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 Table of Contents  
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 13-16

Neuro-interventions in review for cardiologists

1 Department of Neurology, CNC, AIIMS, New Delhi, India
2 Department of Cardiology, CNC, AIIMS, New Delhi, India
3 Department of Cardiology, Fortis Escorts Heart Hospital, New Delhi, India

Date of Web Publication26-May-2016

Correspondence Address:
Sunil Kumar Verma
Department of Neurology, CNC, AIIMS, Ansari Nagar, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2395-5414.182991

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In acute stroke, rapid administration of intravenous recombinant tissue-type plasminogen activator (r-tPA) to stroke patients is the mainstay of treatment. Intravenous r-tPA improves functional outcomes when given within 4.5 h of ischemic stroke onset. Patients eligible for intravenous r-tPA should receive intravenous r-tPA even if endovascular treatments are being considered. Patients should receive endovascular therapy with a stent retriever if they meet appropriate criteria as per the American Heart Association guidelines. With the publication of results of the carotid revascularization endarterectomy versus stenting trial (CREST), there is evidence of no difference in the rate of late ipsilateral stroke after endarterectomy or stenting at 4 and 10 years. CREST provides the physician more options for the treatment of carotid stenosis and has shown that both carotid endarterectomy and carotid artery stenting are effective and safe when performed by experienced operators, and when patients are chosen appropriately.

Keywords: Carotid revascularization endarterectomy versus stenting trial, carotid stenosis, guidelines 2016, review, stroke

How to cite this article:
Vibha D, Verma SK, Padma M V, Mathur A. Neuro-interventions in review for cardiologists. J Pract Cardiovasc Sci 2016;2:13-6

How to cite this URL:
Vibha D, Verma SK, Padma M V, Mathur A. Neuro-interventions in review for cardiologists. J Pract Cardiovasc Sci [serial online] 2016 [cited 2023 Mar 22];2:13-6. Available from: https://www.j-pcs.org/text.asp?2016/2/1/13/182991

  Introduction Top

Stroke and Carotid Stenosis are major causes of vascular morbidity and mortality. Evidence exists for the benefit of intervention strategies providing benefit beyond drug therapy. While neurointerventionists can obviously provide the best care, when available, the lack of sufficient numbers of well trained neurointerventionists, and at the same time, availability of large numbers of neurologists and cardiointerventionists means that a “stroke and carotid intervention” program can be developed with this infrastructure with proper training for a team of neurologists and cardiac interventionists with special interest in carotid interventions. In this issue, therefore we review the recent literature in stroke and carotid interventions.

  Neuro-Intervention in Acute Stroke Top

In 2015, five randomized trials showed the efficacy of endovascular thrombectomy over standard medical care in patients with acute ischemic stroke caused by occlusion of arteries of the proximal anterior circulation: The MR CLEAN,[1] ESCAPE,[2] REVASCAT,[3] SWIFT PRIME,[4] and EXTEND IA were [5] done at the Netherlands, Canada, Spain, the USA and Australia, respectively. This, of course, led to the publication of successive meta-analysis of these trials.[6],[7]

The meta-analysis of individual patient data gives us more precise estimates and re-affirms the consistency of effects across major sub-groups of age and severity across these trials. The data from the 1287 patients (634 assigned to endovascular thrombectomy, 653 assigned to standard care) found an adjusted common odds ratio for reduced disability 2.49, 95% confidence interval (CI) 1.76–3.53; P < 0.0001) at 90 days.[6] The number needed to treat with endovascular thrombectomy to reduce disability by at least one level on modified Rankin scale for one patient was 2.6.

Endovascular thrombectomy is thus of benefit to most patients with acute ischemic stroke caused by occlusion of the proximal anterior circulation, irrespective of patient characteristics or geographical location. The publication of HERMES meta-analysis [6] has led to premature stopping of three on-going trials on the same topic in the UK, France, and the USA.

The salient features and outcomes of the five trials are given in [Table 1].
Table 1: Recent Ischemic Stroke Intervention Trials

Click here to view

  Final Word Top

The use of older devices and stent retrievers reported neutral results on the clinical outcome perhaps due to long delay between symptom onset and treatment, less recanalization, and use of older generation devices. There is evidence for early thrombectomy with stent retrievers. The positive effect in the MR CLEAN trial was time-dependent, with odds ratio decreasing from 3.0 at 3.5 h onset to reperfusion time to 1.5 at 6 h. Treatment effect was not there after 6 h 19 m. These findings justify the time window of treatment within 6 h from symptom onset.

