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Galecio-Castillo M, Guerrero WR, Hassan AE, Farooqui M, Jumaa MA, Divani AA, Abraham MG, Petersen NH, Fifi JT, Malik AM, Siegler JE, Nguyen TN, Sheth SA, Yoo AJ, Linares G, Janjua N, Quispe-Orozco D, Olivé-Gadea M, Tekle WG, Zaidi SF, Sabbagh SY, Barkley T, Prasad A, De Leacy RA, Abdalkader M, Salazar-Marioni S, Soomro J, Gordon W, Turabova C, Rodriguez-Calienes A, Dibas M, Mokin M, Yavagal DR, Ribo M, Jovin TG, Ortega-Gutierrez S. Cervical Dissection in Patients With Tandem Lesions Is Associated With Distal Embolism and Lower Recanalization Success. Stroke 2024; 55:1808-1817. [PMID: 38913799 DOI: 10.1161/strokeaha.123.046148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 05/13/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Tandem lesions consist of cervical internal carotid artery (ICA) stenosis or occlusion, most commonly of atherosclerosis or dissection etiology, plus a large vessel occlusion. In this study, we compare outcomes in patients with atherosclerosis versus dissection of the cervical ICA. METHODS This multicenter retrospective cohort study includes data from tandem lesion patients who underwent endovascular treatment from 2015 to 2020. Atherosclerosis was defined as ICA stenosis/occlusion associated with a calcified lesion and dissection by the presence of a tapered or flame-shaped lesion and intramural hematoma. Primary outcome: 90-day functional independence (modified Rankin Scale score, 0-2); secondary outcomes: 90-day favorable shift in the modified Rankin Scale score, modified Thrombolysis in Cerebral Infarction score 2b-3, modified Thrombolysis in Cerebral Infarction score 2c-3, symptomatic intracranial hemorrhage, parenchymal hematoma type 2, petechial hemorrhage, distal embolization, early neurological improvement, and mortality. Analysis was performed with matching by inverse probability of treatment weighting. RESULTS We included 526 patients (68 [59-76] years; 31% females); 11.2% presented dissection and 88.8%, atherosclerosis. Patients with dissection were younger, had lower rates of hypertension, hyperlipidemia, diabetes, and smoking history. They also exhibited higher rates of ICA occlusion, multiple stents (>1), and lower rates of carotid self-expanding stents. After matching and adjusting for covariates, there were no differences in 90-day functional independence. The rate of successful recanalization was significantly lower in the dissection group (adjusted odds ratio, 0.38 [95% CI, 0.16-0.91]; P=0.031), which also had significantly higher rates of distal emboli (adjusted odds ratio, 2.53 [95% CI, 1.15-5.55]; P=0.021). There were no differences in other outcomes. Acute ICA stenting seemed to increase the effect of atherosclerosis in successful recanalization. CONCLUSIONS This study reveals that among patients with acute stroke with tandem lesions, cervical ICA dissection is associated with higher rates of distal embolism and lower rates of successful recanalization than atherosclerotic lesions. Using techniques to minimize the risk of distal embolism may mitigate this contrast. Further prospective randomized trials are warranted to fully understand these associations.
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Affiliation(s)
- Milagros Galecio-Castillo
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.G.-C., M.F., D.Q.-O., A.R.-C., M.D., S.O.-G.)
| | - Waldo R Guerrero
- Department of Neurology and Brain Repair, University of South Florida, Tampa (W.R.G., M.M.)
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen (A.E.H., W.G.T.)
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.G.-C., M.F., D.Q.-O., A.R.-C., M.D., S.O.-G.)
| | - Mouhammad A Jumaa
- Department of Neurology, ProMedica Toledo Hospital, OH (M.A.J., S.F.Z.)
| | - Afshin A Divani
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque (A.A.D., S.Y.S.)
| | - Michael G Abraham
- Department of Neurology, University of Kansas Medical Center (M. Abraham, T.B.)
| | - Nils H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT (N.H.P., A.P.)
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.F., R.D.L.)
| | - Amer M Malik
- Department of Neurology, University of Miami Miller School of Medicine, FL (A.M.M., D.R.Y.)
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.E.S., T.G.J.)
- Cooper Medical School of Rowan University, Candem, NJ (J.E.S., T.G.J.)
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, MA (T.N.N., M. Abdalkader)
| | - Sunil A Sheth
- Department of Neurology, UT Health McGovern Medical School, Houston, TX (S.S., S.S.-M.)
| | - Albert J Yoo
- Texas Stroke Institute, Dallas-Fort Worth (A.J.Y., J.S.)
| | - Guillermo Linares
- Department of Neurology, Saint Louis University, St. Louis, MO (G.L., W.G.)
| | - Nazli Janjua
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, CA (N.J., C.T.)
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.G.-C., M.F., D.Q.-O., A.R.-C., M.D., S.O.-G.)
| | - Marta Olivé-Gadea
- Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain (M.O.-G., M.R.)
| | - Wondwossen G Tekle
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen (A.E.H., W.G.T.)
| | - Syed F Zaidi
- Department of Neurology, ProMedica Toledo Hospital, OH (M.A.J., S.F.Z.)
| | - Sara Y Sabbagh
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque (A.A.D., S.Y.S.)
| | - Tiffany Barkley
- Department of Neurology, University of Kansas Medical Center (M. Abraham, T.B.)
| | - Ayush Prasad
- Department of Neurology, Yale University School of Medicine, New Haven, CT (N.H.P., A.P.)
| | - Reade A De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.F., R.D.L.)
| | - Mohamad Abdalkader
- Department of Neurology, Boston Medical Center, MA (T.N.N., M. Abdalkader)
| | | | - Jazba Soomro
- Texas Stroke Institute, Dallas-Fort Worth (A.J.Y., J.S.)
| | - Weston Gordon
- Department of Neurology, Saint Louis University, St. Louis, MO (G.L., W.G.)
| | - Charoskhon Turabova
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, CA (N.J., C.T.)
| | - Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.G.-C., M.F., D.Q.-O., A.R.-C., M.D., S.O.-G.)
- Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru (A.R.-C.)
| | - Mahmoud Dibas
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.G.-C., M.F., D.Q.-O., A.R.-C., M.D., S.O.-G.)
| | - Maxim Mokin
- Department of Neurology and Brain Repair, University of South Florida, Tampa (W.R.G., M.M.)
| | - Dileep R Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, FL (A.M.M., D.R.Y.)
| | - Marc Ribo
- Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain (M.O.-G., M.R.)
| | - Tudor G Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.E.S., T.G.J.)
- Cooper Medical School of Rowan University, Candem, NJ (J.E.S., T.G.J.)
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.G.-C., M.F., D.Q.-O., A.R.-C., M.D., S.O.-G.)
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2
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Ingleton A, Raseta M, Chung RE, Kow KJH, Weddell J, Nayak S, Jadun C, Hashim Z, Qayyum N, Ferdinand P, Natarajan I, Roffe C. Is intraprocedural intravenous aspirin safe for patients who require emergent extracranial stenting during mechanical thrombectomy? Stroke Vasc Neurol 2024; 9:279-288. [PMID: 37788913 PMCID: PMC11221300 DOI: 10.1136/svn-2022-002267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 09/06/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Intraoperative antiplatelet therapy is recommended for emergent stenting during mechanical thrombectomy (MT). Most patients undergoing MT are also given thrombolysis. Antiplatelet agents are contraindicated within 24 hours of thrombolysis. We evaluated outcomes and complications of patients stented with and without intravenous aspirin during MT. METHODS All patients who underwent emergent extracranial stenting during MT at the Royal Stoke University Hospital, UK between 2010 and 2020, were included. Patients were thrombolysed before MT, unless contraindicated. Aspirin 500 mg intravenously was given intraoperatively at the discretion of the operator. Symptomatic intracranial haemorrhage (sICH) and the National Institutes for Health Stroke Scale score (NIHSS) were recorded at 7 days, and mortality and functional recovery (modified Rankin Scale: mRS ≤2) at 90 days. RESULTS Out of 565 patients treated by MT 102 patients (median age 67 IQR 57-72 years, baseline median NIHSS 18 IQR 13-23, 76 (75%) thrombolysed) had a stent placed. Of these 49 (48%) were given aspirin and 53 (52%) were not. Patients treated with aspirin had greater NIHSS improvement (median 8 IQR 1-16 vs median 3 IQR -9-8 points, p=0.003), but there were no significant differences in sICH (2/49 (4%) vs 9/53 (17%)), mRS ≤2 (25/49 (51%) vs 19/53 (36%)) and mortality (10/49 (20%) vs 12/53 (23%)) with and without aspirin. NIHSS improvement (median 12 IQR 4-18 vs median 7 IQR -7-10, p=0.01) was greater, and mortality was lower (4/33 (12%) vs 6/15 (40%), p=0.05) when aspirin was combined with thrombolysis, than for aspirin alone, with no increase in bleeding. CONCLUSION Our findings based on registry data derived from routine clinical care suggest that intraprocedural intravenous aspirin in patients undergoing emergent stenting during MT does not increase sICH and is associated with good clinical outcomes, even when combined with intravenous thrombolysis.
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Affiliation(s)
- Adam Ingleton
- Neurosciences, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Marko Raseta
- Statistics and Mathematical Modelling, Department of Molecular Genetics, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Rui-En Chung
- Radiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Kevin Jun Hui Kow
- Radiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Jake Weddell
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Sanjeev Nayak
- Interventional Radiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Changez Jadun
- Interventional Radiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Zafar Hashim
- Interventional Radiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Noman Qayyum
- Interventional Radiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Phillip Ferdinand
- Neurosciences, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Indira Natarajan
- Neurosciences, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Christine Roffe
- Neurosciences, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
- Stroke Research, Keele University, Keele, Staffordshire, UK
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3
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Diana F, Abdalkader M, Behme D, Li W, Maurer CJ, Pop R, Hwang YH, Bartolini B, Da Ros V, Bracco S, Cirillo L, Marnat G, Katsanos AH, Kaesmacher J, Fischer U, Aguiar de Sousa D, Peschillo S, Zini A, Tomasello A, Ribo M, Nguyen TN, Romoli M. Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data. J Neurointerv Surg 2024; 16:243-247. [PMID: 37185107 DOI: 10.1136/jnis-2023-020204] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND The periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of antithrombotics following eCAS. METHODS We followed PRISMA guidelines and searched MEDLINE, Embase, and Scopus from January 1, 2004 to November 30, 2022 for studies evaluating eCAS in tandem occlusion. The primary endpoint was 90-day good functional outcome. Secondary outcomes were symptomatic intracerebral hemorrhage, in-stent thrombosis, delayed stent thrombosis, and successful recanalization. Meta-analysis of proportions and meta-analysis of odds ratios were implemented. RESULTS 34 studies with 1658 patients were included. We found that the use of no antiplatelets (noAPT), single antiplatelet (SAPT), dual antiplatelets (DAPT), or glycoprotein IIb/IIIa inhibitors (GPI) yielded similar rates of good functional outcomes, with a marginal benefit of GPI over SAPT (OR 1.88, 95% CI 1.05 to 3.35, Pheterogeneity=0.31). Sensitivity analysis and meta-regression excluded a significant impact of intravenous thrombolysis and Alberta Stroke Program Early CT Score (ASPECTS). We observed no increase in symptomatic intracerebral hemorrhage (sICH) with DAPT or GPI compared with noAPT or SAPT. We also found similar rates of delayed stent thrombosis across groups, with acute in-stent thrombosis showing marginal, non-significant benefits from GPI and DAPT over SAPT and noAPT. CONCLUSIONS In AIS due to tandem occlusion, the periprocedural antithrombotic regimen of eCAS seems to have a marginal effect on good functional outcome. Overall, high intensity antithrombotic therapy may provide a marginal benefit on good functional outcome and carotid stent patency without a significant increase in risk of sICH.
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Affiliation(s)
- Francesco Diana
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
| | | | - Daniel Behme
- Neuroradiology, University Hospital Magdeburg, Magdeburg, Sachsen-Anhalt, Germany
| | - Wei Li
- Neurology, Hainan Medical University, Haikou, Hainan, China
| | - Christoph Johannes Maurer
- Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Raoul Pop
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Yang-Ha Hwang
- Neurology and Radiology, Kyungpook National University Hospital, Daegu, Korea (the Republic of)
| | - Bruno Bartolini
- Diagnostic and Interventional Radiology, Interventional Neuroradiology Unit, CHUV - Lausanne University Hospital, Lausanne, Switzerland
| | - Valerio Da Ros
- Biomedicine and Prevention, Diagnostic Imaging Unit, Fondazione PTV Policlinico Tor Vergata, Roma, Italy
| | - Sandra Bracco
- Neurology and Human Movement Sciences, Interventional Neuroradiology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Luigi Cirillo
- Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Aristeidis H Katsanos
- Neurology Division, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada
| | - Johannes Kaesmacher
- Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Diana Aguiar de Sousa
- Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria/ CHULN, University of Lisbon, Lisboa, Portugal
| | - Simone Peschillo
- Endovascular Neurosurgery, Pia Fondazione Cardinale G Panico Hospital, Tricase, Italy
- UniCamillus International Medical University, Rome, Italy
| | - Andrea Zini
- Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Emilia-Romagna, Italy
| | - Alejandro Tomasello
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
| | - Marc Ribo
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
- Stroke Unit, Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Thanh N Nguyen
- Radiology, Boston Medical Center, Boston, Massachusetts, USA
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michele Romoli
- Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Emilia-Romagna, Italy
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van Elk T, Maes L, van der Meij A, Lemmens R, Uyttenboogaart M, de Borst GJ, Zeebregts CJ, Nederkoorn PJ. Immediate Carotid Artery Stenting or Deferred Treatment in Patients With Tandem Carotid Lesions Treated Endovascularly for Acute Ischaemic Stroke. EJVES Vasc Forum 2023; 61:31-35. [PMID: 38234597 PMCID: PMC10792755 DOI: 10.1016/j.ejvsvf.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/24/2023] [Accepted: 12/14/2023] [Indexed: 01/19/2024] Open
Abstract
Fifteen to 20% of patients with an acute ischaemic stroke have a tandem lesion defined by the combination of an intracranial large vessel thrombo-embolic occlusion and a high grade stenosis or occlusion of the ipsilateral internal carotid artery. These patients tend to have worse outcomes than patients with isolated intracranial occlusions, with higher rates of disability and death. The introduction of endovascular thrombectomy to treat the intracranial lesion clearly improved the outcome compared with treatment with intravenous thrombolysis alone. However, the best treatment strategy for managing the extracranial carotid artery lesion in patients with tandem lesions remains unknown. Current guidelines recommend carotid endarterectomy for patients with transient ischaemic attack or non-disabling stroke and moderate or severe stenosis of the internal carotid artery, within two weeks of the initial event, to prevent major stroke recurrence and death. Alternatively, the symptomatic carotid artery could be treated by endovascular placement of a stent during endovascular thrombectomy (EVT). This would negate the need for a second procedure, immediately reduce the risk of stroke recurrence, increase patient satisfaction, and could be cost effective. However, the administration of dual antiplatelet therapy could potentially increase the risk of symptomatic intracranial haemorrhage in patients with acute ischaemic stroke. Randomised controlled trials evaluating the efficacy and safety of immediate carotid artery stenting during EVT in acute stroke patients with tandem lesions are currently ongoing and will impact the current guidelines regarding the treatment of patients with acute ischaemic stroke due to these tandem lesions.
