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El-Masri S, Zeng A, Kusuma Y, Ma H, Williams C, Dowling R, Bush S, Mitchell P, Yan B. Adjunctive rescue therapy in acute large vessel occlusion secondary to underlying intracranial atherosclerotic disease. J Stroke Cerebrovasc Dis 2024:107907. [PMID: 39116961 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107907] [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: 02/01/2024] [Revised: 07/14/2024] [Accepted: 07/30/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND The optimal treatment for patients with acute large vessel occlusion (LVO) secondary to intracranial atherosclerotic disease (ICAD) is unclear. Adjunctive rescue therapy with balloon angioplasty or stenting may be necessary to ensure vessel patency. We aimed to compare the safety and clinical outcomes of adjunctive rescue therapy vs lone thrombectomy for ICAD-related-LVO. METHODS A retrospective propensity score matching analysis was performed in acute stroke patients who had endovascular thrombectomy between 2008-2021. We included patients with acute ICAD-related-LVO. The location of ICAD and exposure to thrombolysis were used to generate propensity score matching to estimate the likelihood of treatment by adjunctive rescue therapy. The primary clinical outcome (90-day modified rankin scale 0-2) and safety outcomes (symptomatic intracerebral hemorrhage) were assessed between the two groups. RESULTS One-hundred and forty-four patients were included. The median (IQR) age was 68(59-76) and 52(36%) were females. The baseline NIHSS was 12.5(8-19). Sixty-seven (47%) patients had ICAD in M1 or M2 segments. Forty-six patients (67%) had lone thrombectomy and twenty-one (28%) had adjunctive rescue therapy. Propensity score matching did not demonstrate significant differences in 90-day modified Rankin Score 0-2 between lone thrombectomy (38.8%) and adjunctive rescue therapy (39.3%) (p=0.3). Lone thrombectomy, compared to adjunctive rescue therapy, did not result in significantly more symptomatic intracerebral hemorrhages (2.8% vs 8.3%, p=0.6), nor progressive occlusion (17% vs 19%, p=0.8). CONCLUSION We did not find significant differences in clinical outcomes and safety between lone thrombectomy and adjunctive rescue therapy. Randomized controlled studies are required to resolve the equipoise in treatment of ICAD-related-LVO.
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Affiliation(s)
- Shaddy El-Masri
- Melbourne Brain Centre, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia; Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia.
| | - Angela Zeng
- Melbourne Brain Centre, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia.
| | - Yohanna Kusuma
- Melbourne Brain Centre, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia.
| | - Henry Ma
- Department of Neurology, Monash Hospital, Melbourne, Australia.
| | - Cameron Williams
- Melbourne Brain Centre, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia.
| | - Richard Dowling
- Department of Radiology, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia.
| | - Steven Bush
- Department of Radiology, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia.
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia.
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia.
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Roy JM, Tjoumakaris S. Bailout angioplasty or stenting for large vessel occlusion. Lancet Neurol 2024; 23:753-754. [PMID: 38914086 DOI: 10.1016/s1474-4422(24)00264-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 06/12/2024] [Accepted: 06/13/2024] [Indexed: 06/26/2024]
Affiliation(s)
- Joanna M Roy
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA 19147, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA 19147, USA.
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Rodriguez-Calienes A, Siddiqui FM, Galecio-Castillo M, Mohammaden MH, Dolia JN, Grossberg JA, Pabaney A, Hassan AE, Tekle WG, Saei H, Miller S, Majidi S, T Fifi J, Valestin G, Siegler JE, Penckofer M, Zhang L, Sheth SA, Salazar-Marioni S, Iyyangar A, Nguyen TN, Abdalkader M, Linfante I, Dabus G, Mehta BP, Sessa J, Jumma MA, Sugg RM, Linares G, Nogueira RG, Liebeskind DS, Haussen DC, Ortega-Gutierrez S. Rescue Therapy for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: A Pooled Analysis of the Society of Vascular and Interventional Neurology Registry. Ann Neurol 2024; 96:343-355. [PMID: 38752428 DOI: 10.1002/ana.26967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE We aimed to evaluate the association between rescue therapy (RT) and functional outcomes compared to medical management (MM) in patients presenting after failed mechanical thrombectomy (MT). METHODS This cross-sectional study utilized prospectively collected and maintained data from the Society of Vascular and Interventional Neurology Registry, spanning from 2011 to 2021. The cohort comprised patients with large vessel occlusions (LVOs) with failed MT. The primary outcome was the shift in the degree of disability, as gauged by the modified Rankin Scale (mRS) at 90 days. Additional outcomes included functional independence (90-day mRS score of 0-2), symptomatic intracranial hemorrhage (sICH), and 90-day mortality. RESULTS Of a total of 7,018 patients, 958 presented failed MT and were included in the analysis. The RT group comprised 407 (42.4%) patients, and the MM group consisted of 551 (57.5%) patients. After adjusting for confounders, the RT group showed a favorable shift in the overall 90-day mRS distribution (adjusted common odds ratio = 1.79, 95% confidence interval [CI] = 1.32-2.45, p < 0.001) and higher rates of functional independence (RT: 28.8% vs MM: 15.7%, adjusted odds ratio [aOR] = 1.93, 95% CI = 1.21-3.07, p = 0.005) compared to the MM group. RT also showed lower rates of sICH (RT: 3.8% vs MM: 9.1%, aOR = 0.52, 95% CI = 0.28-0.97, p = 0.039) and 90-day mortality (RT: 33.4% vs MM: 45.5%, aOR = 0.61, 95% CI = 0.42-0.89, p = 0.009). INTERPRETATION Our findings advocate for the utilization of RT as a potential treatment strategy for cases of LVO resistant to first-line MT techniques. Prospective studies are warranted to validate these observations and optimize the endovascular approach for failed MT patients. ANN NEUROL 2024;96:343-355.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Neuroscience, Clinical Effectiveness, and Public Health Research Group, Universidad Cientifica del Sur, Lima, Peru
| | - Fazeel M Siddiqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Mahmoud H Mohammaden
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jaydevsinh N Dolia
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Aqueel Pabaney
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Wondwossen G Tekle
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Hamzah Saei
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Samantha Miller
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Shahram Majidi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johana T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gabrielle Valestin
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Mary Penckofer
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Linda Zhang
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Sunil A Sheth
- Department of Neurology, Radiology, University of Texas Health McGovern Medical School, Houston, TX, USA
| | - Sergio Salazar-Marioni
- Department of Neurology, Radiology, University of Texas Health McGovern Medical School, Houston, TX, USA
| | - Ananya Iyyangar
- Department of Neurology, Radiology, University of Texas Health McGovern Medical School, Houston, TX, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Mohamad Abdalkader
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Italo Linfante
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, FL, USA
| | - Guilherme Dabus
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, FL, USA
| | | | - Joy Sessa
- Memorial Neuroscience Institute, Pembroke Pines, FL, USA
| | | | - Rebecca M Sugg
- University of South Alabama Medical Center, Mobile, AL, USA
| | | | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Diogo C Haussen
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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Gao F, Tong X, Jia B, Wei M, Pan Y, Yang M, Sun D, Nguyen TN, Ren Z, Demiraj F, Yao X, Xu C, Yuan G, Wan Y, Tang J, Wang J, Jiang Y, Wang C, Luo X, Yang H, Shen R, Wu Z, Yuan Z, Wan D, Hu W, Liu Y, Jing P, Wei L, Zheng T, Wu Y, Yang X, Sun Y, Wen C, Chang M, Yin B, Li D, Duan J, Sun D, Guo Z, Xu G, Wang G, Wang L, Wang Y, Jia W, Ma G, Huo X, Mo D, Ma N, Liu L, Zhao X, Wang Y, Fiehler J, Wang Y, Miao Z. Bailout intracranial angioplasty or stenting following thrombectomy for acute large vessel occlusion in China (ANGEL-REBOOT): a multicentre, open-label, blinded-endpoint, randomised controlled trial. Lancet Neurol 2024; 23:797-806. [PMID: 38914085 DOI: 10.1016/s1474-4422(24)00186-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/29/2024] [Accepted: 05/02/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Unsuccessful recanalisation or reocclusion after thrombectomy is associated with poor outcomes in patients with large vessel occlusion (LVO) acute ischaemic stroke (LVO-AIS). Bailout angioplasty or stenting (BAOS) could represent a promising treatment for these patients. We conducted a randomised controlled trial with the aim to investigate the safety and efficacy of BAOS following thrombectomy in patients with LVO. METHODS ANGEL-REBOOT was an investigator-initiated, multicentre, prospective, randomised, controlled, open-label, blinded-endpoint clinical trial conducted at 36 tertiary hospitals in 19 provinces in China. Participants with LVO-AIS 24 h after symptom onset were eligible if they had unsuccessful recanalisation (expanded Thrombolysis In Cerebral Infarction score of 0-2a) or risk of reocclusion (residual stenosis >70%) after thrombectomy. Eligible patients were randomly assigned by the minimisation method in a 1:1 ratio to undergo BAOS as the intervention treatment, or to receive standard therapy (continue or terminate the thrombectomy procedure) as a control group, both open-label. In both treatment groups, tirofiban could be recommended for use during and after the procedure. The primary outcome was the change in modified Rankin Scale score at 90 days, assessed in the intention-to-treat population. Safety outcomes were compared between groups. This trial was completed and registered at ClinicalTrials.gov (NCT05122286). FINDINGS From Dec 19, 2021, to March 17, 2023, 706 patients were screened, and 348 were enrolled, with 176 assigned to the intervention group and 172 to the control group. No patients withdrew from the trial or were lost to follow-up for the primary outcome. The median age of patients was 63 years (IQR 55-69), 258 patients (74%) were male, and 90 patients (26%) were female; all participants were Chinese. After random allocation, tirofiban was administered either intra-arterially, intravenously, or both in 334 [96%] of 348 participants. No between-group differences were observed in the primary outcome (common odds ratio 0·86 [95% CI 0·59-1·24], p=0·41). Mortality was similar between the two groups (19 [11%] of 176 vs 17 [10%] of 172), but the intervention group showed a higher risk of symptomatic intracranial haemorrhage (eight [5%] of 175 vs one [1%] of 169), parenchymal haemorrhage type 2 (six [3%] of 175 vs none in the control group), and procedure-related arterial dissection (24 [14%] of 176 vs five [3%] of 172). INTERPRETATION Among Chinese patients with unsuccessful recanalisation or who are at risk of reocclusion after thrombectomy, BAOS did not improve clinical outcome at 90 days, and incurred more complications compared with standard therapy. The off-label use of tirofiban might have affected our results and their generalisability, but our findings do not support the addition of BAOS for such patients with LVO-AIS. FUNDING Beijing Natural Science Foundation, National Natural Science Foundation of China, National Key R&D Program Beijing Municipal Administration of Hospitals Incubating Program, Shanghai HeartCare Medical Technology, HeMo (China) Bioengineering, Sino Medical Sciences Technology.
