Original Article
Endovascular treatment of acute ischemic stroke: An Indian experience from a tertiary care center Vikram Huded, Rithesh R. Nair, Romnesh de Souza1, Devashish D.Vyas1 Division of Interventional Neurology and Stroke, 1Department of Neurology, Narayana Institute of Neurosciences, Bangalore, Karnataka, India
Abstract
Address for correspondence: Dr. Vikram Huded, Division of Interventional Neurology and Stroke, Narayana Institute of Neurosciences, 258/A, Bommasandra Industrial Area, Hosur Main Road, Bangalore ‑ 560 099, Karnataka, India. E‑mail: [email protected] Received : 04‑03‑2014 Review completed : 15‑04‑2014 Accepted : 03‑06‑2014
Background: In India, late presentation due to poor awareness about stroke precludes intravenous thrombolysis (IVT). Endovascular therapy can be used in these circumstances. We present our experience of endovascular treatment of acute ischemic stroke in a tertiary care center. Aim: Endovascular treatment of acute ischemic stroke in a tertiary care center in India. Settings, Design, Materials, and Methods: The study period was from 2009 till 2013. Consecutive patients with acute ischemic stroke, who either had contraindications to IVT or had failed IVT, underwent endovascular treatment. Before the publication of interventional management of stroke 3 results, we took a few patients, with large vessel occlusions, directly for endovascular treatment. After imaging, patients were considered for endovascular treatment, using either intra‑arterial thrombolysis or mechanical thrombectomy, if there was a documented large vessel occlusion. Outcome was assessed at 3 months using the modified Rankin Scale. Statistical Analysis: Statistical analysis was done using the Statistical Package for the Social Sciences 17.0 software. Results: A total of 45 patients underwent endovascular treatment. The mean age at presentation was 49 years, median National Institutes of Health Stroke Scale (NIHSS) was 19 and the most common site was the middle cerebral artery (23 patients). Solitaire™ stentriever was used in 33 patients. The median pre‑procedure Thrombolysis In Myocardial Infarction (TIMI) score was 0 and the median post‑procedure TIMI score was 3. Nine patients underwent decompressive craniectomy. On follow‑up at 3 months, the median Modified Rankin Scale (mRS) was 0. Eight patients died during 3 months following stroke. Conclusion: Endovascular treatment of acute ischemic stroke is a viable treatment option in patients who either have contraindications to IVT or who fail IVT. Key words: Endovascular, ischemic, solitaire, stentriever, stroke
non‑commnicable diseases are due to stroke. Stroke is responsible for 72% of disability adjusted life years.[1]
Introduction In India, it is estimated that 41% of all deaths due to Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.136919
276
The Prolyse in Acute Cerebral Thromboembolism (PROACT),[2] Mechanical Embolus Removal in Cerebral Ischemia (MERCI)[3], Multi MERCI,[4] Solitaire™ With the Intention for Thrombectomy (SWIFT)[5] and Thrombectomy REvascularization of large Vessel Occlusions (TREVO)[6] in acute ischemic stroke trials showed that the use of endovascular treatment in acute ischemic stroke is beneficial in patients with documented large vessel disease. However, trials such as the Interventional Management of Neurology India | May-Jun 2014 | Vol 62 | Issue 3
Huded, et al.: Indian experience of endovascular treatment of acute ischemic stroke
Stroke 3 (IMS3)[7] trial, Local versus Systemic Thrombolysis for Acute Ischemic Stroke (SYNTHESIS Expansion).[8] trial and Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE)[9] did not show superiority of endovascular treatment over intravenous thombolysis (IVT) during the window period. Current guidelines indicate that endovascular treatment in acute ischemic should be reserved for those patients where there are contraindications for intravenous thrombolysis and in those who fail IVT.
In Myocardial Infarction (TIMI) score, incidence of post procedure complications and 3‑month follow‑up using the Modified Rankin Scale (mRS). Written informed consent of patient’s relatives was obtained prior to the procedure. Data was compared to other similar studies.
In India, the knowledge about stroke symptoms as well as intravenous thrombolysis for stroke is poor, resulting in fewer patients presenting to a tertiary care centre within the window period for IVT. Ongoing anticoagulation in patients with rheumatic heart disease, either for atrial fibrillation or prosthetic heart valves, also precludes IVT. In this scenario, endovascular treatment is an important option for the management of acute ischemic stroke.
