Recanalization therapy for internal carotid artery occlusion presenting as acute ischemic stroke

Decompressive craniectomy for internal carotid artery and middle carotid artery infarctions: a long-term comparative outcome study

OBJECTIVE

Malignant internal carotid artery (ICA) infarction is an entirely different disease entity when compared with middle cerebral artery (MCA) infarction. Because of an increased area of infarction, it is assumed to have a poorer prognosis; however, this has never been adequately investigated. Decompressive craniectomy (DC) for malignant MCA infarction has been shown to improve mortality rates in several randomized controlled trials. Conversely, aggressive surgical decompression for ICA infarction has not been recommended. The authors sought to compare the functional outcomes and survival between patients with ICA infarctions and those with MCA infarctions after DC in the largest series to date to investigate this assumption.

METHODS

A multicenter retrospective review of 154 consecutive DCs for large territory cerebral infarctions performed from 2005 to 2020 were analyzed. Patients were divided into ICA and MCA groups depending on the territory of infarction. Variables, including age, sex, medical comorbidities, laterality of the infarction, preoperative neurological status, primary stroke treatment, and the time from stroke onset to DC, were recorded. Univariable and multivariable analyses were performed for the clinical exposures for functional outcomes (modified Rankin Scale [mRS] score) on discharge and at the 1- and 6-month follow-ups, and for mortality, both inpatient and at the 1-year follow-up. A favorable mRS score was defined as 0-2.

RESULTS

There were 67 patients (43.5%) and 87 patients (56.5%) in the ICA and MCA groups, respectively. Univariable analysis showed that the ICA group had a comparably favorable mRS (OR 0.15 [95% CI 0.18-1.21], p = 0.077). Inpatient mortality (OR 1.79 [95% CI 0.79-4.03], p = 0.16) and 1-year mortality (OR 2.07 [95% CI 0.98-4.37], p = 0.054) were comparable between the groups. After adjustment, a favorable mRS score at 6 months (OR 0.17 [95% CI 0.018-1.59], p = 0.12), inpatient mortality (OR 1.02 [95% CI 0.29-3.57], p = 0.97), and 1-year mortality (OR 0.94 [95% CI 0.41-2.69], p = 0.88) were similar in both groups. The overall survival, plotted using the Cox proportional hazard regression, did not show a significant difference between the ICA and MCA groups (HR 0.581).

CONCLUSIONS

Unlike previous smaller studies, this study found that patients with malignant ICA infarction had a functional outcome and survival that was similar to those with MCA infarction after DC. Therefore, DC can be offered for malignant ICA infarction for life-saving purposes with limited functional recovery.

Is Endovascular Treatment Still Good for Ischemic Stroke in Real World?: A Meta-Analysis of Randomized Control Trial and Observational Study in the Last Decade

BACKGROUND AND PURPOSE

Although endovascular treatment (EVT) for acute ischemic stroke is classified as I evidence, outcomes after EVT in real-world practice appear to be less superior than those in randomized clinical trials (RCTs). Additionally, the effect of EVT is unclear compared with medical treatment (MT) for patients with mild symptoms defined by National Institutes of Health Stroke Scale score <6 or with severe symptoms defined by Alberta Stroke Program Early CT Score <6.

METHODS

Literatures were searched in big databases and major meetings from December 6, 2009, to December 6, 2019, including RCTs and observational studies comparing EVT against MT for patients with acute ischemic stroke. Observational studies were precategorized into 3 groups based on imaging data on admission: mild stroke group with National Institutes of Health Stroke Scale score <6, severe stroke group with Alberta Stroke Program Early CT Score <6 or ischemic core ≥50 mL, and normal stroke group for all others. Outcome was measured as modified Rankin Scale score of 0 to 2, mortality at 90 days, and symptomatic intracranial hemorrhage (sICH) at 24 hours.

RESULTS

Fifteen RCTs (n=3694) and 37 observational studies (n=9090) were included. EVT was associated with higher modified Rankin Scale 0 to 2 rate and lower mortality in RCTs and normal stroke group, whereas EVT was associated with higher sICH rate in normal stroke group, and no difference of sICH rate appeared between EVT and MT in RCTs. In severe stroke group, EVT was associated with higher modified Rankin Scale 0 to 2 rate and lower mortality, whereas no difference of sICH rate was found. In mild stroke group, there was no difference in modified Rankin Scale 0 to 2 rate between EVT and MT, whereas EVT was associated with higher mortality and sICH rate.

CONCLUSIONS

Evidence from RCTs and observational studies supports the use of EVT as the first-line choice for eligible patients corresponding to the latest guideline. For patients with Alberta Stroke Program Early CT Score <6, EVT showed superiority over MT, also in line with the guidelines. On the contrary to the guideline, our data do not support EVT for patients with National Institutes of Health Stroke Scale score <6.

Residual stenosis after carotid artery stenting: Effect on periprocedural and long-term outcomes

Objective

This study investigated the effect of residual stenosis after carotid artery stenting (CAS) on periprocedural and long-term outcomes.

Methods

Patients treated with CAS for symptomatic or asymptomatic carotid arterial stenosis were consecutively enrolled. Residual stenosis was estimated from post-procedure angiography findings. The effects of residual stenosis on 30-day periprocedural outcome and times to restenosis and clinical outcome were analyzed using logistic regression models and Wei-Lin-Weissfeld models, respectively.