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Affiliation(s)
- Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Wei
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ming Yang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA; Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Zeguang Ren
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Francis Demiraj
- Department of Neurology, Florida Atlantic University Schmidt College of Medicine, Boca Raton, FL, USA
| | - Xiaoxi Yao
- Department of Neurology, The First People's Hospital of Chenzhou, Chenzhou, China
| | - Chenghua Xu
- Department of Neurology, The First People's Hospital of Taizhou, Taizhou, China
| | - Guangxiong Yuan
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Yue Wan
- Department of Neurology, The Third People's Hospital of Hubei Province, Wuhan, China
| | - Jianjun Tang
- Department of Neurology, Shanghai Neuromedical Center, Shanghai, China
| | - Jing Wang
- Department of Neurointerventional Radiology, Beijing Fengtai You'anmen Hospital, Beijing, China
| | - Yuanfei Jiang
- Department of Neurology, Tai'an Hospital of Chinese Medicine, Tai'an, China
| | - Chaobin Wang
- Department of Neurology, Beijing Liangxiang Hospital, Beijing, China
| | - Xiang Luo
- Department of Neurology, Tongji Hospital, Tongji Medical College of HUST, Wuhan, China
| | - Haihua Yang
- Department of Neurology, Beijing Daxing People's Hospital, Beijing, China
| | - Ruile Shen
- Department of Neurology, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Zhilin Wu
- Department of Neurointerventional Radiology, YunFu People's Hospital, YunFu, China
| | - Zhengzhou Yuan
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Dongjun Wan
- Department of Neurology, The 940th Hospital of Joint Logistics Support force of Chinese People's Liberation Army, Lanzhou, China
| | - Wei Hu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Yan Liu
- Department of Neurology, JingJiang People's Hospital, The Seventh Affiliated Hospital of Yangzhou University, JingJiang, China
| | - Ping Jing
- Department of Neurology, Wuhan Central Hospital, Wuhan, China
| | - Liping Wei
- Department of Neurology, Luoyang Central Hospital, Luoyang, China
| | - Tuanyuan Zheng
- Department of Neurology, JiuJiang First People's Hospital, JiuJiang, China
| | - Yingchun Wu
- Department of Neurology, Ordos Central Hospital, Ordos, China
| | - Xinguang Yang
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yaxuan Sun
- Department of Neurology, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Changming Wen
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Mingze Chang
- Department of Neurology, Xi'an Third Hospital, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Bo Yin
- Department of Neurosurgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Di Li
- Department of Neurointerventional Radiology, Dalian Municipal Central Hospital, Dalian Medical University, Dalian, China
| | - Jixin Duan
- Department of Neurosurgery, Changsha Hospital of Traditional Chinese Medicine, Changsha, China
| | - Dianjing Sun
- Department of Neurointerventional Radiology, Yantai Mountain Hospital of Yantai City, Yantai, China
| | - Zaiyu Guo
- Center for Neurology, Tianjin TEDA Hospital, Tianjin, China
| | - Guodong Xu
- Department of Neurointerventional Radiology, Heibei Provincial People's Hospital, Shijiazhuang, China
| | - Guoqing Wang
- Department of Neurology, Binzhou People's Hospital, Binzhou, China
| | - Liyu Wang
- Department of Neurointerventional Radiology, Beijing Shunyi Hospital, Beijing, China
| | - Yang Wang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Weihua Jia
- Department of Neurology, Beijing Shijingshan Hospital, Beijing, China
| | - Gaoting Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, JingJiang People's Hospital, The Seventh Affiliated Hospital of Yangzhou University, JingJiang, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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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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6
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Premat K, Dechartres A, Baptiste A, Guedon A, Mazighi M, Spelle L, Denier C, Tuilier T, Hosseini H, Lapergue B, Di Maria F, Bricout N, Henon H, Gory B, Richard S, Chivot C, Courselle A, Velasco S, Lamy M, Costalat V, Arquizan C, Marnat G, Sibon I, Lenck S, Shotar E, Allard J, Sourour N, Degos V, Alamowitch S, Clarençon F. Comparison of rescue intracranial stenting versus best medical treatment alone in acute refractory large vessel occlusion: study protocol for the PISTAR multicenter randomized trial. J Neurointerv Surg 2024:jnis-2024-021502. [PMID: 38538057 DOI: 10.1136/jnis-2024-021502] [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: 01/18/2024] [Accepted: 03/18/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Mechanical thrombectomy (MT) has become a standard treatment for acute ischemic strokes (AIS). However, MT failure occurs in approximately 10-30% of cases, leading to severe repercussions (with mortality rates up to 40% according to observational data). Among the available rescue techniques, rescue intracranial stenting (RIS) appears as a promising option. OBJECTIVE This trial is poised to demonstrate the superiority of RIS in addition to the best medical treatment (BMT) in comparison with BMT alone, in improving the functional outcomes at 3 months for patients experiencing an AIS due to a large vessel occlusion refractory to MT (rLVO). METHODS Permanent Intracranial STenting for Acute Refractory large vessel occlusions (PISTAR) is a multicenter prospective randomized open, blinded endpoint trial conducted across 11 French University hospitals. Adult patients (≥18 years) with an acute intracranial occlusion refractory to standard MT techniques will be randomized 1:1 during the procedure to receive either RIS+BMT (intervention arm) or BMT alone (control arm). RESULTS The primary outcome is the rate of good clinical outcome at 3 months defined as a modified Rankin Scale score ≤2 and evaluated by an independent assessor blinded to the randomization arm. Secondary outcomes include hemorrhagic complications, all adverse events, and death. The number of patients to be included is 346. Two interim analyses are planned with predefined stopping rules. CONCLUSION The PISTAR trial is the first randomized controlled trial focusing on the benefit of RIS in rLVOs. If positive, this study will open new insights into the management of AIS. TRIAL REGISTRATION NUMBER NCT06071091.
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Affiliation(s)
- Kévin Premat
- Department of Interventional Neuroradiology, Sorbonne Université, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Agnès Dechartres
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Département de Santé Publique, Paris, France
| | - Amandine Baptiste
- Clinical Research Unit, Sorbonne Université, APHP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Alexis Guedon
- Department of Neuroradiology, Lariboisière Hospital, Paris, France
| | - Mikael Mazighi
- Department of Vascular Neurology, Lariboisière Hospital, Paris, France
| | - Laurent Spelle
- NEURI The Brain Vascular Center, Bicetre Hospital Interventional Neuroradiology, Le Kremlin-Bicetre, France
- Paris-Saclay University Faculty of Medicine, Le Kremlin-Bicetre, France
| | - Christian Denier
- Department of Neurology, Hopital Bicetre, Le Kremlin-Bicetre, France
| | - Titien Tuilier
- Department of Neuroradiology, Henri-Mondor Hospital, Creteil, France
| | - Hassan Hosseini
- Department of Vascular Neurology, Henri-Mondor Hospital, Créteil, France
| | | | - Federico Di Maria
- Department of Interventional and Diagnostic Neuroradiology, Foch Hospital, Suresnes, France
| | - Nicolas Bricout
- Department of Neuroradiology, Lille University Hospital, Lille, France
| | - Hilde Henon
- Department of Vascular Neurology, Lille University Hospital, Lille, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU de Nancy, Nancy, France
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Cyril Chivot
- Department of Radiology, Amiens University Hospital, Amiens, France
| | - Audrey Courselle
- Department of Neurology, Amiens University Hospital, Amiens, France
| | - Stéphane Velasco
- Department of Radiology, Poitiers University Medical Center, Poitiers, France
| | - Mathias Lamy
- Department of Neurology, Poitiers University Medical Center, Poitiers, France
| | - Vincent Costalat
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | | | - Gaultier Marnat
- Department of Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Igor Sibon
- Department of Neurology, Bordeaux University Hospital, Bordeaux, France
| | - Stephanie Lenck
- Department of Interventional Neuroradiology, Sorbonne Université, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Eimad Shotar
- Department of Interventional Neuroradiology, Sorbonne Université, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Julien Allard
- Department of Interventional Neuroradiology, Sorbonne Université, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Nader Sourour
- Department of Interventional Neuroradiology, Sorbonne Université, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Vincent Degos
- Department of Anesthesiology and NeuroIntensive Care, Sorbonne Université, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Sonia Alamowitch
- Department of Neurology, Sorbonne Université, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Frédéric Clarençon
- Department of Interventional Neuroradiology, Sorbonne Université, APHP, Pitié-Salpêtrière Hospital, Paris, France
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El Naamani K, Momin AA, Hunt A, Jain P, Oghli YS, Ghanem M, Musmar B, El Fadel O, Alhussein A, Alhussein R, Pedapati V, Muharremi E, El-Hajj J, Tjoumakaris SI, Gooch MR, Herial NA, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour PM. Causes and Predictors of 30-Day Readmission in Patients With Stroke Undergoing Mechanical Thrombectomy: A Large Single-Center Experience. Neurosurgery 2024:00006123-990000000-01021. [PMID: 38224235 DOI: 10.1227/neu.0000000000002826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/29/2023] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The 30-day readmission rate has emerged as a metric of quality care and is associated with increased health care expenditure. We aim to identify the rate and causes of 30-day readmission after mechanical thrombectomy and provide the risk factors of readmission to highlight high-risk patients who may require closer care. METHODS This is a retrospective study from a prospectively maintained database of 703 patients presenting for mechanical thrombectomy between 2017 and 2023. All patients who presented with a stroke and underwent a mechanical thrombectomy were included in this study. Patients who were deceased on discharge were excluded from this study. RESULTS Our study comprised 703 patients, mostly female (n = 402, 57.2%) with a mean age of 70.2 years ±15.4. The most common causes of readmission were cerebrovascular events (stroke [n = 21, 36.2%], intracranial hemorrhage [n = 9, 15.5%], and transient ischemic attack [n = 1, 1.7%]).Other causes of readmission included cardiovascular events (cardiac arrest [n = 4, 6.9%] and bradycardia [n = 1, 1.7%]), infection (wound infection postcraniectomy [n = 3, 5.2%], and pneumonia [n = 1, 1.7%]). On multivariate analysis, independent predictors of 30-day readmission were history of smoking (odds ratio [OR]: 2.2, 95% CI: 1.1-4.2) P = .01), distal embolization (OR: 3.2, 95% CI: 1.1-8.7, P = .03), decompressive hemicraniectomy (OR: 9.3, 95% CI: 3.2-27.6, P < .01), and intracranial stent placement (OR: 4.6, 95% CI: 2.4-8.7) P < .01). CONCLUSION In our study, the rate of 30-day readmission was 8.3%, and the most common cause of readmission was recurrent strokes. We identified a history of smoking, distal embolization, decompressive hemicraniectomy, and intracranial stenting as independent predictors of 30-day readmission in patients with stroke undergoing mechanical thrombectomy.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Arbaz A Momin
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Yazan Shamli Oghli
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Marc Ghanem
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Basel Musmar
- School of Medicine, An-Najah National University, Nablus, Palestine
| | - Omar El Fadel
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abdulaziz Alhussein
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Reyoof Alhussein
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Vinay Pedapati
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Eti Muharremi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jad El-Hajj
- Saint George's University School of Medicine, Saint George, Grenada
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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8
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Lazaro TT, Hoang AN, Cotton PC, Dang HQ, Tanweer O, Raper DMS. Management strategies of unanticipated intracranial stenosis during mechanical thrombectomy for acute stroke: A survey of academic neurointerventionalists. Interv Neuroradiol 2023; 29:725-730. [PMID: 35758313 PMCID: PMC10680963 DOI: 10.1177/15910199221110971] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The optimal approach to the management of intracranial atherosclerotic disease (ICAD) at the time of mechanical thrombectomy (MT) for large vessel occlusion (LVO) remains controversial. The goal of this study is to characterize current practices concerning this challenging clinical situation in a survey of practicing neurointerventionalists. METHODS An electronic questionnaire was sent to a cross-section of North American academic neurointerventionalists using publicly available contact information and departmental websites. Prior to analysis, responses were anonymized and categorized by region. RESULTS A total of 136/360 responses were recorded from the U.S. and Canada. The mean number of years of practicing as a neurointerventionalist among the respondents was 10.5 (± 6.2 years). ICAD was perceived as a causative factor during MT for LVO in 5-10% of thrombectomy cases. The most common first-line treatment approach for significant ICAD, assuming a TICI 2b or better reperfusion, was medical therapy (77.9% of respondents), followed by angioplasty + stent placement (8.8% of respondents). There were no significant differences in the first line treatment of ICAD in LVO between geographical regions (p = 0.815). CONCLUSION The approach to underlying ICAD in LVO varies widely; however, the majority of neurointerventionalists prefer medical therapy with DAPT as a first-line treatment approach. The current survey highlights the need for studies that better define the optimal timing and modality of treatment, along with an evidence-based framework for balancing the risks associated with these treatment approaches.
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Affiliation(s)
- Tyler T Lazaro
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Alex N Hoang
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Patrick C Cotton
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Huy Q Dang
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Daniel M S Raper
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
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9
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Jia B, Zhang L, Pan Y, Tong X, Zhang X, Mo D, Ma N, Luo G, Song L, Li X, Wang B, Nguyen TN, Gao F, Miao Z. Rescue angioplasty and/or stenting after mechanical thrombectomy: who can benefit? J Neurointerv Surg 2023:jnis-2023-020824. [PMID: 38050150 DOI: 10.1136/jnis-2023-020824] [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: 07/18/2023] [Accepted: 10/25/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Angioplasty and/or stenting is a rescue therapy for mechanical thrombectomy (MT) in acute intracranial large vessel occlusion. This study was undertaken to determine whether rescue angioplasty and/or stenting improves the outcome after MT and to investigate whether outcomes differ by subgroup of rescue indication. METHODS We performed propensity score matching (PSM) with data from a prospective multicenter registry of patients with acute large vessel occlusion receiving endovascular treatment. Patients were divided into the MT alone group and the MT with rescue therapy group. The primary outcome was functional independence (modified Rankin Scale score of 0-2) at 90 days. PSM was also performed in the failed MT (modified Thrombolysis In Cerebral Infarction (mTICI) 0-2a) and the residual severe stenosis (mTICI 2b-3) subgroups, respectively. RESULTS 326 patients of mean±SD age 62.7±12.0 years (90 women, 27.6%) were matched from 1274 patients. In the matched cohort, functional independence at 90 days was higher in the rescue therapy group than in the MT alone group (44.2% vs 29.5%; OR 1.90, 95% CI 1.18 to 3.06, P=0.008). In the failed MT subgroup with 66 matched pairs, more patients had functional independence in the rescue therapy group than in the MT alone group (39.0% vs 17.0%; OR 3.12, 95% CI 1.29 to 7.59, P=0.01). In the residual stenosis subgroup with 63 matched pairs, functional independence rates were similar in the rescue therapy and the MT alone groups (51.6% vs 55.7%; OR 0.85, 95% CI 0.42 to 1.72, P=0.65). CONCLUSION Rescue angioplasty and/or stenting could improve the clinical outcome in patients with acute large vessel occlusion with failed MT, while no benefit was seen in those with residual severe stenosis but substantial reperfusion.