A total of 45 patients with acute ischemic stroke underwent endovascular treatment during the study period. The mean age of the patients was 49 ± 14 years. Thirty‑two of the patients were male, 13 were females. The median NIHSS was 19. Of the 45 patients, 23 had middle cerebral artery occlusions, 14 had internal carotid artery occlusions, and in 8, the basilar artery was involved. In one patient, access was an issue while in another patient; angioplasty was attempted but was unsuccessful. Of the remaining 43 patients, 33 were treated using the Solitaire™ device, either alone or in combination with other modalities. Seven patients underwent stenting during the procedures, either for obtaining access or for significant residual narrowing.
The PROACT trial,[2] which evaluated the efficacy of intra‑arterial pro‑urokinase in the management of acute ischemic stroke, reported superior recanalization with pro‑urokinase compared to placebo. The SWIFT trial,[5] which compared the Solitaire flow restoration device to the MERCI device, and the TREVO 2 trial,[10] which compared the TREVO device with the MERCI device, concluded that these new generation devices achieved better recanalisation rates and clinical outcomes as compared to the MERCI device. We present our data from a tertiary care center in a major metropolis in India where, between April 2010 and December 2013, 45 patients were treated using endovascular treatment.
Materials and Methods A database is maintained at our center for all patients undergoing endovascular procedures. The data was reviewed retrospectively from 2010 till date. All patients who underwent endovascular treatment were included. The patients were evaluated with either a computed tomography (CT) brain with CT angiogram of neck and intracranial vessels or a magnetic resonance imaging (MRI) with magnetic resonance (MR) time of flight angiogram of neck and intracranial vessels to rule out bleed, quantify infarct size, and document vessel status. Blood tests such as complete blood count, kidney function test, liver function test, and coagulation profile were also done pre‑procedure. Parameters analyzed included age of patients, National Institutes of Health Stroke Scale (NIHSS) on admission, territory of infarct, pre‑ and post‑procedure Thrombolysis Neurology India | May-Jun 2014 | Vol 62 | Issue 3
SPSS version 17.0 software was used to analyze the data.
Results
Two patients had pre‑procedure TIMI scores of 1 on digital subtraction angiogram (DSA), TIMI score for the rest was 0. The median pre‑procedure TIMI score was 0 while the median post‑procedure TIMI score was 3. A total of 32 (71%) patients had a post‑procedure TIMI score of 3, 2 (4%) had a score of 2, 8 had a score of 1 (18%), and 3 had a score of 0 (7%). Access could not be obtained in one patient while in another, angioplasty was attempted but failed. In the post‑operative period, 9 (20%) of the patients underwent decompressive craniectomy. One patient had extravasation of contrast after angioplasty of intradural vertebral artery for residual narrowing. There were three patients who developed intracranial hemorrhage of whom two were symptomatic. Eight patients died in all. At 90‑day follow‑up, 29 (64%) patients had good outcome (mRS 0-2) while 16 patients had poor outcome (mRS 3-6). 23 (51%) patients had complete functional recovery (mRS 0). Eight (18%) patients died. The results are summarized in Table 1.
Discussion Out of 45 patients, 64% achieved mRS of 2 or less while 51% achieved complete functional independence (mRS 0) at 277
Huded, et al.: Indian experience of endovascular treatment of acute ischemic stroke
Table 1: Summary of outcomes Total number (n) Mean age Male: Female Mean time to presentation Median NIHSS on admission Territory of stroke (%)
45 49 years 32:13 227 minutes 19 MCA-23 (51) ICA-14 (31) Basilar artery-8 (18) 3 32 (71%) 1 2 9 (20%) 29 (64%) 23 (51%) 8 (18%) 7
Median post procedure TIMI score TIMI score >2 Intra‑procedure complications Symptomatic ICH Post procedure decompressive craniotomy mRS 2 or less at 90 days mRS 0 at 90‑day follow‑up 90‑day mortality Stenting done during procedure
NIHSS - National institutes of health stroke scale, TIMI - Thrombolysis in myocardial infarction, ICH - international conference on harmonizationm, MCA - Middle cerebral artery, ICA - Internal carotid artery, mRS - Modified rankin scale
Table 2: Comparison of the present study with other studies
This PROACT[2] MERCI[3] Multi SWIFT[5] TREVO[6] study MERCI[4] No Mean age Median NIHSS Vessel (%) MCA ICA BA ICA‑T VA TIMI>2 90 day MRS
