Search

In patients over 80 years old, 4 of the 5 evidence-based acute treatments of ischemic stroke, i.e. stroke unit treatment, antiplatelet therapy, intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are effective but with a higher morbidity than in younger patients. The indications for the more invasive forms of treatment, such as IVT and MT are given in principle but have to be oriented to the individual patient comorbidities. In the case of failure of these procedures a consistent therapeutic target change to palliative measures is appropriate. Decompressive craniotomy in space-occupying media infarction can be indicated up to the relative age limit of 60 years and absolute age limit of 70 years. Patients over 80 years often do not undergo IVT or MT. Although the German approval for alteplase within the framework of IVT over the age of 80 years suggests a careful and critical review of the indications, its use is generally recommended.

Early recanalization of the closed cerebral arteries after acute ischemic stroke (AIS) is the only treatment to minimize long-term disability and to reduce the associated morbidity and mortality. For a long time the only proven causal treatment of AIS was intravenous thrombolysis; however, after the publication of a series of randomized prospective studies concerning endovascular mechanical thrombectomy using stent retriever systems after AIS, new guidelines were published. It was found that endovascular treatment (EVT) dramatically improves the outcome of eligible patients. The stent retriever enables high recanalization rates by clot removal from the cerebral arterial system by means of aspiration of the thrombus via the catheter and/or by entrapping it with a stent system. The management of anesthesia during the procedure is indispensable to prevent hypoxia and hemodynamic instability; however, which form of anesthesia (i.e. general anesthesia vs. conscious sedation) is advantageous for the patient during EVT is controversially discussed. In the first studies using retrospective data conscious sedation resulted in a better outcome compared to general anesthesia following EVT; however, in prospective studies this finding could not be confirmed. To obtain optimal neurological results after AIS and EVT with general anesthesia, it is of tremendous importance not to delay the EVT due to the anesthesiology procedure. Furthermore, hypotension, hypovolemia and hypocapnia should also be strictly avoided. Finally, the optimal anesthesiological approach should be guided by the current clinical state and pre-existing comorbidities of the patient.

Recent non-cirrhotic and non-malignant splanchnic vein thrombosis is now defined as extrahepatic portal vein thrombosis with or without involvement of the mesenteric vein according to the Baveno VI consensus from 2015. An early diagnosis is often challenging due to unspecific symptoms with abdominal pain or diarrhea but extremely important because of the potential acute and chronic complications, such as mesenteric ischemia and portal hypertension; therefore, rapid treatment is crucial. We present two cases of severe splanchnic vein thrombosis, which were treated with catheter-directed local thrombolysis and thrombus aspiration. These minimally invasive catheter-directed techniques have recently been successfully used in selected patients. A review of the literature is provided in this article. In summary, the management of splanchnic vein thrombosis must be individually planned for each patient and should be performed at experienced centers, which can provide all therapeutic options. In selected cases with the correct indications transjugular transhepatic catheter-directed local thrombolysis is a safe option with a good outcome.

How can the overwhelmingly positive results of the five randomized thrombectomy trials published in 2015 be transferred to the clinical routine?Analysis of trial-specific characteristics with regard to implementation of mechanical thrombectomy into clinical routine.Stroke patients with symptomatic proximal artery occlusion are principally eligible for mechanical thrombectomy; however, the stroke patients included in the thrombectomy trials are not representative of all stroke patients. They were carefully selected according to clinical and imaging criteria as well as to the time window from symptom onset. Furthermore, they were treated in highly selected specialized stroke centers. Analysis of the five trials and the Catalan population-based SONIIA registry revealed that the observed number needed to treat (NNT) of 5 to reach a modified Rankin scale (mRS) score of 0-2 only applies to approximately 1 % of all stroke patients. The NNT for the remaining patients who are principally eligible for thrombectomy requires further study. Currently, centralization seems to be useful to facilitate mechanical thrombectomy in routine care leading to several problems that have to be dealt with in particular regions. Secondary transport to thrombectomy centers plays a major role in this context and has to be provided with highest priority.Only careful analysis of study results and the background circumstances will enable adequate organization and successful practical implementation of this highly effective therapy in the clinical routine. Regional conditions have to be considered and will be crucial in this context.

Mechanical thrombectomy with stent retrievers in acute stroke has emerged as the technique with the highest recanalization rate of therapeutic procedures available so far. Recently it was demonstrated that compared to intravenous rTPA alone, mechanical thrombectomy improves outcomes of patients with acute occlusions of intracranial arteries of the anterior circulation in several randomized clinical trials. In this article we will give an overview of the steps required for the thrombectomy procedure.

