Abstract: Article presents a retrospective analysis of using the modified way experience in removing the occlusive substrate from cerebral vessels in the ischemic stroke acute phase after failed standard thrombectomy. Aim: to study the efficacy and advantages of thrombectomy technique from intracranial arteries in patients with acute ischemic stroke combining a stent-retriever with reperfusion catheter in comparison with the standard stent retriever thromboextraction. Methods: we analyzed 54 hospital charts of patients who had underwent endovascular recanalization of intracranial large vessel occlusion in acute ischemic stroke. Patients were divided into two equal groups, depending on thrombus removal method. Standard stent-retriever thrombectomy with a balloon guide-catheter was performed as the first stage in both groups. In 27 cases (1st group), after standard stent-retriever technique failed, we carried out combination of retriever extraction with distal aspiration and a guiding balloon-catheter. If we couldn’t safely insert stent-retriever into catheter of distal approach (during thrombectomy), we switched to vacuum aspiration from guiding balloon-catheter (vacuum-blocked) and removed stent-retriever, microcatheter and distal approach catheter simultaneously without reducing tension. In 27 patients (2nd group) after standard thrombectomy failed we repeated this technique several times. Results: embolic complications relative risk was 2,249, 95% CI (1,126 - 4,492) and reperfusion mTICI 3 100% versus 74,07% rate was higher in the first group, in comparison with the second group. Other complications and hospital outcomes of disease did not differ between groups. Conclusion: a stent retriever combined with distal aspiration and a simultaneous transition to vacuum-blocked extraction using after an unsuccessful standard thrombectomy increases the efficiency of complete reperfusion by 25%. Its use is 1,8 times safer than standard thrombectomy in terms of embolic complications.
Abstract: Introduction: up to the present day, there were no published multicenter randomized researches, that could compare combined concept of thrombectomy, including different methods of stent-retrievers traction with elements of aspiration and thrombolysis. There is no data on the effect of embolic complications after extraction of thrombus from cerebral arteries on outcomes of treatment. Aim: was to increase the effectiveness of treatment of patients with ischemic stroke basing on a comparison of results of various methods of endovascular thrombectomy from cerebral vessels and intravenous thrombolysis, and on the base of assessment of effect of distal embolism on treatment outcomes in acute period of ischemic stroke. Materials and methods: we carried out statistical analysis of results of different methods of thrombectomy in 75 patients and intravenous thrombolysis in 75 patients in acute phase of ischemic stroke. Effect of embolic complications after thrombectomy on outcomes of treatment of ischemic stroke was determined. Results: groups of patients were comparable in age, neurological deficit, sex, localization and stroke subtype. The first group is burdened by the proportion of documented cerebral artery occlusion, diabetes mellitus and ischemic stroke in anamnesis. Differences in deaths and disability rates were not reliable. Thrombectomy demonstrated neurological deficit regression at all evaluation intervals, as well as the superiority of 2 times at achievement of functionally independent outcome in comparison with intravenous thrombolysis group. Conclusions: a