Endovascular treatment of acute ischemic stroke: An Indian experience from a tertiary care center Vikram Huded, Rithesh R. Nair, Romnesh de Souza1, Devashish D.Vyas1 Division of Interventional Neurology and Stroke, 1Department of Neurology, Narayana Institute of Neurosciences, Bangalore, Karnataka, India
Abstract
Address for correspondence: Dr. Vikram Huded, Division of Interventional Neurology and Stroke, Narayana Institute of Neurosciences, 258/A, Bommasandra Industrial Area, Hosur Main Road, Bangalore ‑ 560 099, Karnataka, India. E‑mail: [email protected] Received : 04‑03‑2014 Review completed : 15‑04‑2014 Accepted : 03‑06‑2014
Background: In India, late presentation due to poor awareness about stroke precludes intravenous thrombolysis (IVT). Endovascular therapy can be used in these circumstances. We present our experience of endovascular treatment of acute ischemic stroke in a tertiary care center. Aim: Endovascular treatment of acute ischemic stroke in a tertiary care center in India. Settings, Design, Materials, and Methods: The study period was from 2009 till 2013. Consecutive patients with acute ischemic stroke, who either had contraindications to IVT or had failed IVT, underwent endovascular treatment. Before the publication of interventional management of stroke 3 results, we took a few patients, with large vessel occlusions, directly for endovascular treatment. After imaging, patients were considered for endovascular treatment, using either intra‑arterial thrombolysis or mechanical thrombectomy, if there was a documented large vessel occlusion. Outcome was assessed at 3 months using the modified Rankin Scale. Statistical Analysis: Statistical analysis was done using the Statistical Package for the Social Sciences 17.0 software. Results: A total of 45 patients underwent endovascular treatment. The mean age at presentation was 49 years, median National Institutes of Health Stroke Scale (NIHSS) was 19 and the most common site was the middle cerebral artery (23 patients). Solitaire™ stentriever was used in 33 patients. The median pre‑procedure Thrombolysis In Myocardial Infarction (TIMI) score was 0 and the median post‑procedure TIMI score was 3. Nine patients underwent decompressive craniectomy. On follow‑up at 3 months, the median Modified Rankin Scale (mRS) was 0. Eight patients died during 3 months following stroke. Conclusion: Endovascular treatment of acute ischemic stroke is a viable treatment option in patients who either have contraindications to IVT or who fail IVT. Key words: Endovascular, ischemic, solitaire, stentriever, stroke
non‑commnicable diseases are due to stroke. Stroke is responsible for 72% of disability adjusted life years.[1]
Introduction In India, it is estimated that 41% of all deaths due to Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.136919
276
The Prolyse in Acute Cerebral Thromboembolism (PROACT),[2] Mechanical Embolus Removal in Cerebral Ischemia (MERCI)[3], Multi MERCI,[4] Solitaire™ With the Intention for Thrombectomy (SWIFT)[5] and Thrombectomy REvascularization of large Vessel Occlusions (TREVO)[6] in acute ischemic stroke trials showed that the use of endovascular treatment in acute ischemic stroke is beneficial in patients with documented large vessel disease. However, trials such as the Interventional Management of Neurology India | May-Jun 2014 | Vol 62 | Issue 3
Huded, et al.: Indian experience of endovascular treatment of acute ischemic stroke
Stroke 3 (IMS3)[7] trial, Local versus Systemic Thrombolysis for Acute Ischemic Stroke (SYNTHESIS Expansion).[8] trial and Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE)[9] did not show superiority of endovascular treatment over intravenous thombolysis (IVT) during the window period. Current guidelines indicate that endovascular treatment in acute ischemic should be reserved for those patients where there are contraindications for intravenous thrombolysis and in those who fail IVT.
In Myocardial Infarction (TIMI) score, incidence of post procedure complications and 3‑month follow‑up using the Modified Rankin Scale (mRS). Written informed consent of patient’s relatives was obtained prior to the procedure. Data was compared to other similar studies.
In India, the knowledge about stroke symptoms as well as intravenous thrombolysis for stroke is poor, resulting in fewer patients presenting to a tertiary care centre within the window period for IVT. Ongoing anticoagulation in patients with rheumatic heart disease, either for atrial fibrillation or prosthetic heart valves, also precludes IVT. In this scenario, endovascular treatment is an important option for the management of acute ischemic stroke.