Recently multiple studies demonstrated the advantage of mechanical thrombectomy after thrombotic stroke onset in proximal intracranial arteries over i.v. thrombolysis. In experienced stroke centers, recanalization rates of up to 90% can be achieved. This article is dealing with various pitfalls which could face the interventionalist during endovascular therapy and can complicate or even make the procedure impossible.

The publications of five prospective randomized trials have made 2015 a milestone in the development of stroke therapy. Up till then, IV rtPA had been the only evidence-based recanalizing treatment for ischemic stroke.In this article we review the results of five trials: MR CLEAN, ESCAPE, EXTEND IA, SWIFT PRIME, and REVASCAT.

Recently, five independent randomized controlled clinical trials demonstrated the efficacy and safety of endovascular stroke treatment in stroke patients with occlusion of proximal intracranial arteries. The five trials MR CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME and REVASCAT randomized a total of 1287 stroke patients to either standard treatment, which in the majority of patients consisted of intravenous thrombolysis within 4.5 h of symptom onset or additional endovascular stroke treatment. In all the studies endovascular treatment resulted in a better clinical outcome with an odds ratio for a better clinical outcome 90 days after stroke ranging between 1.7 and 3.1 and an absolute increase in the proportion of patients with functionally independent outcome between 14% and 31%. The overwhelming benefit of endovascular treatment mainly results from mechanical thrombectomy using stent retriever devices and starting endovascular treatment within 6 h of symptom onset in stroke patients.

Due to the positive evidence for mechanical thrombectomy (mTE), it will be increasingly used in future. Profound knowledge of potential complications, prevention and management of complications is necessary to safely implement mTE into clinical practice.Description of specific complications of mTE and their clinical relevance, measures for prevention and management. Summary of the current knowledge on long-term side effects of mTE.Analysis of current trial results and selected case series to address specific topics. Summary of own practical clinical experience.Vascular injury (1-5%) and emboli (5-9%) are the most relevant intraprocedural complications but the clinical outcome is variable. Measures for prevention and management are described in detail. Vasospasms frequently occur (20-26%) but rarely need specific treatment and do not affect the clinical course. In the case of restrictive indications the frequency of symptomatic hemorrhage is similar to that for medicinal treatment (up to 8%). Contrast medium enhancement in the area of the infarction on post-treatment imaging should not be mistaken for hemorrhages. Focal subarachnoid contrast medium enhancement or hemorrhage occurs in up to 24% of cases and is predominantly benign. In follow-up imaging stenoses or occlusions can be detected in 4-10% of the treated vessels, most of which are asymptomatic. They are considered to be caused by microtrauma to the vascular wall.Clinically relevant complications of mTE are rare. Preventive measures and effective management of complications may even increase safety. Stenoses occasionally occur as a long-term side effect but are asymptomatic in the majority of cases.

To determine the importance of mechanical thrombectomy (MT) in the treatment of ischemic stroke.Analysis and comparison of randomized controlled trials (RCT) of MT versus i.v. thrombolysis (IVT) considering pathophysiological and logistic aspects.The use of MT is more effective than IVT for internal carotid artery terminus (ICAT), M1 segment and tandem occlusions, i.e. proximal internal carotid artery (ICA) occlusion or stenosis, even in patients older than 75-80 years of age. Due to the small sample sizes this question cannot be answered for patients with M2 occlusions. It is still uncertain whether MT is needed in patients with a low National Institutes of Health stroke scale (NIHSS) score, whether IVT is needed before MT and what type of imaging should be performed. Approximately one third of eligible patients currently undergo MT in Germany. Results from RCTs with stent retrievers for patients with vertebrobasilar artery occlusions are lacking.After becoming established as a first-line therapy for patients with ICAT, M1 segment and tandem occlusions, the effectiveness of MT with stent retrievers has to proven in patients with more distal occlusions, low NIHSS scores and even vertebrobasilar artery occlusions.

