101
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Garcia-Bermejo P, Patro SN, Ahmed AZ, Al Rumaihi G, Akhtar N, Kamran S, Salam A, Own A, Saqqur M, Shuaib A. Baseline Occlusion Angiographic Appearance on Mechanical Thrombectomy Suggests Underlying Etiology and Outcome. Front Neurol 2019; 10:499. [PMID: 31133981 PMCID: PMC6517505 DOI: 10.3389/fneur.2019.00499] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/24/2019] [Indexed: 11/15/2022] Open
Abstract
Background: Etiology of a large vessel occlusion is relevant in the management of acute ischemic stroke patients and often difficult to determine in the acute phase. Aims: We aim to investigate whether the angiographic appearance of the occlusion is related to its etiology and outcome. Materials and Methods: Patients without cervical carotid occlusions who underwent mechanical thrombectomy in our center from April 2015 to September 2018 were studied. Demographics, clinical and radiological variables and outcome measures, including etiological classification of stroke, were collected. Underlying intracranial atherosclerosis was estimated according to the presence of stenosis after recanalization. Patients were assigned to groups based on the appearance of the occlusion observed in the first angiogram as “tapered” or “non-tapered.” Differences were searched amongst them. Results: 131 patients met inclusion criteria. 31 (23.6%) were “tapered” and 100 (76.3%) non-tapered. Tapered presented lower mean baseline NIHSS (10.3 ± 6.2 vs. 16.1 ± 7.2; p < 0.001), smaller acute infarct cores as CTP CBV ASPECTS (8.6 ± 1.6 vs. 7.2 ± 2.4; p = 0.003), higher proportion of instant re-occlusions (26.7 vs. 8.2%; p = 0.025), fewer complete recanalization (45.2 vs. 71.0%; p = 0.028), and more persistent occlusions (37.5 vs. 10.6%; p = 0.011) on follow up MRA. There were no differences in reperfusion rates (83.9 vs. 84.0%; p = 0.986) nor in good long term functional outcome (50.0 vs. 51.1%; p = 0.921). Intracranial atherosclerosis etiology was more common in tapered than in non-tapered occlusions (54.8 vs. 18.0%; p < 0.001). Conclusion: The angiographic appearance of an occlusion in mechanical thrombectomy patients may determine its etiology, predict likelihood of successful recanalization, and risk of reocclusion.
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Affiliation(s)
- Pablo Garcia-Bermejo
- Neuroradiology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Neurology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Satya Narayana Patro
- Neuroradiology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ayman Z Ahmed
- Neuroradiology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ghaya Al Rumaihi
- Neuroradiology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Neurosurgery Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Naveed Akhtar
- Neurology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Sadaat Kamran
- Neurology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abdul Salam
- Neuroscience Institute, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Own
- Neuroradiology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Maher Saqqur
- Neurology Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine (Neurology), University of Alberta, Edmonton, AB, Canada
| | - Ashfaq Shuaib
- Neuroscience Institute, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine (Neurology), University of Alberta, Edmonton, AB, Canada
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102
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Baek JH, Kim BM. Angiographical Identification of Intracranial, Atherosclerosis-Related, Large Vessel Occlusion in Endovascular Treatment. Front Neurol 2019; 10:298. [PMID: 31040811 PMCID: PMC6476938 DOI: 10.3389/fneur.2019.00298] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 03/08/2019] [Indexed: 01/01/2023] Open
Abstract
Identification of intracranial, atherosclerosis-related, large vessel occlusion (ICAS-LVO) is important to set up an optimal endovascular treatment strategy, as most ICAS-LVOs require specific endovascular modalities for efficient recanalization. However, there is currently no decisive way to identify ICAS-LVO for endovascular treatment. Instead of the few, non-specific, clinical and imaging findings that operators have depended on, this review focused on the occlusion type, one of angiographical methods to identify the ICAS-LVO. Occlusion type was originally devised for predicting procedural details and endovascular outcomes of ICAS-LVO. Among occlusion types, truncal-type occlusion is regarded as a surrogate marker for ICAS-LVO. Although rare, false positives or negatives in truncal-type occlusion are possible. Nonetheless, occlusion type was easy to apply and reliably predictive of procedural outcomes. Furthermore, occlusion type can be determined prior to the procedure, which could allow it to be more helpful in setting up an optimal strategy before starting endovascular treatment.
