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Diana F, Abdalkader M, Behme D, Li W, Maurer CJ, Pop R, Hwang YH, Bartolini B, Da Ros V, Bracco S, Cirillo L, Marnat G, Katsanos AH, Kaesmacher J, Fischer U, Aguiar de Sousa D, Peschillo S, Zini A, Tomasello A, Ribo M, Nguyen TN, Romoli M. Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data. J Neurointerv Surg 2024; 16:243-247. [PMID: 37185107 DOI: 10.1136/jnis-2023-020204] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND The periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of antithrombotics following eCAS. METHODS We followed PRISMA guidelines and searched MEDLINE, Embase, and Scopus from January 1, 2004 to November 30, 2022 for studies evaluating eCAS in tandem occlusion. The primary endpoint was 90-day good functional outcome. Secondary outcomes were symptomatic intracerebral hemorrhage, in-stent thrombosis, delayed stent thrombosis, and successful recanalization. Meta-analysis of proportions and meta-analysis of odds ratios were implemented. RESULTS 34 studies with 1658 patients were included. We found that the use of no antiplatelets (noAPT), single antiplatelet (SAPT), dual antiplatelets (DAPT), or glycoprotein IIb/IIIa inhibitors (GPI) yielded similar rates of good functional outcomes, with a marginal benefit of GPI over SAPT (OR 1.88, 95% CI 1.05 to 3.35, Pheterogeneity=0.31). Sensitivity analysis and meta-regression excluded a significant impact of intravenous thrombolysis and Alberta Stroke Program Early CT Score (ASPECTS). We observed no increase in symptomatic intracerebral hemorrhage (sICH) with DAPT or GPI compared with noAPT or SAPT. We also found similar rates of delayed stent thrombosis across groups, with acute in-stent thrombosis showing marginal, non-significant benefits from GPI and DAPT over SAPT and noAPT. CONCLUSIONS In AIS due to tandem occlusion, the periprocedural antithrombotic regimen of eCAS seems to have a marginal effect on good functional outcome. Overall, high intensity antithrombotic therapy may provide a marginal benefit on good functional outcome and carotid stent patency without a significant increase in risk of sICH.
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Affiliation(s)
- Francesco Diana
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
| | | | - Daniel Behme
- Neuroradiology, University Hospital Magdeburg, Magdeburg, Sachsen-Anhalt, Germany
| | - Wei Li
- Neurology, Hainan Medical University, Haikou, Hainan, China
| | - Christoph Johannes Maurer
- Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Raoul Pop
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Yang-Ha Hwang
- Neurology and Radiology, Kyungpook National University Hospital, Daegu, Korea (the Republic of)
| | - Bruno Bartolini
- Diagnostic and Interventional Radiology, Interventional Neuroradiology Unit, CHUV - Lausanne University Hospital, Lausanne, Switzerland
| | - Valerio Da Ros
- Biomedicine and Prevention, Diagnostic Imaging Unit, Fondazione PTV Policlinico Tor Vergata, Roma, Italy
| | - Sandra Bracco
- Neurology and Human Movement Sciences, Interventional Neuroradiology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Luigi Cirillo
- Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Aristeidis H Katsanos
- Neurology Division, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada
| | - Johannes Kaesmacher
- Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Diana Aguiar de Sousa
- Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria/ CHULN, University of Lisbon, Lisboa, Portugal
| | - Simone Peschillo
- Endovascular Neurosurgery, Pia Fondazione Cardinale G Panico Hospital, Tricase, Italy
- UniCamillus International Medical University, Rome, Italy
| | - Andrea Zini
- Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Emilia-Romagna, Italy
| | - Alejandro Tomasello
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
| | - Marc Ribo
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
- Stroke Unit, Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Thanh N Nguyen
- Radiology, Boston Medical Center, Boston, Massachusetts, USA
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michele Romoli
- Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Emilia-Romagna, Italy
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Si J, Hao J, Zhang M, Liu C, Lin K, Liu W, Wang J, Zhang L. Mechanical thrombectomy via direct carotid artery approach for the treatment of acute anterior circulation large vessel occlusion. Heliyon 2023; 9:e18484. [PMID: 37534010 PMCID: PMC10392079 DOI: 10.1016/j.heliyon.2023.e18484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 08/04/2023] Open
