Table 4 - uploaded by Barry T Katzen
Content may be subject to copyright.
Source publication
Carotid stenting has become an accepted alternative in patients with carotid stenosis. The purpose of this article is to review the relevant trials, describe the different devices available for stenting, the devices for cerebral protection, as well as describe techniques and tricks for successful carotid artery stenting. Understanding how to approp...
Context in source publication
Similar publications
INTRODUÇÃO: O tratamento endovascular da doença aterosclerótica carotídea vem evoluindo continuamente, embora possam ocorrer complicações embólicas ou isquêmicas, mesmo com o uso dos sistemas de proteção cerebral. Este estudo teve como objetivo avaliar os resultados de uma série inicial de pacientes que utilizaram o sistema de reversão de fluxo dur...
Stress concentration in carotid stenosis has been proven to assist plaque morphology in disease diagnosis and vulnerability. This work focuses on numerical analysis of stress and strain distribution in the cross-section of internal carotid artery using a 2D structure-only method. The influence of four different idealized plaque geometries (circle,...
Citations
Introduction
Superbore 0.088″ catheters provide a platform for optimizing aspiration efficiency and flow control during stroke mechanical thrombectomy procedures. New superbore catheters have the distal flexibility necessary to navigate complex neurovascular anatomy while providing the proximal support of traditional 8F catheters. The safety and feasibility of Zoom 88™ superbore angled-tip catheters in the middle cerebral artery (MCA) segments smaller than the catheter diameter have not been previously described.
Methods
Twenty consecutive cases of acute MCA mechanical thrombectomy were retrospectively identified from the senior authors’ prospectively maintained Institutional Review Board-approved database, in which the Zoom 88 (Imperative Care, Campbell, CA) catheter was successfully navigated to at least the M1 segment. Patient demographics, procedural details, and periprocedural information were analyzed. Rates and averages (standard errors) are generally reported.
Results
The average National Institutes of Health Stroke Scale at presentation and age were 15 ± 2 and 73 ± 3 years, respectively. The M1 and M2 occlusions were evenly distributed. The average M1 measurements before thrombectomy ranged from 2.36 ± 0.07 mm proximally to 2.00 ± 0.11 mm distally, and after thrombectomy, they ranged from 2.34 ± 0.07 mm proximally to 1.97 ± 0.10 mm distally. First-pass modified thrombolysis in cerebral infarction (mTICI) 2C/3 recanalization was achieved in 40% of cases, and final mTICI 2C/3 recanalization was achieved in 90% of cases. A single case of mild vasospasm was managed with verapamil. No hemorrhagic or periprocedural complications were noted.
Conclusion
Superbore 0.088″ catheters with flexible distal segments can be safely navigated to the MCA to augment mechanical thrombectomy even when the MCA segment is smaller than the catheter.
Endovascular treatment of acute stroke Stroke represents an enormous health problem and, despite a better understanding of preventive measures, it remains the leading cause of disability and a leading cause of death in adults. A more active attitude has emerged over the past decade and recent advances have allowed recanalization of occluded arteries in patients with acute ischemic stroke. Reperfusion of the ischemic brain is the most effective therapy for acute ischemic stroke. Restoration of flow to the penumbral area saves tissue from infarction. Intravenous (IV) thrombolysis has been most successful in the treatment of mild or moderate strokes caused by small thrombi occlusion of second-degree vessels, but as few as 1-6% of patients meet the criteria for IV thrombolysis. The use of endovascular techniques applying intra-arterial (IA) pharmacologic and mechanical thrombolysis has emerged for selected patients with acute stroke as an encouraging alternative. Such therapy needs to be offered in an experienced stroke center. A multidisciplinary approach with qualified neuro-interventionalists is necessary with a response time less than 60 minutes. Intra-arterial thrombolysis IA thrombolysis for acute management of stroke was solidified by the completion of the Prolyse in Acute Cerebral Thromboembolism (PROACT) studies. Recanalization efficacy and safety of IA recombinant pro-urokinase for middle cerebral artery (MCA) occlusion of 6 hours’ duration was demonstrated in the PROACT I trial while PROACT II demonstrated 15% absolute increase in good outcome. Partial or full recanalization (TIMI 2 or 3) 2 hours after infusion was 66% in the pro-urokinase group and 18% in the heparin-only group in this trial (P < 0.001). These studies have paved the way for additional trials involving IA thrombolysis with newer agents in acute ischemic stroke.
