Endovascular Mechanical Recanalisation of Acute Carotid-T Occlusions: A Single-Center Retrospective Analysis

JET 7 catheter for direct aspiration in carotid T occlusions: preliminary experience and literature review

OBJECTIVE

We report our preliminary experience with the Penumbra JET 7 reperfusion catheter (JET 7), a new large-bore (0.072″) aspiration catheter, in patients with acute ischemic stroke (AIS) due to carotid T occlusion.

METHODS

Data of all eligible patients who received A Direct Aspiration First Pass Technique (ADAPT) for AIS due to carotid T occlusion at our center from March 2018 through June 2020 were retrospectively reviewed. The safety and performance of JET 7 cases and smaller large-bore catheters (LBCs) were compared.

RESULTS

JET 7 was used in 19 patients, and smaller LBCs were used in 41 patients. Median puncture to revascularization time was significantly different between the JET 7 and the smaller LBCs (16 vs. 27 min; P = 0.011). The rate of patients who received rescue therapy with a stent retriever was also significantly different between the JET 7 cases and the smaller LBCs cases (5.3% vs. 22.0%; P = 0.046). Successful revascularization (TICI ≥ 2b) was achieved in 94.7% of JET 7 cases and 75.6% of smaller LBCs cases (P = 0.148). Good functional outcome (mRS 0-2) at 90 days occurred in 63.2% of JET 7 cases and 46.3% of smaller LBCs cases (P = 0.274).

CONCLUSIONS

In this early experience, ADAPT with JET 7 could be considered as one of the possible first-line therapies in carotid T occlusion, showing good rate of vascularization and lower rate of rescue therapy in comparison with smaller LBCs.

Subarachnoid Hemorrhage in Mechanical Thrombectomy for Acute Ischemic Stroke: Analysis of the STRATIS Registry, Systematic Review, and Meta-Analysis

Background: The indications for mechanical thrombectomy in acute ischemic stroke continue to broaden, leading neurointerventionalists to treat vessel occlusions at increasingly distal locations farther in time from stroke onset. Accessing these smaller vessels raises the concern of iatrogenic subarachnoid hemorrhage (SAH) owing to increasing complexity in device navigation and retrieval. This study aims to determine the prevalence of SAH following mechanical thrombectomy, associated predictors, and resulting functional outcomes using a multicenter registry and compare this with a systematic review and meta-analysis of the literature. Methods: Data from STRATIS (The Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke) registry were analyzed dichotomized by the presence or absence of SAH after thrombectomy. Only patients with 24-h post-procedural neuroimaging were included (n = 841). Multivariable logistic regression was performed to identify significant predictors of SAH. A systematic review and random-effects meta-analysis was also conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) protocol. Results: The prevalence of post-thrombectomy SAH was 5.23% in STRATIS with 15.9% (1.84% overall) experiencing neurological decline. Distal location of vessel occlusion (OR 3.41 [95% CI: 1.75-6.63], p < 0.001) and more than 3 device passes (OR 1.34 [95% CI: 1.09-1.64], p = 0.01) were associated with a higher probability of SAH in contrast to a reduction with administration of intravenous tissue plasminogen activator (tPA) (OR 0.48 [95% CI: 0.26-0.89], p = 0.02). There was a trend toward a higher discharge NIHSS (8.3 ± 8.7 vs. 5.3 ± 6.6, p = 0.07) with a significantly reduced proportion achieving functional independence at 90 days (modified Rankin Score 0-2: 32.5% vs. 57.8%, p = 0.002) in SAH patients. Pooled analysis of 10,126 patients from 6 randomized controlled trials and 64 observational studies demonstrated a prevalence of 5.85% [95% CI: 4.51-7.34%, I ²: 85.2%]. Only location of vessel occlusion was significant for increased odds of SAH at distal sites (OR 2.89 [95% CI: 1.14, 7.35]). Conclusions: Iatrogenic SAH related to mechanical thrombectomy is more common with treatment of distally-situated occlusions and multiple device passes. While low in overall prevalence, its effect is not benign with fewer patients reaching post-procedural functional independence, particularly if symptomatic.

Acute Occlusion of the Distal Internal Carotid Artery : Single Center Experience in 46 Consecutive Cases, review of the literature and proposal of a classification

PURPOSE

The acute distal intracranial occlusion of the internal carotid artery (ICA) is a very complex heterogeneous pathology, characterized by various patterns. Aim of this work is to identify the different types and propose a classification.

METHODS

Among the patients admitted for stroke in the anterior circulation from august 2014 to October 2017, 46 (25%) presented with intracranial distal carotid artery occlusion. The mean age of the patients was 71 (SD 13.7), 65,2% female. The protocol included general and specific neurological examinations, CT, CT-Angiography with multiphase CTA, followed by Angiography. The occlusion was treated by aspiration device alone or associated with stent-retriever. NIHSS at the admission, at discharge and modified ranking Scale (mRS) at four months were examined.