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Affiliation(s)
- BaiXue Jia
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Longhui Zhang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuelei Zhang
- Stroke Center, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gang Luo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ligang Song
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoqing Li
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bo Wang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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10
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Webb M, Essibayi MA, Al Kasab S, Maier IL, Psychogios MN, Grossberg JA, Alawieh A, Wolfe SQ, Arthur A, Dumont T, Kan P, Kim JT, De Leacy R, Osbun J, Rai A, Jabbour P, Park MS, Crosa R, Levitt MR, Polifka A, Yoshimura S, Matouk C, Williamson RW, Fragata I, Chowdhry SA, Starke RM, Samaniego EA, Cuellar H, Spiotta A, Mascitelli J. Predictors of Angiographic Outcome After Failed Thrombectomy for Large Vessel Occlusion: Insights from the Stroke Thrombectomy and Aneurysm Registry. Neurosurgery 2023; 93:1168-1179. [PMID: 37377425 DOI: 10.1227/neu.0000000000002560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 04/17/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Mechanical thrombectomy failure (MTF) occurs in approximately 15% of cases. OBJECTIVE To investigate factors that predict MTF. METHODS This was a retrospective review of prospectively collected data from the Stroke Thrombectomy and Aneurysm Registry. Patients who underwent mechanical thrombectomy (MT) for large vessel occlusion (LVO) were included. Patients were categorized by mechanical thrombectomy success (MTS) (≥mTICI 2b) or MTF ( RESULTS A total of 6780 patients were included, and 1001 experienced anterior circulation MTF. Patients in the MTF group were older (73 vs 72, P = .044) and had higher poor premorbid modified Rankin Scale (mRS) (10.8% vs 8.4%, P = .017). Onset to puncture time was greater in the MTF group (273 vs 260 min, P = .08). No significant differences were found between the access site, use of balloon guide catheter, frontline technique, or first-pass devices between the MTF and MTS groups. More complications occurred in the MTF group (14% vs 5.8%), including symptomatic intracerebral hemorrhage (9.4% vs 6.1%) and craniectomies (10% vs 2.8%) ( P < .001). On UVA, age, poor pretreatment mRS, increased number of passes, and increased procedure time were associated with MTF. Internal carotid artery, M1, and M2 occlusions had decreased odds of MTF. Poor preprocedure mRS, number of passes, and procedure time remained significant on MVA. A subgroup analysis of posterior circulation LVO revealed that number of passes and total procedure time correlated with increased odds of MTF ( P < .001) while rescue stenting was associated with less odds of MTF (odds ratio 0.20, 95% CI 0.06-0.63). Number of passes remained significant on MVA of posterior circulation occlusion subgroup analysis. CONCLUSION Anterior circulation MTF is associated with more complications and worse outcomes. No differences were found between techniques or devises used for the first pass during MT. Rescue intracranial stenting may decrease the likelihood of MTF for posterior circulation MT.
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Affiliation(s)
- Matthew Webb
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
| | | | - Sami Al Kasab
- Medical University of South Carolina, Charleston , South Carolina , USA
| | - Ilko L Maier
- University Medical Center Göttingen, Göttingen , Germany
| | | | | | | | | | - Adam Arthur
- University of Tennessee Health Science Center, Memphis , Tennessee , USA
| | - Travis Dumont
- Bannner University of Arizona Medical Center, Tucson , Arizona , USA
| | - Peter Kan
- University of Texas Medical Branch, Galveston , Texas , USA
| | - Joon-Tae Kim
- Chonnam National University Hospital, Gwangju , South Korea
| | | | - Joshua Osbun
- Washington University in St. Louis, St. Louis , Missouri , USA
| | - Ansaar Rai
- Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Pascal Jabbour
- Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Min S Park
- Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Roberto Crosa
- University of Virginia, Charlottesville , Virginia , USA
| | - Michael R Levitt
- Centro Endovascular Neurológico, Médica Uruguaya, Montevideo , Uruguay
| | - Adam Polifka
- University of Washington, Seattle , Washington , USA
| | | | | | | | - Isabel Fragata
- Allegheny General Hospital, Pittsburgh , Pennsylvania , USA
| | | | - Robert M Starke
- NorthShore University Health System, Evanston , Illinois , USA
| | | | | | - Alejandro Spiotta
- Medical University of South Carolina, Charleston , South Carolina , USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
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11
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Wang J, Shang S, Dun W, Chen C, Gao F, Yu J, Han J, Liu F. Short-term efficacy of stenting as a rescue therapy for acute atherosclerotic occlusion in anterior cerebral circulation. Front Neurol 2023; 14:1238998. [PMID: 38020588 PMCID: PMC10646575 DOI: 10.3389/fneur.2023.1238998] [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: 06/12/2023] [Accepted: 09/25/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose The study aimed to explore the efficacy and safety of the Neuroform EZ stent in treating acute anterior circulation large artery occlusion. Methods The clinical data of 42 consecutive patients with acute anterior circulation large atherosclerotic occlusion who were treated with the Neuroform EZ stent from January 2018 to August 2019 in our stroke care center, including baseline characteristics, images, therapeutic condition, and follow-up data were retrospectively analyzed. Results There were 42 mechanical thrombectomy (MT) failure cases of intracranial atherosclerotic stenosis with rescue Neuroform EZ stent implantation, of which 78.6% (33/42) had a good prognosis and 88.1% (37/42) showed no re-stenosis at follow-up. The average time from puncture to recanalization is 79.50 ± 14.19 min. The successful rate of intraoperative stent release is 97.6%, while there is one case of stent displacement, three cases of thrombus escape, and six cases of hemorrhage. Conclusion Rescue therapy of the Neuroform EZ stent for acute anterior circulation large atherosclerotic occlusion can archive good short-term imaging and clinical results, while long-term follow-up is still needed to verify.
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Affiliation(s)
- Jianyi Wang
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Suhang Shang
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Wanghuan Dun
- Department of Rehabilitation, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Chen Chen
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Fan Gao
- Clinical Research Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Jia Yu
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Jianfeng Han
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Fude Liu
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
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12
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Mohammaden MH, Haussen DC, Al-Bayati AR, Hassan AE, Tekle W, Fifi JT, Matsoukas S, Kuybu O, Gross BA, Lang M, Narayanan S, Cortez GM, Hanel RA, Aghaebrahim A, Sauvageau E, Farooqui M, Ortega-Gutierrez S, Zevallos CB, Galecio-Castillo M, Sheth SA, Nahhas M, Salazar-Marioni S, Nguyen TN, Abdalkader M, Klein P, Hafeez M, Kan P, Tanweer O, Khaldi A, Li H, Jumaa M, Zaidi SF, Oliver M, Salem MM, Burkhardt JK, Pukenas B, Kumar R, Lai M, Siegler JE, Peng S, Alaraj A, Nogueira RG. General anesthesia vs procedural sedation for failed NeuroThrombectomy undergoing rescue stenting: intention to treat analysis. J Neurointerv Surg 2023; 15:e240-e247. [PMID: 36597943 DOI: 10.1136/jnis-2022-019376] [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: 07/11/2022] [Accepted: 10/16/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is little data available to guide optimal anesthesia management during rescue intracranial angioplasty and stenting (ICAS) for failed mechanical thrombectomy (MT). We sought to compare the procedural safety and functional outcomes of patients undergoing rescue ICAS for failed MT under general anesthesia (GA) vs non-general anesthesia (non-GA). METHODS We searched the data from the Stenting and Angioplasty In Neuro Thrombectomy (SAINT) study. In our review we included patients if they had anterior circulation large vessel occlusion strokes due to intracranial internal carotid artery (ICA) or middle cerebral artery (MCA-M1/M2) segments, failed MT, and underwent rescue ICAS. The cohort was divided into two groups: GA and non-GA. We used propensity score matching to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included functional independence (90-day mRS0-2) and successful reperfusion defined as mTICI2B-3. Safety measures included symptomatic intracranial hemorrhage (sICH) and 90-day mortality. RESULTS Among 253 patients who underwent rescue ICAS, 156 qualified for the matching analysis at a 1:1 ratio. Baseline demographic and clinical characteristics were balanced between both groups. Non-GA patients had comparable outcomes to GA patients both in terms of the overall degree of disability (mRS ordinal shift; adjusted common odds ratio 1.29, 95% CI [0.69 to 2.43], P=0.43) and rates of functional independence (33.3% vs 28.6%, adjusted odds ratio 1.32, 95% CI [0.51 to 3.41], P=0.56) at 90 days. Likewise, there were no significant differences in rates of successful reperfusion, sICH, procedural complications or 90-day mortality among both groups. CONCLUSIONS Non-GA seems to be a safe and effective anesthesia strategy for patients undergoing rescue ICAS after failed MT. Larger prospective studies are warranted for more concrete evidence.
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Affiliation(s)
- Mahmoud H Mohammaden
- Neurology, Emory University, Atlanta, Georgia, USA
- Marcus Stroke and Neuroscience center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Diogo C Haussen
- Neurology, Emory University, Atlanta, Georgia, USA
- Marcus Stroke and Neuroscience center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | | | - Ameer E Hassan
- Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Wondwossen Tekle
- Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stavros Matsoukas
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Okkes Kuybu
- Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
| | | | - Michael Lang
- Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | | | - Gustavo M Cortez
- Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Amin Aghaebrahim
- Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Mudassir Farooqui
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Santiago Ortega-Gutierrez
- Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Cynthia B Zevallos
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Sunil A Sheth
- Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Michael Nahhas
- Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | | | - Thanh N Nguyen
- Neurology and Radiology, Boston University School of Medicine, Boston, MA, USA
| | | | - Piers Klein
- Neurology and Radiology, Boston University School of Medicine, Boston, MA, USA
| | - Muhammad Hafeez
- Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | | | - Ahmad Khaldi
- Neurosurgery, WellStar Health System, Marietta, Georgia, USA
| | - Hanzhou Li
- Department of Neurosciences, WellStar Health System, Marietta, Georgia, USA
| | - Mouhammad Jumaa
- Neurology, The University of Toledo Medical Center, Toledo, Ohio, USA
| | - Syed F Zaidi
- Neurology, The University of Toledo Medical Center, Toledo, Ohio, USA
| | - Marion Oliver
- Neurology, The University of Toledo Medical Center, Toledo, Ohio, USA
| | - Mohamed M Salem
- Neurosurgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Neurosurgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Bryan Pukenas
- Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rahul Kumar
- Cooper Hospital University Medical Center, Camden, New Jersey, USA
| | - Michael Lai
- Cooper Hospital University Medical Center, Camden, New Jersey, USA
| | - James E Siegler
- Cooper Hospital University Medical Center, Camden, New Jersey, USA
| | - Sophia Peng
- Neurosurgery, University of Illinois Medical Center at Chicago, Chicago, Illinois, USA
| | - Ali Alaraj
- Neurosurgery, University of Illinois Medical Center at Chicago, Chicago, Illinois, USA
| | - Raul G Nogueira
- Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
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Imam YZ, Akhtar N, Kamran S, Garcia-Bermejo P, Al Jerdi S, Zakaria A, Own A, Patro S. Rescue Stent Placement for Acute Ischemic Stroke with Large Vessel Occlusion Refractory to Mechanical Thrombectomy: A Multiethnic Middle Eastern/African/Asian Cohort. J Vasc Interv Radiol 2023; 34:1740-1748. [PMID: 37302471 DOI: 10.1016/j.jvir.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 05/20/2023] [Accepted: 06/04/2023] [Indexed: 06/13/2023] Open
Abstract
PURPOSE To investigate the safety and effectiveness of rescue stent placement in patients who experienced acute stroke in whom mechanical thrombectomy failed. METHODS This was a retrospective review of a multiethnic stroke database. After stent placement, an aggressive antiplatelet protocol was followed with glycoprotein IIb/IIIa infusion. The primary outcomes were incidence of intracerebral hemorrhage (ICH), recanalization score, and favorable prognosis (modified Rankin score ≤ 2) at 90 days. A comparison was made between patients from the Middle East and North Africa (MENA) region and those from other regions. RESULTS Fifty-five patients were included, with 87% being men. The mean age was 51.3 years (SD ±11.8); 32 patients (58%) were from South Asia, 12 (22%) from MENA, 9 (16%) from Southeast Asia, and 2 (4%) from elsewhere. Successful recanalization (modified Thrombolysis in Cerebral Infarction score = 2b/3) was achieved in 43 patients (78%), and symptomatic ICH occurred in 2 patients (4%). A favorable outcome at 90 days was seen in 26 of the 55 patients (47%). Apart from significantly older age-mean, 62.8 years (SD ±13; median, 69 years) versus 48.1 years (SD ±9.3; median, 49 years)-and coronary artery disease burden-4 (33%) versus 1 (2%) (P < .05), patients from MENA had risk factors, stroke severity, recanalization rates, ICH rates, and 90-day outcomes similar to those from South and Southeast Asia. CONCLUSION Rescue stent placement showed good outcomes and a low risk of clinically significant bleeding in a multiethnic cohort of patients from MENA and South and Southeast Asia, similar to that in published literature.
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Affiliation(s)
- Yahia Z Imam
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine-Qatar, Doha, Qatar.
| | - Naveed Akhtar
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Saadat Kamran
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | | | - Ayman Zakaria
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Own
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar
| | - Satya Patro
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Memon MZ, Ezzeldin M, Biswas A, Ahmad R, Nisar T, Singla A, Muhammad N, Shaltoni H, Kan P, Zaidat OO, Khandelwal P. Novel technique of stent placement via gateway balloon in intracranial atherosclerosis-associated large vessel occlusion. J Neuroimaging 2023; 33:773-780. [PMID: 37391866 DOI: 10.1111/jon.13139] [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: 03/12/2023] [Revised: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND AND PURPOSE Neuroform Atlas stent can be deployed directly via gateway balloon for angioplasty and stent placement without the need for exchange maneuver required for Wingspan stent use. We present our initial experience of this strategy in intracranial atherosclerosis-associated large vessel occlusions. METHODS Patients were identified through mechanical thrombectomy (MT) database from January 2020 to June 2022 at our institutions. Due to reocclusion or impending occlusion, rescue angioplasty with stent placement was performed after initial standard MT. Primary outcomes were good angiographic recanalization with modified thrombolysis in cerebral infarction (mTICI) score of 2b-3, rate of intracranial hemorrhage (ICH), and favorable functional outcome at 3 months, that is, modified Rankin Scale (mRS) score of 0-3. RESULTS We identified 22 patients treated using this technique. Among those, 11 were females with their average age at 66 years (range: 52-85). Initial median National Institute of Health Stroke Scale score was 11 (range: 5-30) and all patients received loading doses of aspirin and P2Y₁₂ inhibitor. After performing submaximal angioplasty and Neuroform Atlas stent deployment through the gateway balloon, we achieved final mTICI of 2b-3 in 20 (90%) patients. One patient had ICH post-op that was asymptomatic. Eight (36%) patients had mRS of 0-3 at 90 days. CONCLUSION Our preliminary experience suggests possible safety and feasibility of deploying Neuroform Atlas stent through a compatible Gateway balloon microcatheter without the need for ICH-associated microcatheter exchange. Further studies with long-term clinical and angiographic follow-up are warranted to corroborate our initial findings.