concept to thrombectomy, that supposes different methods of use of stent-retrievers and aspiration demonstrates better functional outcomes in treatment of ischemic stroke in the acute phase compared with intravenous thrombolysis. Embolic complications of reperfusion treatment adversely affect ischemic stroke outcomes and should be considered as a factor requiring minimization. References 1. Domashenko MA, Maksimova MY, Gafarova ME et al. The personification of reperfusion therapy approaches for ischemic stroke. Annals of Clinical and Experimental Neurology. 2017;11(1):7-13 [In Russ]. 2. Powers W, Rabinstein A, Ackerson T et al. 2018 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. 2018; 49(3):e46-e99. https://doi.org/10.1161/STR.0000000000000158 3. Sandercock P, Wardlaw JM, Lindley RI et al.; IST-3 collaborative group. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. The Lancet. 2012;379(9834):2352-2363. https://doi.org/10.1016/S0140-6736(12)60768-5 4. Riedel C, Zimmermann P, Jensen-Kondering U et al. The Importance of Size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke. 2011;42(6):1775-1777. https://doi.org/10.1161/STROKEAHA.110.609693 5. Kharitonova T, Ahmed N, Thoren M et al. Hyperdense Middle Cerebral Artery Sign on Admission CT Scan – Prognostic Significance for Ischaemic Stroke Patients Treated with Intravenous Thrombolysis in the Safe Implementation of Thrombolysis in Stroke International Stroke Thrombolysis Register. Cerebrovascular Diseases. 2008;27(1): 51-59. https://doi.org/10.1159/000172634 6. Thomalla G, Kruetzelmann A, Siemonsen S et al. Clinical and Tissue Response to Intravenous Thrombolysis in Tandem Internal Carotid Artery/Middle Cerebral Artery Occlusion. Stroke. 2008;39(5):1616-1618. https://doi.org/10.1161/STROKEAHA.107.504951 7. Turc G, Bhogal P, Fischer U et al. European Stroke Organisation (ESO) – European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischemic stroke. Journal of NeuroInterventional Surgery. 2019;11(6):535-538. https://doi.org/10.1136/neurintsurg-2018-014568 8. Fransen P, Berkhemer O, Lingsma H et al. Time to Reperfusion and Treatment Effect for Acute Ischemic Stroke: A Randomized Clinical Trial. JAMA Neurology. 2016;73(2):190-196. https://doi.org/10.1001/jamaneurol.2015.3886 9. Goyal M, Demchuk A, Menon B et al. Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. New England Journal of Medicine. 2015;372(11): 1019-1030. https://doi.org/10.1056/NEJMoa1414905 10. Campbell B, Mitchell P, Kleinig T et al. Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. New England Journal of Medicine. 2015;372(11): 1009-1018. https://doi.org/10.1056/NEJMoa1414792 11. Bracard S, Ducrocq X, Mas J et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. The Lancet Neurology. 2016;15(11):1138-1147. https://doi.org/10.1016/S1474-4422(16)30177-6 12. Jovin T, Chamorro A, Cobo E et al. Thrombectomy within 8 Hours after Symptom Onset in Ischemic Stroke. New England Journal of Medicine. 2015;372(24):2296-2306. https://doi.org/10.1056/NEJMoa1503780 13. Muir K, Ford G, Messow C et al. Endovascular therapy for acute ischaemic stroke: the Pragmatic Ischaemic Stroke Thrombectomy Evaluation (PISTE) randomised, controlled trial. Journal of Neurology, Neurosurgery & Psychiatry. 2016;88(1):38-44. https://doi.org/10.1136/jnnp-2016-314117 14. Saver J, Goyal M, Bonafe A et al. Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke. New England Journal of Medicine. 2015;372(24):2285-2295. https://doi.org/10.1056/NEJMoa1415061 15. McCarthy D, Diaz A, Sheinberg D et al. Long-Term Outcomes of Mechanical Thrombectomy for Stroke: A Meta-Analysis. The Scientific World Journal. 