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PubMed1994

Noninvasive monitoring of internal carotid artery dissection.

BACKGROUND AND PURPOSE: Internal carotid artery dissection has increasingly been reported as a cause of transient ischemic attack or stroke. However, scarce data exist on the natural history of the arterial lesions and the temporal profile of recanalization. METHODS: We followed 48 patients with 50 angiographically confirmed internal carotid artery dissections by sequential duplex Doppler studies in 2- to 4-day intervals during the first weeks after the onset of symptoms and after 4 weeks in 1- to 2-month intervals for up to 2 years. We assessed sonographic features as well as the frequency and time course of resolution. RESULTS: Initial Doppler findings were abnormal in all patients, most of whom (68%) presented with a characteristic bidirectional high-resistance Doppler signal in the internal carotid artery. Gradual recanalization was found in 68% of the dissections after an average interval of 51 days. Changes of Doppler flow patterns in follow-up studies and features of intra-arterial angiography correlated with the development of internal carotid artery dissection and mirrored the recanalization process. CONCLUSIONS: Our findings suggest that Doppler sonography provides early recognition of internal carotid artery dissection and monitoring of its resolution. Thus, ultrasound studies may guide clinical decisions according to the development of the dissection.

Adolescent↗

PubMed1999

Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke: Emergency Management of Stroke (EMS) Bridging Trial.

BACKGROUND AND PURPOSE: The purpose of this study was to test the feasibility, efficacy, and safety of combined intravenous (IV) and local intra-arterial (IA) recombinant tissue plasminogen activator (r-TPA) therapy for stroke within 3 hours of onset of symptoms. METHODS: This was a double-blind, randomized, placebo-controlled multi-center Phase I study of IV r-TPA or IV placebo followed by immediate cerebral arteriography and local IA administration of r-TPA by means of a microcatheter. Treatment activity was assessed by improvement on the National Institutes of Health Stroke Scale Score (NIHSSS) at 7 to 10 days. The Barthel Index, modified Rankin Scale, and the Glasgow Outcome Scale measured 3-month functional outcome. Arterial recanalization rates and their relation to total r-TPA dose and time to lysis were measured. Rates of life-threatening bleeding, intracerebral hemorrhage (ICH), or other bleeding complications assessed safety. RESULTS: Thirty-five patients were randomly assigned, 17 into the IV/IA group and 18 into the placebo/IA group. There was no difference in the 7- to 10-day or the 3-month outcomes, although there were more deaths in the IV/IA group. Clot was found in 22 of 34 patients. Recanalization was better (P=0. 03) in the IV/IA group with TIMI 3 flow in 6 of 11 IV/IA patients versus 1 of 10 placebo/IA patients and correlated to the total dose of r-TPA (P=0.05). There was no difference in the median treatment intervals from time of onset to IV treatment (2.6 vs 2.7 hours), arteriography (3.3 vs 3.0 hours), or clot lysis (6.3 vs 5.7 hours) between the IV/IA and placebo/IA groups, respectively. A direct relation between NIHSSS and the likelihood of the presence of a clot was identified. Eight ICHs occurred; all were hemorrhagic infarctions. There were no parenchymal hematomas. Symptomatic ICH within 24 hours occurred in 1 placebo/IA patient only. Beyond 24 hours, symptomatic ICH occurred in 2 IV/IA patients only. Life-threatening bleeding complications occurred in 2 patients, both in the IV/IA group. Moderate to severe bleeding complications occurred in 2 IV/IA patients and 1 placebo/IA patient. CONCLUSIONS: This pilot study demonstrates combined IV/IA treatment is feasible and provides better recanalization, although it was not associated with improved clinical outcomes. The presence of thrombus on initial arteriography was directly related to the baseline NIHSSS. This approach is technically feasible. The numbers of symptomatic ICH were similar between the 2 groups, which suggests that this approach may be safe. Further study is needed to determine the safety and effectiveness of this new method of treatment. Such studies should address not only efficacy and safety but also the cost-benefit ratio and quality of life, given the major investment in time, personnel, and equipment required by combined IV and IA techniques.

Aged↗

PubMed2000

DIAS I: duplex-sonographic assessment of the cerebrovascular status in acute stroke. A useful tool for future stroke trials.