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Affiliation(s)
- Theodora van Elk
- Department of Neurology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Louise Maes
- Department of Neurology, University Hospital Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology, KULeuven - University of Leuven, Leuven, Belgium
| | - Anne van der Meij
- Department of Neurology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Robin Lemmens
- Department of Neurology, University Hospital Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology, KULeuven - University of Leuven, Leuven, Belgium
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Gert J. de Borst
- Department of Surgery (Division of Vascular Surgery), University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Clark J. Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Centre Groningen, Groningen, the Netherlands
| | - Paul J. Nederkoorn
- Department of Neurology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
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Di Donna A, Muto G, Giordano F, Muto M, Guarnieri G, Servillo G, De Mase A, Spina E, Leone G. Diagnosis and management of tandem occlusion in acute ischemic stroke. Eur J Radiol Open 2023; 11:100513. [PMID: 37609048 PMCID: PMC10440394 DOI: 10.1016/j.ejro.2023.100513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023] Open
Abstract
Approximately 20-30% of patients with acute ischemic stroke, caused by large intracranial vessel occlusion, have a tandem lesion, defined as simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery. Patients with tandem lesions have usually worse outcomes than patients with single intracranial occlusions, and intravenous thrombolysis is less effective in these patients. Although endovascular thrombectomy is currently a cornerstone therapy in the management of acute ischemic stroke due to large vessel occlusion, the optimal management of extracranial carotid lesions in tandem occlusion remains controversial. Acute placement of a stent in the cervical carotid artery lesion is the most used therapeutic strategy compared with stented balloon angioplasty and thrombectomy alone without carotid artery revascularization; however, treatment strategies in these patients are often more complex than with single occlusion, so treatment decisions can change based on clinical and technical considerations. The aim of this review is to analyze the results of different studies and trials, investigating the periprocedural neurointerventional management of patients with tandem lesions and the safety, efficacy of the different technical strategies available as well as their impact on the clinical outcome in these patients, to strengthen current recommendations and thus optimize patient care.
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Affiliation(s)
- Antonio Di Donna
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluca Muto
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Flavio Giordano
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Massimo Muto
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluigi Guarnieri
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giovanna Servillo
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Antonio De Mase
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Emanuele Spina
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giuseppe Leone
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
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6
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Keil F, Stahn S, Reitz SC, Lieschke F, du Mesnil de Rochemont R, Hattingen E, Berkefeld J. Elective carotid stenting fulfills quality standards defined in guidelines. ROFO-FORTSCHR RONTG 2023. [PMID: 37963550 DOI: 10.1055/a-2175-4029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
PURPOSE According to evidence from randomized trials and current guidelines, elective carotid artery stenting (CAS) is still considered second-line therapy compared with carotid endarterectomy (CEA). However, the publication of randomized comparative trials for patients with symptomatic stenoses occurred well over 10 years ago. In view of problems regarding German quality assurance when differentiating elective from emergency interventions and low case numbers for CAS indications, it seemed reasonable to present neurologically controlled CAS results and to investigate whether elective CAS consistently fulfills the strict quality criteria and what differences exist with respect to emergency CAS interventions in acute ischemic stroke. MATERIALS AND METHODS Between 01/2012 and 07/2022, 141 elective CAS procedures were performed to treat patients with symptomatic (n = 123) and asymptomatic (n = 18) stenoses. Protection by a filter system was achieved in 134 of these elective procedures (95 %). During the same period, 158 patients underwent carotid stenting for acute stroke. Complication rates were determined using neurologically controlled data. CAS-related complications (stent thrombosis, stent-associated vascular damage, thromboembolism, and symptomatic hemorrhage) were extracted from emergency interventions, and clinical outcome (NIHSS progression) was determined during the inpatient stay. RESULTS The rate of stroke and death determined during the inpatient stay for elective symptomatic patients was 0.8 %. Early treatment within the first 7 days after the index event, age > 70 years, and operator experience were not significant risk factors for the occurrence of complications. No complications were observed after CAS of asymptomatic stenoses. The procedure-related complication rate for emergency procedures was 7.8 %, which was significantly higher than after elective CAS, as expected (p < 0.006). CONCLUSION Even with limited indications and limited case numbers, compliance with the strict quality criteria of the current S3 Guideline 2022 for elective CAS interventions is possible for both symptomatic and asymptomatic stenoses in an experienced center. Emergency CAS interventions have significantly higher complication rates under other conditions and must be considered separately with regard to quality assurance. KEY POINTS · Elective carotid stenting fulfills the strict quality criteria of the current S3 guideline 2022.. · Emergency carotid stenting has significantly higher complication rates than elective procedures.. · Elective and emergency carotid stenting cannot be meaningfully compared.. CITATION FORMAT · Keil F, Stahn S, Reitz SC et al. Elective carotid stenting fulfills quality standards defined in guidelines. Fortschr Röntgenstr 2023; DOI: 10.1055/a-2175-4029.
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Affiliation(s)
- Fee Keil
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
| | - Simon Stahn
- Radiology, Hospital Nordwest Frankfurt, Germany
| | - Sarah Christina Reitz
- Neurosurgery, Hospital of the Goethe University Frankfurt Center of Neurology and Neurosurgery, Frankfurt am Main, Germany
| | - Franziska Lieschke
- Neurology, Hospital of the Goethe University Frankfurt Center of Neurology and Neurosurgery, Frankfurt am Main, Germany
| | | | - Elke Hattingen
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
| | - Joachim Berkefeld
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
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Raha O, Hall C, Malik A, D'Anna L, Lobotesis K, Kwan J, Banerjee S. Advances in mechanical thrombectomy for acute ischaemic stroke. BMJ MEDICINE 2023; 2:e000407. [PMID: 37577026 PMCID: PMC10414072 DOI: 10.1136/bmjmed-2022-000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/25/2023] [Indexed: 08/15/2023]
Abstract
Mechanical thrombectomy is a ground breaking treatment for acute ischaemic stroke caused by occlusion of a large vessel. Its efficacy over intravenous thrombolysis has been proven in multiple trials with a lower number needed to treat than percutaneous coronary intervention for acute myocardial infarction. However, access to this key treatment modality remains limited with a considerable postcode lottery across the UK and many parts of the world. The evidence base for mechanical thrombectomy dates back to 2015. Since then, there have been important advances in establishing and widening the criteria for treatment. This narrative review aims to summarise the current evidence base and latest advances for physicians and academics with an interest in recanalisation treatments for acute ischaemic stroke.
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Affiliation(s)
- Oishik Raha
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Charles Hall
- Interventional Neuroradiology, Imperial College Healthcare NHS Trust, London, UK
| | - Abid Malik
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Lucio D'Anna
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Kyriakos Lobotesis
- Interventional Neuroradiology, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Joseph Kwan
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Soma Banerjee
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
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8
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Kojima T, Aihara M, Naito I, Shimizu T, Miyamoto N, Yamaguchi R, Aishima K, Sato K, Shimauchi-Ohtaki H, Shintoku R, Wakabayashi K, Yoshimoto Y. Management of Cervical Internal Carotid Artery Stenosis or Occlusion in Tandem Lesion with Acute Ischemic Stroke: Which Is More Appropriate Percutaneous Transluminal Angioplasty or Stent? World Neurosurg 2023; 175:e208-e217. [PMID: 36924889 DOI: 10.1016/j.wneu.2023.03.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVE Carotid artery stenting (CAS) is the established treatment strategy of the cervical internal carotid artery (cICA) stenosis, but its use for acute tandem lesions remains controversial. We investigated the clinical and procedural outcomes of management of cICA lesions and evaluated the risk factors for complications. METHODS Fifty patients who underwent acute mechanical thrombectomy for tandem lesion between January 2014 and June 2022 were included. Treatment of the cICA lesion was classified into the CAS group or the non-CAS group. The risk factors for postoperative ischemic events or symptomatic intracranial hemorrhage (sICH) were analyzed. RESULTS The CAS group included 36 patients (72%) and the non-CAS group 14 (28%). Postoperative complications were observed in 9 patients (18%). Thromboembolic complications occurred in 4 patients (29%) of the non-CAS group but in 1 patient (3%) of the CAS group. Severe calcification of the cICA (P = 0.04), non-CAS (P = 0.018), and more than 60% residual stenosis (P = 0.016) were significant risk factors associated with thromboembolic complications. sICH occurred in 4 patients (11%) of the CAS group but in none of the non-CAS group. More than 80% stenosis improvement was significantly associated with sICH (P = 0.049). Twenty-nine patients (58%) had a good clinical outcome at 90 days after onset. CONCLUSIONS Acute CAS is effective for the management for cICA tandem lesions during mechanical thrombectomy, but care not to overextend may be important to reduce the risk of sICH. Severe calcification of the cICA may increase the risk of postoperative thromboembolic complications using non-CAS treatment.
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Affiliation(s)
- Takeo Kojima
- Department of Neurosurgery, Saku Central Hospital Nagano Prefectural Federation of Agricultural Cooperation for Health and Welfare, Saku, Nagano, Japan
| | - Masanori Aihara
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
| | - Isao Naito
- Department of Neurosurgery, Geriatrics Research Institute and Hospital, Maebashi, Gunma, Japan
| | - Tatsuya Shimizu
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Naoko Miyamoto
- Department of Neurosurgery, Geriatrics Research Institute and Hospital, Maebashi, Gunma, Japan
| | - Rei Yamaguchi
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Kaoru Aishima
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Koji Sato
- Department of Neurosurgery, National Hospital Organization Takasaki General Medical Center, Takasaki, Gunma, Japan
| | - Hiroya Shimauchi-Ohtaki
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Ryosuke Shintoku
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Kazuki Wakabayashi
- Department of Neurosurgery, General Fujioka Hospital, Fujioka, Gunma, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Diana F, Romoli M, Toccaceli G, Rouchaud A, Mounayer C, Romano DG, Di Salle F, Missori P, Zini A, Aguiar de Sousa D, Peschillo S. Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis. J Neurointerv Surg 2023; 15:428-432. [PMID: 35428740 DOI: 10.1136/neurintsurg-2022-018683] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/24/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Emergent carotid artery stenting (eCAS) is performed during mechanical thrombectomy for acute ischemic stroke due to tandem occlusion. However, the optimal management strategy in this setting is still unclear. OBJECTIVE To carry out a systematic review and meta-analysis to investigate the safety and efficacy of eCAS in patients with tandem occlusion. METHODS Systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from January 1, 2004 to March 7, 2022 for studies evaluating eCAS and no-stenting approach in patients with stroke with tandem occlusion. Primary endpoint was the 90-day modified Rankin Scale score 0-2; secondary outcomes were (1) symptomatic intracerebral hemorrhage (sICH), (2) recurrent stroke, (3) successful recanalization (Thrombolysis in Cerebral Infarction score 2b-3), (4) embolization in new territories, and (5) restenosis rate. Meta-analysis was performed using the Mantel-Haenszel method and random-effects modeling. RESULTS Forty-six studies reached synthesis. eCAS was associated with higher good functional outcome compared with the no-stenting approach (OR=1.52, 95% CI 1.19 to 1.95), despite a significantly increased risk of sICH (OR=1.97, 95% CI 1.23 to 3.15), and higher successful recanalization rate (OR=1.91, 95% CI 1.29 to 2.85). Restenosis rate was lower in the eCAS group than in the no-stenting group (2% vs 9%, p=0.001). Recanalization rate was higher in retrograde than antegrade eCAS (OR=0.51, 95% CI 0.28 to 0.93). Intraprocedural antiplatelets during eCAS were associated with higher rate of good functional outcome (60% vs 46%, p=0.016) and lower rate of sICH (7% vs 11%; p=0.08) compared with glycoprotein IIb/IIIa inhibitors. CONCLUSIONS In observational studies, eCAS seems to be associated with higher good functional outcome than no-stenting in patients with acute ischemic stroke due to tandem occlusion, despite the higher risk of sICH. Dedicated trials are needed to confirm these results.
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Affiliation(s)
- Francesco Diana
- Neuroradiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Michele Romoli
- Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Giada Toccaceli
- Emergency Neurosurgery, Ospedale Civile 'Santo Spirito', Pescara, Italy
| | - Aymeric Rouchaud
- Interventional Neuroradiology, University Hospital Centre of Limoges, Limoges, France
- BioEMXLim, University of Limoges Medical Faculty, Limoges, France
| | - Charbel Mounayer
- Interventional Neuroradiology, University Hospital Centre of Limoges, Limoges, France
- BioEMXLim, University of Limoges Medical Faculty, Limoges, France
| | | | - Francesco Di Salle
- Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Fisciano, Italy
| | - Paolo Missori
- Human Neurosciences, Neurosurgery, University of Rome La Sapienza, Rome, Italy
| | - Andrea Zini
- Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - Diana Aguiar de Sousa
- Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria/CHULN, University of Lisbon, Santa Maria, Portugal
| | - Simone Peschillo
- Surgical Medical Sciences and Advanced Technologies "G.F. Ingrassia" - Endovascular Neurosurgery, University of Catania, Catania, Italy
- Neurosurgery, Pia Fondazione Cardinale G Panico Hospital, Tricase, Italy
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10
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Sepp D, Berndt M, Mönch S, Ikenberg B, Wunderlich S, Maegerlein C, Zimmer C, Boeckh-Behrens T, Friedrich B. Outcome and risk of hemorrhage in patients with tandem lesions after endovascular treatment: A propensity score-matched case-control study. Heliyon 2023; 9:e14508. [PMID: 36942245 PMCID: PMC10024127 DOI: 10.1016/j.heliyon.2023.e14508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 02/26/2023] [Accepted: 03/08/2023] [Indexed: 03/16/2023] Open
Abstract
Objectives Endovascular treatment of acute stroke patients with large vessel occlusions is well established. But tandem lesions of the internal carotid artery and the intracranial anterior circulation remain a challenge regarding the technical conditions and the putative higher risk of hemorrhage due to often required antiplatelet therapy.This study aims to evaluate the clinical outcome and the risk of hemorrhage after endovascular treatment of tandem lesions, with special regard to the periprocedural antiplatelet regimen. Materials and Methods In this retrospective study, we included 63 consecutive stroke patients with endovascular treated tandem lesions. One hundred eleven patients with a solitary intracranial occlusion were matched using a "propensity score-matched analysis" with the covariates sex, age, wake-up stroke, iv-thrombolysis and NIHSS. Results Rates of successful recanalization (mTICI 2b/3) and periprocedural complications were equal in both groups (P = 0.19; P = 0.35). The rate of good clinical outcome (mRS≤2) was similar, and the incidence of symptomatic hemorrhages was not significantly different (7.9% tandem lesions vs. 5.4% isolated intracranial occlusion, P = 0.51). Even intensified antiplatelet therapy in patients with tandem lesions did not increase the rate of symptomatic intracranial hemorrhages (P = 0.87). Conclusions Clinical outcome and symptomatic intracranial hemorrhages did not differ significantly between endovascular treated patients with tandem lesions and matched patients with solitary intracranial occlusions, regardless of the antiplatelet regimen. Therefore, the complex technical requirements for recanalization of a tandem lesion and the putative higher risk should not result in reluctant treatment that would decrease the chance of a good clinical outcome.
