Ischemic stroke surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]

Overview

Intra-arterial treatment of ischemic stroke requires the patient to be at an experienced stroke center with rapid access to cerebral angiography and qualified interventionalists.The surgical management of ischemic stroke may include mechanical thrombectomy, intra-arterial thrombolysis, and intracranial and extracranial angioplasty and stenting.

Surgery

Intra-arterial treatment of ischemic stroke requires the patient to be at an experienced stroke center with rapid access to cerebral angiography and qualified interventionalists.The surgical management of ischemic stroke may include:[1][2][3][4][5]

Mechanical Thrombectomy

Clinical practice guidelines address thrombectomy.[6]

  • Recanalization by mechanical thrombectomy is achieved by a combination of thrombus fragmentation, retrieval and increased penetration of fibrinolytic agents.
  • Mechanical thrombectomy may be used alone[7] or in comination with intra-arterial thrombolysis
  • Patients eligible for intravenous rtPA should receive intravenous rtPA even if intra-arterial treatments are being considered [8][9][4][10][11][12][13]
  • There are currently four devices cleared by FDA for mechanical thrombectomy[4][5]
  • Merci Retrieval System
  • Penumbra System
  • Solitaire Flow Restoration Device
  • Trevo Retriever

Inclusion criteria for mechanical thrombectomy[14]

  • Ruling out intra-arterial hemorrhage on brain CT and MRI
  • CT, MR angiography or DSA showing intracranial thrombotic occlusion of distal intracranial internal carotid artery, anterior or middle cerebral artery
  • Age>18 years
  • Procedure conducted within 6 hours of onset of ischemic stroke
  • Clinical diagnosis of stroke
  • NIHS score > or equal to 2 points

Exclusion criteria for mechanical thrombectomy[14]

  • Intracranial hemorrhage
  • BP >185/110 mmHg
  • Blood glucose <50mg/dl or >400mg/dl
  • Intravenous treatment with alteplase in a dose >0.9mg/kg
  • Platelet count <40,000/microL [40 x 109/L]
  • International Normalized Ratio [INR] >3.0


2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association[15]

Recommendations for Intracranial Large Artery Atherosclerosis Referenced studies that support recommendations are summarized in online Data Supplements 20-27

Intracranial Large Artery Atherosclerosis

Class IIb
7.    In patients with severe stenosis (70%-99%) of a major intracranial artery and actively progressing symptoms or recurrent TIA or stroke after institution of aspirin and clopidogrel therapy, achievement of SBP <140  mm Hg, and high- intensity statin therapy (so-called medical failures), the usefulness of angioplasty alone or stent placement to prevent ischemic stroke in the territory of the stenotic artery is unknown.(Level of Evidence: C-LD)

Recommendations for Extracranial Carotid Stenosis Referenced studies that support recommendations are summarized in online in Online Data Supplement 28

Extracranial Carotid Stenosis

Class I
1.     In patients with a TIA or nondisabling ischemic stroke within the past 6 months and ipsilateral severe (70%–99%) carotid artery stenosis, carotid endarterectomy (CEA) is recommended to reduce the risk of future stroke, provided that perioperative morbidity and mortality risk is estimated to be <6%..(Level of Evidence: A)

2.     In patients with ischemic stroke or TIA and symptomatic extracranial carotid stenosis who are scheduled for carotid artery stenting (CAS) or CEA, procedures should be performed by operators with established periprocedural stroke and mortality rates of <6% to reduce the risk of surgical adverse events..(Level of Evidence: A)

3.     In patients with carotid artery stenosis and a TIA or stroke, intensive medical therapy, with antiplatelet therapy, lipid-lowering therapy, and treatment of hypertension, is recommended to reduce stroke risk..(Level of Evidence: A)

4.     In patients with recent TIA or ischemic stroke and ipsilateral moderate (50%–69%) carotid steno-sis as documented by catheter-based imaging or noninvasive imaging, CEA is recommended to reduce the risk of future stroke, depending on patient-specific factors such as age, sex, and comorbidities, if the perioperative morbidity and mortality risk is estimated to be <6%.(Level of Evidence: B-R)


Class IIa
5.     In patients ≥70 years of age with stroke or TIA in whom carotid revascularization is being considered, it is reasonable to select CEA over CAS to reduce the periprocedural stroke rate.(Level of Evidence: B-R)

6.     In patients in whom revascularization is planned within 1 week of the index stroke, it is reasonable to choose CEA over CAS to reduce the periprocedural stroke rate.(Level of Evidence: B-R)

7.    In patients with TIA or nondisabling stroke, when revascularization is indicated, it is reasonable to perform the procedure within 2 weeks of the index event rather than delay surgery to increase the likelihood of stroke-free outcome.(Level of Evidence: C-LD)