  Treatment Recommendations Top

  • Mechanical thrombectomy [Figure 1], in addition to intravenous thrombolysis within 4.5 h when eligible, is recommended to treat acute stroke patients with large artery occlusions in the anterior circulation up to 6 h after symptom onset
  • Mechanical thrombectomy should not prevent the initiation of intravenous thrombolysis where this is indicated, and intravenous thrombolysis should not delay mechanical thrombectomy
  • Mechanical thrombectomy should be performed as soon as possible after its indication
  • For mechanical thrombectomy, stent retrievers approved by local health authorities should be considered
  • If intravenous thrombolysis is contraindicated (e.g., warfarin treated with therapeutic INR), mechanical thrombectomy is recommended as the first-line treatment in large vessel occlusions.
Figure 1: Approach to stroke.

Click here to view

The 2015 American Heart Association (AHA)/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment suggests the following:

  • Rapid administration of intravenous recombinant tissue-type plasminogen activator (r-tPA) to stroke patients is the mainstay of treatment of acute ischemic stroke. Intravenous r-tPA improves functional outcomes when given within 4.5 h of ischemic stroke onset
  • Patients eligible for intravenous r-tPA should receive intravenous r-tPA even if endovascular treatments are being considered. Patients should receive endovascular therapy with a stent retriever if they meet appropriate criteria as per the AHA guidelines. Among the various criteria mentioned, some of them include receiving intravenous r-tPA within 4.5 h of onset, occlusion of the ICA or proximal MCA, age ≥18 years, treatment within 6 h of symptoms, and certain appropriate scores beyond the scope of this document
  • In most instances, nonenhanced computed tomography will provide the necessary information to make decisions
  • If endovascular therapy is contemplated, a noninvasive intracranial vascular study is recommended during the initial imaging evaluation [Figure 1].

Carotid artery stenting versus carotid endarterectomy: Unanswered questions yet

Atherosclerotic carotid stenosis accounts for about 15% of ischemic strokes. Carotid artery stenting (CAS) has been developed as an alternative to carotid endarterectomy (CEA) with several potential advantages.

Inclusion criteria for carotid revascularization endarterectomy versus stenting trial (CREST) included asymptomatic patients with carotid stenosis of at least 60% by angiography, 70% by ultrasonography, or 80% by CT angiography (CTA) or magnetic resonance angiography (MRA), if stenosis on ultrasonography was 50–69%; inclusion criteria for symptomatic patients was at least 50% stenosis by angiography, 70% by ultrasound, or 70% by CTA or MRA if stenosis on ultrasonography was 50-–69%. Major exclusion criteria included evolving stroke or major stroke likely to confound study end points, chronic atrial fibrillation, and myocardial infarction (MI) within the previous 30 days or unstable angina.

With the publication of results of the CREST trial,[8],[9] there is evidence of no difference in the rate of late ipsilateral stroke after endarterectomy or stenting at 4 and 10 years. The study included 2502 patients from 117 centers in the USA and Canada. In this study, there was also evidence of increased peri-procedural risk of stroke (4.1% vs. 2.3%, P = 0.01) and MI (1.1% vs. 2.3%, P = 0.03) in the CAS group.

Asymptomatic carotid stenosis constituted 52.5% of the consented patients. Although the rates of postprocedural ipsilateral stroke and all postprocedural strokes were similar in asymptomatic patients and symptomatic patients at 5 and at 10 years, in the CEA and CAS groups, the medical therapy has itself evolved in the past decade. Results of randomized trials including only asymptomatic carotid stenosis (ACT I study)[3] have pointed this as a limitation of their study. Given that the annual risk of a stroke among asymptomatic patients is probably <1% per year with modern medical therapy, the procedure-related risk needs to be balanced against the benefits which the patient is going to get over and above the best medical therapy available today. Interestingly, the peri-procedural risk of death, stroke, or MI was comparable in the two arms in the ACT I study.[10]

The major unanswered questions, therefore, are the risk of peri-procedural events in the real world, given that the two trials have slightly discrepant results. Not all centers have expertize to perform CAS with the risk of <3%, and therefore generalizability of the trial results is doubtful. The decision to intervene in asymptomatic patients still remains, given that there was no medical treatment arm as a comparator. This question may be answered by the on-going CREST2 trial.[11]

The results of CREST will change the way that many practitioners take care of patients with carotid artery disease. Carotid stenosis patients need to be evaluated on an individual basis,[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22] to determine which modality (CAS vs. CEA) is the safest and most effective. CREST provides the physician more options for the treatment of carotid stenosis and has shown that both CEA and CAS are effective and safe when performed by experienced operators, and when patients are chosen appropriately.

  A Comment on the Indian Aspects of Stroke Top

The prevalence rate in India of stroke varies in different studies from 127/100,000 persons in older studies to 545.10/100,000 (95% CI, 479.68–617.05) in a recent study from West Bengal. The annual incidence of stroke in India, age standardized to the world population, is about 154/100,000 per year which higher than Western countries (107/100,000 in the USA).[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39] Hypertension is the most common risk factor.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015;372:1019-30.  Back to cited text no. 2
Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015;372:2296-306.  Back to cited text no. 3
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