2019; 2019:1-9. https://doi.org/10.1155/2019/7403104 16. Logvinenko RL, Domashenko MA, Frantsevich AM et al. Choice of reperfusion strategy in acute period of ischemic stroke. Journal Diagnostic & interventional radiology. 2018;12(2):77-84 [In Russ]. 17. Semitko SP, Analeev AI, Azarov AV et al. Results of primary endovascular treatment of patients with acute ischemic stroke and high risk or contraindication for thrombolytic therapy. Journal Diagnostic & interventional radiology. 2018;12(4):52-58. [In Russ] 18. Kang D, Kim B, Heo J et al. Effect of balloon guide catheter utilization on contact aspiration thrombectomy. Journal of Neurosurgery. 2018;1-7. https://doi.org/10.3171/2018.6.JNS181045 19. Maegerlein C, Monch S, Boeckh-Behrens T et al. PROTECT: PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy – evaluation of a double embolic protection approach in endovascular stroke treatment. Journal of NeuroInterventional Surgery. 2017;10(8):751-755. https://doi.org/10.1136/neurintsurg-2017-013558 20. Goto S, Ohshima T, Ishikawa K et al. A Stent-Retrieving into an Aspiration Catheter with Proximal Balloon (ASAP) Technique: A Technique of Mechanical Thrombectomy. World Neurosurgery. 2018;109:e468-e475. https://doi.org/10.1016/j.wneu.2017.10.004 21. Lee D, Sung J, Kim S et al. Effective use of balloon guide catheters in reducing incidence of mechanical thrombectomy related distal embolization. Acta Neurochirurgica. 2017;159(9):1671-1677. https://doi.org/10.1007/s00701-017-3256-3 22. Stampfl S, Pfaff J, Herweh C et al. Combined proximal balloon occlusion and distal aspiration: a new approach to prevent distal embolization during neurothrombectomy. Journal of NeuroInterventional Surgery. 2016;9(4):346-351. https://doi.org/10.1136/neurintsurg-2015-012208 23. Maus V, Behme D, Kabbasch C et al. Maximizing First-Pass Complete Reperfusion with SAVE. Clinical Neu-roradiology. 2017;28(3):327-338. https://doi.org/10.1007/s00062-017-0566-z 24. Jadhav A, Aghaebrahim A, Horev A et al. Stent Retriever-Mediated Manual Aspiration Thrombectomy for Acute Ischemic Stroke. Interventional Neurology. 2016;6(1-2):16-24. https://doi.org/10.1159/000449321 25. Patent RUS №2670193/ 18.10.18. Byul. №29. Logvinenko RL, Arablinskiy AV, Domashenko MA et al. The method of endovascular combined thrombectomy from cerebral arteries. [In Russ.] Available at (23.09.2019): 26. Hwang Y, Kang D, Kim Y, Kim Y, Park S, Suh C. Outcome of forced-suction thrombectomy in acute intracranial internal carotid occlusion. J Neurointervent Surg. 2012;5(suppl 1):i81-i84. https://doi.org/10.1136/neurintsurg-2012-010277 27. Turk A, Spiotta A, Frei D, Mocco J, Baxter B, Siddiqui A et al. O-002 Initial Clinical Experience with the ADAPT technique: A Direct Aspiration first Pass Technique for Stroke Thrombectomy. J Neurointervent Surg. 2013;5(Suppl 2):A1.2-A1. https://doi.org/10.1136/neurintsurg-2013-010870.2 28. Volodukhin M.U. Roentengen-endovascular method of cerebral flow restoration in acute tandem occlusion of the internal carotid artery with embolism development in middle cerebral artery. Kazan medical journal. 2016;97(3): 457-460 [In Russ]. https://doi.org/10.17750/KMJ2016-457 29. Geroulakos G, Ramaswami G, Nicolaides A et al. Characterization of symptomatic and asymptomatic carotid plaques using high-resolution real-time ultrasonography. British Journal of Surgery. 