BACKGROUND AND PURPOSE: A number of controlled trials have evaluated the benefit of intravenous thrombolysis in acute stroke with inconsistent results. None of these studies assessed the initial vascular status or provided information regarding the recanalization rate after therapy. Further trials need to clarify whether certain subgroups might possibly benefit more than others from intravenous thrombolysis. Therefore, a fast and valid method for assessment of cerebrovascular status is needed. In this multicenter study, we evaluated the potentials and limitations of color-coded duplex sonography (TCCS) for cerebrovascular status assessment in acute stroke patients before and after therapy. Furthermore, we compared the recanalization rate for patients referred to thrombolytic and conservative medical therapy. METHODS: Fifty-eight patients suffering from hemispheric stroke were enrolled consecutively in 8 centers. Duplex sonography was performed on admission, 2 hours after start of therapy, and 24 hours after onset of symptoms. Therapy was started within 6 hours. RESULTS: Intravenous thrombolysis was performed in 18 patients, conservative medical therapy in 39 patients, and early thromboendarterectomy in 1 patient. The middle cerebral artery (MCA) mainstem was patent in 29 patients (53.7%), occluded in 25 (46.3%), and was not assessable in 4 patients. Recanalization of the occluded MCA after 2 and 24 hours was diagnosed in 50% and 78% of the patients treated with rtPA and in 0% and 8% in the conservatively treated patients. CONCLUSIONS: Intravenous thrombolysis is highly effective in restoring blood flow after MCA occlusion. TCCS is suitable for assessment of the cerebrovascular status in acute stroke and therefore might define therapeutically relevant subgroups of patients in future stroke trials on the basis of their vascular pathology.

Adult↗

PubMed1998

Reduced microvascular thrombosis and improved outcome in acute murine stroke by inhibiting GP IIb/IIIa receptor-mediated platelet aggregation.

Treatment options in acute stroke are limited by a dearth of safe and effective regimens for recanalization of an occluded cerebrovascular tributary, as well as by the fact that patients present only after the occlusive event is established. We hypothesized that even if the site of major arterial occlusion is recanalized after stroke, microvascular thrombosis continues to occur at distal sites, reducing postischemic flow and contributing to ongoing neuronal death. To test this hypothesis, and to show that microvascular thrombosis occurs as an ongoing, dynamic process after the onset of stroke, we tested the effects of a potent antiplatelet agent given both before and after the onset of middle cerebral arterial (MCA) occlusion in a murine model of stroke. After 45 min of MCA occlusion and 23 h of reperfusion, fibrin accumulates in the ipsilateral cerebral hemisphere, based upon immunoblotting, and localizes to microvascular lumena, based upon immunostaining. In concordance with these data, there is a nearly threefold increase in the ipsilateral accumulation of 111In-labeled platelets in mice subjected to stroke compared with mice not subjected to stroke. When a novel inhibitor of the glycoprotein IIb/IIIa receptor (SDZ GPI 562) was administered immediately before MCA occlusion, platelet accumulation was reduced 48%, and fibrin accumulation was reduced by 47% by immunoblot densitometry. GPI 562 exhibited a dose-dependent reduction of cerebral infarct volumes measured by triphenyltetrazolium chloride staining, as well as improvement in postischemic cerebral blood flow, measured by laser doppler. GPI 562 caused a dose-dependent increase in tail vein bleeding time, but intracerebral hemorrhage (ICH) was not significantly increased at therapeutic doses; however, there was an increase in ICH at the highest doses tested. When given immediately after withdrawal of the MCA occluding suture, GPI 562 was shown to reduce cerebral infarct volumes by 70%. These data support the hypothesis that in ischemic regions of brain, microvascular thrombi continue to accumulate even after recanalization of the MCA, contributing to postischemic hypoperfusion and ongoing neuronal damage.

Animals↗

PubMed1990

Experimental analysis of sapphire contact probes for Nd-YAG laser angioplasty.