Abstract
Background Mechanical thrombectomy (MT) has become an important treatment method for acute anterior circulation large vessel occlusion. The carotid artery approach is a fast and effective alternative when the transfemoral approach is difficult due to vascular variation. The present study reports on seven cases of acute anterior circulation stroke where direct carotid approach was used to obtain vascular access. Methods and materials Patients with acute anterior circulation large vessel occlusion treated via carotid artery access between January 2018 and January 2020 were retrospectively analyzed. Brain computed tomography (CT) and angiographic imaging results, indications for carotid artery approach and technical aspects of the method, modified thrombolysis in cerebral infarction (mTICI), procedure-related complications, and patient outcomes were evaluated. Results Seven patients were treated using a direct carotid artery approach. Among the seven cases, four patients were treated using percutaneous carotid artery puncture, and two patients were treated with emergency carotid artery incision and thrombectomy. The remaining case involved carotid artery puncture for MCA thrombectomy, followed by carotid artery incision for carotid artery thrombectomy. The carotid artery puncture point was exposed via surgical incision and sutured after MT. Modified Rankin Scale (MRS) scores 90 days after surgery showed good prognosis in three patients, poor prognosis in four patients. Conclusion This case series highlights the advantage of using a transcarotid approach to bypass anatomical barriers to achieve faster reperfusion when the femoral approach is not possible. The carotid artery puncture point was surgically exposed and sutured to reduce the incidence of postoperative complications.
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Affiliation(s)
| | | | | | | | | | | | | | - Liyong Zhang
- Corresponding author. Department of Neurosurgery, Liaocheng People's HospitalNO.45 Huashan Road, Liaocheng, 252000, Shandong, China
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Diana F, Romoli M, Toccaceli G, Rouchaud A, Mounayer C, Romano DG, Di Salle F, Missori P, Zini A, Aguiar de Sousa D, Peschillo S. Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis. J Neurointerv Surg 2023; 15:428-432. [PMID: 35428740 DOI: 10.1136/neurintsurg-2022-018683] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/24/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Emergent carotid artery stenting (eCAS) is performed during mechanical thrombectomy for acute ischemic stroke due to tandem occlusion. However, the optimal management strategy in this setting is still unclear. OBJECTIVE To carry out a systematic review and meta-analysis to investigate the safety and efficacy of eCAS in patients with tandem occlusion. METHODS Systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from January 1, 2004 to March 7, 2022 for studies evaluating eCAS and no-stenting approach in patients with stroke with tandem occlusion. Primary endpoint was the 90-day modified Rankin Scale score 0-2; secondary outcomes were (1) symptomatic intracerebral hemorrhage (sICH), (2) recurrent stroke, (3) successful recanalization (Thrombolysis in Cerebral Infarction score 2b-3), (4) embolization in new territories, and (5) restenosis rate. Meta-analysis was performed using the Mantel-Haenszel method and random-effects modeling. RESULTS Forty-six studies reached synthesis. eCAS was associated with higher good functional outcome compared with the no-stenting approach (OR=1.52, 95% CI 1.19 to 1.95), despite a significantly increased risk of sICH (OR=1.97, 95% CI 1.23 to 3.15), and higher successful recanalization rate (OR=1.91, 95% CI 1.29 to 2.85). Restenosis rate was lower in the eCAS group than in the no-stenting group (2% vs 9%, p=0.001). Recanalization rate was higher in retrograde than antegrade eCAS (OR=0.51, 95% CI 0.28 to 0.93). Intraprocedural antiplatelets during eCAS were associated with higher rate of good functional outcome (60% vs 46%, p=0.016) and lower rate of sICH (7% vs 11%; p=0.08) compared with glycoprotein IIb/IIIa inhibitors. CONCLUSIONS In observational studies, eCAS seems to be associated with higher good functional outcome than no-stenting in patients with acute ischemic stroke due to tandem occlusion, despite the higher risk of sICH. Dedicated trials are needed to confirm these results.
