Brain Ischemic Stroke - From Diagnosis to Treatment

Book Series: Frontiers in Neurosurgery

Volume 3

by

Simone Peschillo

DOI: 10.2174/97816810830941160301
eISBN: 978-1-68108-309-4, 2016
ISBN: 978-1-68108-310-0
ISSN: 2405-7401 (Print)
ISSN: 2405-741X (Online)



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Stroke is thought to be the second biggest killer worldwide, and is responsible for over 5 million deaths per year. Several strategies...[view complete introduction]

Table of Contents

Foreword

- Pp. i-iv (4)

Jaques Théron

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Preface

- Pp. v-vi (2)

Simone Peschillo

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List of Contributors

- Pp. vii-viii (2)

Simone Peschillo

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Epidemiology and Social Costs

- Pp. 3-22 (20)

Simone Peschillo and Francesco Diana

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Brain Ischemia and Stroke: Mechanisms and Opportunities

- Pp. 23-54 (32)

Francesco Orzi and Barbara Casolla

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New Imaging Techniques

- Pp. 55-94 (40)

Elena Fontana, Alessandro Boellis, Lara Cristiano and Alessandro Bozzao

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Medical Acute Stroke Treatment

- Pp. 95-121 (27)

Paolo Candelaresi and Alfonso Ciccone

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Endovascular Stroke Therapy: Devices and Different Approaches

- Pp. 122-151 (30)

Daniele G. Romano, Samuele Cioni and Sandra Bracco

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Mechanical Thrombectomy for Acute Ischemic Stroke: Review of the Evidence

- Pp. 152-169 (18)

Italo Linfante

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Neurosurgery in Brain Ischemic Stroke

- Pp. 170-184 (15)

Paolo Missori and Cristina Mancarella

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Clinical, Pharmacological and Endovascular Management of Cerebral Venous Thrombosis

- Pp. 185-214 (30)

Federico Di Maria, Flore Baronnet-Chauvet, Charlotte Rosso and Frederic Clarençon

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Intracranial Stenosis: Medical and Endovascular Management

- Pp. 215-236 (22)

Alessandro Stecco and Paolo Machì

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Uncommon Cause of Stroke: Diagnosis and Treatment (Part I)

- Pp. 237-375 (139)

Paolo Cerrato, Alessandro Pezzini and Giovanna Vaula

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Uncommon Cause of Stroke: Diagnosis and Treatment (Part II)

- Pp. 376-473 (98)

Paolo Cerrato, Alessandro Pezzini and Giovanna Vaula

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Endovascular Management of Atherosclerotic and Dissected Carotids

- Pp. 474-497 (24)

Guglielmo Pero and Themistoklis Papasilekas

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Intensive Care Management

- Pp. 498-510 (13)

Federico Bilotta, Martina Novelli, Filippo Pecorari and Giovanni Rosa

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The Trials and Tribulations of Ischemic Stroke Therapy

- Pp. 511-528 (18)

Arani Bose, Sophia S. Kuo, Jennifer Wong, John Lockhart and Siu Po Sit

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Evolution of Devices for Endovascular Thrombectomy in Acute Ischemic Stroke: From the Beginning to the Adapt Technique

- Pp. 529-545 (17)

Simone Peschillo and Francesco Diana

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Subject Index

- Pp. 546-561 (16)

Simone Peschillo

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Foreword

I read with a lot of interest the book by Simone Peschillo and his collaborators. This book presents the current knowledge on cerebral ischaemia and its treatment. It will be for sure very useful for all those who are interested on this topic.

It starts by the very concerning epidemiological and economic aspect of the disease and then it presents all the main themes of the subject. It will be a reference book that aims to be complete and it does not only present the therapeutic endo vascular techniques but also, and it is fundamental, all the medical environment and intensive care techniques which are essential.

We can only admire the progresses made, even in the diagnosctic plan. I personnally began to practise neuroradiology 45 years ago … It was the time when the diagnosis of an intracerebral hemorrhage could only be made if this bleeding was voluminous enough to displace the adjacent arteries angiography ...

I had the privilege in 1971 of attending the first french private presentation on CT by Ambrose who showed unrefined images made of black and white spots. It was a revolution : we were able to see directly, for the first time, the image of intracerebral blood. Nowadays, despite of MRI, CT remains a fundamental tool of decision in the field of cerebral ischaemia because it is fast and easily accessible.