1993;80(10): 1274-1277. https://doi.org/10.1002/bjs.1800801016 30. Adams H, Bendixen B, Kappelle L 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(1):35-41. https://doi.org/10.1161/01.str.24.1.35 31. Logvinenko RL, Kokov LS, Shabunin AV, Arablinskiy AlV, Tsurkan VA. Analysis of a modified method for combined removal of throbus from blood vessels of the brain in the treatment of acute ischemic stroke. REJR. 2020; 10 (1):159-177 [In Russ]. https://doi.org/10.21569/2222-7415-2020-10-1-159-177 32. Chen C, Parsons M, Levi C, Spratt N, Miteff F, Lin L et al. Exploring the relationship between ischemic core volume and clinical outcomes after thrombectomy or thrombolysis. Neurology. 2019;93(3):e283-e292. https://doi.org/10.1212/WNL.0000000000007768 33. Southerland A, Johnston K. Considering hyperglycemia and thrombolysis in the Stroke Hyperglycemia Insulin Network Effort (SHINE) trial. Annals of the New York Academy of Sciences. 2012;1268(1):72-78. https://doi.org/10.1111/j.1749-6632.2012.06731.x 34. Lansberg M, Thijs V, Bammer R, Kemp S, Wijman C, Marks M et al. Risk Factors of Symptomatic Intracerebral Hemorrhage After tPA Therapy for Acute Stroke. Stroke. 2007;38(8):2275-2278.
Abstract: The article presents an analysis of the choice of strategy for the treatment of ischemic stroke in the acute period, based on literature review. Aim: was to develop the concept of effective thromboextraction (TE), based on the evaluation of factors influencing results of reperfusion treatment of ischemic stroke (IS), methods of endovascular restoration of cerebral blood flow Materials and methods: meta-analysis of 44 sources of domestic and foreign literature is performed. The analysis of factors limiting the effectiveness of various reperfusion approaches and the analysis of modern methods of thrombectomy are performed. Results: it is established, that SMAT (Solumbra) and PROTECT techniques have an advantage in comparison with aspiration approaches to thrombectomy in reducing the period to full reperfusion; methods with temporary occlusion of the source vessel (BGC) SAVE and PROTECT significantly reduce the risk of stroke spread to new vascular areas of the brain and increase the frequency of successful recanalization. Conclusion: at present time, the PROTECT is the most effective technique in the frequency of successful recanalization, the degree and speed of achieved reperfusion, as well as in the prevention of distal embolization. Extrapolation of experience and principles from other sections of interventional radiology, development of new methods and strategies of brain reperfusion, depending on the morphology of thromboembolism, its size, localization and extent may contribute to improving results of endovascular treatment of ischemic stroke. References 1. Newsletter of the WHO №317, 2015 January. 2. Jansen O., von Kummer R., Forsting M. et al. Thrombolytic therapy in acute occlusion of the intracranial internal carotid artery bifurcation. AJNR Am J Neuroradiol. 1995; Nov-Dec; 16(10): 1977-86. 3. Furlan A., Higashida R., Wechsler L. et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA. 1999 Dec; 282(21): 2003-11. 4. Domashenko M.A., Maksimova M.Yu., 5. Domashenko M.A., Panova K.V., Murtazalieva D.M. i dr. Personifikatsiya tromboliticheskoj terapii patsientov s ishemicheskim insulom [Personification of thrombolytic therapy in patients with ischemic stroke.] Medica mente. 2017; 3(1): 45-48. 6. Emberson J. et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. - 2014; 384(9958): 1929-1935. 7. Fransen P.S., Berkhemer O.A., Lingsma H.F. et al. Time to Reperfusion and Treatment Effect for Acute Ischemic Stroke: A Randomized Clinical Trial. JAMA Neurol. 2016 Feb; 73(2): 190-196. 