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Affiliation(s)
- Muhammad Zeeshan Memon
- Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Mohamad Ezzeldin
- Department of Clinical Sciences, College of Medicine, University of Houston, Houston, Texas, USA
| | - Arundhati Biswas
- Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - Rowaid Ahmad
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Taha Nisar
- Department of Neurology, University of South Alabama
| | - Amit Singla
- Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - Nazar Muhammad
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Hashem Shaltoni
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Peter Kan
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Osama O Zaidat
- Departments of Endovascular Neurosurgery and Stroke, St. Vincent Mercy Medical Center, Toledo, Ohio, USA
| | - Priyank Khandelwal
- Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
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15
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Mowla A, Khatibi K, Razavi SM, Kaneko N, Ponce Mejia LL, Saber H, Tateshima S. Rescue Intracranial Balloon Angioplasty with or without Stent Placement in Acute Strokes with Intracranial Atherosclerotic Disease. World Neurosurg 2023; 176:e8-e13. [PMID: 36681321 DOI: 10.1016/j.wneu.2023.01.057] [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: 08/11/2022] [Revised: 01/14/2023] [Accepted: 01/16/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND Optimal management of acute ischemic stroke (AIS) secondary to intracranial atherosclerotic disease (ICAD) refractory to conventional mechanical thrombectomy remains unclear. We aimed to investigate the clinical outcome of patients undergoing rescue intracranial balloon angioplasty with or without stent placement in the setting of AIS in our institution. METHODS This is a retrospective single-arm observational study to evaluate the efficacy and safety of rescue balloon angioplasty with or without stent placement in emergent large vessel occlusion (EVLO) strokes with underlying ICAD. We included all patients undergoing such rescue intervention within 24 hours of AIS presentation with EVLO between 2017 and 2021. We further evaluated stent or vessel reocclusion. RESULTS Of 20 patients undergoing rescue intervention, 3 cases achieved adequate recanalization of artery using balloon angioplasty alone. Seventeen patients required stent placement. Fourteen (70%) procedures resulted in National Institutes of Health Stroke Scale improvement in postprocedure and upon discharge. Among 6 (30%) procedures with worsening neurological measures, 3 had reoccluded stent 24-48 hours after procedure, 2 had symptomatic hemorrhagic conversion, and 1 had perforator occlusion. Nine patients (45%) had favorable functional outcome (modified Rankin Scale ≤2) at discharge, unchanged or improved at 3-month follow-up. The median modified Rankin Scale score was 4 (Interquartile range: 1.75-4) at discharge, improving to 3 (Interquartile range: 0-4) at 3-month follow-up. Two patients (10%) died during hospital stay. CONCLUSIONS Rescue angioplasty with or without stenting can lead to significant clinical improvement in patients with ICAD presenting with ELVO and refractory to thrombectomy; however, this procedure is associated with a high rate of morbidity in acute setting.
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Affiliation(s)
- Ashkan Mowla
- Division of Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, California, USA.
| | - Kasra Khatibi
- Division of Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, California, USA
| | - Seyed-Mostafa Razavi
- Division of Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, California, USA; Saint Mary's Regional Medical Center, Prime Healthcare, Reno, Nevada, USA
| | - Naoki Kaneko
- Division of Interventional Neuroradiology, Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, California, USA
| | - Lucido Luciano Ponce Mejia
- Division of Interventional Neuroradiology, Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, California, USA
| | - Hamidreza Saber
- Division of Interventional Neuroradiology, Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, California, USA
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, Department of Radiology, David Geffen School of Medicine, University of California Los Angeles, California, USA
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16
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Khachatryan T, Shafie M, Abcede H, Shah J, Nagamine M, Granstein J, Yuki I, Golshani K, Suzuki S, Yu W. Rescue therapy after thrombectomy for large vessel occlusion due to underlying atherosclerosis: review of literature. Front Neurol 2023; 14:1181295. [PMID: 37396754 PMCID: PMC10313123 DOI: 10.3389/fneur.2023.1181295] [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: 03/13/2023] [Accepted: 05/24/2023] [Indexed: 07/04/2023] Open
Abstract
In this review article, we summarized the current advances in rescue management for reperfusion therapy of acute ischemic stroke from large vessel occlusion due to underlying intracranial atherosclerotic stenosis (ICAS). It is estimated that 24-47% of patients with acute vertebrobasilar artery occlusion have underlying ICAS and superimposed in situ thrombosis. These patients have been found to have longer procedure times, lower recanalization rates, higher rates of reocclusion and lower rates of favorable outcomes than patients with embolic occlusion. Here, we discuss the most recent literature regarding the use of glycoprotein IIb/IIIa inhibitors, angioplasty alone, or angioplasty with stenting for rescue therapy in the setting of failed recanalization or instant/imminent reocclusion during thrombectomy. We also present a case of rescue therapy post intravenous tPA and thrombectomy with intra-arterial tirofiban and balloon angioplasty followed by oral dual antiplatelet therapy in a patient with dominant vertebral artery occlusion due to ICAS. Based on the available literature data, we conclude that glycoprotein IIb/IIIa is a reasonably safe and effective rescue therapy for patients who have had a failed thrombectomy or have residual severe intracranial stenosis. Balloon angioplasty and/or stenting may be helpful as a rescue treatment for patients who have had a failed thrombectomy or are at risk of reocclusion. The effectiveness of immediate stenting for residual stenosis after successful thrombectomy is still uncertain. Rescue therapy does not appear to increase the risk of sICH. Randomized controlled trials are warranted to prove the efficacy of rescue therapy.
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Affiliation(s)
- Tigran Khachatryan
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Mohammad Shafie
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Hermelinda Abcede
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Jay Shah
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Masaki Nagamine
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Justin Granstein
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Ichiro Yuki
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Kiarash Golshani
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Shuichi Suzuki
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Wengui Yu
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
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17
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Huo X, Sun D, Chen W, Han H, Abdalkader M, Puetz V, Yi T, Wang H, Liu R, Tong X, Jia B, Ma N, Gao F, Mo D, Yan B, Mitchell PJ, Leung TW, Yavagal DR, Albers GW, Costalat V, Fiehler J, Zaidat OO, Jovin TG, Liebeskind DS, Nguyen TN, Miao Z. Endovascular Treatment for Acute Large Vessel Occlusion Due to Underlying Intracranial Atherosclerotic Disease. Semin Neurol 2023; 43:337-344. [PMID: 37549690 DOI: 10.1055/s-0043-1771207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Intracranial atherosclerotic disease (ICAD) is one of the most common causes of acute ischemic stroke worldwide. Patients with acute large vessel occlusion due to underlying ICAD (ICAD-LVO) often do not achieve successful recanalization when undergoing mechanical thrombectomy (MT) alone, requiring rescue treatment, including intra-arterial thrombolysis, balloon angioplasty, and stenting. Therefore, early detection of ICAD-LVO before the procedure is important to enable physicians to select the optimal treatment strategy for ICAD-LVO to improve clinical outcomes. Early diagnosis of ICAD-LVO is challenging in the absence of consensus diagnostic criteria on noninvasive imaging and early digital subtraction angiography. In this review, we summarize the clinical and diagnostic criteria, prediction of ICAD-LVO prior to the procedure, and EVT strategy of ICAD-LVO and provide recommendations according to the current literature.
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Affiliation(s)
- Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hongxing Han
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | | | - Volker Puetz
- Department of Neurology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hao Wang
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Raynald Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre, Melbourne, Australia
| | - Peter J Mitchell
- Department of Radiology, Melbourne Brain Centre, Melbourne, Australia
| | - Thomas W Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Dileep R Yavagal
- Departments of Neurology and Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Güi-de-Chauliac, CHU de Montpellier, Montpellier, France
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Osama O Zaidat
- Department of Neuroscience, Mercy Saint Vincent Medical Center, Toledo, Ohio
| | - Tudor G Jovin
- Department of Neurology, Cooper University Hospital, Camden, New Jersey
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, California
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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18
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Ma A, Detaram HD, Steinfort B, Harrington T, Nguyen TN, Abdalkader M, Siopis G, Bath PM, Dhillon PS, Podlasek A, Qureshi AI, Qiu Z, Krishnan K. Antiplatelet Therapy in Neurointervention. Semin Neurol 2023; 43:466-479. [PMID: 37562452 DOI: 10.1055/s-0043-1771383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
The aim of this review is to provide an overview of the use of antiplatelet medication in neurointervention, with a focus on the clinical indications for antiplatelet use in both preventing and reducing platelet aggregation. This review will cover current antiplatelet medications, pharmacokinetics, and pharmacodynamics. We will provide an overview of different endovascular devices and discuss the antiplatelet regimes in neurointervention, highlighting gaps in evidence and scope for future studies.Two randomized controlled trials have evaluated antiplatelet use in the setting of acute large vessel occlusion stroke, with neither demonstrating benefit in their overall cohorts. Evidence on antiplatelet medication for both acute and elective stenting for acute stroke and treatment of cerebral aneurysms is currently based on large case series, and practice in neurointervention has increasingly utilized dual antiplatelet regimes with clopidogrel and second-line agents like prasugrel and ticagrelor. Clopidogrel function testing has an increasing role in neurointerventional procedures, particularly for high metal surface area stents such as the braided flow diverter type stents. Intravenous glycoprotein IIB/IIIA inhibitors have been utilized for both acute bridging and rescue therapy.Antiplatelet decision making is complex, and there are few randomized control trials to guide clinical practice. Comparative trials to guide decision making remain important in both the acute and elective settings. Standardised protocols incorporating platelet function testing may play a role in assisting decision making until more robust clinical evidence is available, particularly in the context of acute neurointerventional stenting for stroke and ruptured cerebral aneurysms.
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Affiliation(s)
- Alice Ma
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | | | - Brendan Steinfort
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Tim Harrington
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Centre, Boston, Massachusetts
| | | | - George Siopis
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Permesh Singh Dhillon
- Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- TIME, Imaging Science and Technology, University of Dundee, Dundee, Scotland, United Kingdom
| | - Anna Podlasek
- Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- TIME, Imaging Science and Technology, University of Dundee, Dundee, Scotland, United Kingdom
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, People's Republic of China
| | - Kailash Krishnan
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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19
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Bösel J, Hubert GJ, Jesser J, Möhlenbruch MA, Ringleb PA. Access to and application of recanalizing therapies for severe acute ischemic stroke caused by large vessel occlusion. Neurol Res Pract 2023; 5:19. [PMID: 37198694 DOI: 10.1186/s42466-023-00245-9] [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: 03/10/2023] [Accepted: 05/02/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Groundbreaking study results since 2014 have dramatically changed the therapeutic options in acute therapy for severe ischemic stroke caused by large vessel occlusion (LVO). The scientifically proven advances in stroke imaging and thrombectomy techniques have allowed to offer the optimal version or combination of best medical and interventional therapy to the selected patient, yielding favorable or even excellent clinical outcomes within time windows unheard of before. The provision of the best possible individual therapy has become a guideline-based gold standard, but remains a great challenge. With geographic, regional, cultural, economic and resource differences worldwide, optimal local solutions have to be strived for. AIM This standard operation procedure (SOP) is aimed to give a suggestion of how to give patients access to and apply modern recanalizing therapy for acute ischemic stroke caused by LVO. METHOD The SOP was developed based on current guidelines, the evidence from the most recent trials and the experience of authors who have been involved in the above-named development at different levels. RESULTS This SOP is meant to be a comprehensive, yet not too detailed template to allow for freedom in local adaption. It comprises all relevant stages in providing care to the patient with severe ischemic stroke such as suspicion and alarm, prehospital acute measures, recognition and grading, transport, emergency room workup, selective cerebral imaging, differential treatment by recanalizing therapies (intravenous thrombolysis, endovascular stroke treatmet, or combined), complications, stroke unit and neurocritical care. CONCLUSIONS The challenge of giving patients access to and applying recanalizing therapies in severe ischemic stroke may be facilitated by a systematic, SOP-based approach adapted to local settings.
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Affiliation(s)
- Julian Bösel
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
| | - Gordian J Hubert
- TEMPiS Telestroke Center, Department of Neurology, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Munich, Germany
| | - Jessica Jesser
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter A Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
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20
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Comparison of Safety and Efficacy after Emergency Stenting in Patients Exhibiting Intracranial Atherosclerotic Stenosis Associated with Large-vessel Occlusion with and without Intravenous Infusion of Tirofiban. Cardiovasc Intervent Radiol 2023; 46:377-384. [PMID: 36797426 PMCID: PMC10014670 DOI: 10.1007/s00270-023-03372-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/23/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE Intracranial rescue stent angioplasty is a bailout strategy for acute stroke patients in cases of unsuccessful endovascular thrombectomy due to underlying atherosclerotic stenosis. However, there is no consensus on a preprocedural and intraprocedural antiplatelet regimen. The aim of this single-centre study was to compare the safety and efficacy of emergency stenting in patients exhibiting intracranial atherosclerotic stenosis-related acute large-vessel occlusion with or without peri-interventional intravenous infusion of tirofiban. MATERIALS AND METHODS We performed a retrospective analysis of 78 patients who were treated with rescuestent angioplasty between 2010 and 2019 due to acute ischaemic stroke. The patients were divided into 2 groups: those who received peri-interventional intravenous tirofiban and those who did not receive tirofiban. We compared clinical safety and functional outcomes in both treatment groups with symptomatic haemorrhage as the primary endpoint. Bivariate and multivariable logistic regression was performed to investigate the association between tirofiban and outcome measures. RESULTS Thirty-seven patients were treated with intravenous tirofiban (47.4%), and 41 patients did not receive intravenous tirofiban (52.6%). Statistical analysis revealed no significant difference between the two groups in the rate of symptomatic haemorrhage (16.2% in the tirofiban group versus 14.6% in the control group, p = 0.847). The 3-month mortality (21.6% in the tirofiban group versus 17.1% in the control group, p = 0.611) and good functional outcomes according to the modified Rankin scale (45.9% versus 34.1%, p = 0.289) were comparable. CONCLUSION The results of our study suggest that the application of tirofiban for rescue stenting after failed mechanical thrombectomy is safe.
