stroke. 2017

It is possible to match “benchmark” workflow timings and clinical outcomes in a community setting for acute stroke patients with large vessel occlusion needing endovascular therapy.

The Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke (STRATIS) registry sought to compare real-world patient workflow and outcome of patients with intracranial large vessel occlusion (LVO) requiring endovascular therapy (EVT). A total of 984 eligible patients with large vessel occlusion were enrolled at 55 different sites with an enrolling cap of 75 patients. Patients with pre-treatment modified Rankin score of 0-1, confirmed LVO, NIHSS≥8 with an intention to be treated with a Medtronic market-released neurothrombectomy device (Solitaire and Mindframe) as an initial device for stent assisted thrombectomy within 8 hours from symptom onset.

Out of 1000 patients enrolled, 16 were deemed to be screen failure resulting in intention to treat analysis of 984 patients. 64% of the patients enrolled received intravenous thrombolysis and mean NIHSS of the enrolled patients was 17. 45.2% of patients were transferred from another facility to the enrolling center. Mean distance from field to the enrolling site was 29 miles with 2/3^rd of the patients <25 miles distance from enrolling site. The clinical trials for LVO needing EVT set a few important “benchmarks” for patient workflow: 1) onset to puncture time; 2) door to puncture time (DTP); 3) puncture to reperfusion time (PTR); and 4) the quality of substantial reperfusion (TICI ≥ 2b).