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Affiliation(s)
- Dominik Sepp
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- Corresponding author. Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Maria Berndt
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Sebastian Mönch
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Benno Ikenberg
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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11
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Yu M, Ma Y, Ren H, Huang Y, Yin L, Ma L, Wang Y, Luo B, Wang Z. Emergent Management of Tandem Occlusions in Anterior Circulation Stroke: A Single-Centre Experience. World Neurosurg 2023; 170:e491-e499. [PMID: 36396050 DOI: 10.1016/j.wneu.2022.11.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE For anterior circulation tandem occlusions, the optimal management strategy for extracranial carotid lesions is controversial. We aimed to compare the efficacy and safety of acute stenting (AS) with balloon angioplasty (BA) only. METHODS Clinical data were collected from 98 patients with anterior circulation tandem occlusion who underwent endovascular treatment at our center. Of these patients, 64 and 34 were assigned to the AS and BA groups, respectively. The clinical characteristics and outcome data of the 2 groups were analyzed and compared. RESULTS The proportion of patients with good outcomes was 59.2%. The AS group had a higher rate of successful recanalization (98.4% vs. 82.4%, P = 0.007) and a lower rate of occlusion of the responsible vessel at 90 days (14.1% vs. 32.4%, P = 0.039) than the BA group. The AS group was also significantly better than the BA group in terms of good outcomes (67.2% vs. 44.1%, P = 0.027), but there was no significant difference between the 2 groups in terms of 90-day mortality (6.3% vs. 8.8%, P = 0.691) and asymptomatic intracranial hemorrhage (6.3% vs. 5.9%, P = 1.000). Lower baseline National Institutes of Health Stroke Scale scores were associated with good outcomes (P < 0.001), and the presence of symptomatic intracranial hemorrhage was associated with 90-day mortality (P = 0.003). CONCLUSIONS Acute stent placement in patients with acute ischemic stroke due to anterior circulation tandem occlusion may have a better outcome than BA alone, and the safety of both approaches is comparable.
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Affiliation(s)
- Mingsheng Yu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Yuxiang Ma
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Hecheng Ren
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Ying Huang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Long Yin
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Lin Ma
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Yubo Wang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Bin Luo
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Zengguang Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
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12
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Yu M, Miao X, Huang Y, Ma L, Yin L, Ren H, Wang Z. A clinical application study of a stent placement assessment. Medicine (Baltimore) 2022; 101:e31882. [PMID: 36451472 PMCID: PMC9704916 DOI: 10.1097/md.0000000000031882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Atherosclerotic acute carotid occlusion is a specific type of stroke, and controversy exists regarding the surgical strategy, that is, whether an internal carotid artery stent should be placed immediately after opening the occluded vessel. There is no objective evaluation system for this procedure. In a previous study, we summarized an evaluation decision system Emergent Carotid Artery Stent placement decision Evaluation System (ECASES) for emergency stent placement. STUDY DESIGN This is a prospective, single-center, randomized controlled trial. Patients with acute ischemic stroke caused by atherosclerotic carotid artery occlusion confirmed by imaging (computed tomography/magnetic resonance angiography/digital subtraction angiography) will be randomly divided into the study and control groups, with 101 patients in each group. The study group will undergo surgery according to the ECASES system and the control group will undergo surgery according to the operator's experience. The postoperative outcomes of the 2 groups will be compared. STUDY OUTCOMES Primary outcome: Neurological functional status (modified Rankin Scale and National Institutes of Health Stroke Scale scores) of patients 90 days postoperatively. Secondary outcomes: neurological function changes, hemorrhage events, cerebral edema, postoperative modified treatment in cerebral infarction grade, new cerebral infarction, and reocclusion of responsible vessels. DISCUSSION Currently, no prospective controlled data exist regarding the efficacy and safety of carotid stenting in the acute phase. Previously, we had developed an ECASES stent placement system for acute carotid artery occlusion. The present study will evaluate the efficacy and safety of ECASES in a randomized, double-blind prospective study and clarify its guiding significance in acute atherosclerotic carotid artery occlusion surgery.
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Affiliation(s)
- Mingsheng Yu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Xinglu Miao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Neurosurgery, Jining No.1 People’s Hospital, Jining, Shandong Province, China
| | - Ying Huang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Lin Ma
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Long Yin
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Hecheng Ren
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
- * Correspondence: Hecheng Ren, Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, China (e-mail: ); Zengguang Wang, Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China (e-mail: )
| | - Zengguang Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- * Correspondence: Hecheng Ren, Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, China (e-mail: ); Zengguang Wang, Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China (e-mail: )
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13
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MRI Outcomes Achieved by Simple Flow Blockage Technique in Symptomatic Carotid Artery Stenosis Stenting. J Pers Med 2022; 12:jpm12101564. [PMID: 36294703 PMCID: PMC9604835 DOI: 10.3390/jpm12101564] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 11/30/2022] Open
Abstract
In this study, we aimed to determine the frequency and clinical impact of new ischemic lesions detected with diffusion-weighted-imaging-MRI (DWI-MRI) as well as the clinical outcomes after carotid artery stenting (CAS) using the simple flow blockage technique (SFB). This is a retrospective study with data extraction from a monocentric prospective clinical registry (from 2017 to 2019) of consecutive patients admitted for symptomatic cervical ICA stenosis or web. Herein, patients benefited from DWI-MRI before and within 48 h of CAS for symptomatic ICA stenosis or web. The primary endpoint was the frequency of new DWI-MRI ischemic lesions and the secondary (composite) endpoint was the rate of mortality, symptomatic stroke or acute coronary syndrome within 30 days of the procedure. All of the 82 CAS procedures were successfully performed. Among the 33 patients (40.2%) with new DWI-MRI ischemic lesions, 30 patients were asymptomatic (90.9%). Irregular carotid plaque surface with (n = 13, 44.8%) or without ulceration (n = 12, 60.0%) was associated with higher rates of new DWI-MRI lesions by comparison to patients with a regular plaque (n = 7, 25%) (p = 0.048) using the univariate analysis. Less than half of this CAS cohort using the SFB technique had new ischemic lesions detected with DWI-MRI. Among these patients, more than 90% were asymptomatic. Irregularity of the plaque seems to increase the risk of peri-procedural DWI-MRI lesions.
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14
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Bertog SC, Sievert K, Grunwald IQ, Sharma A, Hornung M, Kühn AL, Vaskelyte L, Hofmann I, Gafoor S, Reinartz M, Matic P, Sievert H. Acute Stroke Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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15
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Veunac L, Saliou G, Knebel JF, Bartolini B, Puccinelli F, Michel P, Hajdu SD. Revascularization of carotid artery occlusion using stenting versus non stenting in endovascular management of tandem occlusion stroke. J Clin Neurosci 2022; 98:15-20. [DOI: 10.1016/j.jocn.2022.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 12/19/2021] [Accepted: 01/25/2022] [Indexed: 10/19/2022]
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16
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Min X, Du J, Bai X, Wei T, Dmytriw AA, Patel AB, Zhang X, Xu X, Feng Y, Wang T, Wang X, Yang K, Hu W, Yi T, Chen W, Jiao L. Antegrade or Retrograde Approach for the Management of Tandem Occlusions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2022; 12:757665. [PMID: 35095720 PMCID: PMC8790816 DOI: 10.3389/fneur.2021.757665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Acute ischemic stroke (AIS) caused by tandem intracranial and extracranial occlusions is not rare. However, optimal strategy between antegrade (extracranial first) or retrograde (intracranial first) approaches still remains elusive. This systematic review and meta-analysis aim to compare the two approaches to provide updated clinical evidence of strategy selection. Methods: PubMed, Ovid, Web of Science, and the Cochrane Library were searched for literature comparing antegrade and retrograde approaches for patients with AIS with concomitant tandem occlusions. Outcomes including successful reperfusion [Throbolysis in Cerebral Infarction (TICI) 2b-3] and 90-day favorable outcome [modified Rankin Scale (mRS) 0-2], any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, procedural complications, and mortality were evaluated. The risk of bias was assessed using the Newcastle-Ottawa Scale and illustrated in the Funnel plot. Heterogeneity was assessed by I 2 statistic. Subgroup and sensitivity analyses were also performed. Results: A total of 11 studies accounting 1,517 patients were included. 831 (55%) patients were treated with an antegrade approach and 686 (45%) patients were treated with the retrograde approach. A higher successful reperfusion rate was achieved in retrograde group than that of antegrade group [83.8 vs. 78.0%; odds ratio (OR): 0.63, 95% CI: 0.40-0.99, p = 0.04]. 90-day favorable outcome (mRS 0-2 at 90 days) also showed significantly higher in retrograde group compared with antegrade group (47.3 vs. 40.2%; OR: 0.72, 95% CI: 0.58-0.89, p = 0.002). The incidence of any intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage, 90-day mortality, and other complications did not differ between two groups. Conclusion: In AIS with tandem occlusions, the retrograde approach might achieve a higher successful reperfusion rate and better functional outcome with a comparable safety profile when compared with an antegrade approach. Further prospective controlled studies with more meticulous design and a higher level of evidence are needed to confirm these results. Systematic Review Registration: "PROSPERO" database (CRD 42020199093), https://www.crd.york.ac.uk/PROSPERO/.
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Affiliation(s)
- Xiaoli Min
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital, Kunming Medical University, Kunming, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianhua Du
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wei
- Library, Kunming Medical University, Kunming, China
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Xin Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weiwu Hu
- Department of Neurology, The First Traditional Chinese Medicine Hospital of Chengde, Chengde, China
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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17
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Zevallos CB, Farooqui M, Quispe-Orozco D, Mendez-Ruiz A, Dajles A, Garg A, Galecio-Castillo M, Patterson M, Zaidat O, Ortega-Gutierrez S. Acute Carotid Artery Stenting Versus Balloon Angioplasty for Tandem Occlusions: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2022; 11:e022335. [PMID: 35023353 PMCID: PMC9238531 DOI: 10.1161/jaha.121.022335] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Despite thrombectomy having become the standard of care for large-vessel occlusion strokes, acute endovascular management in tandem occlusions, especially of the cervical internal carotid artery lesion, remains uncertain. We aimed to compare efficacy and safety of acute carotid artery stenting to balloon angioplasty alone on treating the cervical lesion in tandem occlusions. Similarly, we aimed to explore those outcomes' associations with technique approaches and use of thrombolysis. Methods and Results We performed a systematic review and meta-analysis to compare functional outcomes (modified Rankin Scale), reperfusion, and symptomatic intracranial hemorrhage and 3-month mortality. We explored the association of first approach (anterograde/retrograde) and use of thrombolysis with those outcomes as well. Two independent reviewers performed the screening, data extraction, and quality assessment. A random-effects model was used for analysis. Thirty-four studies were included in our systematic review and 9 in the meta-analysis. Acute carotid artery stenting was associated with higher odds of modified Rankin Scale score ≤2 (odds ratio [OR], 1.95 [95% CI, 1.24-3.05]) and successful reperfusion (OR, 1.89 [95% CI, 1.26-2.83]), with no differences in mortality or symptomatic intracranial hemorrhage rates. Moreover, a retrograde approach was significantly associated with modified Rankin Scale score ≤2 (OR, 1.72 [95% CI, 1.05-2.83]), and no differences were found on thrombolysis status. Conclusions Carotid artery stenting and a retrograde approach had higher odds of successful reperfusion and good functional outcomes at 3 months than balloon angioplasty and an anterograde approach, respectively, in patients with tandem occlusions. A randomized controlled trial comparing these techniques with structured antithrombotic regimens and safety outcomes will offer definitive guidance in the optimal management of this complex disease.
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Affiliation(s)
- Cynthia B Zevallos
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Mudassir Farooqui
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Darko Quispe-Orozco
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Alan Mendez-Ruiz
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Andres Dajles
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Aayushi Garg
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | | | - Mary Patterson
- Department of Neurology Mercy HealthSt. Vincent Hospital Toledo OH
| | - Osama Zaidat
- Department of Neurology Mercy HealthSt. Vincent Hospital Toledo OH
| | - Santiago Ortega-Gutierrez
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA.,Department of Neurosurgery University of Iowa Hospitals and Clinics Iowa City IA.,Department of Radiology University of Iowa Hospitals and Clinics Iowa City IA
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18
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Perekhodov SN, Gorbenko MY, Snitsar AV, Zelenin DA, Varfalomeev SI, Novikov EA, Voronin AP, Pankratov AA. [Hybrid interventions for tandem occlusions in acute phase of ischemic stroke]. Khirurgiia (Mosk) 2022:13-22. [PMID: 36398950 DOI: 10.17116/hirurgia202211113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of hybrid interventions, i.e. endovascular mechanical thrombectomy from intracranial arteries combined with open thrombectomy or carotid endarterectomy from extracranial internal carotid artery. MATERIAL AND METHODS We analyzed 16 patients who underwent mechanical thrombectomy/thrombaspiration combined with open surgery between January 2014 and March 2021. All patients had occlusion of extracranial and intracranial segments internal carotid artery or initial segments of the middle cerebral artery. Baseline data, diagnostic algorithm, timing and results of treatment were analyzed. Study endpoints were technical success of revascularization, clinically significant hemorrhagic transformation, NIHSS and modified Rankin score of neurological impairment, as well as outcome of disease within 90 days. RESULTS We restored patency of ICA and intracranial arteries in 13 out of 16 patients. In 9 patients, we obtained a positive effect with significant regression of neurological symptoms (mRS <2). In 3 patients, severe neurological deficit persisted throughout the entire follow-up period. Four patients died. Thus, effectiveness of technique was 56.2% (t=3), mortality rate was 25% (t=2.3). There was a relationship between the timing of interventions and outcomes of disease. Indeed, all dead and most of disabled patients underwent surgery later than 6 hours from the onset of disease. CONCLUSION Hybrid interventions for tandem occlusions of carotid arteries can significantly increase efficiency and accelerate recanalization of great extracranial vessels in patients with tandem lesions in acute phase of ischemic stroke. Moreover, hybrid interventions significantly reduce the cost of reperfusion procedure. In case of severe atherosclerotic stenosis, simultaneous open endarterectomy from common and internal carotid arteries has a significant advantage over stenting due to no need for antithrombotic therapy.