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Affiliation(s)
- Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byung Moon Kim
- Department of Radiology, Interventional Neuroradiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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103
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Park H, Baek JH, Kim BM. Endovascular Treatment of Acute Stroke Due to Intracranial Atherosclerotic Stenosis-Related Large Vessel Occlusion. Front Neurol 2019; 10:308. [PMID: 31001193 PMCID: PMC6454085 DOI: 10.3389/fneur.2019.00308] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 03/11/2019] [Indexed: 12/21/2022] Open
Abstract
Endovascular treatment (EVT) has become a standard treatment for acute ischemic stroke due to large vessel occlusion (LVO) in the anterior circulation. However, whether EVT tools used for intracranial atherosclerotic stenosis (ICAS)-related LVO are as safe and effective as for use in embolic LVO remains unclear. There have been only a few studies about EVT for ICAS-related LVO, and these studies revealed that mechanical thrombectomy with a stent retriever or contact aspiration was less effective and more time consuming in ICAS-related LVO than in embolic LVO. Because fast and successful recanalization (defined as modified Thrombolysis in Cerebral Ischemia grade, 2b or 3) is the most critical factor influencing favorable outcomes, it is important to determine the appropriate EVT strategy for fast recanalization of ICAS-related LVO. In this report, we review the results of mechanical thrombectomy using stent retriever or contact aspiration and rescue treatments after failure of mechanical thrombectomy for ICAS-related LVO. Finally, we propose the EVT strategy appropriate for ICAS-related LVO based on a literature review and our experience.
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Affiliation(s)
- Hyungjong Park
- Interventional Neuroradiology, Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.,Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea
| | - Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byung Moon Kim
- Interventional Neuroradiology, Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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104
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Baek JH, Kim BM, Heo JH, Kim DJ, Nam HS, Kim YD. Endovascular and Clinical Outcomes of Vertebrobasilar Intracranial Atherosclerosis-Related Large Vessel Occlusion. Front Neurol 2019; 10:215. [PMID: 30941084 PMCID: PMC6433872 DOI: 10.3389/fneur.2019.00215] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/19/2019] [Indexed: 01/01/2023] Open
Abstract
Background and Purpose: Endovascular treatment (EVT) for acute vertebrobasilar intracranial atherosclerosis-related large vessel occlusion (ICAS-LVO) and its outcomes are not well known. We aimed to evaluate endovascular and clinical outcomes of vertebrobasilar ICAS-LVO patients who underwent EVT. Methods: Consecutive acute stroke patients who underwent EVT for vertebrobasilar LVO were retrospectively reviewed. Patients were assigned to the ICAS (+) or the ICAS (–) group based on angiographical findings. Procedural details and clinical outcomes were compared between the ICAS (+) and ICAS (–) groups. Results: This study included 77 patients with acute vertebrobasilar LVO who underwent EVT. Among the study subjects, 24 (31.2%) had an ICAS-LVO. Recanalization was achieved in 19 patients in the ICAS (+) group (79.2%), which was comparable with the ICAS (–) group (84.9%; p = 0.529). However, recanalization using conventional endovascular modalities (stent retriever thrombectomy, contact aspiration thrombectomy, or intra-arterial urokinase infusion) was less successful in the ICAS (+) group (36.8%) than the ICAS (–) group (100.0%; p < 0.001). All the remaining patients in the ICAS (+) group required specific rescue treatments appropriate for ICAS, including balloon angioplasty, stenting, or intra-arterial glycoprotein IIb/IIIa inhibitor infusion to obtain a successful recanalization. Procedural time was not significantly longer in the ICAS (+) group. The rates of favorable outcomes (37.5% vs. 41.5%; p = 0.740), death, and symptomatic intracerebral hemorrhage were not significantly different between the groups. Conclusion: ICAS-LVO was common in patients who underwent EVT for acute vertebrobasilar LVO. Although conventional modalities were often ineffective for vertebrobasilar ICAS-LVO, a comparable recanalization rate could be obtained with ICAS-specific modalities. Recanalization rate and procedural time were comparable, and clinical outcomes did not differ between patients with or without ICAS-LVO.
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Affiliation(s)
- Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Byung Moon Kim
- Department of Radiology, Interventional Neuroradiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Ji Hoe Heo
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Joon Kim
- Department of Radiology, Interventional Neuroradiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyo Suk Nam
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Dae Kim
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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105
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Kim B, Kim BM, Bang OY, Baek JH, Heo JH, Nam HS, Kim YD, Yoo J, Kim DJ, Jeon P, Baik SK, Suh SH, Lee KY, Kwak HS, Roh HG, Lee YJ, Kim SH, Ryu CW, Ihn YK, Jeon HJ, Kim JW, Byun JS, Suh S, Park JJ, Lee WJ, Roh J, Shin BS. Carotid Artery Stenting and Intracranial Thrombectomy for Tandem Cervical and Intracranial Artery Occlusions. Neurosurgery 2019; 86:213-220. [DOI: 10.1093/neuros/nyz026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 01/27/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
It remains controversial whether carotid artery stenting (CAS) is needed in cases of tandem cervical internal carotid artery occlusion (cICAO) and intracranial large vessel occlusion (LVO).