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Affiliation(s)
- Francesco Diana
- Neuroradiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Michele Romoli
- Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Giada Toccaceli
- Emergency Neurosurgery, Ospedale Civile 'Santo Spirito', Pescara, Italy
| | - Aymeric Rouchaud
- Interventional Neuroradiology, University Hospital Centre of Limoges, Limoges, France
- BioEMXLim, University of Limoges Medical Faculty, Limoges, France
| | - Charbel Mounayer
- Interventional Neuroradiology, University Hospital Centre of Limoges, Limoges, France
- BioEMXLim, University of Limoges Medical Faculty, Limoges, France
| | | | - Francesco Di Salle
- Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Fisciano, Italy
| | - Paolo Missori
- Human Neurosciences, Neurosurgery, University of Rome La Sapienza, Rome, Italy
| | - Andrea Zini
- Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - Diana Aguiar de Sousa
- Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria/CHULN, University of Lisbon, Santa Maria, Portugal
| | - Simone Peschillo
- Surgical Medical Sciences and Advanced Technologies "G.F. Ingrassia" - Endovascular Neurosurgery, University of Catania, Catania, Italy
- Neurosurgery, Pia Fondazione Cardinale G Panico Hospital, Tricase, Italy
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Wu W, Cheng Y, Li Y, Jiang J, Chen F, Cai D, Zhang L. Assessment of Primary Collateral Grades Based on the Integrity of Willis' Circle: Predicting the Prognosis of Acute Intracranial Internal Carotid Artery Occlusion Before Thrombectomy. World Neurosurg 2022; 167:e1138-e1146. [PMID: 36087913 DOI: 10.1016/j.wneu.2022.08.137] [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: 06/05/2022] [Revised: 08/28/2022] [Accepted: 08/30/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Endovascular mechanical thrombectomy (EVMT) has shown significant efficacy in improving neurological functions in patients with intracranial internal carotid artery occlusion (IICAO), but its clinical outcomes are variable. We examined the relationship between favorable clinical outcomes after EVMT in IICAO and a set of predictors. METHODS In this retrospective study, 189 patients with IICAO treated by EVMT at 3 centers from November 2015 to December 2020 were included and analyzed. Non-contrast computed tomography and computed tomography angiography were evaluated on admission. The morphology of IICAO was categorized into Ia, Ib, L, or T types, depending on the involvement of the posterior communicating artery origin, proximal anterior cerebral artery, and middle cerebral artery. The Willis' circle was categorized as integrated or compromised Willis' circle. In combination with the involvement of the IICAO and the integrity of Willis' circle, we used the primary collateral grade (PCG) to describe the presence of functional Willisian collaterals. Baseline data including demographics, characteristics, vascular risk factors, and initial National Institutes of Health Stroke Scale scores were collected. Hemorrhagic transformation was evaluated using the 24-hour non-contrast computed tomography after EVMT. Favorable outcomes based on modified Rankin scale, were defined as 0-2 at 90 days. RESULTS A total of 189 patients were included (median age, 69 years; 126 male [66.7%]). 104 patients [55.0%] showed reperfusion after EVMT, but 72 patients [38.1%] achieved favorable outcomes at 90 days. The mortality rate of type Ib was significantly higher than that with type Ia (χ2 = 14.21, P = 0.001). The outcome with different structure of Willis' circle was not statistically different between the 2 groups. A multivariate logistic regression analysis showed that IICAO T-type (odds ratio, 0.028 [95% confidence interval: 0.323-3.829], P = 0.042) and PCG 2 (odds ratio 9.427[95% confidence interval:1.863-47.698], P = 0.007) were predictors of favorable outcomes. CONCLUSIONS Evaluation of PCG by determining the type of IICAO and the integrity of Willis' circle may serve as a valuable indicator for the prognosis and as an essential reference for screening patients before EVMT.
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Affiliation(s)
- Wenjuan Wu
- Department of Radiology, Wuxi Second People's Hospital, Wuxi, China
| | - Yue Cheng
- Department of Radiology, Wuxi Second People's Hospital, Wuxi, China
| | - Yuehua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jingxuan Jiang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Fangming Chen
- Department of Radiology, Wuxi Second People's Hospital, Wuxi, China
| | - Dongmei Cai
- Department of Radiology, Wuxi Xishan People's Hospital, Wuxi, China
| | - Lei Zhang
- Department of Radiology, Wuxi Second People's Hospital, Wuxi, China.