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Affiliation(s)
- S N Perekhodov
- Demikhov Moscow City Clinical Hospital, Moscow, Russia
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - M Yu Gorbenko
- Demikhov Moscow City Clinical Hospital, Moscow, Russia
| | - A V Snitsar
- Demikhov Moscow City Clinical Hospital, Moscow, Russia
| | - D A Zelenin
- Demikhov Moscow City Clinical Hospital, Moscow, Russia
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | | | - E A Novikov
- Demikhov Moscow City Clinical Hospital, Moscow, Russia
| | - A P Voronin
- Demikhov Moscow City Clinical Hospital, Moscow, Russia
| | - A A Pankratov
- Demikhov Moscow City Clinical Hospital, Moscow, Russia
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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19
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Khilchuk AA, Shcherbak SG, Gukov KD, Vlasenko SV. Delayed reperfusion therapy for ischemic stroke tandem occlusion with subsequent secondary prophylaxis of cerebral ischemic events: A case report and literature review. Radiol Case Rep 2021; 16:3708-3720. [PMID: 34630806 PMCID: PMC8493513 DOI: 10.1016/j.radcr.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 08/31/2021] [Accepted: 09/04/2021] [Indexed: 12/05/2022] Open
Abstract
Mechanical thrombectomy is currently the gold standard treatment of large vessel occlusions, especially in anterior circulation acute ischemic stroke. At the same time, the problem of tandem occlusions seems especially important since most of the major clinical mechanical thrombectomy studies did not specifically evaluate patients with concomitant extracranial occlusions or critical stenoses. To date, there is no universally accepted optimal treatment strategy for such tandem lesions in acute ischemic stroke: it remains unclear which lesion – intracranial or extracranial – should be treated first. The selected reperfusion method should be based on the patients’ individual characteristics, data from non-invasive radiologic studies, and the stroke team experience. We present a case of successful reperfusion therapy of acute tandem occlusion of the right internal carotid artery, followed by contralateral carotid artery stenting in a patient with stenosing extracranial atherosclerosis.
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Affiliation(s)
- Anton A Khilchuk
- Interventional Radiology Department, City Hospital #40, 9 Borisova str., Sestroretsk, Saint Petersburg 197706, Russian Federation.,Medical Faculty, Saint-Petersburg State University, Saint Petersburg, Russian Federation
| | - Sergey G Shcherbak
- Medical Faculty, Saint-Petersburg State University, Saint Petersburg, Russian Federation
| | - Kirill D Gukov
- Interventional Radiology Department, City Hospital #40, 9 Borisova str., Sestroretsk, Saint Petersburg 197706, Russian Federation
| | - Sergey V Vlasenko
- Interventional Radiology Department, City Hospital #40, 9 Borisova str., Sestroretsk, Saint Petersburg 197706, Russian Federation.,Medical Faculty, Saint-Petersburg State University, Saint Petersburg, Russian Federation
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20
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Londhe SR, Gg SK, Keshava SN, Mohan C. Indian College of Radiology and Imaging (ICRI) Consensus Guidelines for the Early Management of Patients with Acute Ischemic Stroke: Imaging and Intervention. Indian J Radiol Imaging 2021; 31:400-408. [PMID: 34556925 PMCID: PMC8448212 DOI: 10.1055/s-0041-1734346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The medical science has witnessed significant change in the management of acute stroke patients as a result of recent advances in the field of stroke imaging and endovascular mechanical thrombectomy in addition to intravenous thrombolysis and optimization of stroke services in balance with available resources. Despite initial negative trials, we witnessed the publication of five multicenter randomized clinical trials showing superiority of the endovascular approach over standard medical management in patients with large vessel occlusion. The aim of this study is to provide comprehensive set of evidence-based recommendations regarding imaging and endovascular interventions in acute ischemic stroke patients.
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Affiliation(s)
- Shrikant R Londhe
- Department of Interventional Neuroradiology, Noble Hospital, Pune, Maharashtra, India
| | - Sharath Kumar Gg
- Department of Diagnostic and Interventional Neuroradiology, Apollo Hospitals, Bangalore, Karnataka, India
| | - Shyamkumar N Keshava
- Department of Interventional Radiology, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - Chander Mohan
- Interventional Radiology, ICRI Director, Interventional Radiology, BLK Super Specialty Hospital, Pusa Road, New Delhi, India
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21
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Garg A, Farooqui M, Zevallos CB, Quispe-Orozco D, Mendez-Ruiz A, Zaidat O, Ortega-Gutierrez S. Carotid artery angioplasty versus stenting for management of acute tandem occlusions. J Neurol Sci 2021; 428:117588. [PMID: 34403954 DOI: 10.1016/j.jns.2021.117588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/16/2021] [Accepted: 07/23/2021] [Indexed: 10/20/2022]
Abstract
Background The optimal approach to treat the cervical carotid artery lesion during endovascular thrombectomy (EVT) for acute strokes with tandem occlusions is unclear. While carotid artery stenting (CAS) might be a more definitive recanalization method, the potential risk of intracranial hemorrhage (ICH) limits its routine usage. In this study, we aimed to evaluate the safety outcomes of CAS and carotid artery angioplasty (CAA) in patients with acute tandem occlusions. Methods In this retrospective cohort study, data were obtained from the Nationwide Readmissions Database 2016-2017. The primary safety outcome was a composite of ICH and all-cause in-hospital mortality. Logistic regression analysis was used to compare the in-hospital outcomes. Survival analysis was used to estimate the 30-day readmissions. Results We identified 2042 hospitalizations meeting the study inclusion criteria (median age: 66 years, female 31.3%). Of these, 1391 (68.1%) had undergone CAS and 651 (31.9%) CAA alone. Baseline characteristics between the two groups were similar, except patients with CAS were more likely to be on anti-thrombotic medications and were less likely to have received intravenous thrombolysis. There was no significant difference in the clinical outcomes including ICH, in-hospital mortality, gastrostomy tube placement, prolonged mechanical ventilation, length of stay, hospital charges, and 30-day readmissions between the two groups, however, patients with CAS were more likely to be discharged home after adjusting for the confounding variables [odds ratio (OR) 1.49, 95% confidence interval (CI) 1.05-2.12, P 0.025]. Conclusion The emergent CAS-EVT approach appears to be safe with no adverse outcomes compared to CAA alone.
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Affiliation(s)
- Aayushi Garg
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Cynthia B Zevallos
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Alan Mendez-Ruiz
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Osama Zaidat
- Department of Neurology, Mercy Health - St. Vincent Medical Center, Toledo, OH, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
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22
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Guo X, Miao Z. Advances in mechanical thrombectomy for acute ischaemic stroke from large vessel occlusions. Stroke Vasc Neurol 2021; 6:649-657. [PMID: 34285134 PMCID: PMC8717796 DOI: 10.1136/svn-2021-000972] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/07/2021] [Indexed: 11/17/2022] Open
Abstract
Advances in endovascular treatment of acute ischaemic stroke from intracranial large vessel occlusions have continued in the past decade. Here, we performed a detailed review of all the new trials and studies that had the highest evidence, the guidelines for mechanical thrombectomy, the selection of the particular population outside the guidelines and endovascular therapeutic strategies for acute ischemic stroke from occluded intracranial arteries.
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Affiliation(s)
- Xu Guo
- Intervetional Neurology, Capital Medical University Affiliated Anzhen Hospital, Chaoyang-qu, China
| | - Zhongrong Miao
- Interventinal Neuroradiology, Beijing Tiantan Hospital, Beijing, China
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23
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Da Ros V, Scaggiante J, Pitocchi F, Sallustio F, Lattanzi S, Umana GE, Chaurasia B, Bandettini di Poggio M, Toscano G, Rolla Bigliani C, Ruggiero M, Haznedari N, Sgreccia A, Sanfilippo G, Diomedi M, Finocchi C, Floris R. Mechanical thrombectomy in acute ischemic stroke with tandem occlusions: impact of extracranial carotid lesion etiology on endovascular management and outcome. Neurosurg Focus 2021; 51:E6. [PMID: 34198245 DOI: 10.3171/2021.4.focus21111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/07/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Different etiologies of extracranial internal carotid artery steno-occlusive lesions (ECLs) in patients with acute ischemic stroke (AIS) and tandem occlusion (TO) have been pooled together in randomized trials. However, carotid atherosclerosis (CA) and carotid dissection (CD), the two most common ECL etiologies, are distinct nosological entities. The authors aimed to determine if ECL etiology has impacts on the endovascular management and outcome of patients with TO. METHODS A multicenter, retrospective study of prospectively collected data was conducted. AIS patients were included who had TO due to internal CA or CD and ipsilateral M1 middle cerebral artery occlusion and underwent endovascular treatment (EVT). Comparative analyses including demographic data, safety, successful recanalization rates, and clinical outcome were performed according to EVT and ECL etiology. RESULTS In total, 214 AIS patients with TOs were included (77.6% CA related, 22.4% CD related). Patients treated with a retrograde approach were more often functionally independent at 3 months than patients treated with an antegrade approach (OR 0.6, 95% CI 0.4-0.9). Patients with CD-related TOs achieved 90-day clinical independence more often than patients with CA-related TOs (OR 1.4, 95% CI 1.1-2.0). Emergency stenting use was associated with good 3-month clinical outcome only in patients with CA-related TOs (OR 1.4, 95% CI 1.1-2.1). Symptomatic intracranial hemorrhage (sICH) occurred in 10.7% of patients, without differences associated with ECL etiology. CONCLUSIONS ECL etiology impacts both EVT approach and clinical outcome in patients with TOs. Patients with CD-related TO achieved higher 3-month functional independence rates than patients with CA-related TOs. A retrograde approach can be desirable for both CA- and CD-related TOs, and emergency stenting is likely better justified in CA-related TOs.
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Affiliation(s)
- Valerio Da Ros
- 1Department of Biomedicine, Interventional Neuroradiology Unit, University of Rome Tor Vergata, Rome
| | - Jacopo Scaggiante
- 1Department of Biomedicine, Interventional Neuroradiology Unit, University of Rome Tor Vergata, Rome.,13Medical University of South Carolina, Division of Neuroradiology, Charleston, South Carolina
| | - Francesca Pitocchi
- 1Department of Biomedicine, Interventional Neuroradiology Unit, University of Rome Tor Vergata, Rome
| | | | - Simona Lattanzi
- 3Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona
| | - Giuseppe Emmanuele Umana
- 4Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Bipin Chaurasia
- 5Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Monica Bandettini di Poggio
- 6Ospedale Policlinico San Martino, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova
| | | | - Claudia Rolla Bigliani
- 8Department of Diagnostic and Interventional Neuroradiology, Policlinico Universitario San Martino, Genova
| | | | | | - Alessandro Sgreccia
- 10Department of Clinical Neuroradiology and Interventional Neuroradiology, AOU Ospedali Riuniti, Ancona
| | - Giuseppina Sanfilippo
- 11Department of Diagnostic and Interventional Radiology and Neuroradiology, IRCCS Policlinico San Matteo, Pavia
| | - Marina Diomedi
- 12Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy; and
| | - Cinzia Finocchi
- 6Ospedale Policlinico San Martino, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova
| | - Roberto Floris
- 1Department of Biomedicine, Interventional Neuroradiology Unit, University of Rome Tor Vergata, Rome
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24
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Gigliotti MJ, Sweid A, El Naamani K, Patel N, Cockroft KM, Park C, Kanekar S, Church EW, Tjoumakaris SI, Simon SD. Management of Internal Carotid Artery and Intracranial Anterior Circulation Tandem Occlusion with Stenting versus No Stenting: A Multicenter Study. World Neurosurg 2021; 153:e237-e243. [PMID: 34175489 DOI: 10.1016/j.wneu.2021.06.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tandem occlusion (TO) describes not only occlusion of the middle cerebral artery but a contemporaneous occlusion of the cervical internal carotid artery. There is a paucity of data over whether mechanical thrombectomy (MT) alone, MT with angioplasty, or MT with carotid artery stent placement is superior. We aim to address a gap in the literature comparing carotid stenting with mechanical thrombectomy (CSMT) and carotid angioplasty with mechanical thrombectomy (CAMT) in patients presenting with acute anterior circulation TOs. METHODS This is a multicenter, retrospective study from 2012 to 2020 comparing CSMT and CAMT presenting with acute anterior circulation TOs. Primary outcomes of interest were functional status, perioperative stroke, mortality, and symptomatic intracranial hemorrhage (sICH). A total of 92 patients (66 vs. 26 in CSMT and CAMT, respectively) met inclusion criteria for analysis. RESULTS There was no statistically significant difference in functional outcomes at 90-day follow-up (adjusted odds ratio [aOR] 0.82; 95% confidence interval [CI] 0.20-3.5; P = 0.46). In addition, there was no statistically significant difference in 90-day mortality (aOR 0.361; 95% CI 0.016-2.92; P = 0.532) and perioperative stroke rate (aOR 1.76; 95% CI 0.160-15.6; P = 0.613). However, sICH risk was significantly greater in the stent-treated cohort (aOR 3.94; 95% CI 0.529-37.4; P = 0.003). CONCLUSIONS Functional outcomes, mortality, and perioperative stroke rates do not significantly differ in CSMT and CAMT procedures in the acute setting. However, CSMT-treated patients do appear to have an increased risk of sICH, potentially due to the use of additional antiplatelet agents following stent placement.
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Affiliation(s)
- Michael J Gigliotti
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Neel Patel
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Christian Park
- Department of Radiology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Sangam Kanekar
- Department of Radiology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Ephraim W Church
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | | | - Scott D Simon
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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25
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Kalmar PJ, Tarkanyi G, Nagy CB, Csecsei P, Lenzser G, Bosnyak E, Karadi ZN, Annus A, Szegedi I, Buki A, Szapary L. Comparing Endovascular Treatment Methods in Acute Ischemic Stroke Due to Tandem Occlusion Focusing on Clinical Aspects. Life (Basel) 2021; 11:458. [PMID: 34065422 PMCID: PMC8160775 DOI: 10.3390/life11050458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/12/2021] [Accepted: 05/14/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Acute ischemic strokes (AIS) due to tandem occlusion (TO) of intracranial anterior large vessel and concomitant extracranial internal carotid artery (EICA) are represent in 15-20% of all ischemic strokes. The endovascular treatment (EVT) strategy for those patients is still unclear. Although the intracranial mechanical thrombectomy (MT) is considered as a standard treatment approach, the EICA lesion stent necessity remains a matter of debate. We sought to assess the efficacy and safety of EVT in tandem lesions, particularly the EICA stenting management. METHODS We retrospectively analyzed all patients with anterior circulation stroke associated with EICA lesion and receiving EVT in the three participated stroke centers between November 2017 and December 2020. Patients' data were collected from our prospective stroke registry (STAY ALIVE). Patients enrolled in our study were divided into two groups depending on whether acute carotid stenting (ACS) or balloon angioplasty only (BAO) technique was used. Our primary outcome was the 90-day functional outcome assessed by modified Rankin scale (mRS). Mortality at 90 days and symptomatic intracranial hemorrhage (sICH) were considered as secondary outcomes. RESULTS A total of 101 patients (age: 67 ± 10 years, 38.6% female) were enrolled in our study, including 29 (28.3%) BAO cases, and 72 (71.3%) patients treated with ACS. Patients in the BAO group were slightly older (70 ± 9 years vs. 66 ± 10 years, p = 0.054), and had higher prevalence of comorbidities such as hypertension (100.0% vs. 59.4%, p < 0.001). There was no significant difference in favorable outcomes (51.7% vs. 54.4%, p = 0.808) between the groups. However, we observed a trend towards higher rates of sICH (8.3% vs. 3.4%, p = 0.382) and 90-day mortality (23.5% vs. 13.8%, p = 0.278) with significantly higher frequency of distal embolization (39.1% vs. 17.9%, p = 0.043) in patients with ACS. In the overall population age (p = 0.013), atrial fibrillation (AF) (p = 0.008), National Institutes of Health Stroke Scale (NIHSS) baseline (p = 0.029), and successful recanalization (p = 0.023) were associated with favorable outcome. CONCLUSION Endovascular approach of EICA in addition to MT was safe and effective in tandem occlusion of anterior circulation. Furthermore, our results suggest that balloon angioplasty technique without acute stenting shows a comparable favorable outcome rate to ACS with moderately less hemorrhagic events and mortality rates.