Laser angioplasty may offer percutaneous recanalization of occluded vessels where conventional guidewire and balloon techniques fail. Metal laser thermal angioplasty probes may, however, cause excessive thermal damage due to high tip temperatures (greater than 400.C). Therefore, contact probes made from artificial sapphire crystal designed for general laser surgery are currently being evaluated for use in laser angioplasty with continuous wave Nd-YAG energy. The sapphire modifies the laser energy in various ways, and this paper examines the physical characteristics of five types of rounded sapphire probe (SMTR, MTR, MTRL, OS, LT) and how these properties are affected by clinical usage. The laser beam profile emitted by these probes demonstrates a focal spot 1-2 mm in front of the tip. However, the forward transmission of Nd-YAG energy through the sapphires varied (SMTR, 85%; MTR, 83%; MTRL, 75%; OS, 54%; LT, 69%). Probe heating occurs owing to energy absorption within the sapphire. The surface temperature of the sapphires was measured in air by infrared thermography and the hottest region within the probes localized by an isothermographic technique. At energy settings used clinically (20 J, 10 watts for 2 s) the SMTR, MTR, and MTRL probes exhibited higher temperature rises (94-112.C) than the OS and LT probes (30.C), and heating was localized to the front surface of the former probes. Peak sapphire temperatures remained lower than those of metal probes even at higher energies. After clinical use, the MTR probe demonstrated reduced transmission, beam defocusing, and increased heating, due to surface pitting. Thus, recanalization with sapphire probes occurs by a combination of photothermal and contact thermal effects that are localized to the probe tip and may reduce the degree of thermal injury associated with metal probes. Understanding these basic properties is important to the application and development of contact probes for laser recanalization.

Aluminum↗

PubMed1991

Early exercise test in acute myocardial infarction treated with intravenous streptokinase.

The aim of this study was to assess the value of the early exercise test (ET) in patients with acute myocardial infarction (AMI) treated with IV streptokinase (SK). The authors studied 70 patients with first AMI; 31 were treated with SK and 39 were not. Before discharge everyone was given early exercise up to 5-6 METs and catheterized within 22.9 +/- 7.2 days. There was no significant difference in the number of positive ETs between the two groups (11/31 and 14/39 respectively). There was significant difference in favor of: (1) the recanalization of the infarct-related artery in the SK group, (2) the negative ET in patients with recanalized vessels in both groups, (3) the positive ET in patients with multi-vessel coronary disease. It is concluded that the results of early ET in patients with AMI are related to the recanalization of the infarct-related artery and the coexistence of multi-vessel coronary artery disease, regardless of SK treatment. Patients with successful thrombolysis have negative ET more frequently.

Cardiac Catheterization↗

PubMed1998

Tetranectin levels in patients with acute myocardial infarction and their alterations during thrombolytic treatment.

Tetranectin (TN), a new regulator of fibrinolysis, was studied in the plasma of 60 patients with acute myocardial infarction (AMI) and 30 healthy subjects (HS), in relation to D-dimer (DD) and alpha 2-plasmin inhibitor (alpha 2-PI), to investigate its possible involvement in the pathophysiology of AMI. Thirty patients underwent thrombolytic treatment with fibrin-specific plasminogen activator (rt-PA) (group A); the other 30 patients, according to the exclusion criteria, were conventionally treated (group B). Twenty of the thrombolysized patients established early recanalization (subgroup A1), while 10 failed to respond to thrombolytic treatment (subgroup A2). Median (interquartile range), baseline plasma TN levels were lower in AMI patients compared to HS [8.27 (2.75) mg/L versus 12.1 (0.55) mg/L, P < 10(-6)]. In subgroup A1, TN increased at the end of rt-PA infusion and returned to the baseline levels 12 h later. A positive association between DD and TN release (3 h level minus baseline level) was found (rs = 0.48, P = 0.03) in subgroup A1. No significant alterations of TN levels were observed during therapy in subgroup A2 and group B. TN, DD and alpha 2-PI concentrations in group B remained relatively constant during the study period. This study provides evidence of a significant decrease of TN levels in AMI patients compared to healthy subjects and of a remarkable difference in the evolution of TN levels during thrombolytic treatment with rt-PA between recanalized and non-recanalized AMI patients. Thus, an involvement of TN in the formation and dissolution of fibrin clot in AMI patients is worthy of further investigation.

Aged↗

PubMed2002

Percutaneous transluminal laser angioplasty versus balloon dilation for treatment of popliteal artery occlusions.