8. Seet R.C., Rabinstein A.A. Symptomatic intracranial hemorrhage following intravenous thrombolysis for acute ischemic stroke: a critical review of case definitions. Cerebrovasc Dis. 2012; 34: 106-114. 9. Yaghi S., Eisenberger A., Willey J.Z. Symptomatic intracerebral hemorrhage in acute ischemic stroke after thrombolysis with intravenous recombinant tissue plasminogen activator: a review of natural history and treatment. JAMA Neurol. 2014; 71(9): 1181-1185. 10. Yaghi S., Boehme A.K., Dibu J. et al. Treatment and Outcome of Thrombolysis-Related Hemorrhage: A Multicenter Retrospective Study. JAMA Neurol. 2015; 72(12): 1451-1457. 11. Hacke W., Kaste M., Bluhmki E. et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008; 359: 1317-1329. 12. Nikoubashman O., Reich A., Pjontek R. et al. Postinterventional subarachnoid haemorrhage after endovascular stroke treatment with stent retrievers. Neuroradiology. 2014; Dec; 56(12): 1087-1096. 13. Kornienko V.N., Pronin I.N. Diagnosticheskaya nejroradiologiya. [Diagnostic Neuroradiology]. Moscow. 2006: 1317 [In Russ]. 14. Urbach H. et al. Local intra-arterial thrombolysis in the carotid territory: does recanalization depend on the thromboembolus type? Neuroradiology 2002; 44: 695-699. 15. Riedel C.H., Zimmermann P., Jensen-Kondering U. et al. The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke. 2011;Jun; 42(6):1775-1777. 16. Del Zoppo C.J. et al. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann. Neurol. - 1992, 32: 78-86. 17. Mori E. et al. Intravenous recombinant tissue plasminogen activator in acute carotid territory stroke. Neurology, 1992; 42: 976-982. 18. Shamalov N.A. Optimizatsiya reperfusionnoj terapii u patsientov s ishemicheskim insultom. Diss. dokt. med. nauk [Optimization of reperfusion therapy in patients with ischemic stroke. Dr. med. sci. diss.]. Moscow. 2012: 47 [In Russ]. 19. Lansberg M.G. et al. Risk factors of symptomatic intracerebral hemorrhage after tPA therapy for acute stroke. Stroke. - 2007; 38: 2275-2278. 20. Bracard S., Ducrocq X., Mas J.L., et. al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol. 2016; Oct; 15(11): 1138-1147. 21. Powers W.J., Rabinstein A.A., Ackerson T. et al. 2018 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 2018 Mar; 49(3): 46 - 99. 22. Eva A. Mistry, Akshitkumar M. Mistry, Mohammad Obadah Nakawah, Mechanical Thrombectomy Outcomes with and without Intravenous Thrombolysis in Stroke Patients. Stroke. 2017 Sept; 48(9): 2450-2456. 23. Kaesmacher J., Boeckh-Behrens T., Simon S. et al. Risk of Thrombus Fragmentation during Endovascular Stroke Treatment. AJNR Am J Neuroradiol. 2017 May; 38(5): 991-998. 24. Nikoubashman O., Reich A., Pjontek R. et al. Postinterventional subarachnoid haemorrhage after endovascular stroke treatment with stent retrievers. Neuroradiology. 2014 Dec; 56(12): 1087-1096. 25. Kang D.H., Park J. Endovascular Stroke Therapy Focused on Stent Retriever Thrombectomy and Direct Clot Aspiration: Historical Review and Modern Application J Korean Neurosurgical Society 2017 May; 60(3): 335-347. 26. Kang D.H., Hwang YH., Kim YS. et al. Direct thrombus retrieval using the reperfusion catheter of the penumbra system: forced-suction thrombectomy in acute ischemic stroke. AJNR Am J Neuroradiol. 2011 Feb; 32(2): 283 - 287. 27. Hwang YH., Kang D.H., Kim YW. et al. Outcome of forced-suction thrombectomy in acute intracranial internal carotid occlusion. J Neurointervent Surg. 2013; 5 (Suppl 1): 81-84. 28. Turk AS, Spiotta A, Frei D, et al. Initial clinical experience with the ADAPT technique: a direct aspiration first pass technique for stroke thrombectomy. J Neurointervent Surg. 2014 Apr; 6(3): 231-237. 