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Mechanical Thrombectomy for Distal Occlusions: Efficacy, Functional and Safety Outcomes: Insight from the STAR Collaboration. World Neurosurg 2021; 151:e871-e879. [PMID: 33974981 DOI: 10.1016/j.wneu.2021.04.136] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the standard of care for the treatment of proximal anterior circulation large vessel occlusions. However, little is known about its efficacy and safety in the treatment of distal intracranial occlusions. METHODS This is a multicenter retrospective study of patients treated with MT at 15 comprehensive centers between January 2015 and December 2018. The study cohort was divided into 2 groups based on the location of occlusion (proximal vs. distal). Distal occlusion was defined as occlusion of M3 segment of the middle cerebral artery, any segment of the anterior cerebral artery, or any segment of the posterior cerebral artery. Only isolated distal occlusion was included. Good outcome was defined as 90-day modified Rankin scale score 0-2. RESULTS A total of 4710 patients were included in this study, of whom 189 (4%) had MT for distal occlusions. Compared with the proximal occlusion group, distal occlusion group had a higher rate of good outcome (45% vs. 36%; P = 0.03) and a lower rate of successful reperfusion (78% vs. 84%; P = 0.04). However, the differences did not retain significance in adjusted models. Otherwise there was no difference in the rate of hemorrhagic complications, mortality, or procedure-related complications between the 2 groups. Successful reperfusion, age, and admission stroke severity emerged as predictors of good functional outcome in the distal occlusion group. CONCLUSIONS Thrombectomies of distal vessels achieve high rate of successful reperfusion with similar safety profile to those in more proximal locations.
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202
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Cimflova P, Kappelhof M, Singh N, Kashani N, Ospel JM, McDonough R, Demchuk AM, Menon BK, Sakai N, Chen M, Fiehler J, Goyal M. Factors influencing thrombectomy decision making for primary medium vessel occlusion stroke. J Neurointerv Surg 2021; 14:350-355. [PMID: 33947769 DOI: 10.1136/neurintsurg-2021-017472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND We aimed to explore the preference of stroke physicians to treat patients with primary medium vessel occlusion (MeVO) stroke with immediate endovascular treatment (EVT) in an international cross-sectional survey, as there is no clear guideline recommendation for EVT in these patients. METHODS In the survey MeVO-Finding Rationales and Objectifying New Targets for IntervEntional Revascularization in Stroke (MeVO-FRONTIERS), participants were shown four cases of primary MeVOs (six scenarios per case) and asked whether they would treat those patients with EVT. Multivariable logistic regression with clustering by respondent was performed to assess factors influencing the decision to treat. Dominance analysis was performed to assess the influence of factors within the scenarios on decision making. RESULTS Overall, 366 participants (56 women; 15%) from 44 countries provided 8784 answers to 24 scenarios. Most physicians (59.2%) would treat patients immediately with EVT. Younger patient age (incidence rate ratio (IRR) 1.24, 99% CI 1.19 to 1.30), higher National Institutes of Health Stroke Scale (NIHSS) score (IRR 1.69, 99% CI 1.57 to 1.82), and small core volume (IRR 1.35, 99% CI 1.24 to 1.46) were positively associated with the decision to treat with EVT. Interventionalists (IRR 1.26, 99% CI 1.01 to 1.56) were more likely to treat patients with MeVO immediately with EVT. In the dominance analysis, factors influencing the decision in favor of EVT were (in order of importance): baseline NIHSS, core volume, alteplase use, patients' age, and occlusion site. CONCLUSIONS Most physicians in this survey were interventionalists and would treat patients with MeVO stroke immediately with EVT. This finding supports the need for robust clinical evidence.