In the 70s, there were few interventional neuroradiologists and they were more interested in angiomas and tumors than in cerebral ischaemia. I was personnally rapidly interested in this topic and the 80s were very important for me. In 1980 I began using angioplasty to treat major supra aortic arteries, then in 1983, after Mathias [1] I started simple angioplasty in carotid arteries [2]. I described in 1984 the concept of cerebral protection [3]. After Zeumer [4], I also in 1985 performed our first cases of intra arterial thrombolysis [5]. In 1990 I dared to put in place the first carotid stent [6] and then developed this technique [7, 8]. It activated some turbulences in the vascular surgery environment…

I am now delighted that this tool has become a classic in the treatment of carotid stenoses. Nevertheless let me summarize what I keep thinking on this matter:

At the opposite of the other arteries, post stenting restenoses are quite rare in carotid artery because of its high flow. Long closed stents remain for us the best choice because they treat the whole pathological area and correct partially the artery tortuosity.

The only real difficulty that remains is its approach on atheromatous patients. This is why we described the radial approach [9].

I keep thinking that a cerebral protection is mandatory and that the only real protection is the temporary occlusion of the distal internal catotid artery [10]. Filters offer a protection only for big emboli and are themselves reponsible of emboli. The temporary occlusion of the common carotid artery with simultaneous occlusion of the external carotid artery, that we also have described and later abandoned, seems to be reserved for the treatment of complete occlusions of the internal carotid.

Post revascularisation hemorrhage occurs in most cases on brains with previous silent infarctions. Its occurence is clearly limited by the control of blood pressure. Actually it can also be a delayed embolic hemorrhagic complication.

The book presents a very detailed chapter on non atheromatous arterial lesions. It is a very interesting topic that covers several diseases. We have been early interested in the disease of Takayasu when we worked in Canada [ 11 ] and we performed endovascular treatments on similar cases. More studies will be necessary in the future to adopt a common therapeutic strategy because the reaction to endovascular techniques can be quite different from one disease to the other.

In acute brain ischaemia I have to say my enthusiasm by seeing strengthening in the idea that a cerebrovascular accident is not any more a fate and that it exist therapeutic tools to treat it. After intravenous and intra arterial thrombolysis, mecanichal revascularisation technics are now available and are more and more sofisticated and effective. This book presents the various current possibilities. The time will tell us which ones are the best for each case. What is sure is that the number of necessary intervetionists will grow dramatically in the future. I am delighted at it for the whole world population.

However I would like to add about this topic some personal ideas that have meant a lot to me for years: we know that it is necessary to save time and CT remains the basic emergency investigation which allows make the diagnosis of intracerebral bleeding. We dreamt of CTs in a light truck and we spoke of it for many years. It does exist presently. If we deal with an ischemic case it will allow start immediately the intravenous thrombolysis. Many lives will be saved and many brains will be less damaged.

Arrived at the hospital, unless a complete clearance of the symptoms has be obtained, the patient will have an angiography. The good therapeutic decision will only be taken if the exact state of the cerebral vascularization is known. The cerebral parenchymography [12] remains for me the simplest and most adapted investigation. One single injection of contrast in the aortic arch is sufficient for confirming the arterial occlusion, its site and the exact devascularisation downstream to the occlusion. Anatomical variations are infinite and so are the individual possibilities of revascularisation. Vascularization of the cerebral parenchyma is the only true key point to be known

In the decision of treating, occlusion of lenticulostriate arteries is for me a fundamental point. These arteries are terminal and their wall is very sensitive to ischaemia. It has been shown by Kamyjio on cat that their revasculaization after the 6er hour resulted in high purcentage of bleeding [13]. We have confirmed it [14] in showing that it was possible to eliminate post revascularization hemorrhage : intra arterial thrombolysis should not be performed on a patient after the 6th hour when the lenticulostriate arteries are occluded . On the other hand the therapeutic window can be widened if these arteries are not interested. This way of reasoning is obviously applicable also for the mechanical revascularisation.

Not using these information made that the possible therapeutic window was reduced in order to limitate the hemorrhagic complications. We are convinced that these simple rules should be used by all, day and at night, and that they could save numerous lives and handicaps.

Jaques Théron
Department of Endovascular and Percutaneous Therapy
Hospital Nuestra Señora del Rosario
Madrid
Spain

References

[1] Mathias K. Perkutane tansluminale katheterbehandlung supraaortler arterienobstruktion. Angiology 1981; 3: 47-50.

[2] Théron J, Raymond J, Casasco A, Courtheoux P. Percutaneous angioplasty of atherosclerotic and postsurgical stenosis of carotid arteries. AJNR 1987; 8: 495-500.
[PMID: 2955682]

[3] Théron J, Courtheoux P, Alachkar F, Maiza D. New triple coaxial catheter system for carotid angioplasty with cerebral protection. AJNR 01990; 11: 869-74.
[PMID: 2145730]

[4] Zeumer H, Hackle W, Ringelstein EB. Local intraarterial thrombolysis in vertebrobasilar thromboembolic disease. AJNR 1083; 4: 401-4.