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21
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Li W, Sui X, Li C, Zhao W, Yuan S, Dou S, Han G, Ji K, Ma Q, Ji X. Emergency Angioplasty or Stenting for Stroke Patients with Intracranial Atherosclerotic Large Vessel Occlusion. J Atheroscler Thromb 2023; 30:160-169. [PMID: 35466122 PMCID: PMC9925205 DOI: 10.5551/jat.63381] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
AIM Mechanical thrombectomy (MT) has become the gold standard for the treatment of large vessel occlusion (LVO) in acute ischemic stroke. However, it remains controversial whether emergency angioplasty or stenting in patients with intracranial atherosclerotic stenosis (ICAS) should be adopted. Thus, we performed a retrospective analysis of clinical data to determine whether emergency angioplasty or stenting is necessary. METHODS We retrospectively analyzed data from patients undergoing MT with ICAS-related LVO of the acute anterior circulation between 2017 and 2019. Eligible patients were divided into two treatment groups: those who received rescue angioplasty or stenting [Patients treated with rescue angioplasty or stenting (PTAS) group] and those who received thrombectomy alone (non-PTAS group). The primary outcomes were good prognosis at 90 days (mRS: 0-2). Mortality, symptomatic intracranial hemorrhage, and reocclusion rate were evaluated as secondary outcomes. RESULTS A total of 184 patients with severe stenosis after MT were enrolled, including 64 patients receiving rescue angioplasty or stenting and 120 patients without rescue angioplasty or stenting. Compared with the non-PTAS group, a better functional outcome (mRS0-2) (51.6% vs. 35.0%, adjusted odds ratio: 2.11, 95% confidence interval [CI]: 1.22-4.29; P=0.02), lower 7-day National Institutes of Health Stroke Scale [6 (3-12.75) vs. 10 (4-16); P=0.04], lower 24-h neurological deterioration rate (7.8% vs. 21.7%, P=0.02), and lower 24-h reocclusion rate were observed in the PTAS group (6.3% vs. 17.5%, P=0.03). There were no significant differences in mortality or incidence of symptomatic intracerebral hemorrhage. CONCLUSION Emergency angioplasty or stenting could be a safe and feasible therapeutic option with better outcomes for stroke patients with ICAS-related LVO.
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Affiliation(s)
- Weili Li
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China,Cerebrovascular Diseases Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China,Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xueqin Sui
- Department of General Medicine, Affiliated Hospital of Weifang Medical University, Shandong province, China
| | - Cong Li
- Department of Neurology, Weifang People’s Hospital, Shandong province, China
| | - Wenbo Zhao
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Shuhua Yuan
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China,Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Shoutan Dou
- Department of Neurology, Affiliated Hospital of Weifang Medical University, Shandong province, China
| | - Guosheng Han
- Department of Neurology, Affiliated Hospital of Weifang Medical University, Shandong province, China
| | - Kangxiang Ji
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Qingfeng Ma
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xunming Ji
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China,Cerebrovascular Diseases Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China,Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, China
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Cai J, Xu H, Xiao R, Hu L, Xu P, Guo X, Xie Y, Pan M, Tang J, Gong Q, Liu Y, Su R, Deng J, Wang L. Rescue intracranial stenting for acute ischemic stroke after the failure of mechanical thrombectomy: A systematic review, meta-analysis, and trial sequential analysis. Front Neurol 2023; 14:1023089. [PMID: 36761342 PMCID: PMC9905111 DOI: 10.3389/fneur.2023.1023089] [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: 08/19/2022] [Accepted: 01/06/2023] [Indexed: 01/26/2023] Open
Abstract
Background Intracranial rescue stenting (RS) might be an option for acute ischemic stroke after the failure of mechanical thrombectomy (MT). However, the findings were not consistent in previous systematic reviews, and whether the conclusion was supported by sufficient statistical power is unknown. Aim To examine the effect of RS on acute ischemic stroke after the failure of MT with a systematic review, meta-analysis, and trial sequential analysis (TSA). Methods We searched Ovid Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 15 June 2022, without any language restriction. Studies assessing the effect of RS for acute ischemia stroke after MT failure were included. Two reviewers independently screened the retrieved articles, extracted data, and evaluated the quality of the included studies through the New Ottawa Scale (NOS). The primary outcome was the recanalization rate after RS. Secondary outcomes included modified Rankin Scale (mRS) at 3 months after stroke, symptomatic intracranial hemorrhage (sICH), and mortality rate. We synthesized the data through a random-effects model and performed a TSA analysis. Results We included 15 studies (containing 1,595 participants) after screening 3,934 records. The pooled recanalization rate for rescue stenting was 82% (95% CI 77-87%). Compared with non-stenting, rescue stenting was associated with a higher proportion of patients with 0-2 mRS score (OR 3.96, 95% CI 2.69-5.84, p < 0.001) and a lower 90-day mortality rate (OR 0.46, 95% CI 0.32-0.65, p < 0.001), and stenting did not increase sICH rate (OR 0.63, 95% CI 0.39-1.04, p = 0.075). The TSA analysis showed that the meta-analysis of the mRS score had a sufficient sample size and statistical power. Conclusions Our study showed that rescue stenting was effective and safe for patients with acute ischemia stroke who also had a failed MT, and this result was confirmed in a TSA analysis.
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Affiliation(s)
- Junxiu Cai
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Hai Xu
- Department of Neurology, Ziyang People's Hospital, Ziyang, China
| | - Rongzhou Xiao
- Department of Radiology, Zigong Third People's Hospital, Zigong, China
| | - Liping Hu
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Ping Xu
- Clinical Laboratory, Zigong Third People's Hospital, Zigong, China
| | - Xianbin Guo
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Yu Xie
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Min Pan
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Jie Tang
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Qingtao Gong
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Yan Liu
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Rong Su
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Jiahua Deng
- Department of Neurology, Huili People's Hospital, Huili, China,*Correspondence: Jiahua Deng ✉
| | - Li Wang
- Department of Neurology, Zigong Third People's Hospital, Zigong, China,Li Wang ✉
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Guo S, Jin T, Xu C, Huang W, Shi Z, Geng Y. Rescue stenting after the failure of mechanical thrombectomy to treat acute intracranial atherosclerotic occlusion. Front Neurol 2023; 13:1001496. [PMID: 36703624 PMCID: PMC9873241 DOI: 10.3389/fneur.2022.1001496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023] Open
Abstract
Background Acute ischemic stroke (AIS) with intracranial large vessel occlusion (LVO) is refractory to reperfusion because of the underlying intracranial atherosclerosis (ICAS), and this condition often requires salvage methods such as balloon angioplasty and rescue stenting (RS). In this study, we investigated the short-term outcomes of RS after failed mechanical thrombectomy (MT) for the treatment of acute intracranial atherosclerotic occlusion. Methods We retrospectively evaluated the clinical data of 127 patients who underwent MT for acute intracranial atherosclerotic occlusion in our hospital between August 2018 and January 2022. The degree of recanalization was evaluated immediately after the treatment by Modified Thrombolysis in Cerebral Infarction (mTICI). The modified Rankin Scale (mRS) was used 90 days after treatment to evaluate the neurological functions. In addition, the incidence of symptomatic intracranial hemorrhage (sICH) and postoperative mortality within 90 days of treatment were calculated. Results Among the 127 patients, 86 patients (67.7%) had revascularization (mTICI 2b-3) immediately after MT (non-RS group), and RS was performed in 41 patients (32.3%) after MT failure (RS group). No difference in the sICH rate was observed between the two groups (17.1 vs. 16.3%, p = 0.91). There was a slightly higher mortality rate in the RS group (14.6 vs. 12.8%, p = 0.71); however, the difference was not significant. There was no difference in the proportion of patients in the RS and non-RS groups who had a 90-day mRS score of 0-2 (48.8 vs. 52.3%, p = 0.76). Conclusions Rescue stenting after MT failure might be a feasible rescue modality for treating acute intracranial atherosclerotic occlusion.
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Affiliation(s)
- Shunyuan Guo
- Department of Clinical Medicine, Medical College of Soochow University, Suzhou, Jiangsu, China,Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Tianyu Jin
- Department of Neurology, Zhejiang Chinese Medical University, Hangzhou, China
| | - Chao Xu
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Wei Huang
- Rheumatism and Immunity Research Institute, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Zongjie Shi
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,*Correspondence: Yu Geng ✉
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24
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Sun D, Jia B, Tong X, Kan P, Huo X, Wang A, Raynald, Ma G, Ma N, Gao F, Mo D, Song L, Sun X, Liu L, Deng Y, Li X, Wang B, Luo G, Wang Y, Ren Z, Miao Z. Predictors of parenchymal hemorrhage after endovascular treatment in acute ischemic stroke: data from ANGEL-ACT Registry. J Neurointerv Surg 2023; 15:20-26. [PMID: 35022299 DOI: 10.1136/neurintsurg-2021-018292] [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: 10/01/2021] [Accepted: 12/20/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Parenchymal hemorrhage (PH) is a troublesome complication after endovascular treatment (EVT). OBJECTIVE To investigate the incidence, independent predictors, and clinical impact of PH after EVT in patients with acute ischemic stroke (AIS) due to anterior circulation large vessel occlusion (LVO). METHODS Subjects were selected from the ANGEL-ACT Registry. PH was diagnosed according to the European Collaborative Acute Stroke Study classification. Logistic regression analyses were performed to determine the independent predictors of PH, as well as the association between PH and 90-day functional outcome assessed by modified Rankin Scale (mRS) score. RESULTS Of the 1227 enrolled patients, 147 (12.0%) were diagnosed with PH within 12-36 hours after EVT. On multivariable analysis, low admission Alberta Stroke Program Early CT score (ASPECTS)(adjusted OR (aOR)=1.13, 95% CI 1.02 to 1.26, p=0.020), serum glucose >7 mmol/L (aOR=1.82, 95% CI 1.16 to 2.84, p=0.009), and neutrophil-to-lymphocyte ratio (NLR; aOR=1.05, 95% CI 1.02 to 1.09, p=0.005) were associated with a high risk of PH, while underlying intracranial atherosclerotic stenosis (ICAS; aOR=0.42, 95% CI 0.22 to 0.81, p=0.009) and intracranial angioplasty/stenting (aOR=0.37, 95% CI 0.15 to 0.93, p=0.035) were associated with a low risk of PH. Furthermore, patients with PH were associated with a shift towards to worse functional outcome (mRS score 4 vs 3, adjusted common OR (acOR)=2.27, 95% CI 1.53 to 3.38, p<0.001). CONCLUSIONS In Chinese patients with AIS caused by anterior circulation LVO, the risk of PH was positively associated with low admission ASPECTS, serum glucose >7 mmol/L, and NLR, but negatively related to underlying ICAS and intracranial angioplasty/stenting. TRIAL REGISTRATION NUMBER NCT03370939.
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Affiliation(s)
- Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaoting Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ligang Song
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lian Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yiming Deng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoqing Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bo Wang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gang Luo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zeguang Ren
- Department of Neurosurgery, Cleveland Clinic Martin Health, Port St Lucie, Florida, USA
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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25
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Marnat G, Gory B, Sibon I, Kyheng M, Labreuche J, Boulouis G, Liegey JS, Caroff J, Eugène F, Naggara O, Consoli A, Mazighi M, Maier B, Richard S, Denier C, Turc G, Lapergue B, Bourcier R. Mechanical thrombectomy failure in anterior circulation strokes: Outcomes and predictors of favorable outcome. Eur J Neurol 2022; 29:2701-2707. [PMID: 35648445 PMCID: PMC9541042 DOI: 10.1111/ene.15429] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/18/2022] [Indexed: 12/01/2022]
Abstract
Background and purpose Despite continuous improvement and growing knowledge in the endovascular therapy of large vessel occlusion stroke (LVOS), mechanical thrombectomy (MT) still fails to obtain satisfying intracranial recanalization in 10% to 15% of cases. However, little is known regarding clinical and radiological outcomes among this singularly underexplored subpopulation undergoing failed MT. We aimed to investigate the outcome after failed MT and identify predictive factors of favorable outcome despite recanalization failure. Methods We conducted a retrospective analysis of consecutive patients prospectively included in the ongoing observational multicenter Endovascular Treatment in Ischemic Stroke registry from January 2015 to September 2020. Patients presenting with anterior circulation LVOS treated with MT but experiencing failed intracranial recanalization defined as final modified Thrombolysis In Cerebral Infarction (mTICI) score of 0, 1 and 2a were included. Clinical and radiological outcomes were assessed along with the exploration of predictive factors of Day‐90 favorable outcome. Results The study population comprised 533 patients. Mean age was 68.8 ± 16 years, and median admission National Institutes of Health Stroke Scale (NIHSS) and Alberta Stroke Program Early Computed Tomography Score (ASPECTS) were 17 (IQR 12–21) and 7 (IQR 5–8), respectively. Favorable outcomes were observed in 85 patients (18.2%) and 186 died (39.0%). The rate of symptomatic intracranial hemorrhage was 14.1%. In multivariable analysis, younger age (odds ratio [OR] 0.96, 95% CI 0.94–0.98, p < 0.001), a lower admission NIHSS (OR 0.87, 95% CI 0.83–0.91, p < 0.001), a lower number of MT passes (OR 0.77, 95% CI 0.77–0.87, p < 0.001), a lower delta ASPECTS between initial and Day‐1 imaging (OR 0.83, 95% CI 0.71–0.98, p = 0.026) and stroke etiology [significant difference among etiological subtypes (p = 0.024) with a tendency toward more favorable outcomes for dissection (OR 2.01, 95% CI 0.71–5.67)] were significantly associated with a 90‐day favorable outcome. Conclusions In this large retrospective analysis of a multicenter registry, we quantified the poor outcome after MT failure. We also identified factors associated with favorable outcome despite recanalization failure that might influence therapeutic management.