OBJECTIVE
To investigate the efficacy and safety of CAS in combination with endovascular thrombectomy (CAS-EVT) in cICAO-LVO patients and to compare its outcomes with those of EVT without CAS (EVT-alone).
METHODS
We identified all patients who underwent EVT for tandem cICAO-LVO from the prospectively maintained registries of 17 stroke centers. Patients were classified into 2 groups: CAS-EVT and EVT-alone. Clinical characteristics and procedural and clinical outcomes were compared between 2 groups. We tested whether CAS-EVT strategy was independently associated with recanalization success.
RESULTS
Of the 955 patients who underwent EVT, 75 patients (7.9%) had cICAO-LVO. Fifty-six patients underwent CAS-EVT (74.6%), and the remaining 19 patients underwent EVT-alone (25.4%). The recanalization (94.6% vs 63.2%, P = .002) and good outcome rates (64.3% vs 26.3%, P = .007) were significantly higher in the CAS-EVT than in the EVT-alone. Mortality was significantly lower in the CAS-EVT (7.1% vs 21.6%, P = .014). There was no significant difference in the rate of symptomatic intracranial hemorrhage between 2 groups (10.7 vs 15.8%; P = .684) and according to the use of glycoprotein IIb/IIIa inhibitor (10.0% vs 12.3%; P = .999) or antiplatelet medications (10.2% vs 18.8%; P = .392). CAS-EVT strategy remained independently associated with recanalization success (odds ratio: 24.844; 95% confidence interval: 1.445-427.187).
CONCLUSION
CAS-EVT strategy seemed to be effective and safe in cases of tandem cICAO-LVO. CAS-EVT strategy was associated with recanalization success, resulting in better clinical outcome.
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Affiliation(s)
- Byungjun Kim
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Hospital Stroke Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ji Hoe Heo
- Department of Neurology, Severance Hospital Stroke Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyo Suk Nam
- Department of Neurology, Severance Hospital Stroke Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Dae Kim
- Department of Neurology, Severance Hospital Stroke Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joonsang Yoo
- Department of Neurology, Keimyung University Dongsan Medical center, Daegu, Republic of Korea
| | - Dong Joon Kim
- Department of Radiology, Severance Hospital Stroke Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Pyoung Jeon
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung Kug Baik
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyo Sung Kwak
- Department of Radiology, Chonbuk National University Medical School and Hospital, Jeonju, Republic of Korea
| | - Hong Gee Roh
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Young-Jun Lee
- Department of Radiology, Hanyang University Hospital, Seoul, Republic of Korea
| | - Sang Heum Kim
- Department of Radiology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Chang Woo Ryu
- Department of Radiology, Kyung Hee University Gangdong Hospital, Seoul, Republic of Korea
| | - Yon-Kwon Ihn
- Department of Radiology, St. Vincent's Hospital, Catholic University School of Medicine, Suwon, Republic of Korea
| | - Hong-Jun Jeon
- Department of Neurosurgery, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Kore
| | - Jin Woo Kim
- Department of Radiology, Inje University Ilsan Paik Hospital, Ilsan, Republic of Korea
| | - Jun Soo Byun
- Department of Radiology, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Sangil Suh
- Department of Radiology, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Jeong Jin Park
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Woong Jae Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Jieun Roh
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Byoung-soo Shin
- Department of Neurology, Chonbuk National University Medical School and Hospital, Jeonju, Republic of Korea
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106
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Chung JW, Kim YC, Cha J, Choi EH, Kim BM, Seo WK, Kim GM, Bang OY. Characterization of clot composition in acute cerebral infarct using machine learning techniques. Ann Clin Transl Neurol 2019; 6:739-747. [PMID: 31019998 PMCID: PMC6469248 DOI: 10.1002/acn3.751] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/31/2019] [Accepted: 02/11/2019] [Indexed: 01/01/2023] Open
Abstract
Objective Clot characteristics can provide information on the cause of cerebral artery occlusion and may guide acute revascularization and secondary prevention strategies. We developed a rapid automated clot analysis system using machine learning (ML) and validated its accuracy in patients undergoing endovascular treatment. Methods Pre‐endovascular treatment gradient echo (GRE) images from consecutive patients with middle cerebral artery occlusion were utilized to develop and validate an ML system to predict whether atrial fibrillation (AF) was the underlying cause of ischemic stroke. The accuracy of the ML algorithm was compared with that of visual inspection by neuroimaging specialists for the presence of blooming artifact. Endovascular procedures and outcomes were compared in patients with and without AF. Results Of 67 patients, 29 (43.3%) had AF. Of these, 13 had known AF and 16 were newly diagnosed with cardiac monitoring. By visual inspection, interrater correlation for blooming artifact was 0.73 and sensitivity and specificity for AF were 0.79 and 0.63, respectively. For AF classification, the ML algorithms yielded an average accuracy of > 75.4% in fivefold cross‐validation with clot signal profiles obtained from 52 patients and an area under the curve >0.87 for the average AF probability from five signal profiles in external validation (n = 15). Analysis with an in‐house interface took approximately 3 min per patient. Absence of AF was associated with increased number of passes by stentriever, high reocclusion frequency, and additional use of rescue stenting and/or glycogen IIb/IIIa blocker for recanalization. Interpretation ML‐based rapid clot analysis is feasible and can identify AF with high accuracy, enabling selection of endovascular treatment strategy.