A total of 45 patients with acute ischemic stroke underwent endovascular treatment during the study period. The mean age of the patients was 49 ± 14 years. Thirty‑two of the patients were male, 13 were females. The median NIHSS was 19. Of the 45 patients, 23 had middle cerebral artery occlusions, 14 had internal carotid artery occlusions, and in 8, the basilar artery was involved. In one patient, access was an issue while in another patient; angioplasty was attempted but was unsuccessful. Of the remaining 43 patients, 33 were treated using the Solitaire™ device, either alone or in combination with other modalities. Seven patients underwent stenting during the procedures, either for obtaining access or for significant residual narrowing.
The PROACT trial,[2] which evaluated the efficacy of intra‑arterial pro‑urokinase in the management of acute ischemic stroke, reported superior recanalization with pro‑urokinase compared to placebo. The SWIFT trial,[5] which compared the Solitaire flow restoration device to the MERCI device, and the TREVO 2 trial,[10] which compared the TREVO device with the MERCI device, concluded that these new generation devices achieved better recanalisation rates and clinical outcomes as compared to the MERCI device. We present our data from a tertiary care center in a major metropolis in India where, between April 2010 and December 2013, 45 patients were treated using endovascular treatment.
Materials and Methods A database is maintained at our center for all patients undergoing endovascular procedures. The data was reviewed retrospectively from 2010 till date. All patients who underwent endovascular treatment were included. The patients were evaluated with either a computed tomography (CT) brain with CT angiogram of neck and intracranial vessels or a magnetic resonance imaging (MRI) with magnetic resonance (MR) time of flight angiogram of neck and intracranial vessels to rule out bleed, quantify infarct size, and document vessel status. Blood tests such as complete blood count, kidney function test, liver function test, and coagulation profile were also done pre‑procedure. Parameters analyzed included age of patients, National Institutes of Health Stroke Scale (NIHSS) on admission, territory of infarct, pre‑ and post‑procedure Thrombolysis Neurology India | May-Jun 2014 | Vol 62 | Issue 3
SPSS version 17.0 software was used to analyze the data.
Results
Two patients had pre‑procedure TIMI scores of 1 on digital subtraction angiogram (DSA), TIMI score for the rest was 0. The median pre‑procedure TIMI score was 0 while the median post‑procedure TIMI score was 3. A total of 32 (71%) patients had a post‑procedure TIMI score of 3, 2 (4%) had a score of 2, 8 had a score of 1 (18%), and 3 had a score of 0 (7%). Access could not be obtained in one patient while in another, angioplasty was attempted but failed. In the post‑operative period, 9 (20%) of the patients underwent decompressive craniectomy. One patient had extravasation of contrast after angioplasty of intradural vertebral artery for residual narrowing. There were three patients who developed intracranial hemorrhage of whom two were symptomatic. Eight patients died in all. At 90‑day follow‑up, 29 (64%) patients had good outcome (mRS 0-2) while 16 patients had poor outcome (mRS 3-6). 23 (51%) patients had complete functional recovery (mRS 0). Eight (18%) patients died. The results are summarized in Table 1.
Discussion Out of 45 patients, 64% achieved mRS of 2 or less while 51% achieved complete functional independence (mRS 0) at 277
Huded, et al.: Indian experience of endovascular treatment of acute ischemic stroke
Table 1: Summary of outcomes Total number (n) Mean age Male: Female Mean time to presentation Median NIHSS on admission Territory of stroke (%)
45 49 years 32:13 227 minutes 19 MCA-23 (51) ICA-14 (31) Basilar artery-8 (18) 3 32 (71%) 1 2 9 (20%) 29 (64%) 23 (51%) 8 (18%) 7
Median post procedure TIMI score TIMI score >2 Intra‑procedure complications Symptomatic ICH Post procedure decompressive craniotomy mRS 2 or less at 90 days mRS 0 at 90‑day follow‑up 90‑day mortality Stenting done during procedure
NIHSS - National institutes of health stroke scale, TIMI - Thrombolysis in myocardial infarction, ICH - international conference on harmonizationm, MCA - Middle cerebral artery, ICA - Internal carotid artery, mRS - Modified rankin scale
Table 2: Comparison of the present study with other studies
This PROACT[2] MERCI[3] Multi SWIFT[5] TREVO[6] study MERCI[4] No Mean age Median NIHSS Vessel (%) MCA ICA BA ICA‑T VA TIMI>2 90 day MRS