PURPOSE: To compare the immediate results, complication rates, and long-term outcomes of percutaneous transluminal laser angioplasty (PTLA) versus balloon dilation alone in the treatment of popliteal artery occlusions. METHODS: In a prospective nonrandomized study conducted between December 1994 and June 2000, 215 symptomatic patients with unilateral popliteal occlusions were treated with either dilation alone (88 patients: 52 men; mean age 62 years, range 48-83) or PTLA (127 patients: 70 men; mean age 64 years, range 49-86) using a 308-nm excimer laser followed by dilation. The average occlusion length was 10.4 cm (range 3-14). RESULTS: PTLA was successful in recanalizing 105 (82.7%) arteries, while the recanalization rate for dilation alone was only 70.4% (62/88; p=0.045). After a mean follow-up of 36 months (range 6-52), the primary and secondary patency rates were 21.7% and 50.8%, respectively, in patients with PTLA and 16.3% and 35.2% in the angioplasty group (p=0.762). The complication rates associated with both techniques were similar. CONCLUSIONS: Although initial recanalization may be better with PTLA, it does not appear to add any long-term benefit over balloon dilation alone.

Aged↗

PubMed2005

Endovascular neuroradiological treatment of acute ischemic stroke: techniques and results in 350 patients.

BACKGROUND AND OBJECTIVES: Randomized trials have demonstrated the benefit of intra-arterial thrombolysis (IAT) for treatment of acute ischemic stroke, if performed within 6 hours of symptom onset. METHODS: We report our experience with 350 acute stroke patients who were treated with IAT using urokinase at a single center. Predictors of favorable outcome were low National Institute of Health Stroke Scale (NIHSS) at admission (p<0.001), good collaterals (p<0.001) and successful endovascular recanalization (p<0.001). Recanalization rates of more than 75% could be achieved, when additional endovascular techniques such as mechanical fragmentation of the thrombus, thromboaspiration, percutaneous transluminal angioplasty, and implantation of stents were used. RESULTS AND CONCLUSIONS: Predictors of unfavorable outcome were diabetes mellitus (p<0.001) and symptomatic hemorrhages (p<0.001). The latter occurred in 5% of our population. Preliminary results of new techniques including sonothrombolysis, angiojet aspiration, and laser recanalization of thromboembolic occlusions are discussed.

Basilar Artery↗

PubMed2006

Cholesterol level and symptomatic hemorrhagic transformation after ischemic stroke thrombolysis.

BACKGROUND: Prestroke statin use may improve ischemic stroke outcomes, yet there is also evidence that statins and extremely low cholesterol levels may increase the risk of intracranial hemorrhage. We evaluated the independent effect of statin use and admission cholesterol level on risk of symptomatic hemorrhagic transformation (sHT) after recanalization therapy for acute ischemic stroke. METHODS: We analyzed ischemic stroke patients recorded in a prospectively maintained registry that received recanalization therapies (IV or intra-arterial fibrinolysis or endovascular embolectomy) at a university medical center from September 2002 to May 2006. The independent effect of premorbid statin use on sHT post intervention was evaluated by logistic regression, adjusting for prognostic and treatment variables known to predict increased HT risk after ischemic stroke. RESULTS: Among 104 patients, mean age was 70 years, and 49% were men. Male sex, hypertension, statin use, low total cholesterol and low-density lipoprotein (LDL) cholesterol, current smoking, elevated glucose levels, and higher admission NIH Stroke Scale (NIHSS) score were all associated with a greater risk of sHT in univariate analysis. After adjusting for covariates, low LDL cholesterol (odds ratio [OR], 0.968 per 1-mg/dL increase; 95% CI, 0.941 to 0.995), current smoking (OR, 14.568; 95% CI, 1.590 to 133.493), and higher NIHSS score (OR, 1.265 per 1-point increase; 95% CI, 1.047 to 1.529) were independently associated with sHT risk. CONCLUSIONS: Lower admission low-density lipoprotein cholesterol level with or without statin use, current smoking, and greater stroke severity are associated with greater risk for symptomatic hemorrhagic transformation after recanalization therapy for ischemic stroke.

Aged↗

PubMed2004

Intraarterial thrombolytic therapy within 3 hours of the onset of stroke.