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Affiliation(s)
- Jong-Won Chung
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Yoon-Chul Kim
- Clinical Research Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Jihoon Cha
- Department of Radiology Yonsei University Medical Center Yonsei University College of Medicine Seoul Republic of Korea
| | - Eun-Hyeok Choi
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Byung Moon Kim
- Department of Radiology Yonsei University Medical Center Yonsei University College of Medicine Seoul Republic of Korea
| | - Woo-Keun Seo
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Gyeong-Moon Kim
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Oh Young Bang
- Department of Neurology Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
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107
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Li DD, Huang H, Fang JH, Fu FW, Lin J, Bai GH, Xu SY, Sheng HS, Zhou Q, Zhang N, Yin B. Solitaire Stent Permanent Implantation as an Effective Rescue Treatment for Emergency Large Artery Occlusion. World Neurosurg 2019; 124:e533-e539. [PMID: 30664959 DOI: 10.1016/j.wneu.2018.12.145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/21/2018] [Accepted: 12/24/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND In this study, we present our experiences on the feasibility of rescue permanent Solitaire stent placement for failed mechanical thrombectomy (MT) and our protocol to avoid ineffective stent placement. METHODS We retrospectively evaluated the data for consecutive patients admitted into the Second Affiliated Hospital of Wenzhou Medical University and 2 collaboration hospitals from August 2014 to May 2018 for emergency large artery occlusion. The baseline clinical characteristics and radiologic assessment, interventional data, clinical outcome, and angiographic follow-up data were assessed. Notably, we introduced our protocol for antegrade flow assessment before Solitaire stent detachment to ensure an effective stent implantation. RESULTS Thirty-nine patients (mean age, 68.1 years, mean preprocedural National Institute of Health Scale Score, 22.1) were included, in which 34 patients had anterior circulation large artery occlusion and 5 patients had posterior circulation large artery occlusion. The MT attempts ranged from 1-5 (3.6 on average). The mean onset-to-puncture time was 4.8 hours (ranging from 2.1-7.8 hours) and the mean procedure time was 87.4 minutes (ranging from 32-124 minutes). Modified thrombolysis in cerebral infarction 2b-3 reperfusions were noted in all cases. The immediate, average postprocedure stenosis rate was 25.3%, and the average stenosis rate at the 3-month angiographic follow-up was 34.7% (data from 15 patients). Three patients died. Nineteen (48.7%) patients had good outcome (modified Rankin Scale, mRS ≤2) at the 3-month follow-up. CONCLUSIONS Permanent Solitaire stent placement might be a feasible therapy for patients with MT-failed emergency large artery occlusion. For a successful revascularization, careful antegrade flow assessment before stent detachment is critical.
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Affiliation(s)
- Dan-Dong Li
- Department of Neurosurgery, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| | - Huan Huang
- Department of Radiology, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| | - Jun-Hao Fang
- Department of Neurosurgery, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| | - Fang-Wang Fu
- Department of Neurology, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| | - Jian Lin
- Department of Neurosurgery, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| | - Guang-Hui Bai
- Department of Radiology, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| | - Shang-Yu Xu
- Department of Neurosurgery, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| | - Han-Song Sheng
- Department of Neurosurgery, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| | - Qian Zhou
- Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| | - Nu Zhang
- Department of Neurosurgery, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| | - Bo Yin
- Department of Neurosurgery, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China.