Epidemiology Subarachnoid hemorrhage (SAH) is considered a type of hemorrhagic stroke. The hemorrhage occurs in the space between the pia mater and the arachnoid layer. Trauma is the most common etiology of SAH in most countries of the world. The rates of traumatic SAH are reported to be anywhere from 15% to 61% in those with traumatic brain injury (TBI). In the USA, of the 1.7 million individuals experiencing TBI annually, 300 000 have it severely enough to require hospitalization. Presence of SAH in TBI impacts clinical outcome negatively. When the Glasgow Coma Scale on admission is less than 8 the risk of death is higher than those without SAH on head CT. Spontaneous SAH is most commonly caused by an intracranial aneurysm. This accounts for 2-5% of all strokes. The annual incidence in the USA is 1 per 10 000. The risk is highest for those who are aged 40-60, female, and African American. Aneurysmal SAH can be a devastating disease, with 10-12% dying before making it to the hospital and 50% dying after 30 days. Of those who survive, one-third will have moderate to severe disability and two-thirds will have mild or no disability.
Introduction Hemorrhagic strokes (or intracerebral hemorrhages [ICH]) occur in 10% of all stroke patients. The incidence of stroke has not followed the decreasing trend observed for ischemic stroke. In fact, hospital admissions for hemorrhagic stroke have increased 18% over 10 years. It is noted that anticoagulant-related ICH increased fivefold in the 1990s, as the population is ageing, atrial fibrillation is becoming more recognized, and anticoagulant use is increasing. Although a hemorrhagic stroke is a medical emergency, and typically presents with a catastrophic onset, it is often a manifestation of a longstanding process that may have been unidentified. Several conditions may result in an apparently ‘spontaneous’, but truly secondary, hemorrhage. Table 5.1 shows the most common etiologies of intracranial hemorrhages. Primary hemorrhages are considered those that are associated with arterial hypertension or amyloid angiopathy. Chronic hypertension usually results in deep-seated or subcortical hemorrhages. Those are located in the basal ganglia, thalamus, pons, and cerebellum. They are attributed to longstanding small vessel disease. Many of the superficial or lobar hemorrhages are, likewise, associated with cerebral amyloid angiopathy in the elderly population. It might be a mistake, however, to make etiologic assumptions based only on the presence of certain risk factors, or the location of the hematoma. The advent of modern imaging techniques has revealed an increasing number of structural lesions that would otherwise remain undiagnosed. An adequate workup for secondary causes is always warranted to ensure optimal management and secondary prevention. In all cases, clinical, laboratory, and radiologic data should be taken into account before we reach a safe diagnostic conclusion.
Syndromes Clinical deficits in stroke, encompassing ischemic and hemorrhagic cerebrovascular disease, are protean and identify the function of the tissue damaged. However, common patterns of deficits exist. Recognizing these patterns not only helps with localizing the lesion but can suggest underlying cause, treatment, and help with prognostication. Ischemic syndromes Lacunar (penetrating artery) Small intracranial arteries irrigating subcortical regions are susceptible to occlusion from the effects of hypertension. Microemboli are a less common source of occlusion. Patients with lacunar syndromes lack cortical signs and symptoms, distinguishing them from large vessel syndromes. Classic syndromes are: Ataxic-hemiparesis resulting in isolated unilateral weakness and ataxia. The lesion is along the corticospinal tracts, frequently the centrum semiovale, internal capsule, or basis pontis. Pure motor weakness resulting in isolated unilateral weakness. The lesion is commonly in the internal capsule or basis pontis. Pure sensory loss resulting in isolated unilateral numbness or paresthesia. The lesion is commonly in the thalamus. Sensorimotor dysfunction resulting in unilateral numbness and congruent weakness. The lesion is commonly in the internal capsule. Clumsy hand-dysarthria resulting in mild weakness/clumsiness of the hand and dysarthria with face and tongue weakness. The lesion is commonly in the basis pontis.
Introduction Stroke is a major cause of death and disability worldwide. An estimated 795 000 first and recurrent strokes occur in the USA annually; about 25% of these are recurrent strokes. While acute interventions and advances in acute management of stroke have advanced in recent years, prevention remains key in reducing the overall burden of stroke. Improved control of modifiable risk factors could potentially decrease the burden of cardiovascular disease and stroke in the USA by $13B. Table 20.1 lists important known risk factors for stroke. Non-modifiable factors include age, sex, race, and family history (which may reflect an interaction of environmental, behavioral, susceptibility, and genetic factors). While not amenable to intervention, these latter factors warrant attention, as they may help identify populations and individuals who are at increased risk and who may benefit from screening and from intensive treatment or prevention of modifiable risk factors. Potentially modifiable risk factors are those that can be modified or ameliorated with appropriate behavioral, pharmaceutical, or other medical interventions. Modifiable risk factors, including hypertension, dyslipidemia, diabetes mellitus, and tobacco use, when taken together, account for the majority of strokes. This chapter focuses on eight key modifiable antecedent factors - hypertension, dyslipidemia, atrial fibrillation, diabetes mellitus, tobacco use, hyperhomocysteinemia, alcohol consumption, and obesity and the metabolic syndrome - predisposing to ischemic and hemorrhagic strokes, and outlines preventive treatment options. Carotid stenosis, intracranial atherothrombotic disease, and cardiac disease are discussed elsewhere.
