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Park, Lee, Kim, Oh, Kim, Kim, Kim, and Kim: Clinical Experience of Intra-Arterial Therapy in Patients with Acute Ischemic Stroke from a Single Institute
Neuroradiology
Original Article

Journal of the Korean Society of Radiology 2016; 75(5): 346-353.

Published online: 31 October 2016

DOI: https://doi.org/10.3348/jksr.2016.75.5.346

Clinical Experience of Intra-Arterial Therapy in Patients with Acute Ischemic Stroke from a Single Institute

So Young Park, MD1, Hanbin Lee, MD2, Jonguk Kim, MD2, Seung Hun Oh, MD2, Jinkwon Kim, MD2, Nam Keun Kim, PhD3, Sang Heum Kim, MD4, Ok Joon Kim, MD2

1Department of Neurology, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea.

2Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam, Korea.

3Institute for Clinical Research, School of Medicine, CHA University, Seongnam, Korea.

4Department of Radiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea.

Corresponding author: Ok Joon Kim, MD. Department of Neurology, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam 13496, Korea. Tel. 82-31-780-5481, Fax. 82-31-780-5269, okjun77@cha.ac.kr

Received 16 February 2016       Revised 5 April 2016       Accepted 26 May 2016

Copyright © 2016 The Korean Society of Radiology

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To compare the efficacy and safety between intra-arterial therapy (IAT) and intra-venous and intra-arterial combined therapy (IVIACT) in patients with acute ischemic stroke in the anterior circulation territory.

Materials and Methods

Forty-one patients treated with IAT using Solitaire were retrospectively reviewed. Nineteen patients were treated with IAT, twenty-two patients were treated with IVIACT, and ten patients of the forty-one patients were managed with multimodal treatment like stent, balloon angioplasty etc. We investigated the rate of recanalization and hemorrhage, NIH stroke scale and 3-month modified Rankin Scale.

Results

The overall recanalization rate was 93% and symptomatic ICH occurred in 10% of the patients. There was no difference in hemorrhage, recanalization rate, and early improvement between IAT and IVIACT. Good outcome was more frequently observed in 59% of the patients with IVIACT than 36% of the patients treated with IAT without any significant difference. The patients managed with multimodal treatment did not show any significant hemorrhage outcome.

Conclusion

IAT using Solitaire is a useful treatment method without high risk in patients with acute ischemic stroke in the anterior circulation territory. Also, IVIACT and multimodal treatment might be considered as reasonable therapeutic options in these patients.

Keywords: Stroke, Mechanical Thrombolysis, Tissue Plasminogen Activator

Figures and Tables

Table 1

Clinical Characteristics of the Patients

jksr-75-346-i001
Characteristics Patients (n = 41)
Age, yr, median (IQR) 65 (55–76)
Male sex, no. (%) 28 (68)
Onset to treatment time-hr, median (IQR) 3.4 (1–6)
Baseline NIHSS, median (IQR) 12 (10–16)
Risk factors, no. (%)
 Hypertension 22 (53.7)
 Diabetes 12 (29.3)
 Heart disease 10 (24.4)
 Hyperlipidemia 14 (34.2)
 Previous stroke 5 (12.2)
Occluded artery, no. (%)
 ICA 18 (43.9)
 MCA 23 (56.1)
Recanalization, no. (%)
 Success 38 (92.7)
 Fail 3 (7.3)
Early improvement, no. (%) 19 (46.3)
Intracranial hemorrhage 9 (22.0)
Symptomatic intracranial hemorrhage, no. (%) 4 (10.0)
Good outcome, no. (%) 15 (48.4)*

*Follow-up information was completed 31 patients out of 41 patients.

hr = hour, ICA = internal carotid artery, IQR = interquartile range, MCA = middle cerebral artery, NIHSS = National Institute of Health Stroke Score, no. = number, yr = year

Table 2

Comparison of Outcome between IAT and IVIACT

jksr-75-346-i002
Characteristics IAT (n = 19) IVIACT (n = 22) p-Value
Age, yr, median (IQR) 71 (63–81) 59 (50–72) 0.01
Male sex, no. (%) 12 (63.16) 16 (72.73) 0.52
Onset to treatment time-hr, median (IQR) 5.4 (1.5–8.5) 1.6 (0.6–2.0) < 0.01
Baseline-NIHSS, median (IQR) 12 (10–14) 13 (10–16) 0.36
Risk factors, no. (%)
 Hypertension 13 (68.42) 9 (40.91) 0.08
 Diabetes 5 (26.32) 7 (31.82) 0.70
 Heart disease 5 (26.32) 5 (22.73) 0.79
 Hyperlipidemia 4 (21.05) 10 (45.45) 0.11
 Previous stroke 5 (26.32) 0 (0) 0.01
Occluded artery, no. (%) 0.83
 ICA 8 (42.11) 10 (45.45)
 MCA 11 (57.89) 12 (54.55)
Recanalization, no. (%) 0.64
 Success 18 (94.74) 20 (90.91)
 Fail 1 (5.26) 2 (9.09)
Early improvement, no. (%) 9 (47.37) 10 (47.62) 1.00
Intracranial hemorrhage, no. (%) 6 (31.58) 3 (13.64) 0.17
Symptomatic intracranial hemorrhage, no. (%) 3 (15.79) 1 (4.55) 0.09
Good outcome, no. (%) 5 (35.71)* 10 (58.82)* 0.26

*Follow-up information was completed for 31 patients (14 for IAT, 17 for IVIACT).

hr = hour, IAT = intra-arterial therapy, ICA = internal carotid artery, IQR = interquartile range, IVIACT = intravenous and intra-arterial combined therapy, MCA = middle cerebral artery, NIHSS = National Institute of Health Stroke Score, no. = number, yr = year