OBJECTIVE: The National Institute of Neurological Disorders and Stroke (NINDS) Recombinant Tissue Plasminogen Activator Stroke Study Group showed that recombinant tissue plasminogen activator (rt-PA) administered intravenously within 3 hours of the onset of ischemic stroke can improve clinical outcome. Intraarterial (IA) thrombolysis has been shown to offer advantages over intravenous (IV) thrombolysis, but experience with this type of therapy within 3 hours of the onset of symptoms has not been reported previously. This study is the first retrospective analysis of a two-institution experience with IA thrombolysis within 3 hours of stroke onset. METHODS: A total of 36 patients with angiographically demonstrated occlusions were treated with urokinase or rt-PA within 3 hours of stroke onset. Outcome measures included the percentage of patients with no or minimal neurological disability at 30 to 90 days as measured by the modified Rankin Scale, percentage recanalization, incidence of symptomatic intracranial hemorrhage, and mortality rate. The results were compared with those of the NINDS rt-PA study. RESULTS: The median admission National Institutes of Health Stroke Scale score was 14. Fifty percent of treated patients had a modified Rankin Scale score of 0 or 1 indicating no or little disability at 1 to 3 months compared with 39% of treated patients in the NINDS trial. Recanalization was 75%, symptomatic intracranial hemorrhage was 11% (versus 6.4% with IV rt-PA in the NINDS trial), and the mortality rate was 22% (versus 17% with IV rt-PA in the NINDS trial). CONCLUSION: The results suggest that IA thrombolysis administered within 3 hours of stroke onset is a feasible and viable alternative to IV rt-PA on the basis of improved clinical outcomes, high recanalization percentage, and comparable mortality rate and despite increased symptomatic intracranial hemorrhage. Whether IA thrombolysis is superior to IV therapy awaits further study.

Adult↗

PubMed2005

Intra-arterial thrombolysis for acute ischemic stroke: preliminary experience with platelet glycoprotein IIb/IIIa inhibitors as adjunctive therapy.

OBJECTIVE: To evaluate the safety profile of platelet glycoprotein IIb/IIIa inhibitors administered as adjunctive therapy to patients with large-vessel occlusion and acute ischemic stroke refractory to pharmacological thrombolysis with recombinant tissue plasminogen activator (rtPA) and mechanical disruption, balloon angioplasty, or both. METHODS: Twenty-one patients (mean age, 62 yr; range, 29-88 yr) met the following criteria: 1) large-vessel occlusion and acute ischemic stroke syndrome at presentation, 2) failure to recanalize after administration of rtPA (intra-arterial and/or intravenous) with or without mechanical thrombolysis, and 3) subsequent treatment with IIb/IIIa inhibitors (intra-arterial or intravenous). RESULTS: Eleven patients had ischemia in the dominant hemisphere, 8 in the vertebrobasilar system, and 2 in the nondominant hemisphere. Twelve patients received intravenous rtPA without significant improvement; 9 patients were not candidates for intravenous rtPA. All patients received intra-arterial rtPA. The IIb/IIIa inhibitors were administered intravenously in 3 patients, intra-arterially in 16, and both intravenously and intra-arterially in 2. Balloon angioplasty was performed in 18 patients. Complete or partial recanalization was achieved in 17 of the 21 patients. After thrombolysis, 15 improved clinically. Three patients (14%) sustained an asymptomatic intracerebral hemorrhage after thrombolytic therapy. No patient was clinically worse after intervention. At last follow-up (mean, 8.5 mo), 13 patients were functionally independent (modified Rankin score, 0-3) and 8 were disabled or dead. CONCLUSION: IIb/IIIa inhibitors are an alternative for achieving recanalization. The risk of hemorrhage may be low. As part of an escalating protocol that includes pharmacological and mechanical thrombolysis, IIb/IIIa inhibitors may improve clinical outcomes.

Abciximab↗

PubMed2005

A new model of reversible sinus sagittalis superior thrombosis in the rat: magnetic resonance imaging changes.