RESULTS

The occlusions presented with various patterns. Depending on its site (located at the distal ICA bifurcation or more proximal at the level of the ophthalmic segment of ICA, with or without extent to ICA bifurcation) taking also into account the various involvement of the cerebral vessels and anatomic variations of Circle of Willis, three groups of occlusion types could be identified (T1, T2 and T3). The collateral circulation, and the possibilities of the endovascular revascularization important for the final outcome, were clearly connected with the type of occlusion. NIHSS at admission was 19.1 (Range from 8 to 30, SD 4.4). Good outcome defined as mRS 0-2 at for months was obtained in 17 patients (37%).

CONCLUSIONS

The proposed classification reproduces more precisely the complexity and heterogeneity of this pathology, being useful in the diagnosis and treatment of these patients.

Considerations about Occlusion of the Intracranial Distal Internal Carotid Artery

Occlusion of the intracranial distal internal carotid artery (ICA) is one of the most critical conditions among the cases of acute stroke in the anterior circulation. The introduction of selective endovascular treatment first using thrombolytic agents replaced later by the mechanical thrombectomy using various devices has improved the prognosis in a certain number of these patients. Among the factors influencing the prognosis of these patients, one is the collateral circulation which in these cases is mainly characterized by leptomeningeal anastomoses. The collateral can, however, be impaired, by distal embolization and by anomalies of the Circle of Willis: the aim of this study is to describe these aspects.

Chronic innominate artery occlusion with hyperacute intracranial thromboembolism: Revascularization with simultaneous local thromboaspiration and mechanical thrombectomy

Chronic innominate artery occlusion with acute right internal carotid terminus thromboembolism and successful revascularization using simultaneous local thromboaspiration and mechanical thrombectomy has not been previously described. A 51-year-old male presented with transient left hemiparesis. A CT angiogram of the head and neck demonstrated chronic occlusion of the right innominate artery with no intracranial thromboembolism. More profound symptoms recurred twelve hours after admission. A diagnostic catheter-based angiogram confirmed occlusion of the innominate artery and identified hyper-acute right carotid terminus thromboembolism. Angioplasty of the innominate artery was followed by simultaneous mechanical and aspiration thrombectomy of the right internal carotid artery terminus. Combination local thromboaspiration and mechanical thrombectomy was shown in this case to be effective in achieving a favorable clinical outcome.

Mechanical Thrombectomy in Acute Occlusion of the Carotid-T: A Retrospective Single Centre Study in 51 Patients

BACKGROUND AND PURPOSE

Acute occlusion of the carotid-T is associated with large ischemic lesions, poor outcome and up to 53 % mortality with conservative therapy. Endovascular mechanical thrombectomy (EMT) is a promising alternative treatment of large vessel occlusion. Here, we examine feasibility, safety and efficiency of EMT in acute ischemic stroke due to carotid-T-occlusion.

METHODS

Single centre, retrospective analysis of 51 consecutive patients with acute occlusion of the carotid-T, treated by EMT within 6 h after symptom onset. Most patients (42/51) were treated with stentretrievers, 33 with stentretrievers only. Recanalization was assessed by the Thrombolysis in Cerebral Infarction (TICI) score. Early and mid-term clinical outcome was evaluated by National Institutes of Health Stroke Scale (NIHSS)- and modified Rankin Scale mRS-scores, respectively.

RESULTS

Successful recanalization (TICI 2b/3) was achieved in 78.4 % (40/51). Good clinical outcome (mRS 0-2) was observed in 24.4 % of patients, and only in patients treated successfully (TICI 2b/3). Stentretrievers yielded higher recanalization rates and better clinical outcomes than non-stentretriever devices. A total of 12 patients died (29.3 %) during the 90-day observation period. Clinically relevant procedure-related complications occurred in two patients, consisting in one vessel perforation with a microwire, and one symptomatic parenchymal haemorrhage after initiation of antiplatelet therapy following the inadvertent detachment of a stentretriever. Another symptomatic haemorrhage, not directly procedure-related, occurred in one additional patient.

CONCLUSION

EMT in acute carotid-T-occlusion is efficient, yielding high recanalization rates, and reasonably safe, with a low rate of clinically relevant complications. Successful recanalization seems to be a prerequisite for good clinical outcome in this severe condition.

Intravenous thrombolysis and endovascular therapy for acute ischemic stroke with internal carotid artery occlusion: a systematic review of clinical outcomes

BACKGROUND AND PURPOSE

Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with extremely poor prognosis. The best treatment approach to acute stroke in this setting is unknown. We sought to determine clinical outcomes in patients with acute ischemic stroke attributable to ICA occlusion treated with intravenous (IV) systemic thrombolysis or intra-arterial endovascular therapy.