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108
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Lee JS, Lee SJ, Hong JM, Choi JW, Yoo J, Hong JH, Kim CH, Kim YW, Kang DH, Kim YS, Hwang YH, Sohn SI. Solitaire Thrombectomy for Acute Stroke Due to Intracranial Atherosclerosis-Related Occlusion: ROSE ASSIST Study. Front Neurol 2018; 9:1064. [PMID: 30619033 PMCID: PMC6297378 DOI: 10.3389/fneur.2018.01064] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/22/2018] [Indexed: 01/01/2023] Open
Abstract
Background: Solitaire, a representative stent retriever, has shown high performance in removing embolic clots. However, its reperfusion potential in intracranial atherosclerotic stenosis (ICAS)-related occlusions has rarely been reported. In this ROSE ASSIST study, we hypothesized that Solitaire device is as effective and safe for removing in situ thrombi in ICAS-related occlusions as it is for removal of embolic occlusions. Methods: Data from ASIAN KR, an observational multicenter registry (n = 720) enrolling patients who have undergone endovascular treatment for acute cervicocephalic artery occlusions, were retrospectively reviewed. Through blinded evaluations, occlusions were classified as ICAS-related (significant fixed focal stenosis observed at the occlusion site during endovascular treatment) or embolic (no or minimal stenosis observed). Among patients treated within 720 min after stroke onset, those who undertook Solitaire thrombectomy and whose underlying etiology was ICAS-related or embolic were included. The primary endpoint was immediate successful reperfusion (modified Treatment In Cerebral Ischemia 2b−3) after Solitaire stent retrieval. The safety endpoint included intracerebral hemorrhagic transformation and subarachnoid hemorrhage. Comparative analyses were performed between embolic and ICAS-related occlusions with 2:1 propensity score matching. Results: In total, 303 patients (embolic, 228; ICAS-related, 75) were included in the analyses. As for the primary endpoint, the immediate successful reperfusion rate following Solitaire thrombectomy did not differ between the two etiologic groups after propensity score matching (73.1% embolic vs. 65.8% ICAS-related, p = 0.261). The final successful reperfusion grade was also similar in the two groups (79.3 vs. 72.0%, p = 0.219). The grades and frequencies of intracerebral hemorrhagic transformation and subarachnoid hemorrhage did not differ between groups (p = 0.134 and p = 0.269, respectively). Conclusions: The immediate reperfusion performance in terms of thrombus removal of Solitaire thrombectomy for ICAS-related occlusions was similar to that for embolic occlusions.
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Affiliation(s)
- Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Seong-Joon Lee
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Jin Wook Choi
- Department of Radiology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Joonsang Yoo
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Yong-Won Kim
- Department of Neurology, Kyungpook National University School of Medicine, Daegu, South Korea.,Department of Radiology, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Dong-Hun Kang
- Department of Radiology, Kyungpook National University School of Medicine, Daegu, South Korea.,Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Yong-Sun Kim
- Department of Radiology, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University School of Medicine, Daegu, South Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
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109
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Wareham J, Flood R, Phan K, Crossley R, Mortimer A. A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy. J Neurointerv Surg 2018; 11:675-682. [PMID: 30415225 DOI: 10.1136/neurintsurg-2018-014459] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 10/18/2018] [Accepted: 10/19/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND The crucial role of thrombectomy in the management of emergent large vessel occlusive stroke is not disputed but there is a technical failure rate in a significant minority of patients whose outcomes are often poor. Our objective was to perform a systematic review and meta-analysis to assess the safety and efficacy of permanent self-expandable stent deployment as a bailout procedure in cases of failed anterior circulation thrombectomy. METHODS Two independent reviewers searched the Pubmed (Medline) database for studies reporting outcomes following failed endovascular thrombectomy with subsequent rescue therapy employing self-expandable stents. RESULTS Eight studies (one prospective, seven retrospective) originating from Europe, Asia, and America comprising 160 patients met the inclusion criteria. Estimated baseline National Institutes of Health Stroke Scale score was 17.1 (95% CI 15.7 to 18.4). Following failed thrombetcomy and stent deployment, the rate of favorable outcome (modified Rankin Scale score 0-2) was 43% (95% CI 34% to 53%). Pooled mortality was 21% (95% CI 13% to 33%). Successful recanalization (Thrombolysis in Cerebral Infarction (TICI) 2b-3 or Thrombolysis in Myocardial Infarction (TIMI) 2-3) was 71% (95% CI 63% to 77%). Symptomatic intracerebral hemorrhage was seen in 12% (95% CI 7% to 18%). The Solitaire stent (Medtronic) was the most commonly deployed stent following failed thrombectomy attempts (66%; 95% CI 31% to 89%). Pre- or post-stent angioplasty was performed in 39%of patients (95% CI 29% to 48%). Glycoprotein IIb/IIIa inhibitors were used in 89% (95% CI 71% to 97%). 95% of patients received postprocedural antiplatelet therapy. CONCLUSION A rescue stent procedure seems reasonable as a last resort following failed thrombectomy but currently the level of evidence is limited. Prospective registries may aid in guiding future recommendations.
