|Year : 2016 | Volume
| Issue : 1 | Page : 13-16
Neuro-interventions in review for cardiologists
Deepti Vibha1, Sunil Kumar Verma2, MV Padma1, Atul Mathur3
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 Publication||26-May-2016|
Sunil Kumar Verma
Department of Neurology, CNC, AIIMS, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
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 2021 Jan 27];2:13-6. Available from: https://www.j-pcs.org/text.asp?2016/2/1/13/182991
| Introduction|| |
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|| |
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, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND IA were  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.,
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. 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  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].
| Final Word|| |
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|| |
- 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.
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,, 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) 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.
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.
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,,,,,,,,,,, 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|| |
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).,,,,,,,,,,,,,,,, Hypertension is the most common risk factor.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al.
A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015;372:11-20.
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.
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.
Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al.
Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015;372:2285-95.
Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al.
Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015;372:1009-18.
Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al.
Endovascular thrombectomy after large-vessel ischaemic stroke: A meta-analysis of individual patient data from five randomised trials. Lancet 2016. pii: S0140-673600163-X.
Badhiwala JH, Nassiri F, Alhazzani W, Selim MH, Farrokhyar F, Spears J, et al.
Endovascular thrombectomy for acute ischemic stroke: A meta-analysis. JAMA 2015;314:1832-43.
Brott TG, Hobson RW 2nd
, Howard G, Roubin GS, Clark WM, Brooks W, et al.
Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010;363:11-23.
Brott TG, Howard G, Roubin GS, Meschia JF, Mackey A, Brooks W, et al.
Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med 2016;374:1021-31.
Rosenfield K, Matsumura JS, Chaturvedi S, Riles T, Ansel GM, Metzger DC, et al.
Randomized trial of stent versus surgery for asymptomatic carotid stenosis. N Engl J Med 2016;374:1011-20.
Writing Group Members, Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, et al.
Heart disease and stroke statistics – 2010 update: A report from the American Heart Association. Circulation 2010;121:e46-215.
North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-53.
Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, et al.
Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998;339:1415-25.
Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995;273:1421-8.
Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, et al.
Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: Randomised controlled trial. Lancet 2004;363:1491-502.
Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: Results of a systematic review and analysis. Stroke 2009;40:e573-83.
Stingele R, Berger J, Alfke K, Eckstein HH, Fraedrich G, Allenberg J, et al.
Clinical and angiographic risk factors for stroke and death within 30 days after carotid endarterectomy and stent-protected angioplasty: A subanalysis of the SPACE study. Lancet Neurol 2008;7:216-22.
SPACE Collaborative Group, Ringleb PA, Allenberg J, Brückmann H, Eckstein HH, Fraedrich G, et al.
30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: A randomised non-inferiority trial. Lancet 2006;368:1239-47.
International Carotid Stenting Study investigators, Ederle J, Dobson J, Featherstone RL, Bonati LH, van der Worp HB, et al.
Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): An interim analysis of a randomised controlled trial. Lancet 2010;375:985-97.
Bonati LH, Jongen LM, Haller S, Flach HZ, Dobson J, Nederkoorn PJ, et al.
New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: A substudy of the international carotid stenting study (ICSS). Lancet Neurol 2010;9:353-62.
Gray WA, Hopkins LN, Yadav S, Davis T, Wholey M, Atkinson R, et al.
Protected carotid stenting in high-surgical-risk patients: The ARCHeR results. J Vasc Surg 2006;44:258-68.
Abraham J, Rao PS, Inbaraj SG, Shetty G, Jose CJ. An epidemiological study of hemiplegia due to stroke in South India. Stroke 1970;1:477-81.
Bansal BC, Prakash C, Jain AL, Brahmanandam KR. Cerebrovascular disease in young individuals below the age of 40 years. Neurol India 1973;21:11-8.
Razdan S, Koul RL, Motta A, Kaul S. Cerebrovascular disease in rural Kashmir, India. Stroke 1989;20:1691-3.
Bharucha NE, Bharucha EP, Bharucha AE, Bhise AV, Schoenberg BS. Prevalence of stroke in the Parsi community of Bombay. Stroke 1988;19:60-2.
Dalal PM. Studies in young and elderly: Risk factors and strategies for stroke prevention. J Assoc Physicians India 1997;45:125-31.
Das SK, Sanyal K. Neuroepidemiology of major neurological disorders in rural Bengal. Neurol India 1996;44:47-58.
Saha SP, Bhattacharya S, Das SK, Maity B, Roy T, Raut DK. Epidemiological study of neurological disorders in a rural population of Eastern India. J Indian Med Assoc 2003;101:299-300, 302-4.
Banerjee TK, Mukherjee CS, Sarkhel A. Stroke in the urban population of Calcutta – an epidemiological study. Neuroepidemiology 2001;20:201-7.
Das SK, Banerjee TK, Biswas A, Roy T, Raut DK, Mukherjee CS, et al.
A prospective community-based study of stroke in Kolkata, India. Stroke 2007;38:906-10.
Ahmad OB, Boschi-Pinto C, Lopez AD, Christopher JL, Murray CJ, Lozano R, et al
. Age Standardization of Rates: A New WHO Standard. GPE Discussion Paper Series No. 31, EIP/GPE/EBD. Geneva, Switzerland: World Health Organization; http://www.who.int/healthinfo/paper31.pdf
. [Last accessed 2016 Apr 23].
Dalal PM, Bhattacharjee M. Stroke epidemic in India: Hypertension-stroke control programme is urgently needed. J Assoc Physicians India 2007;55:689-91.
Brown RD, Whisnant JP, Sicks JD, O'Fallon WM, Wiebers DO. Stroke incidence, prevalence, and survival: Secular trends in Rochester, Minnesota, through 1989. Stroke 1996;27:373-80.
Rothwell PM, Coull AJ, Giles MF, Howard SC, Silver LE, Bull LM, et al.
Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet 2004;363:1925-33.
Kolominsky-Rabas PL, Sarti C, Heuschmann PU, Graf C, Siemonsen S, Neundoerfer B, et al.
A prospective community-based study of stroke in Germany – The Erlangen Stroke Project (ESPro): Incidence and case fatality at 1, 3, and 12 months. Stroke 1998;29:2501-6.
Syme PD, Byrne AW, Chen R, Devenny R, Forbes JF. Community-based stroke incidence in a Scottish population: The Scottish borders stroke study. Stroke 2005;36:1837-43.
Tsiskaridze A, Djibuti M, van Melle G, Lomidze G, Apridonidze S, Gauarashvili I, et al.
Stroke incidence and 30-day case-fatality in a suburb of Tbilisi: Results of the first prospective population-based study in Georgia. Stroke 2004;35:2523-8.
Thrift AG, Dewey HM, Macdonell RA, McNeil JJ, Donnan GA. Incidence of the major stroke subtypes: Initial findings from the North East Melbourne stroke incidence study (NEMESIS). Stroke 2001;32:1732-8.