Acute ischemic stroke is the leading cause of acquired disability and its treatment is still a major challenge. For more than a decade, various mechanical devices have been developed for the recanalization of proximal artery occlusions in acute ischemic stroke but most of them have been approved for clinical use, only on the basis of uncontrolled case series. Intravenous thrombolysis with recombinant tissue-specific plasminogen activator administered (iv rtPA) within 4.5 h of symptom onset is so far the only approved medicinal treatment in the acute phase of cerebral infarction. With the introduction of stent retrievers, mechanical thrombectomy has demonstrated substantial rates of partial or complete arterial recanalization and improved outcomes compared with iv rtPA and best medical treatment alone in multiple randomized clinical trials in select patients with acute ischemic stroke and proximal artery occlusions. This review discusses the evolution of endovascular stroke therapy followed by a discussion of the current technical standards of mechanical thrombectomy that have to be considered during endovascular stroke therapy and the updated treatment recommendations of the ESO Karolinska stroke update.

Mechanical devices for the recanalization of vessel occlusions in severe acute ischemic stroke have been developed for more than a decade. Several devices have been approved for clinical use on the basis of uncontrolled case series. Many neurologists have asked for randomized clinical trials comparing the new devices with standard treatment, e.g. thrombolytic therapy within a 4.5 h time window. The first 3 investigator initiated randomized trials published in 2013 failed to show superiority of mechanical thrombectomy over standard treatment. In the aftermath of these negative results several new trials with changes in design (e.g. shorter time window and only proximal vessel occlusions) and the use of modern devices with proven higher recanalization rates, so called stent retrievers, have been launched. In October 2014 the first of these new trials was presented and showed a clear superiority of thrombectomy. Based on this result interim analyses of five other studies were performed and most were prematurely terminated because of overwhelming efficacy. Only one trial testing another type of recanalization device failed to reach a statistically significant result. Currently five studies have already been published and two more studies have been presented at scientific conferences. This article provides an overview of the study protocols and the results of the individual studies, their common features and the characteristics of patients who benefit from this treatment. Finally, the consequences that these results may have for the treatment of patients with severe stroke caused by proximal vessel occlusion are discussed.

Management of ischemic stroke is targeted on four therapeutic objectives: limitation of neurological deficit, prevention of earyl stroke recurrence, protection against complications, and secondary prevention. Intravenous thrombolysis within 4.5h of stroke onset is the only proven therapy to improvefunctional outcome. Although promising, neither endovascular recanalisation nor neuroprotective strategies have demonstrated efficacy so far. Immediate administration of antiplatelet agents like acetylsalicylic acid and clopidogrel - in case of intravenous thrombolysis at the earliest after 24h - is effective to prevent early stroke recurrence, whereas anticoagulants should be ommitted in this stage because of an increased risk of cerebral hemorrhage. Subcutaneous heparin/low molecular weight heparin, mobilisation, nasogastric tube, and decompressive craniectomy may protect from venous thromboembolism, aspiration pneumonia, and malignant brain edema, respectively. Secondary prevention is guided by stroke etiology, e.g. oral anticoagulation in the presence atrial fibrillation or endarterectomy in case of sympomatic high-grade carotid stenosis.

In addition to the long-established local thrombolysis by means of a catheter, other mechanical procedures for the interventional treatment of acute ischemic stroke have been introduced over the last ten years. These new methods have proved to be effective for the recanalization of occluded vessels supplying the brain and can, in principle, also be employed outside of the therapeutic window valid for intravenous thrombolysis. For just this reason such interventionaltherapies are being increasingly used, also in combination with intravenous thrombolysis. However, higher demands are placed on imaging diagnostics in order to protect the patients from unnecessary risks resulting from these invasive measures. Since this is still a very new therapeutic procedure it has not yet been conclusively demonstrated that the interventional method, in spite of all theoretical advantages in comparison with intravenous thrombolysis, really does lead to a better outcome for the patients. The indication must thus be made on an individual basis at the interdisciplinary level.

Early portal vein thrombosis is a frequent and severe complication following pediatric liver transplantation. The clinical presentation is characterized by signs and symptoms of portal hypertension such as ascites and digestive hemorrhage. Primary treatment consists of heparin therapy. In the case of persistent or progressive thrombosis or symptoms, surgical thrombectomy or retransplantation should be considered. However, surgical intervention is associated with significant morbidity and mortality. We report on successful minimally invasive percutaneous thrombus aspiration and thrombolysis for the treatment of acute portal vein thrombosis in a 5-year-old child post liver transplantation.

Ischemic stroke is a medical emergency requiring fast and effective collaboration of neurologists and radiologists. Currently there are promising new developments in the treatment of acute ischemic stroke with efforts being made to reduce the door-to-needle time and to improve recanalization of occluded vessels by new endovascular techniques. Clinical trials have also demonstrated the efficacy of thrombolysis up to 4.5 h and confirmed the importance of the time to treatment for positive outcome.