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Affiliation(s)
- James Wareham
- Department of Neuroradiology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Richard Flood
- Department of Neuroradiology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Neuro Spine Clinic, Sydney, New South Wales, Australia
| | - Robert Crossley
- Department of Neuroradiology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Alex Mortimer
- Department of Neuroradiology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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110
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Baek JH, Kim BM, Heo JH, Kim DJ, Nam HS, Kim YD. Outcomes of Endovascular Treatment for Acute Intracranial Atherosclerosis–Related Large Vessel Occlusion. Stroke 2018; 49:2699-2705. [DOI: 10.1161/strokeaha.118.022327] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jang-Hyun Baek
- From the Department of Neurology, National Medical Center, Seoul, Republic of Korea (J.-H.B.)
- Department of Neurology (J.-H.B., J.H.H., H.S.N., Y.D.K.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung Moon Kim
- Division of Interventional Neuroradiology, Department of Radiology (B.M.K., D.J.K.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Hoe Heo
- Department of Neurology (J.-H.B., J.H.H., H.S.N., Y.D.K.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Joon Kim
- Division of Interventional Neuroradiology, Department of Radiology (B.M.K., D.J.K.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyo Suk Nam
- Department of Neurology (J.-H.B., J.H.H., H.S.N., Y.D.K.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Dae Kim
- Department of Neurology (J.-H.B., J.H.H., H.S.N., Y.D.K.), Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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111
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Kaesmacher J, Gralla J, Mosimann PJ, Zibold F, Heldner MR, Piechowiak E, Dobrocky T, Arnold M, Fischer U, Mordasini P. Reasons for Reperfusion Failures in Stent-Retriever-Based Thrombectomy: Registry Analysis and Proposal of a Classification System. AJNR Am J Neuroradiol 2018; 39:1848-1853. [PMID: 30166434 DOI: 10.3174/ajnr.a5759] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 06/25/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE In 5%-10% of patients with acute ischemic stroke with an intention to treat with mechanical thrombectomy, no reperfusion can be achieved (Thrombolysis in Cerebral Infarction score = 0/1). Purpose of this analysis was a systematic assessment of underlying reasons for reperfusion failures. MATERIALS AND METHODS An intention-to-treat single-center cohort (n = 592) was re-evaluated for all patients in whom no reperfusion could be achieved (n = 63). Baseline characteristics of patients were compared between patients with and without reperfusion failures. After qualitative review of all cases with reperfusion failures, a classification system was proposed and relative frequencies were reported. In a second step, occurrence of delayed recanalization at 24 hours after reperfusion failure and dependency on IV-tPA were evaluated. RESULTS In 63/592 patients with an intention to perform stent-retriever thrombectomy, no reperfusion was achieved (TICI 0/1, 10.6%, 95% CI, 8.2%-13.1%). Older patients (adjusted OR per yr = 1.03; 95% CI, 1.01-1.05) and patients with M2 occlusion (adjusted OR = 3.36; 95% CI, 1.82-6.21) were at higher risk for reperfusion failure. In most cases, no reperfusion was a consequence of technical difficulties (56/63, 88.9%). In one-third of these cases, reperfusion failures were due to the inability to reach the target occlusion (20/63, 31.7%), while "stent-retriever failure" occurred in 39.7% (25/63) of patients. Delayed recanalization was very rare (18.2%), without dependence on IV-tPA pretreatment status. CONCLUSIONS Reasons for reperfusion failure in stent-retriever thrombectomy are heterogeneous. The failure to establish intracranial or cervical access is almost as common as stent-retriever failure after establishing intracranial access. Systematic reporting standards of reasons may help to further estimate relative frequencies and thereby guide priorities for technical development and scientific effort.
