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

Intra-arterial fibrinolysis

  • Intra-arterial fibrinolysis may be used alone or in combination with mechanical thrombectomy.[1][4][15][16][17]
  • 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][16]
  • 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. 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.
  16. 16.0 16.1 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.
  17. 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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