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Affiliation(s)
- Gaultier Marnat
- Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Benjamin Gory
- CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, Nancy, France.,IADI, INSERM-U1254, Université de Lorraine, Nancy, France
| | - Igor Sibon
- Neurology Department, Bordeaux University Hospital, Bordeaux, France
| | - Maeva Kyheng
- CHU Lille, Department of Biostatistics, Lille, France
| | | | | | | | - Jildaz Caroff
- Neuroradiolology Department, CHU Kremlin Bicêtre, Paris, France
| | - François Eugène
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Rennes, Rennes, France
| | - Olivier Naggara
- Department of Neuroradiology, GHU Paris, Centre Hospitalier Sainte-Anne, Université de Paris, INSERM-UMR-894, Paris, France
| | - Arturo Consoli
- Department of Stroke Center and Diagnostic and Interventional Neuroradiology, University of Versailles and Saint Quentin-en-Yvelines, Foch Hospital, Suresnes, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris, FHU-NeuroVASC, Paris, INSERM-1148, France
| | - Benjamin Maier
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris, FHU-NeuroVASC, Paris, INSERM-1148, France
| | | | | | - Guillaume Turc
- Department of Neurology, GHU Paris, Centre Hospitalier Sainte-Anne, Paris, France
| | - Bertrand Lapergue
- Department of Neurology, University of Versailles and Saint-Quentin-en-Yvelines, Foch Hospital, Suresnes, France
| | - Romain Bourcier
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nantes, Nantes, France
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Fiedler J, Roubec M, Grubhoffer M, Ostrý S, Procházka V, Langová K, Školoudík D. Emergent microsurgical intervention for acute stroke after mechanical thrombectomy failure: a prospective study. J Neurointerv Surg 2022; 15:439-445. [PMID: 35428739 PMCID: PMC10176344 DOI: 10.1136/neurintsurg-2022-018643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/03/2022] [Indexed: 11/04/2022]
Abstract
BackgroundDespite all the gains that have been achieved with endovascular mechanical thrombectomy revascularization and intravenous thrombolysis logistics since 2015, there is still a subgroup of patients with salvageable brain tissue for whom persistent emergent large vessel occlusion portends a catastrophic outcome.ObjectiveTo test the safety and efficacy of emergent microsurgical intervention in patients with acute ischemic stroke and symptomatic middle cerebral artery occlusion after failure of mechanical thrombectomy.MethodsA prospective two-center cohort study was conducted. Patients with acute ischemic stroke and middle cerebral artery occlusion for whom recanalization failed at center 1 were randomly allocated to the microsurgical intervention group (MSIG) or control group 1 (CG1). All similar patients at center 2 were included in the control group 2 (CG2) with no surgical intervention. Microsurgical embolectomy and/or extracranial–intracranial bypass was performed in all MSIG patients at center 1.ResultsA total of 47 patients were enrolled in the study: 22 at center 1 (12 allocated to the MSIG and 10 to the CG1) and 25 patients at center 2 (CG2). MSIG group patients showed a better clinical outcome on day 90 after the stroke, where a modified Rankin Scale score of 0–2 was reached in 7 (58.3%) of 12 patients compared with 1/10 (10.0%) patients in the CG1 and 3/12 (12.0%) in the CG2.ConclusionsThis study demonstrated the potential for existing microsurgical techniques to provide good outcomes in 58% of microsurgically treated patients as a third-tier option.
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Affiliation(s)
- Jiří Fiedler
- Department of Neurosurgery, Nemocnice České Budějovice, České Budějovice, Jihočeský, Czech Republic
- Department of Neurosurgery, Univerzita Karlova Lékařská fakulta v Plzni, Plzeň, Plzeňský, Czech Republic
| | - Martin Roubec
- Department of Neurology, University Hospital Ostrava, Ostrava, Moravskoslezský, Czech Republic
- Center for Health Research, Faculty of Medicine, University of Ostrava, Ostrava, Moravskoslezský, Czech Republic
| | - Marek Grubhoffer
- Department of Neurosurgery, Nemocnice České Budějovice, České Budějovice, Jihočeský, Czech Republic
- Department of Neurosurgery, Univerzita Karlova Lékařská fakulta v Plzni, Plzeň, Plzeňský, Czech Republic
| | - Svatopluk Ostrý
- Department of Neurology, Nemocnice České Budějovice, České Budějovice, Jihočeský, Czech Republic
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Praha, Praha, Czech Republic
| | - Václav Procházka
- Department of Radiology, University Hospital Ostrava, Ostrava, Moravskoslezský, Czech Republic
| | - Kateřina Langová
- Department of Biophysics, Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Olomoucký, Czech Republic
| | - David Školoudík
- Center for Health Research, Faculty of Medicine, University of Ostrava, Ostrava, Moravskoslezský, Czech Republic
- Department of Radiology, University Hospital Ostrava, Ostrava, Moravskoslezský, Czech Republic
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Sajja KC, Huded V, Prajapati C, Male S, Sharma MK, Shah S, Bohra V, Chakravarthi S, Prasanna LS, Sura PR, Paramasivam S, Gorijala VK, Guntamukkala A, Somasundaram K, Vemuri RT. Rescue Stenting for Refractory Large Vessel Occlusions in the Thrombectomy Era: Intracranial Use of Coronary Stents in Low-mid Economic Settings. Cureus 2022; 14:e23847. [PMID: 35402111 PMCID: PMC8982903 DOI: 10.7759/cureus.23847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/27/2022] Open
Abstract
Background: Failed mechanical thrombectomy due to a refractory emergent large vessel occlusion (RELVO) in patients presenting with an acute stroke poses a major challenge to the outcomes. Objective: We demonstrate the use of coronary stents in the intracranial circulation as rescue stenting for an already expensive mechanical thrombectomy procedure in a mid-low socioeconomic setting. Methods: A retrospective, multicenter study was conducted between December 2015 and January 2021. The studied cohort were patients who required the use of a rescue stenting using a coronary stent for emergent large vessel occlusion to avoid failed recanalization. Failed recanalization was defined as failed vessel recanalization after at least two passes. Patient demographic data, procedure specifics, type of stent used, and procedural outcomes were collected. Results: A total of 26 patients with acute ischemic stroke were included from eight different centers across India. Out of 26 patients, 19 (73.0%) were male and seven were female (26.9%). The mean age was 53.6 years, the youngest patient was 23 years old and the eldest was 68 years old. Seven patients (26.9%) had posterior circulation stroke due to occlusion of the vertebral or basilar artery and 19 patients (73.0%) had anterior circulation stroke median NIHSS at presentation was 16 (range 10 to 28) in anterior circulation stroke and 24 (range 16 to 30) in posterior circulation stroke. Intravenous thrombolysis with tissue plasminogen activator (IV tPA) was given in three patients (11.5%). The hospital course of two patients was complicated by symptomatic intracranial hemorrhage (sICH), which was fatal. Favorable revascularization outcome and favorable functional outcome was achieved in 22 patients (84.6%), three patients passed away (11.5%), and one patient was lost to follow up. Conclusions: Overall, our study finds that rescue stenting using coronary stents can potentially improve outcomes in refractory large vessel occlusions while minimizing costs in low-mid economic settings.
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28
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Marnat G, Finistis S, Delvoye F, Sibon I, Desilles JP, Mazighi M, Gariel F, Consoli A, Rosso C, Clarençon F, Elhorany M, Denier C, Chalumeau V, Caroff J, Veunac L, Bourdain F, Darcourt J, Olivot JM, Bourcier R, Dargazanli C, Arquizan C, Richard S, Lapergue B, Gory B. Safety and Efficacy of Cangrelor in Acute Stroke Treated with Mechanical Thrombectomy: Endovascular Treatment of Ischemic Stroke Registry and Meta-analysis. AJNR Am J Neuroradiol 2022; 43:410-415. [PMID: 35241418 PMCID: PMC8910798 DOI: 10.3174/ajnr.a7430] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/23/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Rescue therapies are increasingly used in the setting of endovascular therapy for large-vessel occlusion strokes. Among these, cangrelor, a new P2Y12 inhibitor, offers promising pharmacologic properties to join the reperfusion strategies in acute stroke. We assessed the safety and efficacy profiles of cangrelor combined with endovascular therapy in patients with large-vessel-occlusion stroke. MATERIALS AND METHODS We performed a retrospective patient data analysis in the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France from July 2018 to December 2020 and conducted a systematic review and meta-analysis using several data bases. Indications for cangrelor administration were rescue strategy in case of refractory intracranial occlusion with or without intracranial rescue stent placement, and cervical carotid artery stent placement in case of cervical occlusion (tandem occlusion or isolated cervical carotid occlusion). RESULTS In the clinical registry, 44 patients were included (median initial NIHSS score, 12; prior intravenous thrombolysis, 29.5%). Intracranial stent placement was performed in 54.5% (n = 24/44), and cervical stent placement, in 27.3% (n = 12/44). Adjunctive aspirin and heparin were administered in 75% (n = 33/44) and 40.9% (n = 18/44), respectively. Rates of symptomatic intracerebral hemorrhage, parenchymal hematoma, and 90-day mortality were 9.5% (n = 4/42), 9.5% (n = 4/42), and 24.4% (n = 10/41). Favorable outcome (90-day mRS, 0-2) was reached in 51.2% (n = 21/41), and successful reperfusion, in 90.9% (n = 40/44). The literature search identified 6 studies involving a total of 171 subjects. In the meta-analysis, including our series data, symptomatic intracerebral hemorrhage occurred in 8.6% of patients (95% CI, 5.0%-14.3%) and favorable outcome was reached in 47.6% of patients (95% CI, 27.4%-68.7%). The 90-day mortality rate was 22.6% (95% CI, 13.6%-35.2%). Day 1 artery patency was observed in 89.7% (95% CI, 81.4%-94.6%). CONCLUSIONS Cangrelor offers promising safety and efficacy profiles, especially considering the complex endovascular reperfusion procedures in which it is usually applied. Further large prospective data are required to confirm these findings.
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Affiliation(s)
- G. Marnat
- From the Department of Diagnostic and Interventional Neuroradiology (G.M., F.G.), University Hospital of Bordeaux, Bordeaux, France
| | - S. Finistis
- Aristotle University of Thessaloniki (S.F.), AhepaHospital, Thessaloniki, Greece
| | - F. Delvoye
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - I. Sibon
- Department of Neurology (I.S.), Stroke Center, University Hospital of Bordeaux, Bordeaux, France
| | - J.-P. Desilles
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - M. Mazighi
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - F. Gariel
- From the Department of Diagnostic and Interventional Neuroradiology (G.M., F.G.), University Hospital of Bordeaux, Bordeaux, France
| | - A. Consoli
- Department of Diagnostic and Interventional Neuroradiology (A.C.), Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | | | - F. Clarençon
- Neuroradiology (F.C., M.E.), Centre Hospitalier Universitaire Pitié Salpétrière Hospital, Paris, France
| | - M. Elhorany
- Neuroradiology (F.C., M.E.), Centre Hospitalier Universitaire Pitié Salpétrière Hospital, Paris, France
| | | | - V. Chalumeau
- Neuroradiolology (V.C., J.C.) Centre Hospitalier Universitaire Kremlin Bicêtre, Le Kremlin Bicêtre, France
| | - J. Caroff
- Neuroradiolology (V.C., J.C.) Centre Hospitalier Universitaire Kremlin Bicêtre, Le Kremlin Bicêtre, France
| | - L. Veunac
- Neuroradiolology (L.V.), Centre Hospitalier Cõte Basque, Bayonne, France
| | | | - J. Darcourt
- Neuroradiolology (J.D.), Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | | | - R. Bourcier
- Department of Neuroradiology (R.B.), University Hospital of Nantes, Nantes, France
| | - C. Dargazanli
- Departments of Interventional Neuroradiology (C. Dargazanli)
| | - C. Arquizan
- Neurology (C.A.), Centre Hospitalier Regional Universitaire Gui de Chauliac, Montpellier, France
| | - S. Richard
- Department of Neurology (S.R.), Université de Lorraine, Centre Hospitalier Regional Universitaire Nancy, Nancy, France
| | - B. Lapergue
- Department of Neurology (B.L.), Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - B. Gory
- Department of Diagnostic and Therapeutic Neuroradiology (B.G.), Université de Lorraine, Centre Hospitalier Regional Universitaire Nancy, Nancy, France,Université de Lorraine (B.G.), Imagerie Adaptative Diagnostique et Interventionnelle, Institut National de la Santé et de la Recherche Médicale U1254, Nancy, France
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Wu Y, Wang J, Sun R, Feng G, Li W, Gui Y, Zheng Y. A Novel Endovascular Therapy Strategy for Acute Ischemic Stroke Due to Intracranial Atherosclerosis-Related Large Vessel Occlusion: Stent-Pass-Aspiration-resCuE-Micowire-Angioplasty (SPACEMAN) Technique. Front Neurol 2022; 13:798542. [PMID: 35237229 PMCID: PMC8882581 DOI: 10.3389/fneur.2022.798542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/19/2022] [Indexed: 11/20/2022] Open
Abstract
Background There is no clear consensus on the optimal endovascular treatment strategy for patients with ischemic stroke caused by ICAS-related large vessel occlusion (LVO). SPACEMAN, a novel thrombectomy technique that entails passing an aspiration catheter over the stent retriever and then retaining the microwire for angioplasty, has not been described. The aim of this prospective study was to evaluate our initial application of SPACEMAN and compare this technique with the Solumbra technique. Methods Forty-four consecutive patients with acute ischemic stroke resulting from ICAS-related LVO were randomly divided into two groups: Solumbra group (n = 22) and SPACEMAN group (n = 22). Demographic and clinical data were prospectively collected. Modified Rankin Scale (mRS) score of ≤ 2 of anterior circulation and mRS score ≤ 3 of posterior circulation at 3 months post-discharge was regarded as good prognosis. Results The SPACEMAN group showed reduced mean time from femoral access to recanalization compared with the Solumbra group (39.55 ± 10.63 min vs. 50.73 ± 9.89 min, P = 0.001). The overall recanalization rate in the entire cohort was 93.18% (41/44). At 3-month follow-up, the overall good prognosis rate was 47.73%; 13 patients (59.09%) in the SPACEMAN group and 8 (36.36%) in the Solumbra group showed good prognosis. One patient in the SPACEMAN group (4.55%) and two patients in the Solumbra group (9.09%) developed symptomatic intracranial hemorrhage. The overall mortality rate was 4.55% (2/44). Conclusions This study suggests that SPACEMAN exhibits a shorter operation revascularization time than the standard thrombectomy. Complications and prognosis were comparable between the two groups. The safety and efficacy of this novel technique need to be studied in larger patient series.
