Treatment Strategy for Progressive Cervical Internal Carotid Artery Stenosis Under Restriction of the Use of Antiplatelet Drugs

Cervical carotid occlusion in acute ischemic stroke: Should we give tPA?

Background:

Acute ischemic stroke (AIS) due to cervical internal carotid artery (cICA) occlusion is challenging to treat, with the lower revascularization rates, higher risk for complications, and poor response to thrombolytic therapy compared to isolated intracranial occlusions. While emergent revascularization through mechanical thrombectomy (MT) improves outcomes, the impact of tissue plasminogen activator (tPA) on outcomes in this subgroup of patients remains unclear. The objective of this study is to report our preliminary experience in treating AIS with cICA occlusions secondary to severe atherosclerotic stenosis and to establish the need for further clinical studies to determine the optimal intervention strategy for these lesions.

Methods:

Data were collected on patients who presented with acute cICA occlusion who underwent MT and either acute or staged carotid angioplasty and stenting. We compare patients who received tPA to those who did not, analyzing revascularization times, outcomes, and complications between the two populations, and discuss how this influenced our preferred treatment approach.

Results:

Twenty-one patients met inclusion criteria, seven of who received tPA and 14 did not receive tPA before surgical intervention. Procedural and functional outcomes were similar between the two populations. TPA administration correlated with a higher rate of vessel reocclusion in staged procedures and trended toward higher rates of symptomatic ICH and 90-day mortality.

Conclusion:

Emergent revascularization with acute cICA stenting carries advantages, but its safety is precluded by tPA administration. We suggest a trial which randomizes patients with cICA occlusions to receiving either tPA or dual antiplatelet therapy before surgical intervention, aiming to ultimately improved outcomes in these patients.

TIMING OPTIMIZATION OF HEAD AND NECK CT ANGIOGRAPHY VIA THE INVERSE PROBLEM ALGORITHM: in vivo SURVEY FOR 1001 PATIENTS IN 2020–2021

This study processed the recent in vivo survey results for over a thousand patients and optimized their neck and head CT angiography triggered timing (CTA-TT) via the inverse problem algorithm, which ensured the maximal ratio of both left and right arterial to upper sinuses (LRA/US). These results are instrumental in examining the ischemic stroke syndromes along the neck and head. These 1001 patients were randomly categorized into test surveyed (802 patients) and verification group (199 patients), then a six factors semi-empirical formula was constructed by the STATISTICA program. The six factors were assigned a patient’s biological data and preset of the CTA facility; namely Age, mean arterial pressure (MAP), heart rate (HR), contrast media dose (CMD), Pre (injected pressure of CMD), and body surface area (BSA). Each factor was normalized into dimensionless values and incorporated into the dataset matrix [Formula: see text] to analyze the coefficient matrix [Formula: see text]. The derived semi-empirical formula closely correlated with experimental data, according to the loss function [Formula: see text], correlation coefficient [Formula: see text], and variance of 0.8965. The formula verification for 199 more patients (verification group) yielded a correlation coefficient [Formula: see text]. Thus, it can be used for the CTA-TT estimation of patients without their preliminary tests, avoiding unnecessary irradiation. The estimated LRA/US was [Formula: see text] for the verification group in this study. A simplified three-factor formula, featuring only age, MAP, and BSA, was also proposed.

A SIX-PARAMETER SEMI-QUANTITATIVE ANALYSIS OF 251 PATIENTS FOR THE ENHANCED TRIGGERED TIMING OF HEAD AND NECK CT ANGIOGRAPHY SCANNING VIA THE INVERSE PROBLEM ALGORITHM

In this study, the correlation between triggered timing for head and neck CT angiography (TT CTA) scanning and the average of CT values of both left and right arterial to upper sinuses (LRA/US) reaching a maximal ratio was surveyed and explored using the inverse problem algorithm according to a six-factor semi-quantitative analysis of 251 patients. Six risk factors, namely TT CTA, mean arterial pressure (MAP), heart rate (HR), contrast media solution (CMS), given pressure (Pre), and body surface area (BSA) were used to identify a nonlinear first-order regression correlation between projected and actual LRA/US values. The respective 22 terms were derived via the STATISTICA program. In doing so, a customized loss function ([Formula: see text]) was defined according to the total fluctuation between theoretically projected and actual LRA/US values for all 216 patients. Thus, [Formula: see text] individual data points were included in the algorithm to optimize the compromised solution array [[Formula: see text]] of LRA/US values. The results exhibited a close correlation with loss function [Formula: see text], correlation coefficient [Formula: see text], and a 93.13% variance. Another group of 35 patients with similar symptoms was selected to verify the prediction accuracy and exhibited a high coincidence, although the reverse calculation-based correlation between CC CTA and LRA/US was still controversial from a clinical viewpoint. The proposed algorithm is considered quite instrumental in predicting the LRA/US with ischemic stroke symptoms in the CTA examination.

INVERSE PROBLEM ALGORITHM APPLICATION TO SEMI-QUANTITATIVE ANALYSIS OF 272 PATIENTS WITH ISCHEMIC STROKE SYMPTOMS: CAROTID STENOSIS RISK ASSESSMENT FOR FIVE RISK FACTORS

This study proposes the inverse problem algorithm (IPA) with five risk factors applied to the semi-quantitative analysis of carotid stenosis 272 patients with suspected ischemic stroke. The IPA is known to provide a substantiated machine learning-based prediction of the expected outcomes by solving an inverse matrix of variable coefficients. In case of carotid stenosis prediction, such risk factors as patient’s age, mean arterial pressure (MAP), glucose AC, low-density lipoprotein-cholesterol (LDL-C), and C-Reactive protein (CRP) were assessed for the main group of 217 patients. Their results were processed by the STATISTICA program with a customized loss function ([Formula: see text]), yielding the first-order nonlinear semi-empirical formula with 16 terms. The loss function was calculated via the total mismatch between the theoretical predictions and true carotid stenosis cases (%) for all 217 patients. Thus, the carotid stenosis (%) compromised solution array [[Formula: see text]] was optimized using [Formula: see text] individual data points via the proposed algorithm. The results showed a complete regression with loss function [Formula: see text]=2.3543, variance [Formula: see text]=87.46%, and correlation coefficient [Formula: see text]. The reference group of 55 more patients with the same preliminary diagnosis and symptoms was selected to validate the method predictive feasibility, which was found quite satisfactory. The decreasing order of three dominant risk factors was as follows: CRP, glucose AC, and MAP, whereas age and LDL-C weakly influenced the program computation results. The IPA showed a strong convergence by its default characteristic. The reduction of the number of variables in computation deteriorated the prediction accuracy, exhibiting the algorithm’s high sensitivity to the number of variables.

A Case of Intravascular Treatment for Acute Ischemic Stroke with Internal Carotid Artery Stenosis That Developed While Driving

Objective

We report a case of acute cerebral infarction that may have been associated with high-energy trauma due to onset while driving.

Case Presentation

A 67-year-old man had a traffic accident. His neurological symptoms were left hemiplegia and contrast CT revealed right middle cerebral artery occlusion. Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) and intravascular treatment were performed. Right carotid artery angiography demonstrated internal carotid artery stenosis. Middle cerebral artery (MCA) revascularization was performed only by percutaneous transluminal angioplasty (PTA) of the internal carotid artery. Thoracic hemorrhage was observed a few hours after surgery, and hemostasis was performed by thoracotomy. Carotid artery stenting (CAS) was performed 8 days after onset. The patient was transferred to a convalescent rehabilitation hospital.

Conclusion

Rt-PA and acute CAS were not recommended for cerebral infarction due to traffic accident.