OBJECTIVE: The causes of cerebral sinus and vein occlusion and the accompanying parenchymal changes remain largely unexplained. The clinical variability and low incidence of the disease complicate systematic clinical investigations. Animal studies are indispensable; however, existing animal models of sinus thrombosis do not allow for long-term follow-up studies and are not suitable for pharmacological recanalization because sinus thrombosis is induced by ligation and injection of thrombogenic substances and does not resemble sinus thrombosis in humans. METHODS: We induced thrombosis of the superior sagittal sinus (SSS) by careful topical application of ferric chloride onto the SSS of rats, leading to highly reproducible occlusions. Magnetic resonance imaging was performed immediately after initiation of thrombosis and on postoperative Days 1, 2, and 7. Diffusion- and T2-weighted images allowed for calculation of the apparent diffusion coefficient and T2 relaxation time. Vascular status was assessed by venous magnetic resonance angiography. Neurological deficits were assessed with the rotarod test. RESULTS: Seven days after induction of thrombosis, partial recanalization (50.7% of the SSS remaining occluded) was accompanied by a resolution of early generalized changes of the apparent diffusion coefficient and of T2 relaxation time, indicating edema of the entire brain parenchyma. Compared with sham-treated animals, clinical skills in the experimental group improved over time, which was statistically independent from the degree of recanalization. Histopathological analysis revealed no signs of cerebral infarction. CONCLUSION: This is the first animal model of SSS thrombosis that offers the possibility to investigate pathophysiological aspects of the disease as well as the influence of therapy on the nature of disease progression.

Animals↗

PubMed2006

Repeat endovascular treatment in post-embolization recurrent intracranial aneurysms.

OBJECTIVE: The purpose of this study was to describe clinical situations requiring repeat embolization in patients previously treated by endovascular coil embolization for intracranial aneurysms, and to report on our experiences of repeat embolization (RE). METHODS: A total of 466 patients harboring 522 intracranial aneurysms were treated by endovascular coil embolization at our institution during the period between December 1992 and August 2004. We studied 32 patients who underwent repeat coil embolization (RE) owing to recanalization or aneurysm recurrence. Radiological and clinical data were reviewed to determine the reasons, results, and technical problems of RE. RESULTS: Thirty-nine sessions of RE were performed in 32 patients; four patients underwent RE twice and another patient three times. The major reason for RE was asymptomatic aneurysmal recanalization owing to coil compaction and/or loosening. The time interval between RE and the previous embolization was 12 months or less in 27 sessions. Complete or near complete occlusion of the aneurysm was achieved in all cases without procedure-related morbidity or mortality. Radiolucent gaps between the coil masses were observed in 17 cases. CONCLUSION: RE is a safe and effective treatment option in cases of recanalized or recurrent aneurysms. Close follow-up evaluation is essential in patients with intracranial aneurysms after coil embolization.

Adult↗

PubMed2006

Intra-arterial reteplase and intravenous abciximab in patients with acute ischemic stroke: an open-label, dose-ranging, phase I study.

OBJECTIVE: New approaches are focusing on using a combination of medication that lyse fibrin and prevent aggregation of platelets to achieve higher rates of recanalization and improved clinical outcomes. METHODS: A prospective, nonrandomized, open-label trial evaluated the safety of an escalating dose of reteplase in conjunction with intravenous abciximab (platelet glycoprotein IIb/IIIa inhibitor) in patients with acute ischemic stroke (3-6 h after symptom onset). The primary endpoint was symptomatic intracerebral hemorrhage at 24 to 72 hours, and secondary endpoints were partial or complete recanalization (> or = one grade improvement), early neurological improvement (decrease in National Institutes of Health Stroke Scale > or = 4 at 24 h), and favorable outcome at 1 month (defined by modified Rankin scale < or = 2). RESULTS: A total of 20 patients (mean age, 65 yr; 13 men) were recruited. Five patients were recruited in each of the escalating tiers of intra-arterial reteplase (0.5, 1, 1.5, and 2 units). Intravenous abciximab (0.25 mg/kg bolus followed by 0.125 mug/kg/min) was successfully administered in 18 out of 20 patients. The safety stopping rule was not activated in any of the tiers. One symptomatic intracerebral hemorrhage was observed in one of the 20 patients (in the 1-unit tier). Partial or complete recanalization was observed in 13 of the 20 patients. Thirteen patients demonstrated early neurological improvement, and favorable outcome at 1 month was observed in six patients. CONCLUSION: In this study, a combination of intra-arterial reteplase and intravenous abciximab was safely administered to patients with ischemic stroke presenting between 3 and 6 hours after symptom onset.

Abciximab↗

PubMed2006

Endovascular management of acute symptomatic intracranial arterial occlusion.