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Affiliation(s)
- Petra Cimflova
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Medical Imaging, Fakultní nemocnice u sv Anny v Brně, Brno, Czech Republic
| | - Manon Kappelhof
- Radiology and Nuclear Medicine, University of Amsterdam, Amsterdam, The Netherlands.,Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Nishita Singh
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Nima Kashani
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada.,Neuroradiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Johanna Maria Ospel
- Radiology and Nuclear Medicine, Universitatsspital Basel, Basel, Switzerland
| | - Rosalie McDonough
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada.,Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Andrew M Demchuk
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Bijoy K Menon
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Michael Chen
- Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Mayank Goyal
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
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203
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Meyer L, Stracke CP, Jungi N, Wallocha M, Broocks G, Sporns PB, Maegerlein C, Dorn F, Zimmermann H, Naziri W, Abdullayev N, Kabbasch C, Behme D, Jamous A, Maus V, Fischer S, Möhlenbruch M, Weyland CS, Langner S, Meila D, Miszczuk M, Siebert E, Lowens S, Krause LU, Yeo LLL, Tan BYQ, Anil G, Gory B, Galván J, Arteaga MS, Navia P, Raz E, Shapiro M, Arnberg F, Zelenák K, Martinez-Galdamez M, Fischer U, Kastrup A, Roth C, Papanagiotou P, Kemmling A, Gralla J, Psychogios MN, Andersson T, Chapot R, Fiehler J, Kaesmacher J, Hanning U. Thrombectomy for Primary Distal Posterior Cerebral Artery Occlusion Stroke: The TOPMOST Study. JAMA Neurol 2021; 78:434-444. [PMID: 33616642 DOI: 10.1001/jamaneurol.2021.0001] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Importance Clinical evidence of the potential treatment benefit of mechanical thrombectomy for posterior circulation distal, medium vessel occlusion (DMVO) is sparse. Objective To investigate the frequency as well as the clinical and safety outcomes of mechanical thrombectomy for isolated posterior circulation DMVO stroke and to compare them with the outcomes of standard medical treatment with or without intravenous thrombolysis (IVT) in daily clinical practice. Design, Setting, and Participants This multicenter case-control study analyzed patients who were treated for primary distal occlusion of the posterior cerebral artery (PCA) of the P2 or P3 segment. These patients received mechanical thrombectomy or standard medical treatment (with or without IVT) at 1 of 23 comprehensive stroke centers in Europe, the United States, and Asia between January 1, 2010, and June 30, 2020. All patients who met the inclusion criteria were matched using 1:1 propensity score matching. Interventions Mechanical thrombectomy or standard medical treatment with or without IVT. Main Outcomes and Measures Clinical end point was the improvement of National Institutes of Health Stroke Scale (NIHSS) scores at discharge from baseline. Safety end point was the occurrence of symptomatic intracranial hemorrhage and hemorrhagic complications were classified based on the Second European-Australasian Acute Stroke Study (ECASSII). Functional outcome was evaluated with the modified Rankin Scale (mRS) score at 90-day follow-up. Results Of 243 patients from all participating centers who met the inclusion criteria, 184 patients were matched. Among these patients, the median (interquartile range [IQR]) age was 74 (62-81) years and 95 (51.6%) were female individuals. Posterior circulation DMVOs were located in the P2 segment of the PCA in 149 patients (81.0%) and in the P3 segment in 35 patients (19.0%). At discharge, the mean NIHSS score decrease was -2.4 points (95% CI, -3.2 to -1.6) in the standard medical treatment cohort and -3.9 points (95% CI, -5.4 to -2.5) in the mechanical thrombectomy cohort, with a mean difference of -1.5 points (95% CI, 3.2 to -0.8; P = .06). Significant treatment effects of mechanical thrombectomy were observed in the subgroup of patients who had higher NIHSS scores on admission of 10 points or higher (mean difference, -5.6; 95% CI, -10.9 to -0.2; P = .04) and in the subgroup of patients without IVT (mean difference, -3.0; 95% CI, -5.0 to -0.9; P = .005). Symptomatic intracranial hemorrhage occurred in 4 of 92 patients (4.3%) in each treatment cohort. Conclusions and Relevance This study suggested that, although rarely performed at comprehensive stroke centers, mechanical thrombectomy for posterior circulation DMVO is a safe, and technically feasible treatment option for occlusions of the P2 or P3 segment of the PCA compared with standard medical treatment with or without IVT.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Paul Stracke
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Interventional Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Noël Jungi
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marta Wallocha
- Department of Endovascular Therapy, Alfried-Krupp Hospital Essen, Essen, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter B Sporns
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Franziska Dorn
- Institute of Neuroradiology, University Hospitals, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Hanna Zimmermann
- Institute of Neuroradiology, University Hospitals, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Weis Naziri
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Department of Neuroradiology, University Hospital Luebeck, Luebeck, Germany
| | - Nuran Abdullayev
- Department of Neuroradiology, University of Cologne, Cologne, Germany
| | | | - Daniel Behme
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital Goettingen, Goettingen, Germany
| | - Ala Jamous
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital Goettingen, Goettingen, Germany
| | - Volker Maus
- Department of Diagnostic and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Universitätsklinik der Ruhr-Universität Bochum, Bochum, Germany
| | - Sebastian Fischer