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Affiliation(s)
- Peter Janos Kalmar
- Department of Neurology, Medical School, University of Pécs, 7623 Pécs, Hungary; (P.J.K.); (G.T.); (E.B.); (Z.N.K.)
| | - Gabor Tarkanyi
- Department of Neurology, Medical School, University of Pécs, 7623 Pécs, Hungary; (P.J.K.); (G.T.); (E.B.); (Z.N.K.)
| | - Csaba Balazs Nagy
- Department of Neurosurgery, Medical School, University of Pécs, 7623 Pécs, Hungary; (C.B.N.); (P.C.); (G.L.); (A.B.)
| | - Peter Csecsei
- Department of Neurosurgery, Medical School, University of Pécs, 7623 Pécs, Hungary; (C.B.N.); (P.C.); (G.L.); (A.B.)
| | - Gabor Lenzser
- Department of Neurosurgery, Medical School, University of Pécs, 7623 Pécs, Hungary; (C.B.N.); (P.C.); (G.L.); (A.B.)
| | - Edit Bosnyak
- Department of Neurology, Medical School, University of Pécs, 7623 Pécs, Hungary; (P.J.K.); (G.T.); (E.B.); (Z.N.K.)
| | - Zsofia Nozomi Karadi
- Department of Neurology, Medical School, University of Pécs, 7623 Pécs, Hungary; (P.J.K.); (G.T.); (E.B.); (Z.N.K.)
| | - Adam Annus
- Department of Neurology, University of Szeged, 6725 Szeged, Hungary;
| | - Istvan Szegedi
- Department of Neurology, University of Debrecen, 4032 Debrecen, Hungary;
| | - Andras Buki
- Department of Neurosurgery, Medical School, University of Pécs, 7623 Pécs, Hungary; (C.B.N.); (P.C.); (G.L.); (A.B.)
| | - Laszlo Szapary
- Department of Neurology, Medical School, University of Pécs, 7623 Pécs, Hungary; (P.J.K.); (G.T.); (E.B.); (Z.N.K.)
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26
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Successful recanalization after stenting in acute basilar occlusion from vertebral V2 dissection: A telescoping stents technique with long term follow-up. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.100962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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27
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Beutler BD, Rangaswamy R, Bruno AJ, Tabaac BJ. Acute bilateral internal carotid artery occlusion: A novel approach to management of a catastrophic clinical entity. Clin Imaging 2021; 76:166-174. [PMID: 33636514 DOI: 10.1016/j.clinimag.2021.02.013] [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: 09/03/2020] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute bilateral internal carotid artery occlusion (ABICAO) represents a rare but potentially-lethal clinical entity. Guidelines for management remain to be established. However, emergent intervention is vital to prevent loss of brainstem reflexes and death. PURPOSE We describe two patients who presented with ABICAO and detail a novel management approach with carotid angioplasty and stent placement. In addition, we review the literature on ABICAO. RESULTS Two patients presented within a two-week period with marked neurologic deficits. Imaging studies showed ABICAO. The first patient was initially treated with tissue plasminogen activator. No improvement occurred after two days, prompting the medical team to attempt urgent carotid artery angioplasty and stenting. However, the patient continued to deteriorate and died shortly after the intervention. The second patient underwent emergent carotid artery angioplasty and stenting within hours of presentation and recovered with only mild residual neurologic deficits. CONCLUSION Further research on ABICAO management is required to establish clinical practice guidelines. However, as evidenced by our two patients, endovascular thrombectomy should be performed as early as possible in appropriate candidates; an unfavorable outcome may occur if treatment is delayed. Based on the limited available data, emergent angioplasty and stenting should be considered a first-line intervention for patients presenting with this rare and oft-lethal event.
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Affiliation(s)
- Bryce D Beutler
- University of Southern California, Keck School of Medicine, Department of Radiology, Los Angeles, CA, USA.
| | - Rajesh Rangaswamy
- Reno Radiological Associates, Reno, NV, USA; Renown Regional Medical Center, Reno, NV, USA; University of Nevada, Reno School of Medicine, Reno, NV, USA
| | | | - Burton J Tabaac
- Renown Regional Medical Center, Reno, NV, USA; University of Nevada, Reno School of Medicine, Reno, NV, USA; Renown Health, Acute Care Neurology Division, Reno, NV, USA
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Jost A, Roels C, Brown M, Janjua R, Heck D. Low-Dose Eptifibatide for Tandem Occlusion in Stroke: Safety and Carotid Artery Patency. AJNR Am J Neuroradiol 2021; 42:738-742. [PMID: 33541892 DOI: 10.3174/ajnr.a6985] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/21/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Maintaining carotid patency and avoiding symptomatic intracranial hemorrhage are competing concerns in tandem occlusions. This study provides data regarding the safety and efficacy of eptifibatide in stroke from tandem occlusion of the extracranial carotid artery and the intracranial carotid or middle cerebral artery. MATERIALS AND METHODS This is a retrospective analysis of 58 consecutive patients who received low-dose eptifibatide (135-mcg/kg bolus, 1-mcg/kg/min infusion) during treatment of tandem occlusions. Brain imaging and carotid sonography were performed at 24-36 hours. mRS was documented at 90 days, and carotid sonography, at 30-60 days. RESULTS The median age and NIHSS score were 64 years and 15, respectively. Twenty-five patients (43%) received tPA. ASPECTSs were 8-10 in 47 (81%) and 5-7 in 11 (19%) patients. Thirty-eight patients had angioplasty/stent placement acutely; 20 had angioplasty alone. Symptomatic intracranial hemorrhage occurred in 1 patient (2%). TICI 2b or higher was achieved in 56 patients (96%). Fifty-seven of 58 patients had clinical follow-up at 90 days (1 lost to follow up). The 90-day mRS was 0-2 in 42 patients (72%). There were 4/58 (7%) re-occlusions within 24-36 hours, all originally treated with stent placement. Forty-nine of 53 surviving patients had carotid sonography at 30-60 days, with 3 delayed re-occlusions, 2 with stents and 1 with angioplasty alone. The overall carotid patency at 30-60 days was 42/49 (86%). Carotid re-occlusion was not associated with clinical decline. CONCLUSIONS Low-dose eptifibatide seemed to be safe in tandem occlusions (symptomatic intracranial hemorrhage, 2%), although asymptomatic cervical carotid artery re-occlusions still occurred in 14% of patients.
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Affiliation(s)
- A Jost
- From the Wake Forest School of Medicine (A.J.), Winston Salem, North Carolina
| | - C Roels
- Departments of Pharmacy (C.R.)
| | - M Brown
- Triad Radiology Associates (M.B., D.H.), Forsyth Medical Center, Winston Salem, North Carolina
| | - R Janjua
- Neurosurgery (R.J.), Novant Health, Forsyth Medical Center, Winston Salem, North Carolina
| | - D Heck
- Triad Radiology Associates (M.B., D.H.), Forsyth Medical Center, Winston Salem, North Carolina
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29
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Nolan NM, Regenhardt RW, Koch MJ, Raymond SB, Stapleton CJ, Rabinov JD, Silverman SB, Leslie-Mazwi TM, Patel AB. Treatment Approaches and Outcomes for Acute Anterior Circulation Stroke Patients with Tandem Lesions. J Stroke Cerebrovasc Dis 2021; 30:105478. [PMID: 33248344 PMCID: PMC7855424 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105478] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/11/2020] [Accepted: 11/13/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Endovascular thrombectomy (EVT) has revolutionized stroke care for large vessel occlusions (LVOs). However, over half treated remain functionally disabled or die. Patients with tandem lesions, or severe stenosis/occlusion of the cervical internal carotid artery (ICA) with intracranial LVO, may have technical EVT challenges and worse outcomes. We sought to compare treatments and outcomes for patients with anterior circulation tandem lesions versus isolated LVOs. MATERIALS AND METHODS Consecutive tandem lesion and isolated intracranial LVO patients were identified at a single center. Demographics, medical history, presentations, treatments, and outcomes were collected and analyzed. RESULTS From 381 EVT patients, 62 had tandem lesions related to atherosclerosis (74%) or dissection (26%). Compared to isolated intracranial LVOs, they were younger (63 vs 70, p = 0.003), had less atrial fibrillation (13% vs 40%, p < 0.0001), less adequate reperfusion (TICI 2b-3, 58% vs 82%, p < 0.0001), more intracranial hemorrhage (ICH, 13% vs 5%, p = 0.037), but similar 90-day functional independence (mRS 0-2, 34% vs 43%, p = 0.181). The cervical ICA was treated before intracranial EVT (57%), after (13%), not acutely (22%), or was inaccessible (8%). Acute cervical ICA treatments were stenting (57%) or angioplasty alone (13%). Neither acute stenting nor order of treatment was associated with outcomes (TICI 2b-3, ICH, or 90-day mRS 0-2). Among acutely stented, neither alteplase nor antiplatelets were associated with outcomes or stent patency. CONCLUSIONS Tandem lesions were associated with less reperfusion, more ICH, but similar 90-day functional independence. No treatment approach was associated with outcomes. These data illustrate the technical challenges of tandem lesion treatment and underscore the importance of developing new approaches.
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MESH Headings
- Aged
- Aged, 80 and over
- Carotid Artery, Internal, Dissection/diagnostic imaging
- Carotid Artery, Internal, Dissection/mortality
- Carotid Artery, Internal, Dissection/physiopathology
- Carotid Artery, Internal, Dissection/therapy
- Carotid Stenosis/diagnostic imaging
- Carotid Stenosis/mortality
- Carotid Stenosis/physiopathology
- Carotid Stenosis/therapy
- Cerebrovascular Circulation
- Databases, Factual
- Endovascular Procedures/adverse effects
- Endovascular Procedures/instrumentation
- Endovascular Procedures/mortality
- Female
- Functional Status
- Humans
- Intracranial Arteriosclerosis/diagnostic imaging
- Intracranial Arteriosclerosis/mortality
- Intracranial Arteriosclerosis/physiopathology
- Intracranial Arteriosclerosis/therapy
- Ischemic Stroke/diagnostic imaging
- Ischemic Stroke/mortality
- Ischemic Stroke/physiopathology
- Ischemic Stroke/therapy
- Male
- Middle Aged
- Recovery of Function
- Retrospective Studies
- Risk Factors
- Stents
- Thrombectomy/adverse effects
- Thrombectomy/mortality
- Thrombolytic Therapy/adverse effects
- Thrombolytic Therapy/mortality
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Neal M Nolan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Robert W Regenhardt
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
| | - Matthew J Koch
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Scott B Raymond
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Scott B Silverman
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
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Zapata-Arriaza E, de Albóniga-Chindurza A, Ortega-Quintanilla J, Escudero-Martínez I, Moniche F, Medina-Rodríguez M, Pardo-Galiana B, Rodríguez JAC, Hernández LL, Ainz L, Pérez-Sánchez S, Domínguez-Mayoral A, Barragán A, Cayuela A, Montaner J, García AG. Clinical Outcomes of Mechanical Thrombectomy in Stroke Tandem Lesions According to Intracranial Occlusion Location. J Stroke 2021; 23:124-127. [PMID: 33600709 PMCID: PMC7900399 DOI: 10.5853/jos.2020.02747] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/16/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Elena Zapata-Arriaza
- Interventional Neurorradiology Department, Stroke Research Program, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | - Asier de Albóniga-Chindurza
- Interventional Neurorradiology Department, Stroke Research Program, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | - Joaquin Ortega-Quintanilla
- Interventional Neurorradiology Department, Stroke Research Program, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | - Irene Escudero-Martínez
- Neurology Department, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | - Francisco Moniche
- Neurology Department, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | - Manuel Medina-Rodríguez
- Neurology Department, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | - Blanca Pardo-Galiana
- Neurology Department, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | | | - Lucía Lebrato Hernández
- Neurology Department, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | - Leire Ainz
- Neurology Department, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | | | | | - Ana Barragán
- Department of Neurology, Virgen Macarena University Hospital, Seville, Spain
| | - Aurelio Cayuela
- Clinical Management of Public Health, Prevention and Health Promotion Unit, Southern Health Management Area of Seville, Hospital de Valme, Seville, Spain
| | - Joan Montaner
- Department of Neurology, Virgen Macarena University Hospital, Seville, Spain
| | - Alejandro González García
- Interventional Neurorradiology Department, Stroke Research Program, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
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Endovascular treatment of acute ischemic stroke due to tandem lesions of the anterior cerebral circulation: a multicentric Italian observational study. Radiol Med 2021; 126:804-817. [PMID: 33502665 PMCID: PMC8154792 DOI: 10.1007/s11547-020-01331-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/22/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Acute ischemic stroke (AIS) due to tandem lesions (TLs) of extracranial Internal Carotid Artery and Anterior Cerebral Circulation are challenging for endovascular treatment (EVT). This study aims to evaluate feasibility, safety and efficacy of EVT for TLs' AIS, with or without emergent carotid artery stenting (eCAS), in a real-life scenario. METHODS Retrospective review of prospectively collected non-randomized thrombectomy databases from five stroke centers between 2015 and 2019. Consecutive patients with TLs' AIS were selected. Clinical, neuroimage and procedure features, as well as antiplatelet therapy regimen, were evaluated. Primary outcome was 90-day mRS ≤ 2. Secondary outcomes included: mTICI score 2b-3, extracranial recanalization, procedural complications, symptomatic intracerebral hemorrhage (SICH) and 90-day mortality. RESULTS Two hundred twenty-seven patients were enrolled (67.8% males; mean age 65.9 ± 12.9 years). We obtained mTICI 2b-3 in 77.1%, extracranial recanalization in 86.8%, 90-day mRS (available in 201/227 cases) ≤ 2 in 49.8%. Procedural complications occurred in 16.7%, SICH in 9.7%; 90-day mortality rate (available in 201/227 cases) was 14.4%. The strongest predictors of good clinical outcome were young age (p < 0.0001), low baseline NIHSS (p = 0.008), high baseline ASPECTS (p < 0.0001), good collateral flow (p = 0.013) and extracranial recanalization (p = 0.001). The most significant predictors of SICH were low baseline ASPECTS (p < 0.0001), occurrence of complications (p < 0.0001) and eCAS (p = 0.002). CONCLUSION In our real-life series, the EVT for TLs' AIS was feasible, safe and effective in improving 90-day functional outcome with acceptable morbi-mortality rates. ECAS increased the risk of SICH, independently from the antiplatelet therapy regimen.