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Affiliation(s)
- J Kaesmacher
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini)
- Department of Neurology (J.K., M.R.H., M.A., U.F.), University Hospital Bern and University of Bern, Inselspital, Bern, Switzerland
| | - J Gralla
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini)
| | - P J Mosimann
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini)
| | - F Zibold
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini)
| | - M R Heldner
- Department of Neurology (J.K., M.R.H., M.A., U.F.), University Hospital Bern and University of Bern, Inselspital, Bern, Switzerland
| | - E Piechowiak
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini)
| | - T Dobrocky
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini)
| | - M Arnold
- Department of Neurology (J.K., M.R.H., M.A., U.F.), University Hospital Bern and University of Bern, Inselspital, Bern, Switzerland
| | - U Fischer
- Department of Neurology (J.K., M.R.H., M.A., U.F.), University Hospital Bern and University of Bern, Inselspital, Bern, Switzerland
| | - P Mordasini
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini)
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112
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Lee JS, Lee SJ, Yoo JS, Hong JH, Kim CH, Kim YW, Kang DH, Kim YS, Hong JM, Choi JW, Ovbiagele B, Demchuk AM, Sohn SI, Hwang YH. Prognosis of Acute Intracranial Atherosclerosis-Related Occlusion after Endovascular Treatment. J Stroke 2018; 20:394-403. [PMID: 30309234 PMCID: PMC6186924 DOI: 10.5853/jos.2018.01627] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 09/04/2018] [Indexed: 01/01/2023] Open
Abstract
Background and Purpose Little is known about prognosis after endovascular therapy (EVT) for acute large artery occlusion (LAO) caused by underlying intracranial atherosclerotic stenosis (ICAS). Therefore, we investigated the prognosis following EVT according to the underlying etiology of LAO.
Methods Patients from the Acute Stroke due to Intracranial Atherosclerotic occlusion and Neurointervention-Korean Retrospective (ASIAN KR) registry (n=720) were included if their occlusion was in the intracranial anterior circulation and their onset-to-puncture time was <24 hours. Occlusion was classified according to etiology as follows: no significant stenosis after recanalization (Embolic group), and fixed significant focal stenosis in the occlusion site with flow impairment or re-occlusion observed during EVT (ICAS group). Patients were excluded when significant extracranial carotid lesions existed, and when the intracranial occlusion was intractable to EVT so that the etiology was undetermined. The effect of angiographic etiologic classification on outcomes was evaluated using multivariable analysis that was adjusted for potential confounders.
Results Among eligible patients (n=520), 421 and 99 were classified in the Embolic and ICAS groups, respectively. Patients in the Embolic and ICAS groups had similar successful reperfusion rates with EVT (79.6% vs. 76.8%, P=0.537) and 3-month functional independence (54.5% vs. 45.5%, P=0.104). In multivariable analysis, ICAS-related occlusion (odds ratio, 0.495; 95% confidence interval, 0.269 to 0.913; P=0.024) showed poorer 3-month functional independence compared to embolic occlusion.
Conclusions After EVT, patients with acute ICAS-related occlusion have relatively poor functional outcomes compared to those with embolic occlusion. Novel strategies need to be developed to improve EVT outcomes for ICAS occlusion.
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Affiliation(s)
- Jin Soo Lee
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Korea
| | - Seong-Joon Lee
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Korea
| | - Joon Sang Yoo
- Department of Neurology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Yong-Won Kim
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.,Department of Radiology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Dong-Hun Kang
- Department of Radiology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.,Department of Neurosurgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yong-Sun Kim
- Department of Radiology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Korea
| | - Jin Wook Choi
- Department of Radiology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Korea
| | - Bruce Ovbiagele
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
| | - Andrew M Demchuk
- Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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113
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Delgado F, Oteros R, Jimenez-Gomez E, Bravo Rey I, Bautista MD, Valverde Moyano R. Half bolus dose of intravenous abciximab is safe and effective in the setting of acute stroke endovascular treatment. J Neurointerv Surg 2018; 11:147-152. [DOI: 10.1136/neurintsurg-2018-014163] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 11/03/2022]
Abstract
BackgroundA stent is often necessary for the treatment of stroke. In such cases,it is essential for the patient to have antiplatelet therapy. There are several methods of antiaggregation, such as oral loading doses of aspirin and clopidogrel, intravenous aspirin, or intravenous glycoprotein IIb/IIIa receptor antagonists, such as abciximab. The aim of this study was to evaluate the incidence of symptomatic intracerebral hematoma (sICH) associated with our antiplatelet protocol: intravenous abciximab bolus at half the dose (0125 mg/kg) at the time of the stenting procedure; oral aspirin (150 mg) and clopidogrel (75 mg) daily added the next day after CT shows no significant hematoma.Materials and methodsRetrospective review of our database of endovascular management of large acute vessel occlusion treated with intravenous abciximab between January 2015 and March 2018. Demographics data, material, drugs, and complications were registered. Fisher tests were used to compare the incidence of sICH in the literature where abciximab 0.25 mg/kg plus maintenance doses are often administrated.ResultsIntravenous abciximab was administered to 99 patients. No sICH was observed. According to the European Cooperative Acute Stroke Study Scale, there were 8 cases of hemorrhagic infarction 1, 5 cases of hemorrhagic infarction 2, 4 cases of parenchymal hemorrhage 1, and no cases of parenchymal hemorrhage 2. A comparison between sICH with conventional antiplatelet doses based on the literature showed a statistically significant difference favoring our protocol.ConclusionIn the endovascular treatment of acute ischemic stroke, a bolus dose of 0125 mg/kg of abciximab with no maintenance doses, followed by 150 mg of aspirin and 75 mg of clopidogrel orally the next day, is safe and effective.