- Department of Diagnostic and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Universitätsklinik der Ruhr-Universität Bochum, Bochum, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Sönke Langner
- Institute for Diagnostic and Interventional Radiology, Pediatric and Neuroradiology, University Hospital Rostock, Rostock, Germany
| | - Dan Meila
- Department of Interventional Neuroradiology, Johanna-Étienne-Hospital, Neuss, Germany
| | - Milena Miszczuk
- Institute of Neuroradiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan Lowens
- Department of Radiology, Klinikum Osnabrück, Osnabrück, Germany
| | - Lars Udo Krause
- Department of Neurology, Klinikum Osnabrück, Osnabrück, Germany
| | - Leonard L L Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin Yong-Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gopinathan Anil
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Diagnostic Imaging, National University Health System, Singapore
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France.,Université de Lorraine, Imagerie Adaptative Diagnostique et Interventionnelle, INSERM U1254, Nancy, France
| | - Jorge Galván
- Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Miguel Schüller Arteaga
- Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Pedro Navia
- Department of Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Eytan Raz
- Department of Radiology, New York Langone Medical Center, New York
| | - Maksim Shapiro
- Department of Radiology, New York Langone Medical Center, New York
| | - Fabian Arnberg
- Department of Neuroradiology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Kamil Zelenák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Mario Martinez-Galdamez
- Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Kastrup
- Department of Neurology, Hospital Bremen-Mitte, Bremen, Germany
| | - Christian Roth
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany.,Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - André Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Department of Neuroradiology, University Hospital Luebeck, Luebeck, Germany
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marios-Nikos Psychogios
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Rene Chapot
- Department of Endovascular Therapy, Alfried-Krupp Hospital Essen, Essen, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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204
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Sporns PB, Fiehler J, Ospel J, Safouris A, Hanning U, Fischer U, Goyal M, McTaggart R, Brehm A, Psychogios M. Expanding indications for endovascular thrombectomy-how to leave no patient behind. Ther Adv Neurol Disord 2021; 14:1756286421998905. [PMID: 33796144 PMCID: PMC7970189 DOI: 10.1177/1756286421998905] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 01/18/2021] [Indexed: 01/01/2023] Open
Abstract
Endovascular thrombectomy (EVT) has become standard of care for large vessel occlusion strokes but current guidelines exclude a large proportion of patients from this highly effective treatment. This review therefore focuses on expanding indications for EVT in several borderline indications such as patients in the extended time window, patients with extensive signs of infarction on admission imaging, elderly patients and patients with pre-existing deficits. It also discusses the current knowledge on intravenous thrombolysis as an adjunct to EVT and EVT as primary therapy for distal vessel occlusions, for tandem occlusions, for basilar artery occlusions and in pediatric patients. We provide clear recommendations based on current guidelines and further literature.
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Affiliation(s)
- Peter B. Sporns
- Department of Neuroradiology, Clinic for
Radiology & Nuclear Medicine, University Hospital Basel, Petersgraben 4,
Basel, 4031, Switzerland
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg,
Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg,
Germany
| | - Johanna Ospel
- Department of Neuroradiology, Clinic for
Radiology & Nuclear Medicine, University Hospital Basel, Basel,
Switzerland
| | | | - Uta Hanning
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg,
Germany
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern
University Hospital, University of Bern, Bern, Switzerland
| | - Mayank Goyal
- Department of Radiology, University of Calgary,
Calgary, AB, Canada
| | - Ryan McTaggart
- Department of Interventional Radiology, Warren
Alpert Medical School of Brown University, Providence, RI, USA
| | - Alex Brehm
- Department of Neuroradiology, Clinic for
Radiology & Nuclear Medicine, University Hospital Basel, Basel,
Switzerland
| | - Marios Psychogios
- Department of Neuroradiology, Clinic for
Radiology & Nuclear Medicine, University Hospital Basel, Basel,
Switzerland
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205
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Ospel JM, Goyal M. A review of endovascular treatment for medium vessel occlusion stroke. J Neurointerv Surg 2021; 13:623-630. [PMID: 33637570 DOI: 10.1136/neurintsurg-2021-017321] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/17/2021] [Accepted: 02/17/2021] [Indexed: 11/04/2022]
Abstract
Medium-vessel occlusions (MeVOs), that is, occlusions of the M2/3 middle cerebral artery, A2/3 anterior cerebral artery, and P2/3 posterior cerebral artery segments, account for 25%-40% of all acute ischemic stroke cases. Clinical outcomes of MeVO stroke with intravenous thrombolysis, which is the current standard of care, are moderate at best. With improving imaging technologies and a growing literature, MeVOs are increasingly recognized as a target for endovascular treatment (EVT). For the time being, there is limited but promising evidence for the safety and efficacy of MeVO EVT, and many neurointerventionists are already routinely offering EVT for MeVO stroke, despite the lack of clear guideline recommendations. In this article, we review the evidence on endovascular treatment for MeVO stroke and summarize the available literature on current imaging strategies, commonly used EVT selection criteria, EVT techniques, and outcome assessment for MeVO stroke.