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Chen SJ, Liu RR, Shang YR, Xie YJ, Guo XH, Huang MJ, Yang XF, Fu QZ, Qi JS, Shen DY, Li JY. An Ultrasound Model to Predict the Short-Term Effects of Endovascular Stent Placement in the Treatment of Carotid Artery Stenosis. Front Cardiovasc Med 2021; 7:607367. [PMID: 33553258 PMCID: PMC7862114 DOI: 10.3389/fcvm.2020.607367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/21/2020] [Indexed: 11/20/2022] Open
Abstract
Purpose: The present study aimed to explore the predictive ability of an ultrasound linear regression equation in patients undergoing endovascular stent placement (ESP) to treat carotid artery stenosis-induced ischemic stroke. Methods: Pearson's correlation coefficient of actual improvement rate (IR) and 10 preoperative ultrasound indices in the carotid arteries of 64 patients who underwent ESP were retrospectively analyzed. A predictive ultrasound model for the fitted IR after ESP was established. Results: Of the 10 preoperative ultrasound indices, peak systolic velocity (PSV) at stenosis was strongly correlated with postoperative actual IR (r = 0.622; P < 0.01). The unstable plaque index (UPI; r = 0.447), peak eccentricity ratio (r = 0.431), and plaque stiffness index (β; r = 0.512) moderately correlated with actual IR (P < 0.01). Furthermore, the resistance index (r = 0.325) and the dilation coefficient (r = 0.311) weakly correlated with actual IR (P < 0.05). There was no significant correlation between actual IR and the number of unstable plaques, area narrowing, pulsatility index, and compliance coefficient. In combination, morphological, hemodynamic, and physiological ultrasound indices can predict 62.39% of neurological deficits after ESP: fitted IR = 0.9816 – 0.1293β + 0.0504UPI – 0.1137PSV. Conclusion: Certain carotid ultrasound indices correlate with ESP outcomes. The multi-index predictive model can be used to evaluate the effects of ESP before surgery.
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Affiliation(s)
- Sheng-Jiang Chen
- Department of Ultrasound, The First Affiliated Hospital, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Rui-Rui Liu
- Department of Ultrasound, The First Affiliated Hospital, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Yi-Ran Shang
- Department of Ultrasound, The First Affiliated Hospital, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Yu-Juan Xie
- Department of Ultrasound, The First Affiliated Hospital, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Xiao-Han Guo
- Department of Ultrasound, The First Affiliated Hospital, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Meng-Jiao Huang
- Department of Ultrasound, The First Affiliated Hospital, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Xiao-Feng Yang
- Department of Ultrasound, The First Affiliated Hospital, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Qi-Zhi Fu
- Department of Neurology, The First Affiliated Hospital, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Ji-Sheng Qi
- Department of Neurology, The First Affiliated Hospital, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Dong-Yan Shen
- Department of Vascular Surgery, The First Affiliated Hospital, College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Jia-Yan Li
- Department of Ultrasound, Luoyang Dongfang Hospital, The Third Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
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33
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Khripun AI, Salikov AV, Mironkov AB, Pryamikov AD, Asratyan SA, Suryakhin VS, Kamchatnov PR, Sazhina OA, Zakharov KA. [Results of endovascular treatment of acute tandem occlusion of internal carotid and middle cerebral arteries]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 120:5-10. [PMID: 33449526 DOI: 10.17116/jnevro20201201225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the results of endovascular treatment of patients with ischemic stroke caused by acute tandem occlusion of the internal carotid and middle cerebral arteries (ICA and MCA). MATERIAL AND METHODS Endovascular intervention was performed in 8 patients with tandem occlusion of ICA and MCA. The neurological deficit on admission was 17.4±5.6 NIHSS points and the average ASPECTS score was 9.5±0.8. The time from the onset of neurological symptoms to reperfusion was 224±68 min. Thrombolytic therapy was initiated before brain revascularization and continued intraoperatively in 4 out of 8 patients. ICA stenting after aspiration thrombectomy was required in 6 patients. Both antegrade (n=4) and retrograde (n=2) methods of brain revascularization were used. RESULTS The rate of detection of tandem lesion in patients with ischemic stroke who underwent endovascular treatment was 5.4%. Technical success in restoring blood flow in the ICA basin at extra-and intra-cranial levels (mTICI 2b/3) was achieved in 7 (87.5%) patients. Intracranial hemorrhagic complications that affected the outcome of the disease were clinically significant in 25% of patients (n=2). The mortality rate was 37.5% (n=3). A satisfactory clinical result (a deficit of 0-2 mRS scores) was achieved at discharge in one of 5 surviving patients. CONCLUSION Further studies of choosing the optimal surgical tactics for tandem occlusion of ICA and MCA, taking into account its effectiveness and safety, are need.
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Affiliation(s)
- A I Khripun
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Salikov
- Buyanov City Clinical Hospital, Moscow, Russia
| | - A B Mironkov
- Pirogov Russian National Research Medical University, Moscow, Russia.,Buyanov City Clinical Hospital, Moscow, Russia
| | - A D Pryamikov
- Pirogov Russian National Research Medical University, Moscow, Russia.,Buyanov City Clinical Hospital, Moscow, Russia
| | | | | | - P R Kamchatnov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - O A Sazhina
- Buyanov City Clinical Hospital, Moscow, Russia
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Abstract
Endovascular therapy (EVT) has become the standard treatment for large-vessel occlusion (LVO) acute ischemic stroke (AIS). EVT is now indicated in patients up to 24h from their last known well, provided that the patient meets specific clinical and imaging criteria. Improvements in thrombectomy devices, techniques, and operator experience have allowed successful EVT of ICA terminus, M1-MCA occlusions as well as proximal M2-MCA, basilar artery occlusions, and revascularization of tandem lesions. Mechanical thrombectomy failures still occur due to several factors, however, highlighting the need for further device and technical improvements. An ongoing debate exists regarding the need for pre-EVT thrombolytic agents, thrombectomy techniques, distal occlusions, anesthesia methods, the role of advanced neuroimaging, the treatment of patients with larger infarct core, and those presenting with milder stroke symptoms. Many of these questions are the subject of current or upcoming clinical trials. This review aims to provide an outline and discussion about the established recommendations and emerging topics regarding EVT for LVO AIS.
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Affiliation(s)
- Fabio Settecase
- Neuroradiology Division, Department of Radiology, University of British Columbia, Vancouver, BC, Canada; Diagnostic and Interventional Neuroradiology Division, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada; Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States.
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Zevallos CB, Farooqui M, Quispe-Orozco D, Mendez-Ruiz A, Patterson M, Below K, Martins SO, Mansour OY, Mont'Alverne F, Nguyen TN, Lemme L, Siddiqui AH, Fraser JF, Jadhav AP, Zaidat OO, Ortega-Gutierrez S. Proximal Internal Carotid artery Acute Stroke Secondary to tandem Occlusions (PICASSO) international survey. J Neurointerv Surg 2020; 13:1106-1110. [PMID: 33323501 DOI: 10.1136/neurintsurg-2020-017025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/19/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND While mechanical thrombectomy (MT) is the standard of care for large vessel occlusion strokes, the optimal management of tandem occlusions (TO) remains uncertain. We aimed to determine the current practice patterns among stroke physicians involved in the treatment of TO during MT. METHODS We distributed an online survey to neurovascular practitioners (stroke neurologists, neurointerventionalists, neurosurgeons, and radiologists), members of professional societies. After 2 months the site was closed and data were extracted and analyzed. We divided respondents into acute stenting and delayed treatment groups and responses were compared between the two groups. RESULTS We received 220 responses from North America (48%), Latin America (28%), Asia (15%), Europe (5%), and Africa (4%). Preferred timing for cervical revascularization varied among respondents; 51% preferred treatment in a subsequent procedure during the same hospitalization whereas 39% preferred to treat during MT. Angioplasty and stenting (41%) was the preferred technique, followed by balloon angioplasty and local aspiration (38%). The risk of intracerebral hemorrhage was the most compelling reason for not stenting acutely (68%). There were no significant differences among practice characteristics and timing groups. Most practitioners (70%) agreed that there is equipoise regarding the optimal endovascular treatment of cervical lesions in TO; hence, 77% would participate in a randomized controlled trial. CONCLUSIONS The PICASSO survey demonstrates multiple areas of uncertainty regarding the medical and endovascular management of TOs. Experts acknowledged the need for further evidence and their willingness to participate in a randomized controlled trial to evaluate the best treatment for the cervical TO lesion.
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Affiliation(s)
- Cynthia B Zevallos
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Alan Mendez-Ruiz
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mary Patterson
- Neurology, Mercy Health St Vincent Hospital, Toledo, Ohio, USA
| | - Kristine Below
- Neurology, Mercy Health St Vincent Hospital, Toledo, Ohio, USA
| | - Sheila O Martins
- Neurology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ossama Y Mansour
- Neurology, Stroke and NeuroInterventional Unit, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | | | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Luis Lemme
- Interventional Neuroradiology, Centro Endovascular Neurologico Buenos Aires, Buenos Aires, Argentina
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Justin F Fraser
- Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
| | | | - Osama O Zaidat
- Neuroscience, St Vincent Mercy Hospital, Toledo, Indiana, USA
| | - Santiago Ortega-Gutierrez
- Division of Neurointerventional Surgery-Interventional Neuroradiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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The use of cangrelor in neurovascular interventions: a multicenter experience. Neuroradiology 2020; 63:925-934. [PMID: 33174182 DOI: 10.1007/s00234-020-02599-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/03/2020] [Indexed: 01/16/2023]
Abstract
PURPOSE Thromboembolic events represent the most common procedure-related complication associated with neurointerventions. Cangrelor is a potent, intravenous (IV), P2Y12-receptor antagonist with a rapid onset and offset presented as an alternative antiplatelet agent. We aim to evaluate the safety and effectiveness of IV cangrelor in neurovascular intervention. METHODS This is a retrospective analysis of data from four cerebrovascular interventional centers. We identified patients who underwent acute neurovascular intervention and received cangrelor as part of their optimum care. Patients were divided into 2 groups: ischemic and aneurysm. Periprocedural thromboembolic events, hemorrhagic complications, and outcomes were analyzed. RESULTS Sixty-six patients were included, 42 allocated into the ischemic group (IG), and 24 into aneurysm group (AG). The IG periprocedural symptomatic complication rate was 9.5%, represented by 3 postoperative intracranial hemorrhages and 1 retroperitoneal hematoma. At discharge, 47.6% had a favorable outcome and the mortality rate was 2.4%, related to clinical deterioration of a large infarct. In the AG, 4.2% had a periprocedural complication during or after cangrelor infusion, represented by an intracranial hemorrhage in an initially ruptured aneurysm. Favorable clinical outcome was seen in 56.2% and 87.7% of ruptured and unruptured aneurysms, respectively, upon discharge. CONCLUSIONS Cangrelor may be a feasible alternative for patients requiring immediate intervention with the use of endoluminal devices. It allows the possibility for a secure transition to long-term ticagrelor and progression to surgery in the setting of unexpected complications.
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Renú A, Blasco J, Laredo C, Llull L, Urra X, Obach V, López-Rueda A, Rudilosso S, Zarco F, González E, Guio JD, Amaro S, Chamorro A. Carotid stent occlusion after emergent stenting in acute ischemic stroke: Incidence, predictors and clinical relevance. Atherosclerosis 2020; 313:8-13. [PMID: 33002751 DOI: 10.1016/j.atherosclerosis.2020.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/02/2020] [Accepted: 09/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Emergent stent placement may be required during neurothrombectomy. Our aim was to investigate the incidence, predictors and clinical relevance of early extracranial carotid stent occlusion following neurothrombectomy. METHODS We retrospectively analyzed a cohort of 761 consecutive neurothrombectomies performed at our center between May 2010 and August 2018, from whom a total of 106 patients had acute internal carotid artery occlusions. Early stent occlusion was defined as complete vessel occlusion within 24 h of neurothrombectomy. Clinical outcome was evaluated at day 90 with the modified Rankin Score scale (mRS). Pretreatment, procedural and outcome variables were recorded and analyzed using logistic regression. RESULTS Carotid stenting was performed in 99 (13%) patients. Of those, 22 (22%) had early stent occlusion at follow-up. Stent occlusion was associated with a lower use of post-stenting angioplasty [adjusted OR (aOR) = 11.2, 95%CI = 2.49-50.78, p = 0.002)], increased residual intrastent stenosis (aOR = 2.1, 95%CI = 1.38-3.06, p < 0.001) and unsuccesful intracranial recanalization (modified TICI score 0-2a) (aOR = 13.5, 95%CI = 1.97-92.24, p = 0.008). Stent occlusion was associated with poor clinical outcome at day 90 (poorer mRS shift, aOR = 3.9, 95%CI = 1.3-11.3, p = 0.014; mRS>2, aOR = 6.3, 95%CI = 1.8-22.7, p = 0.005), and with an increased rate of symptomatic intracranial hemorrhage at 24 h (14% versus 1%, p = 0.033). CONCLUSIONS Early carotid stent occlusion occurred in one out of five neurothrombectomies and was associated with periprocedural factors that included increased residual intrastent stenosis, a lower use of post-stenting angioplasty and unsuccessful intracranial recanalization. Further investigation is warranted for the evaluation of strategies aimed to prevent carotid stent occlusion.
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Affiliation(s)
- Arturo Renú
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Jordi Blasco
- Radiology Department, Hospital Clinic, Barcelona, Spain
| | - Carlos Laredo
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Laura Llull
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Xabier Urra
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Victor Obach
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Elisabet González
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - José David Guio
- Radiology Department, Hospital General Universitario, Ciudad Real, Spain
| | - Sergio Amaro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
| | - Angel Chamorro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
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Park JS, Lee JM, Kwak HS, Chung GH. Endovascular treatment of acute carotid atherosclerotic tandem occlusions: Predictors of clinical outcomes as technical aspects and location of tandem occlusions. J Stroke Cerebrovasc Dis 2020; 29:105090. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/30/2020] [Accepted: 06/22/2020] [Indexed: 11/25/2022] Open
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39
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Piñana C, Gramegna LL, Folleco E, Requena M, Hernandez D, Tomasello Weitz A. Preliminary Experience Using a Covered Stent Graft in Patients with Acute Ischemic Stroke and Carotid Tandem Lesion. Cardiovasc Intervent Radiol 2020; 43:1679-1686. [PMID: 32676962 DOI: 10.1007/s00270-020-02594-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/04/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Endovascular treatment with a covered heparin-bonded stent graft has been shown to be feasible and safe for treatment of peripheral artery disease, but its role in carotid disease remains unclear. The purpose of this study was to determine the feasibility and safety of a covered stent graft in treating cervical carotid artery disease in a consecutive series of patients with acute ischemic stroke (AIS) due to tandem lesion in a single high-volume Comprehensive Stroke Center. METHODS A retrospective review of all patients that underwent carotid endovascular interventions during mechanical thrombectomy for AIS using a self-expanding covered stent graft at Vall d'Hebron University Hospital between 2016 and 2018 was conducted. Patient clinical and angiographical characteristics as well as postoperative outcome and follow-up were recorded. RESULTS A total of eight patients were treated with the covered stents, and we observed significant improvement in stroke severity at 24 h in 5/8 patients (mean NIHSS 18 ± 5 vs 12 ± 8, p = 0.02). Successful recanalization (TICI 2b-3) after thrombectomy was achieved in 5/8 (62.5%) patients. One stent occluded during the procedure. At 3-month follow-up, stents were patent in three (37.5%) patients (two with mRS 3 and one with mRS 1). The stents of the remaining four patients (62.5%) were occluded (one with mRS 2 and three with mRS 4), although the patients did not show signs of stroke recurrence. CONCLUSION The preliminary results of our study show that the self-expanding covered stent graft did not achieve satisfactory patency at 90-days among patients with AIS and tandem lesions, suggesting that its use in the carotid circulation may not be recommended in the context of AIS.