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114
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Nappini S, Limbucci N, Leone G, Rosi A, Renieri L, Consoli A, Laiso A, Valente I, Rosella F, Rosati R, Mangiafico S. Bail-out intracranial stenting with Solitaire AB device after unsuccessful thrombectomy in acute ischemic stroke of anterior circulation. J Neuroradiol 2018; 46:141-147. [PMID: 29920349 DOI: 10.1016/j.neurad.2018.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 04/26/2018] [Accepted: 05/25/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Recent trials established the efficacy of mechanical stent-retriever thrombectomy for treatment of stroke patients with large vessel occlusion (LVO) in the anterior circulation. However, stent-retriever thrombectomy may not accomplish successful recanalization in all patients. The aim of this study is to report the role of bail-out permanent stenting after failure of mechanical thrombectomy. METHODS Among 430 patients included in a prospectively maintained database, we analysed 325 cases of anterior circulation LVO. Mechanical thrombectomy (mTICI 2b-3) was effective in 213/325 (65%) and failed in 112/325 (35%). Bail-out intracranial stenting was performed in 17/325 (5.2%) patients. In all cases a fully retrievable detachable stent was used (Solitaire AB, Medtronic). RESULTS No intraprocedural technical complications occurred. Successful reperfusion (mTICI 2b/3) was achieved in 12/17 patients (70.6%). Three (17.6%) patients died: one extensive infarction in the internal carotid artery territory, one large intracerebral haemorrhage, and one massive pulmonary embolism. Haemorrhagic conversion, both symptomatic and asymptomatic, occurred in 2/17 (11.7%). Good clinical outcome (mRS 0-2) at 3-months was achieved in 41.2% of patients. CONCLUSION Bail-out intracranial stenting after unsuccessful thrombectomy is technically feasible and the associated haemorrhagic risk seems acceptable in selected patients. We suggest that bail-out intracranial stenting, is safe and effective in selected patients with LVO stroke who failed to respond to thrombectomy.
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Affiliation(s)
- Sergio Nappini
- Neurovascular Interventional Unit, Careggi University Hospital, Florence. Largo P. Palagi, 1-50134 Florence, Italy.
| | - Nicola Limbucci
- Neurovascular Interventional Unit, Careggi University Hospital, Florence. Largo P. Palagi, 1-50134 Florence, Italy.
| | - Giuseppe Leone
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy.
| | - Andrea Rosi
- Neurovascular Interventional Unit, Careggi University Hospital, Florence. Largo P. Palagi, 1-50134 Florence, Italy.
| | - Leonardo Renieri
- Neurovascular Interventional Unit, Careggi University Hospital, Florence. Largo P. Palagi, 1-50134 Florence, Italy.
| | - Arturo Consoli
- Neurovascular Interventional Unit, Careggi University Hospital, Florence. Largo P. Palagi, 1-50134 Florence, Italy.
| | - Antonio Laiso
- Neurovascular Interventional Unit, Careggi University Hospital, Florence. Largo P. Palagi, 1-50134 Florence, Italy.
| | - Iacopo Valente
- Department of Bioimaging and Radiological Sciences, Institute of Radiology, "A. Gemelli" Hospital-Catholic University, Rome, Italy.
| | - Francesco Rosella
- Department of Bioimaging and Radiological Sciences, Institute of Radiology, "A. Gemelli" Hospital-Catholic University, Rome, Italy.
| | - Riccardo Rosati
- Vascular and Interventional Radiology Unit, Department of Radiological, Oncological and Anatomo-pathological Sciences, Sapienza University of Rome, Rome, Italy.
| | - Salvatore Mangiafico
- Neurovascular Interventional Unit, Careggi University Hospital, Florence. Largo P. Palagi, 1-50134 Florence, Italy.
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Affiliation(s)
- Jens Fiehler
- From the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
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