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Affiliation(s)
- Johanna Maria Ospel
- Radiology, Universitatsspital Basel, Basel, Switzerland.,Clinical Neuroscienes, University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Clinical Neuroscienes, University of Calgary, Calgary, Alberta, Canada .,Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
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206
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Goyal M, Kappelhof M, McDonough R, Ospel JM. Secondary Medium Vessel Occlusions: When Clots Move North. Stroke 2021; 52:1147-1153. [PMID: 33467882 DOI: 10.1161/strokeaha.120.032799] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Medium vessel occlusions (MeVOs, ie, M2, M3, A2, A3, P2, and P3 segment occlusions) are increasingly recognized as a target for endovascular treatment in acute ischemic stroke. It is important to note that not all MeVOs are equal. Primary MeVOs occur de novo with the underlying mechanisms being very similar to large vessel occlusion strokes. Secondary MeVOs arise from large vessel occlusions through clot migration or fragmentation, either spontaneously or following treatment with intravenous thrombolysis or endovascular treatment. Currently, there are little data on the prevalence, management, and prognosis of acute ischemic stroke due to secondary MeVOs. This type of stroke is, however, likely to become more relevant in the future as indications for endovascular treatment continue to broaden. In this article, we describe different types of secondary MeVOs, imaging findings associated with them, challenges related to the diagnosis of secondary MeVOs, and their potential implications for treatment strategies and clinical outcomes.
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Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences (M.G., M.K., J.M.O.), University of Calgary, Canada.,Department of Radiology (M.G.), University of Calgary, Canada
| | - Manon Kappelhof
- Department of Clinical Neurosciences (M.G., M.K., J.M.O.), University of Calgary, Canada.,University Medical Center Amsterdam, the Netherlands (M.K.)
| | - Rosalie McDonough
- Department of Neuroradiology, University Hospital Hamburg Eppendorf, Germany (R.M.)
| | - Johanna Maria Ospel
- Department of Clinical Neurosciences (M.G., M.K., J.M.O.), University of Calgary, Canada.,Department of Neuroradiology, University Hospital Basel, Switzerland (J.M.O.)
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207
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Rikhtegar R, Mosimann PJ, Weber R, Wallocha M, Yamac E, Mirza-Aghazadeh-Attari M, Chapot R. Effectiveness of very low profile thrombectomy device in primary distal medium vessel occlusion, as rescue therapy after incomplete proximal recanalization or following iatrogenic thromboembolic events. J Neurointerv Surg 2021; 13:1067-1072. [PMID: 33468609 PMCID: PMC8606433 DOI: 10.1136/neurintsurg-2020-017035] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/24/2020] [Accepted: 11/28/2020] [Indexed: 12/18/2022]
Abstract
Background Recent progress with smaller retrievers has expanded the ability to reach distal brain arteries. We herein report recanalization, bleeding complications and short-term clinical outcomes with the smallest currently known low profile thrombectomy device in patients with primary or secondary distal medium vessel occlusion (DMVO). Methods We performed a retrospective analysis of 115 patients receiving mechanical thrombectomy (MT) in DMVO using the extended Thrombolysis in Cerebral Infarction (eTICI), European Cooperative Acute Stroke Study (ECASS) II classification, The National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores at admission and discharge to evaluate outcomes. Patients were stratified into three groups: (1) primary isolated distal occlusion (n=34), (2) secondary distal occlusion after MT of a proximal vessel occlusion (n=71), or (3) during endovascular treatment of aneurysms or arteriovenous malformations (AVMs) (n=10). Results Successful distal recanalization, defined as an eTICI score of 2b67, 2c and 3, was achieved in 74.7% (86/115) of patients. More specifically, it was 70.5% (24/34), 73.2% (52/71), and 100% (10/10) of primary DMVO, secondary DMVO after proximal MT, and rescue MT during aneurysm or AVM embolization, respectively. Symptomatic intraparenchymal bleeding occurred in 6.9% (eight patients). In-hospital mortality occurred in 18.1% (19/105) of patients with stroke. The most common cause of death was large infarct, old age, and therapy limitation. Conclusion Direct or rescue MT of DMVO using a very low profile thrombectomy device is associated with a high rate of successful recanalization and a reasonable rate of symptomatic hemorrhagic complication, despite a risk of 18.1% hospital mortality in elderly patients. Further trials are needed to confirm our results and assess long-term clinical outcomes.