8.     In patients with symptomatic severe stenosis (≥70%) in whom anatomic or medical conditions are present that increase the risk for surgery (such as radiation-induced stenosis or restenosis after CEA) it is reasonable to choose CAS to reduce the periprocedural complication rate.(Level of Evidence: C-LD)


Class IIb
9.  In symptomatic patients at average or low risk of complications associated with endovascular intervention, when the ICA stenosis is ≥70% by noninvasive imaging or >50% by catheter-based imaging and the anticipated rate of periprocedural stroke or death is <6%, CAS may be considered as an alternative to CEA for stroke prevention, particularly in patients with significant cardiovascular comorbidities predisposing to cardiovascular complications with endarterectomy.(Level of Evidence: A)

10.  In patients with a recent stroke or TIA (past 6 months), the usefulness of trans-carotid artery revascularization (TCAR) for prevention of recurrent stroke and TIA is uncertain.(Level of Evidence: B-NR)

Recommendations for Extracranial Vertebral Artery Stenosis Referenced studies that support recommendations are summarized in online data supplement 28

Extracranial Vertebral Artery Stenosis

Class I
1.   In patients with recently symptomatic extra-cranial vertebral artery stenosis, intensive medical therapy (antiplatelet therapy, lipid lowering, BP control) is recommended to reduce stroke risk.(Level of Evidence: A)


Class IIb
2.   In patients with ischemic stroke or TIA and extracranial vertebral artery stenosis who are having symptoms despite optimal medical treatment, the usefulness of stenting is not well established.(Level of Evidence: B-R)

3.   In patients with ischemic stroke or TIA and extracranial vertebral artery stenosis who are having symptoms despite optimal medical treatment, the usefulness of open surgical procedures, including vertebral endarterectomy and vertebral artery transposition, is not well established(Level of Evidence: C-EO)


Recommendations for Moyamoya Disease Referenced studies that support recommendations are summarized in online Data supplement 30

Class IIa
1.  In patients with moyamoya disease and a history of ischemic stroke or TIA, surgical revascularization with direct or indirect extracranial-intracranial bypass can be beneficial for the prevention of ischemic stroke or TIA. (Level of Evidence: C-LD)

Recommendations for AF Referenced studies that support recommendations are summarized in online Data Supplement 32

Class IIb
8.     In patients with stroke or TIA in the setting of nonvalvular AF who have contraindications for lifelong anticoagulation but can tolerate at least 45 days, it may be reasonable to consider percutaneous closure of the left atrial appendage with the Watchman device to reduce the chance of recurrent stroke and bleeding (Level of Evidence: B-R)

Recommendations for Valvular Disease Referenced studies that support recommendations are summarized in online data supplement 33 and 34

Class IIa
5.     In patients with ischemic stroke or TIA and IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy, early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is reasonable to reduce the risk of recurrent embolism if there is no evidence of intracranial hemorrhage or extensive neurological damage(Level of Evidence: B-NR)
Class IIb
7.      In patients with ischemic stroke or TIA and native left-sided valve endocarditis who exhibit mobile vegetations >10 mm in length, early surgery (during initial hospitalization before completion of a full therapeutic course of anti-biotics) may be considered to reduce the risk of recurrent embolism if there is no evidence of intracranial hemorrhage or extensive neurological damage.(Level of Evidence: B-NR)

8.     In patients with ischemic stroke or TIA and IE, early valve surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) may be considered in patients with an indication for surgery who have no evidence of intracranial hemorrhage or extensive neurological damage(Level of Evidence: B-NR) 9.     In patients with IE and major ischemic stroke, delaying valve surgery for at least 4 weeks may be considered for patients with IE and major ischemic stroke or intracranial hemorrhage if the patient is hemodynamically stable.(Level of Evidence: B-NR)

Recommendations for PFO Referenced studies that support recommendations are summarized in online Data Supplements 38 and 39

Class I
1.     In patients with a non-lacunar ischemic stroke of undetermined cause and a PFO, recommendations for PFO closure versus medical management should be made jointly by the patient, a cardiologist, and a neurologist, taking into account the probability of a causal role for the PFO.(Level of Evidence: C-EO)
Class IIa
2.     In patients 18 to 60 years of age with a non-lacunar ischemic stroke of undetermined cause despite a thorough evaluation and a PFO with high-risk anatomic features,* it is reasonable to choose closure with a transcatheter device and long-term antiplatelet therapy over anti-platelet therapy alone for preventing recurrent stroke(Level of Evidence: B-R)
Class IIb
3.     In patients 18 to 60 years of age with a non-lacunar ischemic stroke of undetermined cause despite a thorough evaluation and a PFO without high-risk anatomic features,* the ben-efit of closure with a transcatheter device and long-term antiplatelet therapy over antiplatelet therapy alone for preventing recurrent stroke is not well established.(Level of Evidence: C-LD)