[5] Théron J, Courtheoux P, Casasco A, et al. The carotid territory. AJNR 1989; 10: 753-65.
[PMID: 2505504]

[6] Théron J, Guimaraens L, Casasco A, et al. Angioplasty of brachiocephalic vessels. In: Vinuela V, Halbach VV, Dion JE, eds. Interventional neuroradiology: endovascular therapy of the central nervous system. 1992. p. New YorkRaven Press

[7] Théron J, Payelle G, Coskun O, Huet H, Guymararens L. Carotid artery stenosis: treatment with protected balloon an-gioplasty and stent placement Radiology 1996; 201(3): 627-36.
[PMID: 8939208]

[8] Théron J, Guimaraens L, Casasco A, et al. “Protected” wallstenting of atheromatous stenoses at the ca-rotid bifurcation. Interventional Neuroradiol 2003; 9: 99-126.

[9] Théron J, Guimaraens L, Casasco A, et al. The treatment of supraaortic arterial lesions. Interventional Neuroradiol 2007; 13: 133-44.

[10] Théron J, Reul J, Venturi C, Bedogni F, Milosevic Z. Immediate and mid-term clinical outcome of patients treated with the TwinOne® cerebral protection system - multicen-tric trial : 209 Cases. Cardiovasc Interventional Radiol 2009.

[11] Theron J, Tyler JL. Takayasu’s arteritis of the aortic arch: endovascular treatment and correlation with positron emission tomography. AJNR 1987; 8: 621-6.

[12] Theron J, De Oliveira D, Alachkar F, Maiza D. Dynamic digitalized parenchymography. Neuroradiology 1992; 34: 361-4.

[13] Kamijyo Y, Garcia JH, Cooper J. The cat. A model of hemorragic and subcortical infarction. J Neuropathol Exp Neurol 1977; 36: 338-50.
[PMID: 839241]

[14] Théron J, Coskun O, Huet H, Oliveira G, Toulas P, Payelle P. The carotid territory. Interventional Neuroradiology 1996; 2(2): 111-26.
[PMID: 20682124]


Preface

Brain Ischemic Stroke - From Diagnosis to Treatment

Someone suffers a stroke every 40 seconds in the USA; every year over 15 million people throughout the world suffer a stroke and 5 million are left significantly disabled. Stroke is thought to be the second biggest killer worldwide, and is responsible for over 5 million deaths per year.

The total economic burden of stroke is of the order of £7bilion per annum in England and Wales.

Even though many efforts to treat as much as possible stroke patients have been made, many of it are still left undertreated, mainly due to the short time window and other contraindications for intravenous (i.v.) rtPA. Furthermore, much more evidence demonstrates that endovascular treatment, in selected patients, is much more resolutive.

Various strategies have been developed to increase the number of treated patients: regarding the diagnosis, new neuroimaging tools allows neurologists and neurointerventionists to evaluate either the ischemic core and the vessel pattern and collateral status; regarding medical treatment, new molecules are being tested in RCTs (randomized clinical trials) with extended time windows.

In this context, endovascular treatment is a new technique that allows neurointerventionists to treat patients in whom intravenous rtPA has failed and those in extended time windows, in particular in large-vessels occlusion.

Regarding this novel approach, a new era has emerged with new devices (i.e. stent-retrievers and aspiration techniques), which have demonstrated in recently published RCTs higher rates of recanalization and clear superiority compared to previous devices.

Several ongoing RCTs are now investigating whether bridging therapy is more effective than i.v. treatment alone, whether mechanical thrombectomy is more successful than the best medical treatment in patients ineligible for i.v. thrombolysis and which kind of endovascular treatment is much effective.

The purpose of this eBook is to take stock of the latest news on the ischemic stroke treatment.

In 2020, mortality will be doubled due to this serious disease; everyone, health care assistants, social assistants and politicians as well, should be first in line to fight this battle.

This eBook is addressed not only to specialists in the treatment of patients with ischemic stroke, but also nurses, physiotherapists and finally non-medical personnel whose task is to decide on health care.

Simone Peschillo
Department of Neurology and Psychiatry
Endovascular Neurosurgery/Interventional Neuroradiology
‘Sapienza’ University of Rome
Rome
Italy

List of Contributors

Editor(s):
Simone Peschillo
Department of Neurology and Psychiatry
Endovascular Neurosurgery/Interventional Neuroradiology
‘Sapienza’ University of Rome
Rome
Italy




Contributor(s):
A. Allocca
Policlinico Umberto I°
“Sapienza” University of Rome
Rome
Italy


A. Ciccone
Department of Neurosciences
Carlo Poma Hospital
Mantua
Italy


A. Santodirocco
Department of Neurology and Psychiatry, Interventional Neuroradiology
“Sapienza” University of Rome
Rome
Italy


Alessandro Boellis
NESMOS Department
University of Rome “Sapienza”. S. Andrea Hospital
Rome
Italy