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Affiliation(s)
- Reza Rikhtegar
- Department of Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | - Pascal John Mosimann
- Department of Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | - Ralph Weber
- Department of Neurology, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | - Marta Wallocha
- Department of Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | - Elif Yamac
- Department of Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Essen, Essen, Germany
| | | | - René Chapot
- Department of Intracranial Endovascular Therapy, Alfried Krupp Krankenhaus Essen, Essen, Germany
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208
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Amukotuwa SA, Wu A, Zhou K, Page I, Brotchie P, Bammer R. Time-to-Maximum of the Tissue Residue Function Improves Diagnostic Performance for Detecting Distal Vessel Occlusions on CT Angiography. AJNR Am J Neuroradiol 2021; 42:65-72. [PMID: 33431503 DOI: 10.3174/ajnr.a6891] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/28/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Detecting intracranial distal arterial occlusions on CTA is challenging but increasingly relevant to clinical decision-making. Our purpose was to determine whether the use of CTP-derived time-to-maximum of the tissue residue function maps improves diagnostic performance for detecting these occlusions. MATERIALS AND METHODS Seventy consecutive patients with a distal arterial occlusion and 70 randomly selected controls who underwent multimodal CT with CTA and CTP for a suspected acute ischemic stroke were included in this retrospective study. Four readers with different levels of experience independently read the CTAs in 2 separate sessions, with and without time-to-maximum of the tissue residue function maps, recording the presence or absence of an occlusion, diagnostic confidence, and interpretation time. Accuracy for detecting distal occlusions was assessed using receiver operating characteristic analysis, and areas under curves were compared to assess whether accuracy improved with use of time-to-maximum of the tissue residue function. Changes in diagnostic confidence and interpretation time were assessed using the Wilcoxon signed rank test. RESULTS Mean sensitivity for detecting occlusions on CTA increased from 70.7% to 90.4% with use of time-to-maximum of the tissue residue function maps. Diagnostic accuracy improved significantly for the 4 readers (P < .001), with areas under the receiver operating characteristic curves increasing by 0.186, 0.136, 0.114, and 0.121, respectively. Diagnostic confidence and speed also significantly increased. CONCLUSIONS All assessed metrics of diagnostic performance for detecting distal arterial occlusions improved with the use of time-to-maximum of the tissue residue function maps, encouraging their use to aid in interpretation of CTA by both experienced and inexperienced readers. These findings show the added diagnostic value of including CTP in the acute stroke imaging protocol.
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Affiliation(s)
- S A Amukotuwa
- From the Department of Diagnostic Imaging (S.A.A., A.W., K.Z.), Monash Health, Clayton, Australia .,Department of Radiology (S.A.A., P.B.), Barwon Health, Geelong, Australia
| | - A Wu
- From the Department of Diagnostic Imaging (S.A.A., A.W., K.Z.), Monash Health, Clayton, Australia
| | - K Zhou
- From the Department of Diagnostic Imaging (S.A.A., A.W., K.Z.), Monash Health, Clayton, Australia
| | - I Page
- Department of Radiology (I.P., R.B.), The Royal Melbourne Hospital, Parkville, Australia
| | - P Brotchie
- Department of Radiology (S.A.A., P.B.), Barwon Health, Geelong, Australia
| | - R Bammer
- Department of Radiology (I.P., R.B.), The Royal Melbourne Hospital, Parkville, Australia
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209
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Molad J. CT Perfusion: More Than What You Thought. AJNR Am J Neuroradiol 2021; 42:73-74. [PMID: 33431504 DOI: 10.3174/ajnr.a6969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- J Molad
- Department of Stroke and NeurologyTel-Aviv Sourasky Medical CenterTel-Aviv, Israel
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210