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Affiliation(s)
- Carlos Piñana
- Interventional Neuroradiology Section, Department of Radiology, Vall d'Hebron University Hospital, Pg. Vall d'Hebron, 119-129, 08035, Barcelona, Spain.,Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Laura Ludovica Gramegna
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Edgar Folleco
- Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Manuel Requena
- Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Barcelona, Spain.,Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - David Hernandez
- Interventional Neuroradiology Section, Department of Radiology, Vall d'Hebron University Hospital, Pg. Vall d'Hebron, 119-129, 08035, Barcelona, Spain.,Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Alejandro Tomasello Weitz
- Interventional Neuroradiology Section, Department of Radiology, Vall d'Hebron University Hospital, Pg. Vall d'Hebron, 119-129, 08035, Barcelona, Spain. .,Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Barcelona, Spain.
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40
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Lee D, Lee DH, Suh DC, Kim BJ, Kwon SU, Kwon HS, Lee JS, Kim JS. Endovascular Treatment in Patients with Cerebral Artery Occlusion of Three Different Etiologies. J Stroke 2020; 22:234-244. [PMID: 32635687 PMCID: PMC7341019 DOI: 10.5853/jos.2019.02404] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 04/29/2020] [Indexed: 01/06/2023] Open
Abstract
Background and Purpose The outcome of endovascular treatment (EVT) may differ depending on the etiology of arterial occlusion. This study aimed to assess the differences in EVT outcomes in patients with intracranial arterial steno-occlusion (ICAS-O), artery-to-artery embolism (AT-O), and cardiac embolism (CA-O). Methods We retrospectively analyzed 330 patients with ischemic stroke who underwent EVT between January 2012 and August 2017. Patients were classified according to the etiology. The clinical data, EVT-related factors, and clinical outcomes were compared. The modified Rankin Scale (mRS) score at 3 months, determined using ordinal logistic regression (shift analysis), was the primary outcome. Results CA-O (n=149) was the most common etiology, followed by ICAS-O (n=63) and AT-O (n=49). Age, initial National Institutes of Health Stroke Scale (NIHSS) score, and rate of hemorrhagic transformation were significantly higher in patients with CA-O compared to AT-O and ICAS-O. The time from onset-to-recanalization was the shortest in the CA-O (356.0 minutes) groups, followed by the AT-O (847.0 minutes) and ICAS-O (944.0 minutes) groups. The rates of successful recanalization, mRS distribution, and favorable outcomes at 3 months (mRS 0–2; CA-O, 36.9%, AT-O, 53.1%; and ICAS-O, 41.3%) did not differ among the three groups. Baseline NIHSS score (odds ratio, 0.87; 95% confidence interval, 0.83 to 0.91) could independently predict a favorable shift in mRS distribution. Conclusions The functional outcomes of ICAS-O and AT-O were similar to those of CA-O, despite the delay in symptom onset-to-recanalization, suggesting that the therapeutic time window may be extended in these patients.
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Affiliation(s)
- Dongwhane Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok Hee Lee
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Chul Suh
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bum Joon Kim
- Department of Neurology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyuk Sung Kwon
- Department of Neurology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Ji-Sung Lee
- Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Fernández Menéndez S, Murias Quintana E, Vega Valdés P, Morales Deza E, López-Cancio E, Benavente Fernández L, González Delgado M, Rico-Santos M, Calleja Puerta S, Larrosa Campo D. Efficacy and Safety of Endovascular Treatment in Acute Tandem Carotid Occlusions: Analysis of a Single-Center Cohort. Cerebrovasc Dis Extra 2020; 10:50-58. [PMID: 32580191 PMCID: PMC7383215 DOI: 10.1159/000507919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/14/2020] [Indexed: 01/11/2023] Open
Abstract
Introduction Acute ischemic strokes with tandem occlusions, which represent 10–20% of all ischemic strokes, have a particularly poor prognosis. Since emergent treatment of tandem lesions has not been specifically addressed in randomized trials, there is an absence of standardized management. Objective We sought to assess the efficacy and safety of acute endovascular treatment in stroke due to tandem occlusions in our center and compare the results with previous reports. Methods From a prospective registry we analyzed data of 99 consecutive patients (males: 77.7%, mean age ± SD: 67.5 ± 9.5 years) with stroke due to tandem occlusions who underwent treatment with emergent carotid stenting and intracranial mechanical thrombectomy. Successful recanalization was defined as a TICI score of 2b-3 and a good functional outcome was defined as a modified Rankin scale score ≤2 at 90 days. Symptomatic intracranial hemorrhage (sICH) was considered when associated with worsening on the National Institutes of Health Stroke Scale (≥4 points). Results A successful recanalization rate was achieved in 87.8 and 48.5% of the patients had a good functional outcome. sICH and mortality rates were 12.1 and 20.2%, respectively, and 21.2% of the patients received combined treatment with intravenous thrombolysis, which did not affect neither the prognosis nor the recanalization or sICH rates. The time from symptom onset to recanalization and the degree of recanalization were the main factors associated with prognosis and the occurrence of sICH. Conclusions Our results suggest that endovascular treatment with emergent carotid stenting and intracranial thrombectomy in patients with acute stroke due to tandem occlusions is an effective and safe procedure.
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Affiliation(s)
| | | | - Pedro Vega Valdés
- Service of Radiology, University Hospital "Central de Asturias" and ISPA, Oviedo, Spain
| | - Edison Morales Deza
- Service of Radiology, University Hospital "Central de Asturias" and ISPA, Oviedo, Spain
| | - Elena López-Cancio
- Service of Neurology, University Hospital "Central de Asturias" and ISPA, Oviedo, Spain
| | | | | | - Maria Rico-Santos
- Service of Neurology, University Hospital "Central de Asturias" and ISPA, Oviedo, Spain
| | - Sergio Calleja Puerta
- Service of Neurology, University Hospital "Central de Asturias" and ISPA, Oviedo, Spain
| | - Davinia Larrosa Campo
- Service of Neurology, University Hospital "Central de Asturias" and ISPA, Oviedo, Spain,
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42
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Dufort G, Chen BY, Jacquin G, Keezer M, Labrie M, Rioux B, Stapf C, Ziegler D, Poppe AY. Acute carotid stenting in patients undergoing thrombectomy: a systematic review and meta-analysis. J Neurointerv Surg 2020; 13:141-145. [PMID: 32532859 DOI: 10.1136/neurintsurg-2020-015817] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The benefit of acute carotid stenting compared with no acute stenting on clinical outcomes among patients with tandem lesions (TL) undergoing endovascular thrombectomy (EVT) remains unknown. METHODS We conducted a a systematic review and meta-analysis of studies comparing acute carotid stenting versus no stenting among TL patients undergoing EVT with regards to 90 day modified Rankin Scale (mRS) score, symptomatic intracerebral hemorrhage (sICH), and mortality. Four reviewers screened citations for eligibility and two assessed retained studies for risk of bias and data extraction. A random effects model was used for the synthesis of aggregated data. RESULTS 21 studies (n=1635 patients) were identified for the systematic review; 19 were cohort studies, 1 was a post-hoc analysis of an EVT trial, and 1 was a pilot randomized controlled trial. 16 studies were included in the meta-analysis. Acute stenting was associated with a favorable 90 day mRS score: OR 1.43 (95% CI 1.07, 1.91). No significant heterogeneity between studies was found for this outcome (I2=17.0%; χ2=18.07, p=0.26). There were no statistically significant differences for 3 month mortality (OR 0.80 (95% CI 0.50, 1.28)) or sICH (OR 1.41 (95% CI 0.91, 2.19)). CONCLUSIONS This meta-analysis suggests that among TL patients undergoing EVT, acute carotid stenting is associated with a greater likelihood of favorable outcome at 90 days compared with no stenting.
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Affiliation(s)
- Gabrielle Dufort
- Neurosciences, Universite de Montreal, Montreal, Quebec, Canada.,Neurology, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
| | - Bing Yu Chen
- Medicine, McGill University, Montreal, Quebec, Canada
| | - Grégory Jacquin
- Neurosciences, Universite de Montreal, Montreal, Quebec, Canada.,Neurology, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada.,Axe Neurosciences, Centre de Recherche du CHUM (CRCHUM), Montreal, Quebec, Canada
| | - Mark Keezer
- Neurosciences, Universite de Montreal, Montreal, Quebec, Canada.,Neurology, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada.,Axe Neurosciences, Centre de Recherche du CHUM (CRCHUM), Montreal, Quebec, Canada
| | - Marilyn Labrie
- Neurosciences, Universite de Montreal, Montreal, Quebec, Canada
| | - Bastien Rioux
- Neurosciences, Universite de Montreal, Montreal, Quebec, Canada.,Neurology, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
| | - Christian Stapf
- Neurosciences, Universite de Montreal, Montreal, Quebec, Canada.,Neurology, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada.,Axe Neurosciences, Centre de Recherche du CHUM (CRCHUM), Montreal, Quebec, Canada
| | - Daniela Ziegler
- Bibliothèque du Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Alexandre Y Poppe
- Neurosciences, Universite de Montreal, Montreal, Quebec, Canada .,Neurology, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada.,Axe Neurosciences, Centre de Recherche du CHUM (CRCHUM), Montreal, Quebec, Canada
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43
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Zhu F, Hossu G, Soudant M, Richard S, Achit H, Beguinet M, Costalat V, Arquizan C, Consoli A, Lapergue B, Rouchaud A, Macian-Montoro F, Biondi A, Moulin T, Marnat G, Sibon I, Paya C, Vannier S, Cognard C, Viguier A, Mazighi M, Obadia M, Hassen WB, Turc G, Clarençon F, Samson Y, Dumas-Duport B, Preterre C, Barbier C, Boulanger M, Janot K, Annan M, Bricout N, Henon H, Soize S, Moulin S, Labeyrie MA, Reiner P, Pop R, Wolff V, Ognard J, Timsit S, Reyre A, Perot C, Papagiannaki C, Triquenot-Bagan A, Bracard S, Anxionnat R, Derelle AL, Tonnelet R, Liao L, Schmitt E, Planel S, Guillemin F, Gory B. Effect of emergent carotid stenting during endovascular therapy for acute anterior circulation stroke patients with tandem occlusion: A multicenter, randomized, clinical trial (TITAN) protocol. Int J Stroke 2020; 16:342-348. [DOI: 10.1177/1747493020929948] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and hypothesis There is no consensus on the optimal endovascular management of the extracranial internal carotid artery steno-occlusive lesion in patients with acute ischemic stroke due to tandem occlusion. We hypothesized that intracranial mechanical thrombectomy plus emergent internal carotid artery stenting (and at least one antiplatelet therapy) is superior to intracranial mechanical thrombectomy alone in patients with acute tandem occlusion. Study design TITAN is an investigator-initiated, multicenter, prospective, randomized, open-label, blinded-endpoint (PROBE) study. Eligibility requires a diagnosis of acute ischemic stroke, pre-stroke modified Rankin Scale (mRS)≤2 (no upper age limit), National Institutes of Health Stroke Scale (NIHSS)≥6, Alberta Stroke Program Early Computed Tomography Score (ASPECTS)≥6, and tandem occlusion on the initial catheter angiogram. Tandem occlusion is defined as large vessel occlusion (intracranial internal carotid artery , M1 and/or M2 segment) and extracranial severe internal carotid artery stenosis ≥90% (NASCET) or complete occlusion. Patients are randomized in two balanced parallel groups (1:1) to receive either intracranial mechanical thrombectomy plus internal carotid artery stenting (and at least one antiplatelet therapy) or intracranial mechanical thrombectomy alone within 8 h of stroke onset. Up to 432 patients are randomized after tandem occlusion confirmation on angiogram. Study outcomes The primary outcome measure is complete reperfusion rate at the end of endovascular procedure, assessed as a modified Thrombolysis in Cerebral Infarction (mTICI) 3, and ≥4 point decrease in NIHSS at 24 h. Secondary outcomes include infarct growth, recurrent clinical ischemic event in the ipsilateral carotid territory, type and dose of antiplatelet therapy used, mRS at 90 (±15) days and 12 (±1) months. Safety outcomes are procedural complications, stent patency, intracerebral hemorrhage, and death. Economics analysis includes health-related quality of life, and costs utility comparison, especially with the need or not of endarterectomy. Discussion TITAN is the first randomized trial directly comparing two types of treatment in patients with acute ischemic stroke due to anterior circulation tandem occlusion, and especially assessing the safety and efficacy of emergent internal carotid artery stenting associated with at least one antiplatelet therapy in the acute phase of stroke reperfusion. Trial registration ClinicalTrials.gov NCT03978988
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Affiliation(s)
- François Zhu
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
| | - Gabriela Hossu
- CIC 1433, Technological Innovation, IADI, INSERM U1254, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - Marc Soudant
- CIC 1433 Clinical Epidemiology, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - Sébastien Richard
- CIC 1433 Plurithematic, Nancy University Hospital, Université de Lorraine, Nancy, France
- Department of Neurology, Stroke Unit, Université de Lorraine, Nancy University Hospital, Nancy, France
| | - Hamza Achit
- CIC 1433 Clinical Epidemiology, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - Mélanie Beguinet
- CIC 1433 Clinical Epidemiology, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - Vincent Costalat
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | | | - Arturo Consoli
- Department of Diagnostic and Interventional Neuroradiology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Aymeric Rouchaud
- Department of Interventional Neuroradiology, CHU Dupuytren, Limoges, France
| | | | - Alessandra Biondi
- Department of Neuroradiology and Endovascular Therapy, Besançon University Hospital, Besancon, France
| | - Thierry Moulin
- Department of Neurology, Besançon University Hospital, Besancon, France
| | - Gaultier Marnat
- Department of Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Igor Sibon
- Department of Neurology, Stroke Center, University Hospital of Bordeaux, Bordeaux, France
| | - Christophe Paya
- Department of Neuroradiology, Rennes University Hospital, Rennes, France
| | - Stéphane Vannier
- Department of Neurology, Rennes University Hospital, Rennes, France
| | - Christophe Cognard
- Department of Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Alain Viguier
- Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Michael Obadia
- Department of Neurology, Stroke Unit, Rothschild Foundation Hospital, Paris, France
| | - Wagih B Hassen
- Department of Neuroradiology, Saint-Anne Hospital, Paris, France
| | - Guillaume Turc
- Department of Neurology, Stroke Unit, Saint-Anne Hospital, Paris, France
| | | | - Yves Samson
- Department of Neurology, Stroke Unit, Pitié-Salpêtrière Hospital, Paris, France
| | | | - Cécile Preterre
- Department of Neurology, Nantes University Hospital, Nantes, France
| | - Charlotte Barbier
- Department of Neuroradiology, Caen University Hospital, Caen, France
| | | | - Kevin Janot
- Department of Neuroradiology, Tours University Hospital, Lille, France
| | - Mariam Annan
- Department of Neurology, Tours University Hospital, Lille, France
| | - Nicolas Bricout
- Department of Neuroradiology, Lille University Hospital, Lille, France
| | - Hilde Henon
- Department of Neurology, Lille University Hospital, Lille, France
| | - Sébastien Soize
- Department of Neuroradiology, Reims University Hospital, Lille, France
| | - Solène Moulin
- Department of Neurology, Reims University Hospital, Lille, France
| | | | - Peggy Reiner
- Department of Neurology, Lariboisière Hospital, Paris, France
| | - Raoul Pop
- Department of Neuroradiology, Strasbourg University Hospital, Strasbourg, France
| | - Valérie Wolff
- Department of Neurology, Stroke Unit, Strasbourg University Hospital, Strasbourg, France
| | - Julien Ognard
- Department of Neuroradiology, Brest University Hospital, Brest, France
| | - Serge Timsit
- Department of Neurology, Brest University Hospital, Brest, France
| | - Anthony Reyre
- Department of Neuroradiology, Marseille University Hospital, Marseille, France
| | - Charline Perot
- Department of Neurology, Marseille University Hospital, Marseille, France
| | | | | | - Serge Bracard
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
- CIC 1433, Technological Innovation, IADI, INSERM U1254, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - René Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
- CIC 1433, Technological Innovation, IADI, INSERM U1254, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - Anne-Laure Derelle
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
| | - Romain Tonnelet
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
| | - Liang Liao
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
- CIC 1433, Technological Innovation, IADI, INSERM U1254, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - Emmanuelle Schmitt
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
| | - Sophie Planel
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
| | - Francis Guillemin
- CIC 1433 Clinical Epidemiology, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
- CIC 1433, Technological Innovation, IADI, INSERM U1254, Nancy University Hospital, Université de Lorraine, Nancy, France
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Poppe AY, Jacquin G, Roy D, Stapf C, Derex L. Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions. AJNR Am J Neuroradiol 2020; 41:1142-1148. [PMID: 32499251 DOI: 10.3174/ajnr.a6582] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 03/17/2020] [Indexed: 11/07/2022]
Abstract
Approximately 15% of patients undergoing endovascular thrombectomy for anterior circulation acute ischemic stroke have a tandem lesion, defined as a severe stenosis or occlusion of the cervical internal carotid artery ipsilateral to its intracranial occlusion. Patients with tandem lesions have worse outcomes than patients with isolated intracranial occlusions, but the optimal management of their carotid lesions during endovascular thrombectomy remains controversial. The main options commonly used in current practice include acute stent placement in the carotid lesion versus thrombectomy alone without definitive revascularization of the carotid artery. While treatment decisions for these patients are often complex and strategies vary according to clinical, anatomic, and technical considerations, only results from randomized trials comparing these approaches are likely to strengthen current recommendations and optimize patient care.