29. Lee D.H., Sung J.H., Kim S.U. et al. Effective use of balloon guide catheters in reducing incidence of mechanical thrombectomy related distal embolization. Acta Neurochirurgica 2017 Sept; 159(9): 1671-1677. 30. Kang D.H., Kim YW., Hwang YH. et al. Switching strategy for mechanical thrombectomy of acute large vessel occlusion in the anterior circulation. Stroke. 2013; Dec; 44(12): 3577-3579. 31. Deshaies EM. Tri-axial system using the Solitaire-FR and Penumbra Aspiration Microcatheter for acute mechanical thrombectomy. J Clin Neurosci. 2013; 20(9): 1303-1305. 32. Humphries W., Hoit D., Doss V.T. et al. Distal aspiration with retrievable stent assisted thrombectomy for the treatment of acute ischemic stroke. J Neurointerv Surg. 2015; 7(2): 90-94. 33. Lee J.S., Hong J.M., Lee S.J. et al. The combined use of mechanical thrombectomy devices is feasible for treating acute carotid terminus occlusion. Acta Neurochir (Wien) 2013; 155(4): 635 - 641. 34. Jadhav A.P, Aghaebrahim A., Horev A. et. al. Jovina, Stent Retriever-Mediated Manual Aspiration Thrombectomy for Acute Ischemic Stroke. Interv Neurol. 2017 Mar; 6(1-2): 16 - 24. 35. Maegerlein C., Mцnch S., Boeckh-Behrens T. et al. PROTECT: PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy - evaluation of a double embolic protection approach in endovascular stroke treatment. J Neurointerv Surg. 2017; 0: 1 - 5. 36. Maus V., Behme D., Kabbasch C. et al. Maximizing First-Pass Complete Reperfusion with SAVE. Clin Neuroradiol. 2017 Feb 13. doi: 10.1007/s00062-017-0566-z. 37. Wiesmann M., Brockmann M.A., Heringer S. et al. Active push deployment technique improves stent/vesselwall interaction in endovascular treatment of acute stroke with stent retrievers. J Neurointerv Surg. 2017 Mar; 9(3): 253 - 256. 38. Nikoubashman O., Alt J.P, Nikoubashman A. et al. Optimizing endovascular stroke treatment: removing the microcatheter before clot retrieval with stent-retrievers increases aspiration flow. J Neurointerv Surg. 2017 May; 9(5): 459-462. 39. Volodyukhin M.U., Novozhilova A.A. Sposob vosstanovleniya krovotoka pri sochetannom tromboze vnutrennej sonnoj I srednej mozgovoj arterij [A method for restoring of blood flow in a combined thrombosis of the internal carotid and middle cerebral artery]. Patent RF №2629046, 2016. 40. Volodyukhin M.U. Rentgenendovaskulyarnyj metod vosstanovleniya cerebral'nogo krovotoka pri ostroy tandemnoj okklyuzii vnutrennej sonnoj arterii s razvitiem embolii v srednyuyu mozgovuyu arteriyu. [Endovascular method of cerebral blood flow restoration in acute tandem occlusion of the internal carotid artery with embolism development in the middle cerebral artery.] Kazanskij meditsinskijzhurnal. 2016; 97(3): 457-460. 41. Noser EA, Shaltoni HM, Hall CE, et al. Aggressive mechanical clot disruption: a safe adjunct to thrombolytic therapy in acute stroke? Stroke 2005; 36: 292-296. 42. Nakano S., Iseda T., Yoneyama T. et al. Direct percutaneous transluminal angioplasty for acute middle cerebral artery trunk occlusion: an alternative option to intra-arterial thrombolysis. Stroke 2002; 33: 2872-2876. 43. Qureshi AI, Siddiqui AM, Suri MF. et al. Aggressive mechanical clot disruption and low-dose intra-arterial third-generation thrombolytic agent for ischemic stroke: a prospective study. Neurosurgery 2002; 51: 1319-1329. 44. von Gadow N., Nikoubashman O., Freiherr J. et al. Endovascular stroke treatment now and then-procedural and clinical effectiveness and safety of different mechanical thrombectomy techniques over time. Quant Imaging Med Surg. 2017 Feb; 7(1): 1-7.
