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Mechanical Thrombectomy for Acute Ischemic Stroke: A Case Study Using the Penumbra Stroke System

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Abstract

Over recent years, there have been dramatic advances in the ability to treat an acute ischemic stroke. Thrombolysis with intravenous recombinant tissue plasminogen activator can now be performed up to 4.5 hr after stroke onset in certain circumstances, and new mechanical thrombectomy devices allow intervention up to and beyond 8 hr in some instances. The Penumbra Stroke System (Penumbra Inc., Alameda, CA), one of these mechanical thrombectomy devices, uses a series of catheters to aspirate thrombus from occluded cerebral arteries and thus restore flow to the adjacent ischemic brain.

This case study highlights the clinical and procedural issues involved in the treatment and postprocedural care of a patient with an acute ischemic stroke treated with the Penumbra Stroke System.

Introduction

Ischemic stroke is one of the leading causes of morbidity and mortality in the Western world, and in the United States, stroke is the number one cause of adult disability (Goldstein et al., 2011). The goal of acute stroke treatment is to minimize, or even prevent altogether, any significant neurologic damage. With an acute occlusion of an intracranial artery, there is a dramatic reduction in local cerebral perfusion, and within a short time, the affected area of brain will become irreversibly damaged. Although this central area or ischemic core cannot be saved, there will often be a larger surrounding area that is poorly perfused but which is still salvageable. It is this so called “penumbra” that is the target for acute stroke treatments that aim to restore blood flow.

In 1996, the Food and Drug Administration (FDA) approved the first treatment for acute ischemic stroke. Based on a large, National Institutes of Health funded, multicenter, prospective randomized clinical trial, intravenous tissue plasminogen activator (IV tPA) was approved as a thrombolytic drug for use in selected ischemic stroke patients presenting within 3 hr of symptom onset (The National Institutes of Neurological Disorders and Stroke rt-PA Stroke Study Group, 1995). Over the ensuing years, research has sought to increase this “therapeutic window.” Initially, studies using the catheter-based intra-arterial delivery of thrombolytics to occluded cerebral arteries demonstrated that patients could be treated safely and effectively up to 6 hr after stroke onset (del Zoppo et al., 1998; Furlan et al., 1999). More recently, a large European study has prompted the use of IV tPA up to 4.5 hr after stroke onset in certain patients (Hacke et al., 2008). However, despite these successes, concerns over hemorrhage risk and the length of time required to deliver tPA intra-arterially prompted the development of mechanical endovascular techniques to reopen occluded arteries in the setting of an ischemic stroke.

Mechanical thrombectomy devices have the theoretical advantage of providing faster restoration of flow without the need for drug thrombolysis, thus potentially decreasing the incidence of hemorrhagic conversion in the region of the stroke. The first mechanical retrieval approved by the FDA in 2004 was the Merci retriever (Stryker, Kalamazoo, MI). This corkscrew-shaped flexible nickel-titanium wire is used to ensnare the occluding thrombus, which is then removed by traction. Although this device enjoyed some early success, multiple attempts are often needed to complete revascularization, and the device can be challenging to use with results being very user dependent (Gobin et al., 2004). The Merci device was soon followed by the Penumbra Stroke System (Penumbra Inc., Alameda, CA), a suction catheter combined with a novel “separator” wire (Penumbra Pivotal Stroke Trial Investigators, 2009; Tarr et al., 2010). Various microcatheter sizes are available for intracranial use (Figure 1A), and suction is applied through an aspiration pump (Figure 1B). The separator wire (Figure 1A) is passed in and out of the microcatheter tip to maintain patency and macerate the clot as it is aspirated. This system allows rapid removal of large quantities of thrombus and is relatively straightforward to use. Unlike the Merci device, the Penumbra Stroke System has the added advantage of not requiring the operator to traverse the occluded segment of the vessel, thus eliminating the need to pass the microcatheter blindly into the distal artery.

In this case study, we described the case of a patient with an acute ischemic stroke who was treated emergently with mechanical thrombectomy using the Penumbra Stroke System.

Section snippets

Presentation

The patient is a 51-year-old man. He has a history of hypertension and is a long-term smoker. At around 10:00 p.m., while watching television, his wife saw him slouch over to his right side and slide off the couch. His wife called 911, and he was taken emergently by ambulance to the local hospital. On examination at this facility, he was noted to be globally aphasic with a right hemiplegia. A noncontrast head computed tomography (CT) scan was obtained, which revealed a hyperdense left middle

Summary and conclusions

There have been considerable recent advances in the acute care of ischemic stroke patients. The extension of the time window for intravenous tPA and the advent of various mechanical thrombectomy devices now give patients more hope for a meaningful recovery (Adams et al., 2007). Radiology nurses, radiology technologists, and neuroscience nurses play an important role in the successful care and treatment of these often critically ill patients.

Michelle M. Rohde, BSN, RN, is from the Department of Radiology in the Penn State Hershey Medical Center at Hershey, PA; Department of Nursing in the Penn State Hershey Medical Center at Hershey, PA

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Cited by (0)

Michelle M. Rohde, BSN, RN, is from the Department of Radiology in the Penn State Hershey Medical Center at Hershey, PA; Department of Nursing in the Penn State Hershey Medical Center at Hershey, PA

Susan J. Pazuchanics, BSN, RN, CCRN, is from the Department of Nursing in the Penn State Hershey Medical Center at Hershey, PA

Gayle Watson, MSN, RN, CCRN, is from the Department of Nursing in the Penn State Hershey Medical Center at Hershey, PA; Penn State Hershey Stroke Center in the Penn State Hershey Medical Center at Hershey, PA

Jessica M. Vesek, BS, RT(R), is from the Department of Radiology in the Penn State Hershey Medical Center at Hershey, PA

Einar Bogason, MD, is from the Department of Neurosurgery in the Penn State Hershey Medical Center at Hershey, PA

Kevin M. Cockroft, MD, MSc, is from the Department of Neurosurgery in the Penn State Hershey Medical Center at Hershey, PA; Department of Radiology in the Penn State Hershey Medical Center at Hershey, PA, and Penn State Hershey Stroke Center in the Penn State Hershey Medical Center at Hershey, PA.

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