4.     In patients 18 to 60 years of age with a non-lacunar ischemic stroke of undetermined cause despite a thorough evaluation and a PFO, the comparative benefit of closure with a transcatheter device versus warfarin is unknown(Level of Evidence: C-LD)

Recommendation for Cardiac Tumors Referenced studies that support the recommendation are summarized in online data supplement 42

Class IIa
1.     In patients with stroke or TIA found to have a left-sided cardiac tumor, resection of the tumor can be beneficial to reduce the risk of recurrent stroke.(Level of Evidence: C-LD)

Recommendations for Dissection Referenced studies that support recommendations are summarized in online Data Supplements 43 and 44

Class IIb
3.     In patients with stroke or TIA and extracranial carotid or vertebral artery dissection who have recurrent events despite antithrombotic therapy, endovascular therapy may be considered to prevent recurrent stroke or TIA. (Level of Evidence: C-LD)

Recommendations for Carotid Web Referenced studies that support recommendations are summarized in online data supplement 53

Class IIb
2.     In patients with carotid web in the distribution of ischemic stroke refractory to medical man-agement, with no other attributable cause of stroke despite comprehensive workup, carotid stenting or CEA may be considered to prevent recurrent ischemic stroke. (Level of Evidence: C-LD)

Recommendations for Fibromuscular Dysplasia Referenced studies that support recommendations are summarized in online data supplement 54

Class IIb
3.     In patients with cervical carotid artery FMD and recurrent ischemic stroke without other attributable causes despite optimal medical management, carotid angioplasty with or without stenting may be reasonable to prevent ischemic stroke.(Level of Evidence: C-LD)

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association[16]

Mechanical Thrombectomy Eligibility–Vessel Imaging

Class I
1. For patients who otherwise meet criteria for mechanical thrombectomy, noninvasive vessel imaging of the intracranial arteries is recommended during the initial imaging evaluation. (Level of Evidence: A)
2. For patients with suspected LVO who have not had noninvasive vessel imaging as part of their initial imaging assessment for stroke, noninvasive vessel imaging should then be obtained as quickly as possible (eg, during alteplase infusion if feasible).(Level of Evidence: A)
Class IIa
1.In patients with suspected intracranial LVO and no history of renal impairment, who otherwise meet criteria for mechanical thrombectomy, it is reasonable to proceed with CTA if indicated before obtaining a serum creatinine concentration. (Level of Evidence: B-NR)
Class IIb
1. In patients who are potential candidates for mechanical thrombectomy, imaging of the extracranial carotid and vertebral arteries, in addition to the intracranial circulation, may be reasonable to provide useful information on patient eligibility and endovascular procedural planning.(Level of Evidence: C-EO)
2. It may be reasonable to incorporate collateral flow status into clinical decision-making in some candidates to determine eligibility for mechanical thrombectomy.(Level of Evidence: C-LD)

Mechanical Thrombectomy Eligibility–Multimodal Imaging

Class I
1. When selecting patients with AIS within 6 to 24 hours of last known normal who have LVO in the anterior circulation, obtaining CTP or DW-MRI, with or without MRI perfusion, is recommended to aid in patient selection for mechanical thrombectomy, but only when patients meet other eligibility criteria from one of the RCTs that showed benefit from mechanical thrombectomy in this extended time window.. (Level of Evidence: A)
2. When evaluating patients with AIS within 6 hours of last known normal with LVO and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of ≥6, selection for mechanical thrombectomy based on CT and CTA or MRI and MRA is recommended in preference to performance of additional imaging such as perfusion studies.(Level of Evidence: A)

Intra-arterial fibrinolysis

  • Intra-arterial fibrinolysis may be used alone or in combination with mechanical thrombectomy.[1][4][17][18][19]
  • Dose of rt-PA is adjusted according to the need for recanalizaton as procedure is done under direct visualization
  • The dose of rt-PA is one fourth the dose used in intravenous fibrinolysis

Indications

  • Selected patients with major stroke of <6 hours’ duration due to an occlusion of the middle cerebral artery[5][18]
  • Intrarterial thrombolysis is usually done in cases of ischemic stroke in which intravenous thrombolysis is contraindicated such as major surgery[5]
  • May be used in patients with angiographically determined acute basilar artery thrombosis without evidence of infarction on MRI or CT scan

Intracranial and extracranial angioplasty and stenting

The usefulness of these procedures is not well established. However, they may be used in patients with cervical atherosclerosis and dissection.[4]

For AHA/ASA guidelines for surigcal management in patients with ischemic stroke, please click here