Table 3

The Clinical Characteristics, Detailed Intervention, and Outcome of the Patients Receiving Multimodal Treatment

jksr-75-346-i003
Patient Age Onset to Treatment Time (h) Occluded Artery IV tPA Additional Methods of IA Treatment Recanalization Baseline NIHSS Post NIHSS mRS Symptomatic Hemorrhage
1 63 5.5 ICA No Balloon angioplasy Success 6 0 0 No
2 66 1.5 ICA No Balloon angioplasy Success 9 9 4 No
3 47 10.0 MCA No Balloon angioplasty + tirofiban Success 9 3 2 No
4 54 1.0 ICA No Stent Success 9 1 1 No
5 69 4.5 ICA No Stent + tirofiban Success 10 1 NS* No
6 68 1.3 ICA Yes Stent Success 15 4 2 No
7 74 1.0 ICA Yes Stent Success 10 4 3 No
8 57 1.5 MCA Yes Stent Success 8 3 1 No
9 50 0.5 MCA Yes Stent Success 17 3 1 Yes
10 36 1.0 MCA Yes Tirofiban Success 10 10 NS* No

*Not sufficient data.

IA = intra-arterial, ICA = internal carotid artery, IV tPA = intra-venous tissue plasminogen activator, MCA = middle cerebral artery, mRS = modified Rankin Scale, NIHSS = National Institute of Health Stroke Score

References

1. Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA. 1995; 274:1017–1025.
2. Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet. 1998; 352:1245–1251.
3. Riedel CH, Zimmermann P, Jensen-Kondering U, Stingele R, Deuschl G, Jansen O. The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke. 2011; 42:1775–1777.
4. Lee M, Hong KS, Saver JL. Efficacy of intra-arterial fibrinolysis for acute ischemic stroke: meta-analysis of randomized controlled trials. Stroke. 2010; 41:932–937.
5. Roth C, Papanagiotou P, Behnke S, Walter S, Haass A, Becker C, et al. Stent-assisted mechanical recanalization for treatment of acute intracerebral artery occlusions. Stroke. 2010; 41:2559–2567.
6. Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, et al. 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. 2015; 46:3020–3035.
7. de Los Ríos la Rosa F, Khoury J, Kissela BM, Flaherty ML, Alwell K, Moomaw CJ, et al. Eligibility for intravenous recombinant tissue-type plasminogen activator within a population: the Effect of the European Cooperative Acute Stroke Study (ECASS) III Trial. Stroke. 2012; 43:1591–1595.
8. Cho KH, Ko SB, Kim DH, Park HK, Cho AH, Hong KS, et al. Focused update of Korean clinical practice guidelines for the thrombolysis in acute stroke management. Korean J Stroke. 2012; 14:95–105.
9. Deshmukh VR, Fiorella DJ, Albuquerque FC, Frey J, Flaster M, Wallace RC, et al. Intra-arterial thrombolysis for acute ischemic stroke: preliminary experience with platelet glycoprotein IIb/IIIa inhibitors as adjunctive therapy. Neurosurgery. 2005; 56:46–54. discussion 54-55.
10. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993; 24:35–41.
11. Wilson JT, Hareendran A, Grant M, Baird T, Schulz UG, Muir KW, et al. Improving the assessment of outcomes in stroke: use of a structured interview to assign grades on the modified Rankin Scale. Stroke. 2002; 33:2243–2246.
12. Fugate JE, Klunder AM, Kallmes DF. What is meant by "TICI"? AJNR Am J Neuroradiol. 2013; 34:1792–1797.
13. Mazya M, Egido JA, Ford GA, Lees KR, Mikulik R, Toni D, et al. Predicting the risk of symptomatic intracerebral hemorrhage in ischemic stroke treated with intravenous alteplase: safe Implementation of Treatments in Stroke (SITS) symptomatic intracerebral hemorrhage risk score. Stroke. 2012; 43:1524–1531.
14. Schwab S, Steiner T, Aschoff A, Schwarz S, Steiner HH, Jansen O, et al. Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke. 1998; 29:1888–1893.
15. Flint AC, Duckwiler GR, Budzik RF, Liebeskind DS, Smith WS. MERCI and Multi MERCI Writing Committee. Mechanical thrombectomy of intracranial internal carotid occlusion: pooled results of the MERCI and Multi MERCI Part I trials. Stroke. 2007; 38:1274–1280.
16. Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 2012; 380:1241–1249.
17. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015; 372:1019–1030.
18. Zaidat OO, Suarez JI, Santillan C, Sunshine JL, Tarr RW, Paras VH, et al. Response to intra-arterial and combined intravenous and intra-arterial thrombolytic therapy in patients with distal internal carotid artery occlusion. Stroke. 2002; 33:1821–1826.
19. Wolfe T, Suarez JI, Tarr RW, Welter E, Landis D, Sunshine JL, et al. Comparison of combined venous and arterial thrombolysis with primary arterial therapy using recombinant tissue plasminogen activator in acute ischemic stroke. J Stroke Cerebrovasc Dis. 2008; 17:121–128.
20. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015; 372:11–20.
21. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015; 372:2285–2295.
22. Park JH, Park SK, Jang KS, Jang DK, Han YM. Critical use of balloon angioplasty after recanalization failure with retrievable stent in acute cerebral artery occlusion. J Korean Neurosurg Soc. 2013; 53:77–82.
23. Mordasini P, Brekenfeld C, Byrne JV, Fischer U, Arnold M, Heldner MR, et al. Technical feasibility and application of mechanical thrombectomy with the Solitaire FR Revascularization Device in acute basilar artery occlusion. AJNR Am J Neuroradiol. 2013; 34:159–163.
24. Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. American Heart Association Stroke Council. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009; 40:2945–2948.
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