Designed for use by busy professionals who need quick answers, this revised and updated second edition of The Stroke Book is a concise and practical reference for anyone involved in managing critically ill cerebrovascular patients. • Covers a wide range of common conditions such as ischemic and hemorrhagic strokes, subarachnoid hemorrhages and intracranial aneurysms • Provides focused protocols for assessing and treating stroke patients in the emergency room, intensive care unit or general hospital setting • A new chapter summarizes key clinical trials for stroke therapies • User-friendly format • Packed with algorithms, tables and summary boxes for immediate access to key information • A color plate section illustrates key pathology and diagnostic imagingWritten by experienced contributors from leading stroke centers, this is an essential companion for navigating stroke-related clinical situations successfully and making informed decisions about treatment.
Time is brain. Every minute matters in patients with acute stroke. There is a limited time window for acute intervention since the ischemic tissue may no longer be salvageable hours after stroke onset, in most patients. The first 24 hours of acute stroke are critical. Rapid and efficient clinical examination and diagnostic evaluation are necessary to deliver acute therapies in a timely fashion. Evaluations of increasing detail can be performed at later stages to help formulate long-term treatment and prevention strategies. The management of acute stroke during the first 24 hours involves a chain of successive healthcare providers, including ambulance personnel, emergency department (ED) physicians, neurologists, and nursing staff. Pre-hospital stroke evaluation and management in the field are covered in detail elsewhere. This chapter will focus on in-hospital management. The major goal of acute stroke management is resuscitation of the penumbral tissue to minimize neurological deficits. If reperfusion of the penumbra occurs rapidly, neurons recover and the patient improves. With no reperfusion, a time-related cascade converts ailing neurons in salvageable penumbral tissue to permanent infarction. In order to achieve this goal, the management of acute stroke patients during the first 24 hours should aim to: Stabilize the patient’s medical condition Confirm the diagnosis of stroke rapidly and efficiently Utilize laboratory and examination data to determine the best treatment option(s) Prevent stroke worsening and complications.
Introduction Stroke, although rare during pregnancy, is a much-feared complication. This is not only due to concern for the long-term outcome of the mother, but also for the fetus. Additionally, practitioners often feel especially challenged by questions of safety and efficacy of diagnostic modalities and therapeutic options in a pregnant woman. This chapter will attempt to clearly present the types and causes of stroke during pregnancy and the peripartum period, as well as discuss options for diagnosis and treatment in such cases. Ischemic strokes are not more common during most of pregnancy, but increase in frequency postpartum All forms of stroke, including ischemic strokes, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and cerebral venous thrombosis (CVT), are seen during and shortly after pregnancy. Thankfully, stroke during pregnancy and the puerperium is not common. Systematic studies in many countries have noted rates of 4-34/100 000 deliveries, the majority of which were sustained around delivery or postpartum and the rest were primarily in the latter half of pregnancy. Of note, during pregnancy the incidence of ischemic stroke is not increased over the baseline rate of stroke in young women. The first several weeks postpartum, however, are associated with a higher risk of stroke than is seen in the general population of young women.
The clinical bedside evaluation of stroke patients is a vital part of the workup. A detailed history and physical exam is necessary, as localization, etiology, and comorbidities need to be quickly assessed. The history and physical is vital and is the best way to diagnose stroke imitators. It is important to emphasize that in the acute setting, when a patient is still in the window for tPA, certain aspects of the history and physical examination will have to be abbreviated and focused so as not to delay necessary therapy. Firstly, it is important to establish time of onset of symptoms when you first meet the patient. If the patient is unable to communicate, you will have to find out this information from actual witnesses of the event. It is critical that no assumptions are made about time of onset based on the time EMS was called. Often family or friends may not seek help until a significant amount of time has elapsed. Of note, if a patient wakes up with stroke symptoms, the accepted time of onset is the last time the patient was seen at his/her baseline. The second thing to determine in your initial assessment is the patient’s National Institutes of Health stroke scale (NIHSS). Although the NIHSS has many limitations, it is our best tool for initially assessing a patient having an acute stroke. You will do well to find out from the patient or from family which deficits are new and which are baseline for the patient. As you do the NIHSS pay attention to the constellation of deficits and try to determine whether most of the deficits can be attributed to blockage of bloodflow to a particular vascular territory. Given the importance of brain imaging in the acute setting it is reasonable to postpone parts of your evaluation until after some initial imaging (head CT without contrast or a hyperacute MRI scan) is obtained.