References

  1. ↑ 1.0 1.1 Khalessi AA, Natarajan SK, Orion D, Binning MJ, Siddiqui A, Levy EI; et al. (2011). "Acute stroke intervention". JACC Cardiovasc Interv. 4 (3): 261–9. doi:10.1016/j.jcin.2010.11.015. PMID 21435602.
  2. ↑ Meyers PM, Schumacher HC, Connolly ES, Heyer EJ, Gray WA, Higashida RT (2011). "Current status of endovascular stroke treatment". Circulation. 123 (22): 2591–601. doi:10.1161/CIRCULATIONAHA.110.971564. PMC 3257061. PMID 21646506.
  3. ↑ Chimowitz MI (2013). "Endovascular treatment for acute ischemic stroke--still unproven". N Engl J Med. 368 (10): 952–5. doi:10.1056/NEJMe1215730. PMID 23394477.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM; et al. (2013). "Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association". Stroke. 44 (3): 870–947. doi:10.1161/STR.0b013e318284056a. PMID 23370205.
  5. ↑ 5.0 5.1 5.2 5.3 Meyers PM, Schumacher HC, Higashida RT, Barnwell SL, Creager MA, Gupta R; et al. (2009). "Indications for the performance of intracranial endovascular neurointerventional procedures: a scientific statement from the American Heart Association Council on Cardiovascular Radiology and Intervention, Stroke Council, Council on Cardiovascular Surgery and Anesthesia, Interdisciplinary Council on Peripheral Vascular Disease, and Interdisciplinary Council on Quality of Care and Outcomes Research". Circulation. 119 (16): 2235–49. doi:10.1161/CIRCULATIONAHA.109.192217. PMID 19349327.
  6. ↑ Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC; et al. (2015). "2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 46 (10): 3020–35. doi:10.1161/STR.0000000000000074. PMID 26123479.
  7. ↑ Coutinho JM, Liebeskind DS, Slater LA, Nogueira RG, Clark W, Dávalos A; et al. (2017). "Combined Intravenous Thrombolysis and Thrombectomy vs Thrombectomy Alone for Acute Ischemic Stroke: A Pooled Analysis of the SWIFT and STAR Studies". JAMA Neurol. 74 (3): 268–274. doi:10.1001/jamaneurol.2016.5374. PMID 28097310.
  8. ↑ Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD; et al. (2013). "Endovascular therapy after intravenous t-PA versus t-PA alone for stroke". N Engl J Med. 368 (10): 893–903. doi:10.1056/NEJMoa1214300. PMC 3651875. PMID 23390923. Review in: Ann Intern Med. 2013 May 21;158(10):JC12
  9. ↑ Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R; et al. (2013). "Endovascular treatment for acute ischemic stroke". N Engl J Med. 368 (10): 904–13. doi:10.1056/NEJMoa1213701. PMC 3708480. PMID 23387822 : 23387822 Check |pmid= value (help).
  10. ↑ Smith WS, Sung G, Starkman S; et al. (2005). "Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial". Stroke. 36 (7): 1432–8. doi:10.1161/01.STR.0000171066.25248.1d. PMID 15961709.
  11. ↑ Celia Witten (2004). "Concentric Merci Retriever product licence" (PDF). FDA.
  12. ↑ Smith WS (2006). "Safety of mechanical thrombectomy and intravenous tissue plasminogen activator in acute ischemic stroke. Results of the multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI) trial, part I". AJNR Am J Neuroradiol. 27 (6): 1177–82. PMID 16775259.
  13. ↑ Smith WS, Sung G, Saver J; et al. (2008). "Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial". Stroke. 39 (4): 1205–12. doi:10.1161/STROKEAHA.107.497115. PMID 18309168.
  14. ↑ 14.0 14.1 Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ; et al. (2015). "A randomized trial of intraarterial treatment for acute ischemic stroke". N Engl J Med. 372 (1): 11–20. doi:10.1056/NEJMoa1411587. PMID 25517348. Review in: Evid Based Med. 2015 Dec;20(6):209 Review in: Ann Intern Med. 2015 May 19;162(10):JC2-4
  15. ↑ Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D; et al. (2021). "2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association". Stroke. 52 (7): e364–e467. doi:10.1161/STR.0000000000000375. PMID 34024117 Check |pmid= value (help).
  16. ↑ Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K; et al. (2019). "Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke. 50 (12): e344–e418. doi:10.1161/STR.0000000000000211. PMID 31662037.
  17. ↑ Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R; et al. (2013). "Endovascular treatment for acute ischemic stroke". N Engl J Med. 368 (10): 904–13. doi:10.1056/NEJMoa1213701. PMC 3708480. PMID 23387822.
  18. ↑ 18.0 18.1 Lee M, Hong KS, Saver JL (2010). "Efficacy of intra-arterial fibrinolysis for acute ischemic stroke: meta-analysis of randomized controlled trials". Stroke. 41 (5): 932–7. doi:10.1161/STROKEAHA.109.574335. PMID 20360549.
  19. ↑ Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C; et al. (1999). "Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism". JAMA. 282 (21): 2003–11. PMID 10591382.


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