METHODS

Using the PubMed database, we searched for studies that included patients with acute ischemic stroke attributable to ICA occlusion who received treatment with IV thrombolysis or intra-arterial endovascular interventions. Studies providing data on functional outcomes beyond 30 days and mortality and symptomatic intracerebral hemorrhage (sICH) rates were included in our analysis. We compared the proportions of patients with favorable functional outcomes, sICH, and mortality rates in the 2 treatment groups by calculating χ(2) and confidence intervals for odds ratios.

RESULTS

We identified 28 studies with 385 patients in the IV thrombolysis group and 584 in the endovascular group. Rates of favorable outcomes and sICH were significantly higher in the endovascular group than the IV thrombolysis-only group (33.6% vs 24.9%, P=0.004 and 11.1% vs 4.9%, P=0.001, respectively). No significant difference in mortality rate was found between the groups (27.3% in the IV thrombolysis group vs 32.0% in the endovascular group; P=0.12).

CONCLUSIONS

According to our systematic review, endovascular treatment of acute ICA occlusion results in improved clinical outcomes. A higher rate of sICH after endovascular treatment does not result in increased overall mortality rate.

Manual aspiration thrombectomy through balloon-tipped guide catheter for rapid clot burden reduction in endovascular therapy for ICA L/T occlusion

INTRODUCTION

Timely recanalization during endovascular procedures for acute ischemic stroke can be challenging in cases with large clot burden, such as those encountered in the terminal internal carotid T- or L-type occlusion.

METHODS

A novel but simple technique to achieve fast reduction in clot burden in stroke patients with occlusion of the internal carotid artery termination is described where manual suction using a 60-ml syringe applied through an 8-F balloon guide catheter positioned in the cervical carotid vasculature with proximal flow arrest allows subsequent revascularization of the residual middle cerebral artery clot.

RESULTS

The use of manual suction through a balloon-tipped guide catheter in internal carotid artery L- or T-type occlusion is illustrated. This resulted in a significant reduction of the clot burden and facilitated further interventions leading to full recanalization.

CONCLUSION

Manual suction using a 60-ml syringe through a balloon guide catheter is a useful and feasible technique that facilitates thrombectomy of large burden cerebral clots.

Safety and efficacy of mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke: a systematic review

Purpose

In recent years, mechanical thrombectomy using Solitaire stent retrieval has been tried for treating acute ischemic stroke with a large artery occlusion. We systematically reviewed published articles to appraise the evidence that supports the safety and efficacy of the mechanical thrombectomy in acute strokes with Solitaire stent.

Materials and Methods

Systematic searches using Medline and Scopus were performed for studies evaluating mechanical thrombectomy using a Solitaire stent in acute ischemic stroke. Articles were included if they were published since 2008, contained at least 5 subjects, and provided clinical results.

Results

Thirteen articles (262 cases) were included in this review. The mean time of the procedures ranged from 37 to 95.6 minutes in 10 studies. The success of recanalization was achieved in 89.7% and the recanalization rate varied from 66.7% to 100% in all 13 studies. The overall rates of the symptomatic hemorrhagic complications and mortality were 6.8% and 11.1%, respectively. A favorable outcome of mRS 2 or under was 47.3%. Procedure-induced complications developed in 3.4%.

Conclusion

The present review suggested that mechanical thrombectomy using a Solitaire stent in acute ischemic stroke was effective in recanalizing the occluded artery. The rate of procedural complications was small.

Treatment of acute ischemic stroke: beyond thrombolysis and supportive care

The initial therapeutic approach to acute ischemic stroke consists of thrombolytic therapy and early initiation of supportive care, usually commenced prior to the determination of the underlying stroke etiology. Varying stroke mechanisms may call for specific, etiology-based treatment. The majority of strokes result from cardioembolism, large-vessel atherothromboembolism, and small-vessel occlusive disease. There are scant data to support the use of acute anticoagulation therapy over anti-platelet therapy in cardioembolic stroke and large-vessel atherosclerosis, although it may be reasonable in a certain subset of patients. However, augmentation of blood flow with early surgery, stenting, or induced hypertension, may play a role in patients with large artery stenosis. The less commonly identified stroke mechanisms may warrant special consideration in treatment. Controversy remains regarding the optimal anti-thrombotic treatment of arterial dissection. Reversible cerebral vasoconstriction syndrome may benefit from therapy with calcium channel blockers, high-dose steroids, or magnesium, although spontaneous recovery may occur. Inflammatory vasculopathies, such as isolated angiitis of the central nervous system and temporal arteritis, require prompt diagnosis as the mainstay of therapy is immunosuppression. Cerebral venous thrombosis is a rare cause of stroke, but one that needs early identification and treatment with anticoagulation. Rapid determination of stroke mechanism is essential for making these critical early treatment decisions.