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Sweid A, Sajja KC, Mouchtouris N, Weinberg JH, Shivashankar K, Saad H, Abbas R, El Naamani K, Ramesh S, Schaefer J, Saiegh FA, Jabbour P, Herial NA, Zarzour H, Tjoumakaris S, Romo V, Rosenwasser RH, Gooch MR. Rescue stenting for acute ischemic stroke with Refractory Emergent Large vessel occlusion in the modern thrombectomy era. Clin Neurol Neurosurg 2022; 215:107183. [DOI: 10.1016/j.clineuro.2022.107183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/20/2022] [Accepted: 02/19/2022] [Indexed: 11/03/2022]
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Effect of telestroke practices on short-term mortality in ischemic stroke patients. JOURNAL OF CONTEMPORARY MEDICINE 2022. [DOI: 10.16899/jcm.973616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Nguyen L, Maingard J, Jhamb A, Brooks M, Barras C, Kok HK, Asadi H. Intracranial atherosclerotic disease and acute ischaemic stroke: A review of diagnosis and management. J Med Imaging Radiat Oncol 2021; 66:391-403. [PMID: 34894071 DOI: 10.1111/1754-9485.13366] [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: 04/14/2021] [Accepted: 11/23/2021] [Indexed: 11/29/2022]
Abstract
Intracranial atherosclerotic disease is highly prevalent and a common cause of ischaemic stroke globally. With the increasing use of endovascular treatment for acute stroke management, computed tomography and magnetic resonance imaging have become an essential part of patient selection. In this review, we present the typical imaging findings of intracranial atherosclerosis and an overview of management as relevant to diagnostic and interventional radiologists.
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Affiliation(s)
- Lauren Nguyen
- NeuroInterventional Radiology Unit, Monash Health, Melbourne, Victoria, Australia
| | - Julian Maingard
- NeuroInterventional Radiology Unit, Monash Health, Melbourne, Victoria, Australia.,Department of Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Ashu Jhamb
- Interventional Neuroradiology Service, Austin Health, Melbourne, Victoria, Australia
| | - Mark Brooks
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,Interventional Neuroradiology Service, Austin Health, Melbourne, Victoria, Australia
| | - Christen Barras
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,The University of Adelaide, Adelaide, South Australia, Australia
| | - Hong Kuan Kok
- Department of Radiology, Northern Health, Melbourne, Victoria, Australia
| | - Hamed Asadi
- NeuroInterventional Radiology Unit, Monash Health, Melbourne, Victoria, Australia.,Department of Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia.,Interventional Neuroradiology Service, Austin Health, Melbourne, Victoria, Australia
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Hassan AE, Ringheanu VM, Preston L, Tekle WG, Qureshi AI. Acute intracranial stenting with mechanical thrombectomy is safe and efficacious in patients diagnosed with underlying intracranial atherosclerotic disease. Interv Neuroradiol 2021; 28:419-425. [PMID: 34515574 PMCID: PMC9326867 DOI: 10.1177/15910199211039403] [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] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate whether significant differences exist in recanalization rates and primary outcomes between patients who undergo mechanical thrombectomy alone versus those who undergo mechanical thrombectomy with acute intracranial stenting. METHODS Through the utilization of a prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2020, variables such as demographics, co-morbid conditions, symptomatic intracerebral hemorrhage, mortality rate at discharge, and good/poor outcomes in regard to modified thrombolysis in cerebral infarction score and modified Rankin Scale were examined. The outcomes between patients receiving acute intracranial stenting + mechanical thrombectomy and patients that underwent mechanical thrombectomy alone were compared. RESULTS There were a total of 420 acute ischemic stroke patients who met criteria for the study (average age 70.6 ± 13.01 years; 46.9% were women). Analysis of 46 patients from the acute stenting + mechanical thrombectomy group (average age 70.34 ± 13.75 years; 37.0% were women), and 374 patients from the mechanical thrombectomy alone group (average age 70.64 ± 12.92 years; 48.1% were women). Four patients (8.7%) in the acute stenting + mechanical thrombectomy group experienced intracerebral hemorrhage versus 45 patients (12.0%) in the mechanical thrombectomy alone group (p = 0.506); no significant increases were noted in the median length of stay (7 vs 8 days; p = 0.208), rates of modified thrombolysis in cerebral infarction 2B-3 recanalization (p = 0.758), or good modified Rankin Scale scores (p = 0.806). CONCLUSION Acute intracranial stenting in addition to mechanical thrombectomy was not associated with an increase in overall length of stay, intracerebral hemorrhage rates, or any change in discharge modified Rankin Scale. Further research is required to determine whether mechanical thrombectomy and acute intracranial stenting in acute ischemic stroke patients is unsafe.
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Affiliation(s)
- Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA.,Department of Clinical Research, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA.,Neuroscience Department, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Victor M Ringheanu
- Department of Clinical Research, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Laurie Preston
- Department of Clinical Research, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA.,Neuroscience Department, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Wondwossen G Tekle
- Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA.,Neuroscience Department, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA.,Department of Neurology, University of Missouri School of Medicine, Columbia, Missouri, USA
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Rozes C, Maier B, Gory B, Bourcier R, Kyheng M, Labreuche J, Consoli A, Mazighi M, Blanc R, Caroff J, Eugene F, Naggara O, Gariel F, Sibon I, Lapergue B, Marnat G. Influence of prior intravenous thrombolysis on outcome after failed mechanical thrombectomy: ETIS registry analysis. J Neurointerv Surg 2021; 14:688-692. [PMID: 34413246 DOI: 10.1136/neurintsurg-2021-017867] [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: 06/13/2021] [Accepted: 07/15/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Despite constant improvements in recent years, sufficient reperfusion after mechanical thrombectomy (MT) is not reached in up to 15% of patients with large vessel occlusion stroke (LVOS). The outcome of patients with unsuccessful reperfusion after MT especially after intravenous thrombolysis (IVT) use is not known. We investigated the influence of initial IVT in this particular group of patients with failed intracranial recanalization. METHODS We conducted a retrospective analysis of the Endovascular Treatment in Ischemic Stroke (ETIS) registry from January 2015 to December 2019. Patients presenting with LVOS of the anterior circulation and final modified Thrombolysis in Cerebral Infarction score (mTICI) of 0, 1 or 2a were included. Posterior circulation, isolated cervical carotid occlusions and successful reperfusions (mTICI 2b, 2c or 3) were excluded. The primary endpoint was favorable outcome (modified Rankin Scale score of 0-2) after 3 months. Secondary endpoints were safety outcomes including mortality, any intracranial hemorrhage (ICH), parenchymal hematoma (PH) and symptomatic intracranial hemorrhage (sICH) rates. RESULTS Among 5076 patients with LVOS treated with MT, 524 patients with insufficient recanalization met inclusion criteria, of which 242 received IVT and 282 did not. Functional outcome was improved in the MT+IVT group compared with the MT alone group, although the difference did not reach statistical significance (23.0% vs 12.9%; adjusted OR=1.82; 95% CI 0.98 to 3.38; p=0.058). However, 3 month mRS shift analysis showed a significant benefit of IVT (adjusted OR=1.68; 95% CI 1.56 to 6.54). ICH and sICH rates were similar in both groups, although PH rate was higher in the MT+IVT group (adjusted OR=3.20; 95% CI 1.56 to 6.54). CONCLUSIONS Among patients with LVOS in the anterior circulation and unsuccessful MT, IVT was associated with improved functional outcome even after unsuccessful MT. Despite recent trials questioning the place of IVT in the LVOS reperfusion strategy, these findings emphasize a subgroup of patients still benefiting from IVT.
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Affiliation(s)
- Claire Rozes
- Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Benjamin Maier
- Interventional Neuroradiology, Adolphe de Rothschild Ophthalmological Foundation, Paris, France
| | - Benjamin Gory
- Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France.,INSERM U1254, Université de Lorraine, Nancy, France
| | - Romain Bourcier
- Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Maeva Kyheng
- CHU Lille, EA 2694, Santé publique: épidémiologie et qualité des soins, Université de Lille, Lille, Hauts-de-France, France
| | | | | | - Mikael Mazighi
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France.,Université de Paris, Paris, France
| | - Raphaël Blanc
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Jildaz Caroff
- Department of Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | | | - Olivier Naggara
- Neuroradiology, Centre Hospitalier Sainte Anne, Paris, Île-de-France, France.,INSERM UMR 894, Paris, France
| | - Florent Gariel
- Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Igor Sibon
- UMR 5287 CNRS; EPHE PSL Research University, Université de Bordeaux, Bordeaux, France.,Neurology Department, CHU de Bordeaux, Bordeaux, France
| | | | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, Aquitaine, France
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35
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Marnat G, Delvoye F, Finitsis S, Lapergue B, Gariel F, Consoli A, Desilles JP, Mazighi M, Dargazanli C, Bourcier R, Darcourt J, Chalumeau V, Elhorany M, Clarençon F, Richard S, Gory B, Sibon I. A Multicenter Preliminary Study of Cangrelor following Thrombectomy Failure for Refractory Proximal Intracranial Occlusions. AJNR Am J Neuroradiol 2021; 42:1452-1457. [PMID: 34117019 DOI: 10.3174/ajnr.a7180] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/09/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE Rescue endovascular and pharmacologic approaches are increasingly being adopted after recanalization failure of acute large-vessel occlusion strokes with mechanical thrombectomy, with encouraging results. The safety and efficacy of glycoprotein IIb/IIIa inhibitors in ischemic stroke have been investigated, though cangrelor, a recent intravenous P2Y12-receptor inhibitor with a rapid onset/offset of action and a short half-life, may be a valuable option. We compared the safety and efficacy of cangrelor with those of glycoprotein IIb/IIIa inhibitors for refractory occlusions. MATERIALS AND METHODS We performed a retrospective analysis of the ongoing prospective, multicenter, observational Endovascular Treatment in Ischemic Stroke Registry in France between May 2012 and February 2020. Refractory intracranial occlusions of the anterior and posterior circulation were included and defined as recanalization failure of large-vessel occlusion stroke, perioperative target artery reocclusion, or high risk of early reocclusion related to an arterial wall lesion. The primary end point was a favorable outcome, defined as a 90-day mRS of 0-2. Secondary end points were reperfusion, intracranial hemorrhage, and procedural complications. RESULTS Among 69 patients, 15 were treated with cangrelor, and 54, with glycoprotein IIb/IIIa inhibitors. The favorable outcome (adjusted OR = 2.22; 95% CI, 0.42-11.75; P = .348) and mortality (adjusted OR = 0.44; 95% CI, 0.06-3.16; P = .411) rates were similar in both groups. There was no difference in the rates of any intracranial hemorrhage (adjusted OR = 0.40; 95% CI, 0.08-2.09; P = .280), symptomatic intracranial hemorrhage (6.7% versus 0.0%, P = .058), or procedural complications (6.7% versus 20.4%, P = .215). Reperfusion rates were higher in the cangrelor group, though the difference did not reach statistical significance (93.3% versus 75.0% for modified TICI 2b-3; adjusted OR =10.88; 95% CI, 0.96-123.84; P = .054). CONCLUSIONS Cangrelor seems to be as safe as glycoprotein IIb/IIIa inhibitors for managing refractory intracranial occlusion and leads to satisfactory brain reperfusion. Cangrelor is a promising agent in this setting, and additional studies are warranted to confirm our findings.
