Advances in revascularization for acute ischemic stroke treatment: an update.

Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) is the established treatment for acute ischemic stroke patients presenting within 4.5 h of stroke onset based on the results of the National Institute of Neurological Disorders and Stroke Study Group trial and European Cooperative Acute Stroke Study III. In a significant number of patients, however, intravenous thrombolysis with rt-PA remains ineffective, with lower rates of recanalization, especially for proximal occlusions and a large thrombus burden. Newer thrombolytic agents, such as reteplase, tenecteplase or desmoteplase, offer pharmacokinetic and hemodynamic advantages over rt-PA and have been, or are currently being, tested for safety and efficacy in clinical trials. Agents such as direct fibrinolytics that do not depend on the availability of plasminogen are also being studied in ongoing trials. Endovascular revascularization is an evolving treatment option enabling mechanical clot disruption or extraction in combination with local directed pharmacological thrombolysis. Several new endovascular devices have been successfully tested for safety in acute ischemic stroke patients and are now being tested for efficacy in larger clinical trials. Continued innovation and refinement of endovascular technology and techniques, including combination therapy such as bridging therapy and the use of stent-like devices, is expected to increase technical success and improve overall efficacy and time to recanalization with minimal procedure-related morbidity in the treatment of acute ischemic stroke

Proposed methodology and classification of Infarct in New Territory (INT) after endovascular stroke treatment

While the overall complication rates for endovascular treatment for acute stroke has been extremely low in recent trials, it is important to separate out and accurately document complications. One of these complications that is usually related to the endovascular intervention is Infarct in New Territory (INT). We propose a standardized methodology for documenting INT after the procedure. This new classification takes into account variations in vascular anatomy and location of the occlusion. In addition, given that after the recent trials, vascular imaging (eg, CT angiography (CTA)) is now the standard of care in the work up of acute ischemic stroke, this classification utilizes the information on the preprocedure non-invasive vascular imaging, the angiography images from end of procedure and the location of lesions on the follow-up sca

Hemodynamic alterations measured with phase-contrast MRI in a giant cerebral aneurysm treated with a flow-diverting stent

Many risk factors have been proposed in the development of the cerebral aneurysms. Hemodynamics including blood velocity, volume flow rate (VFR), and intravascular pressure are thought to be prognostic indicators of aneurysm development. We hypothesize that treatment of cerebral aneurysm using a flow-diverting stent will bring these hemodynamic parameters closer to those observed on the contralateral side. In the current study, a patient with a giant cerebral aneurysm was studied pre- and postoperatively using phase contrast MRI (PC-MRI) to measure the hemodynamic changes resulting from the deployment of a flow-diverting stent. PC-MRI was used to calculate intravascular pressure, which was compared to more invasive endovascular catheter-derived measurements. After stent placement, the measured VFRs in vessels of the treated hemisphere approached those measured on the contralateral side, and flow symmetry changed from a laterality index of -0.153 to 0.116 in the middle cerebral artery. Pressure estimates derived from the PC-MRI velocity data had an average difference of 6.1% as compared to invasive catheter transducer measurements. PC-MRI can measure the hemodynamic parameters with the same accuracy as invasive methods pre- and postoperatively