OBJECTIVE: Acute ischemic stroke has reached epidemic proportions in the United States, affecting approximately 700,000 people annually. With the recent technological advancements in endovascular devices, clinicians now have tools capable of recanalizing acute intracranial occlusions. The combination of pharmacological thrombolysis and mechanical clot perturbation may result in increased rates of angiographic recanalization, which may lead to improvement in patient outcomes after acute stroke. METHODS: In this article, the various intra-arterial pharmacological and mechanical therapies used by interventionists to treat acute stroke are described. Strategies for using combinations of these therapies are discussed, as are preliminary radiographic and clinical outcomes. Techniques for complex mechanical stroke interventions are discussed in detail. RESULTS: Several advances in endovascular stroke technologies are becoming increasingly available. CONCLUSION: With proper patient selection, these therapies may lead to increased recanalization rates and better patient outcomes.

Acute Disease↗

PubMed1988

Effects of coronary thrombolysis on left ventricular ejection fraction in patients with acute myocardial infarction.

Left ventriculograms were performed on 65 patients with acute myocardial infarction, once upon admission and again 3 months later. In 29 cases urokinase was injected intravenously and/or intracoronarily. The other 17 were treated without urokinase. In 8 out of 29 patients whose infarct-related coronary arteries remained completely occluded following urokinase therapy, the global ejection fraction was reduced from 54 +/- 3% during the acute stage to 46 +/- 5% during the chronic stage (p less than 0.001). However, for the 21 patients whose coronary arteries were successfully recanalized, the 2 values were the same (52 +/- 2%). The highest global ejection fractions were seen in 19 spontaneously recanalized patients (acute: 54 +/- 2%, chronic: 55 +/- 2%). For the 8 unsuccessful patients, the regional ejection fraction for the infarcted portion was reduced from 20 +/- 5% during the acute stage to 18 +/- 6% during the chronic stage. But for the successful patients there was an improvement from 22 +/- 2% during the acute stage to 27 +/- 2% during the chronic stage. Again, the regional ejection fraction was the highest for the spontaneously recanalized group, being 31 +/- 2% and 36 +/- 3% during the acute and chronic stages, respectively. These results indicate that if the coronary artery remains occluded during the acute stage the reduced left ventricular function continues to deteriorate even more during the chronic stage. Successful coronary thrombolysis, however, might salvage the infarcted myocardium as well as preserve the function of the left ventricle.

Chronic Disease↗

PubMed1999

Percutaneous transluminal angioplasty of the subclavian arteries.

PURPOSE: To review the feasibility, risks, and long-term results of subclavian artery angioplasty with and without Palmaz stent placement. METHODS: Over a 9-year period, 113 patients (67 males; mean age 63 +/- 13 years) underwent percutaneous balloon angioplasty of subclavian occlusive lesions for a variety of indications: vertebrobasilar insufficiency (n = 70), upper limb ischemia (n = 50), coronary steal syndrome (n = 6), or anticipated coronary artery bypass grafting using the internal mammary artery in 12 asymptomatic patients. There were 94 (83%) stenoses and 19 (17%) occlusions with a mean percent stenosis of 80.1% +/- 7.4% (range 70 to 100). Mean lesion length was 24 +/- 8 mm (range 10 to 50). Beginning in 1989, stents were implanted for suboptimal dilation; in 1995, stenting became routine. RESULTS: Overall, 103 (91%) of 113 lesions were successfully treated; 10 (53%) occlusions could not be recanalized. Fifty-one stents were implanted in 46 patients. There were 3 (2.6%) procedural complications: a transient ischemic attack, one major (fatal) stroke, and an arterial thrombosis 24 hours after the procedure (treated medically) (0.9% major stroke and death rate). During a mean 4.3-year follow-up (range to 10), 16 (15.5%) restenoses were treated with angioplasty (n = 4), stenting (n = 7), or surgery (n = 5). Primary and secondary patencies for all treated lesions (n = 113) at 8 years were 75% and 81%, respectively; in patients without initial stent placement, the rates were 69% and 76%, while in those with stents, the rates rose slightly to 87% and 94% at 2.5 years (NS). Patency rates for all 103 recanalized lesions were 83% and 90% at 8 years (81% and 90% without stent and 87% and 94% with stent at 2.5 years, respectively [NS]). CONCLUSIONS: Balloon angioplasty with or without stenting is safe and effective for treating subclavian artery occlusive diseases with good long-term patency. Recanalization of occlusions is more difficult to achieve. Stents (implanted only for suboptimal dilation) do not seem to improve long-term patency.

Adult↗