Results

A total of 412 patients (age, 64.7 ± 17.0 years; male, 82.0%) were enrolled. The median baseline stenosis was 80% (interquartile range [IQR], 70–90%), which improved to 10% (0–30%) for residual stenosis. Residual stenosis was significantly associated with periprocedural outcome (adjusted odds ratio, 0.983; 95% confidence interval [CI], 0.965–0.999, P = 0.01) after adjustment for baseline stenosis, age, hypertension, symptomaticity, and statin use. Over the 5-year observation period, residual stenosis did not increase the global hazard for restenosis and clinical outcome (adjusted hazard ratio, 1.011; 95% CI, 0.997–1.025. In the event-specific model, residual stenosis increased the hazard for restenosis (adjusted hazard ratio, 1.041; 1.012–1.072) but not for clinical outcome (adjusted hazard ratio, 1.011; 0.997–1.025).

Conclusions

Residual stenosis after carotid artery stenting may be useful to predict periprocedural outcome and restenosis.

Endovascular thrombectomy versus medical treatment for large vessel occlusion stroke with mild symptoms: A meta-analysis

It remains controversial as to whether mechanical thrombectomy (MT) is safer and more beneficial in patients with large vessel occlusion stroke (LVOS) presenting with a National Institutes of Health Stroke Scale score ≤ 8. We therefore conducted a meta-analysis of the published data.We searched PubMed and Embase and pooled relevant data in the meta-analyses using fixed effects models. Only studies that directly compared best medical therapy alone (BMT) with MT were included. We used odds ratios to analyze the associations between MT and 90-day functional outcome (evaluated using the modified Rankin Scale (mRS)), mortality, and rates of symptomatic intracerebral hemorrhage (sICH) in patients with LVOS and minor symptoms. Five studies including a total of 581 patients met our inclusion criteria. A significant difference was found that the patients treated with MT were associated with improved 90-day mRS score (OR, 1.68; 95% CI, 1.08-2.61) compared with BMT group. There was no difference in 90-day mortality between the two groups. However, sICH occurred more frequently in the MT group than the BMT group (OR, 3.89; 95% CI, 1.83-8.27). Patients with LVOS with minor or mild symptoms who underwent primary thrombectomy had a significantly improved 90-day mRS score compared to those who received BMT alone. Meanwhile, the risk of sICH was higher in the MT group than that in BMT group. Future randomized clinical controlled trials evaluating the role of endovascular reperfusion for LVOS with minimal symptoms are warranted.

Reperfusion therapy in acute ischemic stroke: dawn of a new era?

Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging-based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes.

Wire escalation in emergent revascularization procedures of internal carotid artery occlusions: the use of high tip stiffness microguidewires

Objective

We examined the usefulness and safety of high tip stiffness cardiac microguidewires in the endovascular revascularization of selected cases of internal carotid artery (ICA) occlusion.

Methods

Files of patients with acute ischemic symptoms due to ICA occlusions managed from August 2010 to August 2016 by urgent endovascular revascularization were retrospectively reviewed with a waiver of informed consent. Cases where there was escalation to stiff tipped cardiovascular microguidewires after at least two failed attempts to cross the carotid occlusion with standard neuro-microguidewires were included. Radiological and interventional data were recorded.

Results

63 patients with acute carotid occlusions underwent emergent endovascular revascularization in the study period; 5/63 patients met the inclusion criteria. In 4/5 patients, there was no angiographic evidence of the remnant origin of the ICA; in 1/5 there was a wide round shaped proximal calcified cap that precluded soft guidewire entry. In all cases, antegrade wiring was achieved only after switching to stiffer guidewires designed for the management of chronic cardiac occlusions. The use of these stiffer tip wires was considered of critical importance in achieving the successful performance of the ICA revascularization procedure. In all patients, revascularization was achieved, and 90 day modified Rankin Scale score ranged from 0 to 2.

Conclusions

When regular neuro-guidewires do not allow antegrade wiring in cases of ICA occlusion, wire escalation to high tip stiffness guidewires may improve success. These wires, designed to deal with chronic total coronary occlusions, can serve as a platform for new neuro-guidewires to be used in the challenging field of resistant supra-aortic occlusions.

Emergency revascularization of acute internal carotid artery occlusion: Follow the spike, it guides you

The present study sought to examine the incidence of the angiographic "spike sign" and to assess its predictive significance for achieving carotid revascularization in 54 patients with acute internal carotid artery (ICA) occlusions that required urgent endovascular revascularization. Clinical and imaging files of consecutive patients with ICA occlusion who were treated in a tertiary care academic medical center from 2011-2015 were retrospectively examined under Institutional Review Board approval with a waiver of the requirement for informed consent. All proximal ICA occlusions were treated by stent-assisted carotid angioplasty, and all distal embolic occlusions were managed with stent-assisted mechanical thrombectomy. The study included 24 patients with acute ICA occlusion (group 1) and 30 patients with tandem ICA-intracranial occlusions (group 2). The spike sign was seen in 16/24 patients in group 1 (67%), and successful ICA revascularization was achieved in 14/16 (88%). The sign was seen in 26/30 patients in group 2 (87%), and ICA revascularization was successful in all 26 (100%). The remaining 12 patients had no spike sign, and ICA revascularization was successful in only 7/12 (58%). The spike sign is a transient finding that represents the proximal patent remnant of the stenotic corridor in fresh clot. Acute ICA occlusion frequently leaves the spike sign as a marker of the recent thrombotic event. The spike vertex points to the "path of least resistance" for the guidewire to cross the occlusion and engage the true arterial lumen, a critical step during ICA endovascular revascularization.