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Affiliation(s)
- G Marnat
- Neuroradiology Department (G.M., F.G.) and Neurology (I.S.), Bordeaux University Hospital, Bordeaux, France
| | - F Delvoye
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - S Finitsis
- Aristotle University of Thessaloniki (S.F.), Ahepa Hospital, Thessaloniki, Greece
| | - B Lapergue
- Department of Neurology (B.L.), Foch Hospital, Versailles Saint-Quentin-en-Yvelines University, Suresnes, France
| | - F Gariel
- Neuroradiology Department (G.M., F.G.) and Neurology (I.S.), Bordeaux University Hospital, Bordeaux, France
| | - A Consoli
- Department s of Neuroradiology (A.C.) and Neurology (B.L.), Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - J-P Desilles
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - M Mazighi
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - C Dargazanli
- Department of Neuroradiology (C.D.), Centre Hospitalier Régional Universitaire Gui de Chauliac, Montpellier, France
| | - R Bourcier
- Department of Neuroradiology (R.B.), University Hospital of Nantes, Nantes, France
| | - J Darcourt
- Department of Neuroradiology (J.D.), University Hospital of Toulouse, Toulouse, France
| | - V Chalumeau
- Department of Neuroradiology (M.E., F.C.), Pitié-Salpêtrière Hospital, Paris, France
| | - M Elhorany
- Department of Neuroradiology (M.E., F.C.), Pitié-Salpêtrière Hospital, Paris, France
| | - F Clarençon
- Department of Neuroradiology (M.E., F.C.), Pitié-Salpêtrière Hospital, Paris, France
| | - S Richard
- Department of Neurology (S.R.), Université de Lorraine, Centre Hospitalier Régional Universitaire-Nancy, Stroke Unit, Nancy, France
- Institut national de la santé et de la recherche médicale U1116 (S.R.), Centre Hospitalier Régional Universitaire-Nancy, Nancy, France
| | - B Gory
- Department of Diagnostic and Therapeutic Neuroradiology (B.G.), Université de Lorraine, CHRU-Nancy, Nancy, France
- Institut National de la Santé et de la Recherche Mmédicale U1254 (B.G.), Université de Lorraine, Imagerie Adaptative Diagnostique et Interventionnelle, Nancy, France
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Lee JS, Hwang YH, Sohn SI. Factors Contributing to an Efficacious Endovascular Treatment for Acute Ischemic Stroke in Asian Population. Neurointervention 2021; 16:91-110. [PMID: 33765729 PMCID: PMC8261106 DOI: 10.5469/neuroint.2020.00339] [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: 09/20/2020] [Accepted: 02/19/2021] [Indexed: 12/13/2022] Open
Abstract
Although randomized control trials about endovascular treatment (EVT) of emergent large vessel occlusion (LVO) have demonstrated the success of mechanical thrombectomy as the choice of treatment, a wide range of caveats remain unaddressed. Asian patients were rarely included in the trials, thereby raising the question of whether the treatment could be generalized. In addition, there remains a concern on the feasibility of the method with respect to its application against intracranial atherosclerosis (ICAS)-related LVO, frequently observed in the Asian population. It is important to include evidence on ICAS LVO from Asian countries in the future for a comprehensive understanding of LVO etiology. Besides the issues with EVT, prognostic concerns in diabetes patients, acute kidney injury following EVT, neuroprotective management against reperfusion injury, and other peri-EVT issues should be considered in clinical practice. In the current article, we present an in-depth review of the literature that revises information pertaining to such concerns.
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Affiliation(s)
- Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Kyemyung University School of Medicine, Daegu, Korea
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Watershed subarachnoid hemorrhage after middle cerebral artery rescue stenting in patients with acute ischemic stroke. Neuroradiology 2021; 63:1383-1388. [PMID: 33760956 PMCID: PMC8295148 DOI: 10.1007/s00234-021-02692-0] [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: 01/26/2021] [Accepted: 03/15/2021] [Indexed: 11/24/2022]
Abstract
Cortical subarachnoid hemorrhage is an infrequent subtype of non-aneurysmal subarachnoid hemorrhage, rarely reported in watershed territories (wSAH) after carotid stenting. It has never been reported after treatment of middle cerebral artery stenosis (MCAS) that is increasingly used in selected patients, as rescue treatment of failed mechanical thrombectomy, due to recent advancements in endovascular interventions. We present a series of patients with MCAS that developed a wSAH after stenting.
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Pearce S, Maingard JT, Kuan Kok H, Barras CD, Russell JH, Hirsch JA, Chandra RV, Jhamb A, Thijs V, Brooks M, Asadi H. Antiplatelet Drugs for Neurointerventions: Part 2 Clinical Applications. Clin Neuroradiol 2021; 31:545-558. [PMID: 33646319 DOI: 10.1007/s00062-021-00997-4] [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: 12/02/2020] [Accepted: 01/15/2021] [Indexed: 02/06/2023]
Abstract
Endovascular techniques have expanded to include balloon and stent-assistance, flow diversion and individualized endovascular occlusion devices, to widen the treatment spectrum for more complex aneurysm morphologies. While usually well-tolerated by patients, endovascular treatment of intracranial aneurysms carries the risk of complications, with procedure-related ischemic complications being the most common. Several antiplatelet agents have been studied in a neurointerventional setting for both prophylaxis and in the setting of intraprocedural thrombotic complications. Knowledge of these antiplatelet agents, evidence for their use and common dosages is important for the practicing neurointerventionist to ensure the proper application of these agents.Part one of this two-part review focused on basic platelet physiology, pharmacology of common antiplatelet medications and future directions and therapies. Part two focuses on clinical applications and evidence based therapeutic regimens.
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Affiliation(s)
- Samuel Pearce
- Department of Radiology, Western Health, 160 Gordon St, 3011, Footscray, Victoria, Australia. .,Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.
| | - Julian T Maingard
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia
| | - Hong Kuan Kok
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Interventional Radiology Service, Northern Health Radiology, Melbourne, Victoria, Australia
| | - Christen D Barras
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jeremy H Russell
- Department of Neurosurgery, Austin Health, Melbourne, Victoria, Australia
| | - Joshua A Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronil V Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Imaging, Monash University, Melbourne, Victoria, Australia
| | - Ash Jhamb
- Interventional Neuroradiology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Austin Health, Melbourne, Victoria, Australia
| | - Mark Brooks
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Interventional Neuroradiology service, Radiology Department, Austin Health, Melbourne, Victoria, Australia
| | - Hamed Asadi
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.,Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Interventional Neuroradiology service, Radiology Department, Austin Health, Melbourne, Victoria, Australia
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Narsinh KH, Kilbride BF, Mueller K, Murph D, Copelan A, Massachi J, Vitt J, Sun CH, Bhat H, Amans MR, Dowd CF, Halbach VV, Higashida RT, Moore T, Wilson MW, Cooke DL, Hetts SW. Combined Use of X-ray Angiography and Intraprocedural MRI Enables Tissue-based Decision Making Regarding Revascularization during Acute Ischemic Stroke Intervention. Radiology 2021; 299:167-176. [PMID: 33560189 DOI: 10.1148/radiol.2021202750] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background For patients with acute ischemic stroke undergoing endovascular mechanical thrombectomy with x-ray angiography, the use of adjuncts to maintain vessel patency, such as stents or antiplatelet medications, can increase risk of periprocedural complications. Criteria for using these adjuncts are not well defined. Purpose To evaluate use of MRI to guide critical decision making by using a combined biplane x-ray neuroangiography 3.0-T MRI suite during acute ischemic stroke intervention. Materials and Methods This retrospective observational study evaluated consecutive patients undergoing endovascular intervention for acute ischemic stroke between July 2019 and May 2020 who underwent either angiography with MRI or angiography alone. Cerebral tissue viability was assessed by using MRI as the reference standard. For statistical analysis, Fisher exact test and Student t test were used to compare groups. Results Of 47 patients undergoing acute stroke intervention, 12 patients (median age, 69 years; interquartile range, 60-77 years; nine men) underwent x-ray angiography with MRI whereas the remaining 35 patients (median age, 80 years; interquartile range, 68-86 years; 22 men) underwent angiography alone. MRI results influenced clinical decision making in one of three ways: whether or not to perform initial or additional mechanical thrombectomy, whether or not to place an intracranial stent, and administration of antithrombotic or blood pressure medications. In this initial experience, decision making during endovascular acute stroke intervention in the combined angiography-MRI suite was better informed at MRI, such that therapy was guided in real time by the viability of the at-risk cerebral tissue. Conclusion Integrating intraprocedural 3.0-T MRI into acute ischemic stroke treatment was feasible and guided decisions of whether or not to continue thrombectomy, to place stents, or to administer antithrombotic medication or provide blood pressure medications. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Lev and Leslie-Mazwi in this issue.
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Affiliation(s)
- Kazim H Narsinh
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Bridget F Kilbride
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Kerstin Mueller
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Daniel Murph
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Alexander Copelan
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Jonathan Massachi
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Jeffrey Vitt
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Chung-Huan Sun
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Himanshu Bhat
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Matthew R Amans
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Christopher F Dowd
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Van V Halbach
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Randall T Higashida
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Terilyn Moore
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Mark W Wilson
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Daniel L Cooke
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Steven W Hetts
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
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Srinivasan VM, Lazaro TT, Srivatsan A, Cooper P, Phillips M, Garcia R, Chen SR, Johnson JN, Burkhardt JK, Collins DE, Kan P. Applications of a Novel Microangioscope for Neuroendovascular Intervention. AJNR Am J Neuroradiol 2020; 42:347-353. [PMID: 33361372 DOI: 10.3174/ajnr.a6900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/05/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Visualization in neuroendovascular intervention currently relies on biplanar fluoroscopy and contrast administration. With the advent of endoscopy, direct visualization of the intracranial intravascular space has become possible with microangioscopes. We analyzed the efficacy of our novel microangioscope to enable direct observation and inspection of the cerebrovasculature, complementary to a standard fluoroscopic technique. MATERIALS AND METHODS Iterations of microangioscopes were systematically evaluated for use in neurodiagnostics and neurointerventions in both live animal and human cadaveric models. Imaging quality, trackability, and navigability were assessed. Diagnostic procedures assessed included clot identification and differentiation, plaque identification, inspection for vessel wall injury, and assessment of stent apposition. Interventions performed included angioscope-assisted stent-retriever thrombectomy, clot aspiration, and coil embolization. RESULTS The microangioscope was found helpful in both diagnosis and interventions by independent evaluators. Mean ratings of the imaging quality on a 5-point scale ranged from 3.0 (clot identification) to 4.7 (Pipeline follow-up). Mean ratings for clinical utility ranged from 3.0 (aspiration thrombectomy) to 4.7 (aneurysm treatment by coil embolization and WEB device). CONCLUSIONS This fiber optic microangioscope can safely navigate and visualize the intravascular space in human cadaveric and in vivo animal models with satisfactory resolution. It has potential value in diagnostic and neurointerventional applications.
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Affiliation(s)
- V M Srinivasan
- From the Department of Neurosurgery (V.M.S., T.T.L., A.S., R.G., J.N.J., J.-K.B., P.K.)
| | - T T Lazaro
- From the Department of Neurosurgery (V.M.S., T.T.L., A.S., R.G., J.N.J., J.-K.B., P.K.)
| | - A Srivatsan
- From the Department of Neurosurgery (V.M.S., T.T.L., A.S., R.G., J.N.J., J.-K.B., P.K.)
| | - P Cooper
- Vena Medical (P.C., M.P.), Kitchener, Ontario, Canada
| | - M Phillips
- Vena Medical (P.C., M.P.), Kitchener, Ontario, Canada
| | - R Garcia
- From the Department of Neurosurgery (V.M.S., T.T.L., A.S., R.G., J.N.J., J.-K.B., P.K.)
| | - S R Chen
- Department of Interventional Radiology (S.R.C.), The MD Anderson Cancer Center, Houston, Texas
| | - J N Johnson
- From the Department of Neurosurgery (V.M.S., T.T.L., A.S., R.G., J.N.J., J.-K.B., P.K.)
| | - J-K Burkhardt
- From the Department of Neurosurgery (V.M.S., T.T.L., A.S., R.G., J.N.J., J.-K.B., P.K.)
| | - D E Collins
- Center for Comparative Medicine (D.E.C.) Baylor College of Medicine, Houston, Texas
| | - P Kan
- From the Department of Neurosurgery (V.M.S., T.T.L., A.S., R.G., J.N.J., J.-K.B., P.K.)
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Mild angioplasty with a stent retriever for acute atherothrombotic middle cerebral artery occlusion: A case report. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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42
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Rescue stenting versus medical care alone in refractory large vessel occlusions: a systematic review and meta-analysis. Neuroradiology 2020; 62:629-637. [PMID: 31927615 DOI: 10.1007/s00234-020-02360-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/02/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Mechanical thrombectomy (MT) failure is associated with very poor prognosis. Permanent intracranial stenting (PIS) may be useful in such refractory occlusions. However, this strategy requires an aggressive antithrombotic regimen that may be harmful in extended strokes. The aim of this study was to compare clinical outcomes between patients with refractory acute large vessel occlusions (LVOs) treated by PIS versus patients for whom the procedure was stopped without recanalization. METHODS We conducted a systematic review by searching for articles in PubMed, the Cochrane Library, and ClinicalTrials.gov from January 2015 to September 2019. Two reviewers independently selected studies comparing PIS after failed MT in addition to usual care versus usual care only. A comparative meta-analysis was performed using random-effects models to estimate odds ratios of favorable clinical outcome at 90 days, defined as a modified Rankin scale 0-2, mortality and symptomatic intracranial hemorrhage (SICH). RESULTS Four comparative studies were included for a total of 352 patients: 149 in the PIS group versus 203 in the control group. PIS was associated with significantly higher rates of 90-day favorable clinical outcome (odds ratio [OR], 2.87 [95% confidence interval (95% CI), 1.77-4.66]; p < 0.001; I2, 0%) and lower mortality (OR, 0.39 [0.16-0.93]; p = 0.03; I2, 43%), whereas SICH rates did not significantly differ (OR, 0.68 [0.37-1.27]; p = 0.23; I2, 0%). CONCLUSION From observational study results, attempting PIS after failed MT seems to improve clinical outcomes without increasing the risk of intracranial bleeding. Randomized trials are needed to confirm these results.
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