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Nogueira RG, Mohammaden MH, Haussen DC, Budzik RF, Gupta R, Krajina A, English JD, Malek AR, Sarraj A, Narata AP, Taqi MA, Frankel MR, Miller TR, Grobelny T, Baxter BW, Bartolini BM, Jenkins P, Estrade L, Liebeskind D, Veznedaroglu E. Endovascular therapy in the distal neurovascular territory: results of a large prospective registry. J Neurointerv Surg 2020; 13:979-984. [PMID: 33323503 DOI: 10.1136/neurintsurg-2020-016851] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/13/2020] [Accepted: 11/13/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND There is a paucity of data regarding mechanical thrombectomy (MT) in distal arterial occlusions (DAO). We aim to evaluate the safety and efficacy of MT in patients with DAO and compare their outcomes with proximal arterial occlusion (PAO) strokes. METHODS The Trevo Registry was a prospective open-label MT registry including 2008 patients from 76 sites across 12 countries. Patients were categorized into: PAO: intracranial ICA, and MCA-M1; and DAO: MCA-M2, MCA-M3, ACA, and PCA. Baseline and outcome variables were compared across the PAO vs DAO patients with pre-morbid mRS 0-2. RESULTS Among 407 DAOs including 350 (86.0%) M2, 25 (6.1%) M3, 10 (2.5%) ACA, and 22 (5.4%) PCA occlusions, there were 376 DAO with pre-morbid mRS 0-2 which were compared with 1268 PAO patients. The median baseline NIHSS score was lower in DAO (13 [8-18] vs 16 [12-20], P<0.001). There were no differences in terms of age, sex, IV-tPA use, co-morbidities, or time to treatment across DAO vs PAO. The rates of post-procedure reperfusion, symptomatic intracranial hemorrhage (sICH), and 90-mortality were comparable between both groups. DAO showed significantly higher rates of 90-day mRS 0-2 (68.3% vs 56.5%, P<0.001). After adjustment for potential confounders, the level of arterial occlusion was not associated with the chances of excellent outcome (DAO for 90-day mRS 0-1: OR; 1.18, 95% CI [0.90 to 1.54], P=0.225), successful reperfusion or SICH. However, DAO patients were more likely to be functionally independent (mRS 0-2: OR; 1.45, 95% CI [1,09 to 1.92], P=0.01) or dead (OR; 1.54, 95% CI [1.06 to 2.27], P=0.02) at 90 days. CONCLUSION Endovascular therapy in DAO appears to result in a comparable safety and technical success profile as in PAO. The potential benefits of DAO thrombectomy should be investigated in future randomized trials.
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Affiliation(s)
- Raul G Nogueira
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mahmoud H Mohammaden
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Diogo C Haussen
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ronald F Budzik
- Department of Neuroradiology, Riverside Methodist Hospital, Columbus, Ohio, USA
| | - Rishi Gupta
- Department of Neurosciences, WellStar Health System, Atlanta, Georgia, USA
| | - Antonin Krajina
- Department of Neuroradiology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Joey D English
- Department of Neurology, California Pacific Medical Center, San Francisco, California, USA
| | - Ali R Malek
- Neurointerventional & Comprehensive Stroke Program, Saint Mary Medical Center, Long Beach, California, USA
| | - Amrou Sarraj
- Neurology, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Ana Paula Narata
- Department of Radiology, Diagnostic and Interventional Neuroradiology Section, Regional University Hospital Centre Tours, Tours, Centre, France
| | - Muhammad Asif Taqi
- Department of Neurology, Vascular Neurology of Southern California, Thousand Oaks, California, USA
| | - Michael R Frankel
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Timothy Ryan Miller
- Department of Radiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Thomas Grobelny
- Advocate Neurovascular Center, Advocate Health Care Library Network, Park Ridge, Illinois, USA
| | - Blaise W Baxter
- Department of Radiology, University of Tennessee, Chattanooga, TN, USA
| | | | - Paul Jenkins
- Division of Biostatistics, Stryker Neurovascular, Fremont, California, USA
| | - Laurent Estrade
- Department of Interventional Neuroradiology, Centre Hospitalier Regional Universitaire de Lille, Lille, France
| | | | - Erol Veznedaroglu
- Department of Neurosciences, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
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211
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Mistry EA, Dumont AS. Medium Vessel Occlusion and Acute Ischemic Stroke: A Call for Treatment Paradigm Reappraisal. Stroke 2020; 51:3200-3202. [PMID: 33070709 PMCID: PMC8018715 DOI: 10.1161/strokeaha.120.032357] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eva A. Mistry
- Department of Neurology, Vanderbilt University Medical Center
| | - Aaron S. Dumont
- Department of Neurological Surgery, Tulane University School of Medicine
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