Neurointervention.  2021 Jul;16(2):91-110. 10.5469/neuroint.2020.00339.

Factors Contributing to an Efficacious Endovascular Treatment for Acute Ischemic Stroke in Asian Population

• Lee JS
• Hwang YH
• Sohn SI

• KMID: 2517734
• DOI: http://doi.org/10.5469/neuroint.2020.00339

Abstract

Although randomized control trials about endovascular treatment (EVT) of emergent large vessel occlusion (LVO) have demonstrated the success of mechanical thrombectomy as the choice of treatment, a wide range of caveats remain unaddressed. Asian patients were rarely included in the trials, thereby raising the question of whether the treatment could be generalized. In addition, there remains a concern on the feasibility of the method with respect to its application against intracranial atherosclerosis (ICAS)-related LVO, frequently observed in the Asian population. It is important to include evidence on ICAS LVO from Asian countries in the future for a comprehensive understanding of LVO etiology. Besides the issues with EVT, prognostic concerns in diabetes patients, acute kidney injury following EVT, neuroprotective management against reperfusion injury, and other peri-EVT issues should be considered in clinical practice. In the current article, we present an in-depth review of the literature that revises information pertaining to such concerns.

Keyword

Cerebral infarction; Endovascular procedures; Intracranial atherosclerosis; Diabetes mellitus; Acute kidney injury; Reperfusion injury

Figure

• 

  Fig. 1. Representative images of infarct volume and hemorrhagic transformation among rat models with cerebral ischemia in the presence or absence of diabetes mellitus (DM) induction. (A, B) Models of 30-minute ischemia and reperfusion in the unilateral middle cerebral artery with a thread (0.5 hours transient middle cerebral artery occlusion [tMCAO], sacrificed 24 hours after reperfusion); T2-weighted imaging by 9.4T magnetic resonance imaging taken in the Institute for Basic Science (Suwon, Korea) (left) and cresyl violet staining (right). (A) In a non-DM rat, the cerebral infarction is relatively small. (B) In a DM rat, the infarction is evident on the entire middle cerebral artery (MCA) territory induced only by 30-minute ischemia. (C, D) Models of 2 hours ischemia and reperfusion in the MCA (2 hours tMCAO, sacrificed 24 and 8 hours after reperfusion in non-DM and DM rats, respectively); cresyl violet (left) and hematoxylin and eosin staining (right). (C) The evident territorial infarction is induced by 2 hours tMCAO, the most common rodent model of cerebral ischemia, in a non-DM rat. (D) The territorial infarction is evident in the early time point, and prominent hemorrhagic transformation is shown in a DM rat with 2 hours tMCAO. The serum HbA1c was around 10–11%, 4 weeks after intraperitoneal streptozotocin injection in the DM rats. Materials are from the corresponding author’s own laboratory (JSL; Suwon, Korea). Low magnification, ×6.7. High magnification, ×400.

• 

  Fig. 2. The possible pathomechanism of poor prognosis in patients with diabetes mellitus or admission hyperglycemia who have acute ischemic stroke and endovascular treatment. Although there are overlapped features among the representative complications, including infarct growth, hemorrhagic transformation, and acute kidney injury, the main contributing factors seem to be somewhat distinctive. Infarct growth may be attributable to admission hyperglycemia especially upon recanalization failure. Although hemorrhagic transformation and acute kidney injury share a common factor, diabetes mellitus, different factors seem to respectively affect each complication. Hemorrhagic transformation more likely occurs after reperfusion injury. Severe stroke might indirectly affect the occurrence of acute kidney injury (dashed line).

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