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ORIGINAL ARTICLE
Year : 2014  |  Volume : 62  |  Issue : 3  |  Page : 276-279

Endovascular treatment of acute ischemic stroke: An Indian experience from a tertiary care center


1 Division of Interventional Neurology and Stroke, Narayana Institute of Neurosciences, Bangalore, Karnataka, India
2 Department of Neurology, Narayana Institute of Neurosciences, Bangalore, Karnataka, India

Date of Submission04-Mar-2014
Date of Decision15-Apr-2014
Date of Acceptance03-Jun-2014
Date of Web Publication18-Jul-2014

Correspondence Address:
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
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.136919

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 » Abstract 

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.


Keywords: Endovascular, ischemic, solitaire, stentriever, stroke


How to cite this article:
Huded V, Nair RR, de Souza R, DVyas D. Endovascular treatment of acute ischemic stroke: An Indian experience from a tertiary care center. Neurol India 2014;62:276-9

How to cite this URL:
Huded V, Nair RR, de Souza R, DVyas D. Endovascular treatment of acute ischemic stroke: An Indian experience from a tertiary care center. Neurol India [serial online] 2014 [cited 2019 Aug 19];62:276-9. Available from: http://www.neurologyindia.com/text.asp?2014/62/3/276/136919



 » Introduction Top


In India, it is estimated that 41% of all deaths due to non-commnicable diseases are due to stroke. Stroke is responsible for 72% of disability adjusted life years. [1]

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 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 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.

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 Top


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 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.

SPSS version 17.0 software was used to analyze the data.


 » Results Top


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.

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].
Table 1: Summary of outcomes

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 » Discussion Top


Out of 45 patients, 64% achieved mRS of 2 or less while 51% achieved complete functional independence (mRS 0) at 3-month follow-up. The median NIHSS score at admission was 18, indicating that the stroke was severe and that these patients were likely to have a severe residual neurological deficit.

There was only one intra-procedure complication, showing that endovascular procedures are safe when done by experienced operators. Decompressive craniectomy was done in 9 (20%) of the patients, out of which only one was for symptomatic intracranial hemorrhage, the rest were for edema, either due to large stroke or reperfusion.

Our recanalization rates and mortality rates are comparable to other studies [Table 2] while the proportion of good outcome is better than those studies. We agree that our patients on an average are younger than those reported in other studies. We are currently investigating this phenomenon.
Table 2: Comparison of the present study with other studies

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In our study, we found that the outcome at 3 months with endovascular treatment is better for patients who presented within 5 hours from onset of stroke symptoms, as seen in [Figure 1].
Figure 1: Outcomes based on time from onset

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 » Conclusion Top


We conclude that endovascular treatment is a viable option in appropriately selected patients. In patients who present outside the window period for IVT or contraindication for IVT or failed IVT, imaging evidence of large vessel occlusion will help in determining patients who will benefit from endovascular treatment. Further trials are required to determine the efficacy of endovascular treatment using newer devices in patients with acute ischemic stroke.

 
 » References Top

1.Biswas T. India unveils plans to improve stroke research and care. Lancet 2013;381:190.  Back to cited text no. 1
    
2.del Zoppo GJ, Higashida RT, Furlan AJ, Pessin MS, Rowley HA, Gent M. PROACT: A phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. PROACT Investigators. Prolyse in Acute Cerebral Thromboembolism. Stroke 1998;29:4-11.  Back to cited text no. 2
    
3.Smith WS, Sung G, Starkman S, Saver JL, Kidwell CS, Gobin YP, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: Results of the MERCI trial. Stroke 2005;36:1432-8.  Back to cited text no. 3
    
4.Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS, et al. Multi MERCI Investigators. Mechanical thrombectomy for acute ischemic stroke: Final results of the Multi MERCI trial. Stroke 2008;39:1205-12.  Back to cited text no. 4
    
5.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;380:1241-9.  Back to cited text no. 5
    
6.Jansen O, Macho JM, Killer-Oberpfalzer M, Liebeskind D, Wahlgren N; TREVO Study Group. Neurothrombectomy for the treatment of acute ischemic stroke: Results from the TREVO study. Cerebrovasc Dis 2013;36:218-25.  Back to cited text no. 6
    
7.Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Interventional Management of Stroke (IMS) III Investigators. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013;368:893-903.  Back to cited text no. 7
    
8.Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, et al. SYNTHESIS Expansion Investigators. Endovascular treatment for acute ischemic stroke. N Engl J Med 2013;368:904-13.  Back to cited text no. 8
    
9.Kidwell CS, Jahan R, Gornbein J, Alger JR, Nenov V, Ajani Z, et al. MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013;368:914-23.  Back to cited text no. 9
    
10.Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): A randomised trial. Lancet 2012;380:1231-40.  Back to cited text no. 10
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]

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2 Endovascular treatment of acute ischemic stroke: Not yet a panacea for all troubles
R Rajan,D Khurana
Neurology India. 2014; 62(4): 468
[Pubmed] | [DOI]



 

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