Alessandro Bozzao
NESMOS Department
University of Rome “Sapienza”. S. Andrea Hospital
Rome
Italy


Alessandro Pezzini
Department of Clinical Science
Neurological Clinical Brescia University
Italy


Arani Bose
Penumbra Inc.
Alameda
California
USA


Barbara Casolla
Department of Neurosciences
Mental Health and Sensory Organs, University of Rome “La Sapienza”
Rome
Italy


C. Rosso
APHP, Urgences Cérébro-Vasculaires
Groupe Hospitalier Pitié-Salpêtrière, 75013
Paris
France
/
Facultéde Médecine
UniversitéParis 6 “Pierre et Marie Curie” (UPMC)
75005 Paris
France


Cristina Mancarella
Department of Neurology and Psychiatry, Neurosurgery, Policlinico Umberto I
“Sapienza” University of Rome
Rome
Italy


Elena Fontana
NESMOS Department
University of Rome “Sapienza”. S. Andrea Hospital
Rome
Italy


F. Diana
Department of Radiology
“Sapienza” University of Rome
Rome
Italy


F. Di Maria
APHP, Service de Neuroradiologie Interventionnelle Groupe Hospitalier Pitié
Salpêtrière, 75013
Paris
France


F. Baronnet-Chauvet
APHP, Urgences Cérébro-Vasculaires
Groupe Hospitalier Pitié-Salpêtrière, 75013
Paris
France


F. Clarençon
APHP, Service de Neuroradiologie Interventionnelle Groupe Hospitalier Pitié
Salpêtrière, 75013
Paris
France
/
APHP, Urgences Cérébro-Vasculaires
Groupe Hospitalier Pitié-Salpêtrière, 75013
Paris
France


Francesco Orzi
Department of Neurosciences
Mental Health and Sensory Organs, University of Rome “La Sapienza”
Rome
Italy


Federico Bilotta
Department of Anestehsiology, Critical care and Pain medicine
“Sapienza” University of Rome
Rome
Italy


Filippo Pecorari
Department of Anestehsiology, Critical care and Pain medicine
“Sapienza” University of Rome
Rome
Italy


Francesco Diana
CHRU Montpellier, Service de Neuroradiologie
Hopital Gui de Chauliac, 80 Avenue Augustin Fliche
34295 Montpellier Cedex 5
France


Giovanna Vaula
Stroke Unit, Department of Neuroscience
Turin University Molinette Hospital
Turin
Italy


Guglielmo Pero
Department of Neuroradiology
Niguarda Ca’ Granda Hospital
Milan
Italy


Giovanni Rosa
Department of Anestehsiology, Critical care and Pain medicine
“Sapienza” University of Rome
Rome
Italy


Italo Linfante
Miami Cardiac and Vascular Institute and Neuroscience Center Baptist Hospital
Miami
FL
USA


Jennifer Wong
Penumbra Inc.
Alameda
California
USA


John Lockhart
Penumbra Inc.
Alameda
California
USA


Lara Cristiano
NESMOS Department
University of Rome “Sapienza”. S. Andrea Hospital
Rome
Italy


Machì Paolo
CHRU Montpellier, Service de Neuroradiologie
Hopital Gui de Chauliac, 80 Avenue Augustin Fliche
34295 Montpellier Cedex 5
France


Martina Novelli
Department of Anestehsiology, Critical care and Pain medicine
“Sapienza” University of Rome
Rome
Italy


P. Candelaresi
Department of Emergency Medicine
San Carlo Borromeo Hospital
Milan
Ìtaly


Paolo Cerrato
Stroke Unit, Department of Neuroscience
Turin University Molinette Hospital
Turin
Italy


Paolo Missori
Department of Neurology and Psychiatry, Neurosurgery, Policlinico Umberto I
“Sapienza” University of Rome
Rome
Italy


S. Peschillo
Department of Neurology and Psychiatry, Endovascular Neurosurgery/Interventional Neuroradiology
“Sapienza” University of Rome
Rome
Italy


Samuele Cioni
Unit of Neurointerventional, Division of Neuroradiology, Department of Neurological and Neurosensorial Sciences
University Hospital of Siena
Siena
Italy


Sandra Bracco
Unit of Neurointerventional, Division of Neuroradiology, Department of Neurological and Neurosensorial Sciences
University Hospital of Siena
Siena
Italy


Stecco Alessandro
Neuroradiology Unit, Radiology Dept
Novara Maggiore Hospital
Italy


Siu Po Sit
Penumbra Inc.
Alameda
California
USA


Sophia S. Kuo
Penumbra Inc.
Alameda
California
USA


Simone Peschillo
Neuroradiology Unit, Radiology Dept
Novara Maggiore Hospital
Italy


Themistoklis Papasilekas
Department of Neuroradiology
Niguarda Ca’ Granda Hospital
Milan
Italy




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