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Affiliation(s)
- A Y Poppe
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.) .,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - G Jacquin
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.).,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - D Roy
- Radiology (Neuroradiology) (D.R.), Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - C Stapf
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.).,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - L Derex
- Stroke Center (L.D.), Department of Neurology, Neurological Hospital, Hospices Civils de Lyon, Lyon, France.,EA 7425 HESPER (L.D.), Health Services and Performance Research, Claude Bernard Lyon 1 University, Lyon, France
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45
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Wang D, Zhang L, Hu X, Zhu J, Tang X, Ding D, Wang H, Kong Y, Cai X, Lin L, Fang Q. Intravenous Thrombolysis Benefits Mild Stroke Patients With Large-Artery Atherosclerosis but No Tandem Steno-Occlusion. Front Neurol 2020; 11:340. [PMID: 32431662 PMCID: PMC7214684 DOI: 10.3389/fneur.2020.00340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/07/2020] [Indexed: 01/01/2023] Open
Abstract
At present, there is controversy regarding whether thrombolysis is beneficial for patients suffering from a mild stroke. In this study, we therefore sought to determine whether the therapeutic benefit of thrombolysis is dependent upon stroke subtype for those with mild stroke. We conducted a retrospective analysis of data from consecutive mild stroke patients (National Institutes of Health Stroke Scale ≤5) with and without recombinant tissue plasminogen activator (rt-PA) therapy. The TOAST (Trial of Org 10172 in acute stroke treatment) criteria was used to determine stroke subtypes. Patients suffering from large-artery atherosclerosis (LAA) were subdivided based upon whether or not they exhibited tandem steno-occlusion, as defined by the association of a proximal intracranial occlusion and a cervical internal carotid artery lesion (complete occlusion or severe stenosis ≥ 90%). For this study, favorable outcomes at 90 days of onset (modified Rankin Scale Score [mRS] of 0–1) were the primary measured outcome. Three hundred thirty-nine patients were included in the study. For patients with non-LAA, there were not statistically significant improvements in favorable outcomes for rt-PA treatment (p = 0.889, 0.929, 0.708; respectively). For patients with LAA, compared with non-treated group, rt-PA-treated patients had a significant in the rate of favorable outcomes at 90 days (82.8 vs. 64.9%; OR 2.59; 95%CI, 1.13–5.92; P = 0.024). Among LAA patients exhibiting tandem lesions, favorable outcomes were observed in 66.7% of rt-PA-treated patients, with no significant differences to those observed in untreated patients (OR 1.00; 95%CI, 0.23–4.28; p = 1.000). Among LAA patients without tandem lesions, compared with non-treated group, we found that rt-PA treatment was associated with a significant beneficial impact on favorable outcomes after 90 days (64.4 vs. 88.4%; OR 4.20; 95%CI, 1.43–12.30; p = 0.009). Our findings suggest that intravenous rt-PA is only beneficial in mild stroke patients with LAA-type strokes that do not exhibit tandem steno-occlusion.
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Affiliation(s)
- Dapeng Wang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Lulu Zhang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiaowei Hu
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Juehua Zhu
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiang Tang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Dongxue Ding
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Hui Wang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Yan Kong
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiuying Cai
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Longting Lin
- Hunter Medical Research Institute, University of Newcastle, New Lambton, NSW, Australia
| | - Qi Fang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
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46
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Gemmete JJ, Wilseck Z, Pandey AS, Chaudhary N. Treatment Strategies for Tandem Occlusions in Acute Ischemic Stroke. Semin Intervent Radiol 2020; 37:207-213. [PMID: 32419734 DOI: 10.1055/s-0040-1709207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
There is no consensus for the treatment of a tandem occlusion (TO) in a patient presenting with an acute ischemic stroke. In this review article, we will focus on the controversial treatment strategies for TOs. First, we will discuss treatment options including retrograde, antegrade, and delayed approaches. Second, the role of carotid stent placement versus balloon angioplasty for the extracranial occlusion will be presented. Third, anticoagulation and antiplatelet regimens for the treatment TOs published in the literature will be reviewed. Finally, we will discuss whether there is a role for coil occlusion of the cervical carotid artery or whether staged carotid revascularization days after mechanical thrombectomy of the intracranial occlusion maybe appropriate. The optimal treatment strategy of TO has not been established and further larger trials need to be performed to answer the question.
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Affiliation(s)
- Joseph J Gemmete
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan.,Department of Neurosurgery, Michigan Medicine, Ann Arbor, Michigan
| | - Zachary Wilseck
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan
| | - Aditya S Pandey
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan.,Department of Neurosurgery, Michigan Medicine, Ann Arbor, Michigan
| | - Neeraj Chaudhary
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan.,Department of Neurosurgery, Michigan Medicine, Ann Arbor, Michigan
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47
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Brandel MG, Elsawaf Y, Rennert RC, Steinberg JA, Santiago-Dieppa DR, Wali AR, Olson SE, Pannell JS, Khalessi AA. Antiplatelet therapy within 24 hours of tPA: lessons learned from patients requiring combined thrombectomy and stenting for acute ischemic stroke. J Cerebrovasc Endovasc Neurosurg 2020; 22:1-7. [PMID: 32596137 PMCID: PMC7307608 DOI: 10.7461/jcen.2020.22.1.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/24/2020] [Accepted: 03/02/2020] [Indexed: 01/01/2023] Open
Abstract
Objective Although stroke guidelines recommend antiplatelets be started 24 hours after tissue plasminogen activator (tPA), select mechanical thrombectomy (MT) patients with luminal irregularities or underlying intracranial atherosclerotic disease may benefit from earlier antiplatelet administration. Methods We explore the safety of early (<24 hours) post-tPA antiplatelet use by retrospectively reviewing patients who underwent MT and stent placement for acute ischemic stroke from June 2015 to April 2018 at our institution. Results Six patients met inclusion criteria. Median presenting and pre-operative National Institutes of Health Stroke Scale scores were 14 (Interquartile Range [IQR] 5.5–17.3) and 16 (IQR 13.7–18.7), respectively. Five patients received standard intravenous (IV) tPA and one patient received intra-arterial tPA. Median time from symptom onset to IV tPA was 120 min (IQR 78–204 min). Median time between tPA and antiplatelet administration was 4.9 hours (IQR 3.0–6.7 hours). Clots were successfully removed from the internal carotid artery (ICA) or middle cerebral artery (MCA) in 5 patients, the anterior cerebral artery (ACA) in one patient, and the vertebrobasilar junction in one patient. All patients underwent MT before stenting and achieved thrombolysis in cerebral infarction 2B recanalization. Stents were placed in the ICA (n=4), common carotid artery (n=1), and basilar artery (n=1). The median time from stroke onset to endovascular access was 185 min (IQR 136–417 min). No patients experienced symptomatic post-procedure intracranial hemorrhage (ICH). Median modified Rankin Scale score on discharge was 3.5. Conclusions Antiplatelets within 24 hours of tPA did not result in symptomatic ICH in this series. The safety and efficacy of early antiplatelet administration after tPA in select patients following mechanical thrombectomy warrants further study.
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Affiliation(s)
- Michael G Brandel
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - Yasmeen Elsawaf
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - Jeffrey A Steinberg
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | | | - Arvin R Wali
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - Scott E Olson
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - J Scott Pannell
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California, San Diego, La Jolla, CA, USA
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48
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Simultaneous Angioplasty and Mechanical Thrombectomy in Tandem Carotid Occlusions. Incidence of Reocclusions and Prognostic Predictors. J Stroke Cerebrovasc Dis 2020; 29:104578. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/07/2019] [Accepted: 11/26/2019] [Indexed: 11/22/2022] Open
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49
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Vu-Dang L, Nguyen QA, Nguyen-Thi-Thu T, Tran AT, Le-Chi C, Le-Hoang K, Nguyen-Tat T, Nguyen-Huu A, Pham-Minh T, Chu-Dinh T, Chu DT. Endovascular Treatment for Acute Tandem Occlusion Stroke: Results from Case Series of 17 Patients. Ann Indian Acad Neurol 2020; 23:78-83. [PMID: 32055126 PMCID: PMC7001425 DOI: 10.4103/aian.aian_464_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background and Purpose: Tandem occlusive lesion, a major challenge for thrombectomy in acute anterior circulation strokes, is poorly represented in randomized trials. This study demonstrates the findings of thrombectomy in tandem occlusion and comparative analysis of two treatment groups (extracranial versus intracranial first subgroup). Patients and Methods: We enrolled and divided 17 patients with acute tandem ischemic stroke who received endovascular treatment into two groups. Group 1 with completed (100%) internal carotid artery (ICA) occlusion was treated by an extracranial stent, whereas Group 2 with severe (70%–99%) ICA occlusion was prioritized with intracranial thrombectomy. Data of clinical parameters, imaging and angiographic results, periprocedural complications, and results after 3 months were collected and analyzed. Results: The mean age of patients was 70.2 ± 8.8 years, and males accounted for 94.1%. The National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score (ASPECTS) baseline were 16.6 ± 4.2 and 7.6 ± 1.1, respectively, with occlusive side was 52.9% on the right. Group 1 including ten cases (58.8%) was treated extracranial lesion with carotid stent before intracranial thrombectomy, and Group 2 with seven cases (41.2%) was prioritized intracranial thrombectomy. In total 17 procedures, there were ten stent retrievers (58.8%), four aspirations (23.5%), and three Solumbra (17.7%). No re-occlusion of carotid stent postoperation was recorded. The good revascularization (thrombolysis in cerebral infarction 2b-3) was archived in 82.4% of patients, while symptomatic hemorrhage was seen in 2 cases (11.8%). Three months after treatment, patients with favorable clinical outcome (Modified Rankin Scale ≤2) accounted for 47.1%. Conclusion: Our study determined a promising outcome with reasonable good recanalization and clinical recovery for endovascular intervention in tandem ischemic. In the subgroup of treatment, “extracranial stent first” had more complex disease with completed ICA occlusion which required longer procedure time may lead to worse outcome.
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Affiliation(s)
- Luu Vu-Dang
- Radiology Faculty, Hanoi Medical University, Danang, Vietnam.,Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | - Quang-Anh Nguyen
- Radiology Faculty, Hanoi Medical University, Danang, Vietnam.,Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | | | - Anh-Tuan Tran
- Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | - Cong Le-Chi
- Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | - Kien Le-Hoang
- Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | | | - An Nguyen-Huu
- Radiology Faculty, Hanoi Medical University, Danang, Vietnam
| | - Thong Pham-Minh
- Radiology Faculty, Hanoi Medical University, Danang, Vietnam.,Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | - Thien Chu-Dinh
- Institute for Research and Development, Duy Tan University, Danang, Vietnam
| | - Dinh-Toi Chu
- Faculty of Biology, Hanoi National University of Education, Hanoi, Vietnam
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50
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Park SE, Choi DS, Baek HJ, Ryu KH, Ha JY, Choi HC, Lee S, Won J, Jung S. Emergent carotid artery stenting in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion: Comparison of tandem intracranial occlusion and isolated cervical internal carotid artery occlusion. Interv Neuroradiol 2020; 26:425-432. [PMID: 31992107 DOI: 10.1177/1591019919899755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Acute ischemic strokes caused by steno-occlusive lesion of the cervical internal carotid artery are associated with poor clinical outcome. We evaluated the clinical efficacy of emergent carotid artery stenting for the management of these lesions. We compared the clinical outcomes regarding the intracranial lesion, namely tandem occlusions versus isolated cervical internal carotid artery occlusion. MATERIALS AND METHODS We retrospectively reviewed patients with acute ischemic stroke who underwent carotid artery stenting for cervical internal carotid artery steno-occlusive lesion between 2011 and 2018. After dividing the patients into two groups according to the presence or absence of intracranial lesions (tandem group and isolated cervical group), we analyzed demographic data, angiographic findings, and clinical outcomes. A modified Rankin Scale score ≤2 was defined as a favorable clinical outcome. RESULTS Of 75 patients, 46 patients (61.3%) had tandem lesions, and the remaining 29 had only cervical internal carotid artery steno-occlusive lesion. Successful stenting was performed in all patients with favorable clinical outcomes (64.0%). Successful reperfusion score (thrombolysis in cerebral infarction ≥2 b) was 84.0%; tandem group (76.1%) versus isolated cervical group (96.6%) of cases. Mean modified Rankin Scale score at 90-days was 2.09. The rate of favorable clinical outcome showed no statistically significant difference between the two groups (p = 0.454). CONCLUSIONS Endovascular treatment in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion is a technically feasible and clinically effective intervention regardless of intracranial occlusion. Therefore, we recommend endovascular treatment regardless of the presence of concomitant intracranial artery occlusion for patients with acute ischemic stroke caused by cervical internal carotid artery steno-occlusive lesion.
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Affiliation(s)
- Sung E Park
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Dae S Choi
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Hye J Baek
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Kyeong H Ryu
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Ji Y Ha
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Ho C Choi
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Sangmin Lee
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Jungho Won
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Seunguk Jung
- Department of Neurology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, South Korea
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