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Veunac L, Saliou G, Knebel JF, Bartolini B, Puccinelli F, Michel P, Hajdu SD. Revascularization of carotid artery occlusion using stenting versus non stenting in endovascular management of tandem occlusion stroke. J Clin Neurosci 2022; 98:15-20. [DOI: 10.1016/j.jocn.2022.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 12/19/2021] [Accepted: 01/25/2022] [Indexed: 10/19/2022]
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Surgical therapy for chronic internal carotid artery occlusion: a systematic review and meta-analysis. Updates Surg 2021; 73:2065-2078. [PMID: 33864610 DOI: 10.1007/s13304-021-01055-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
Chronic internal carotid artery occlusion (CICAO) significantly increases the risk of recurrent stroke. Given unfavorable outcomes, revascularization procedures are not generally recommended for CICAO. In the last several years, loads of studies reported successful surgical revascularization for CICAO with promising success rate and favorable short-term outcomes. Meanwhile, due to the lack of high-quality evidence, the safety and efficacy of revascularization procedures remain debatable. This systematic review aims to scrutinize current evidence for the applicability of revascularization for CICAO. We also investigated potential predictors of postoperative prognosis. We searched clinical studies on surgical treatment of CICAO on the Medline, Cochrane library, and Embase databases, published from Jan 1990 to Jan 2021. Surgical operation was restricted to bypass surgery, endarterectomy, endovascular therapy, and hybrid surgery. Controlled clinical studies were included for clinical outcomes. Large-sample single-arm studies were supplemented to assess complications and success rate. Co-primary endpoints were technical success rate and neurological function; secondary endpoints were recurrent stroke/cerebrovascular events, complications, and deaths within follow-up. This systematic review has been registered in PROSPERO (CRD42020181250). One RCT and 5 cohort studies with a total of 465 patients were included in this review. Seven single-arm studies were supplemented for assessing success rate and complications. Bypass surgery presented the highest graft patency of 96% and a low incidence of complications, but no benefits on neurological function, recurrent stroke, or deaths. Endovascular therapy (carotid stenting) was characterized by a relatively lower technical success rate, significant neurological function recovery, and nonsignificant reduction of cerebrovascular events and deaths. Hybrid surgery was considered as a potential treatment for CICAO because of a high technical success rate and significant neurological improvement. Endarterectomy is only suitable for short-segment occlusion. Prospective clinical trials should focus on carotid stenting and hybrid surgery for their significant capacity of improving neurologic function and potential capacity of reducing deaths and cerebrovascular events.
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Delvoye F, Maier B, Escalard S, Labreuche J, Thion LA, Aknouche S, Hebert S, Redjem H, Smajda S, Ciccio G, Allard J, Sabben C, Obadia M, Maertens de Noordhout A, Olivot JM, Blanc R, Piotin M, Desilles JP, Mazighi M. Antiplatelet Therapy During Emergent Extracranial Internal Carotid Artery Stenting: Comparison of Three Intravenous Antiplatelet Perioperative Strategies. J Stroke Cerebrovasc Dis 2020; 30:105521. [PMID: 33310073 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105521] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/25/2020] [Accepted: 11/29/2020] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Guidelines for antiplatelet therapy administration, during emergent stenting for extra-cranial internal carotid artery (EC-ICA) occlusion in the setting of acute ischemic stroke (AIS) are lacking. Different antiplatelet regimen are used in association to endovascular therapy (EVT) for the treatment of EC-ICA lesions. We aimed to compare the clinical and radiological effects of three intravenous antiplatelet agents used during emergent EC-ICA stenting. MATERIAL AND METHODS Clinical data were collected from January 2015 to December 2019 in a monocentric prospective registry of AIS patients treated by EVT. All patients who underwent emergent EC-ICA stenting were sorted regarding the intravenous antiplatelet agent used during the procedure. RESULTS Among 218 patients treated by EVT for an EC-ICA occlusion of the anterior circulation during the study period, 70 underwent an emergent stenting of the EC-ICA. 60 were included in the present study, 9 received intravenous (IV) Cangrelor, 8 IV abciximab and 43 Aspirin. The rate of favorable neurological outcome, defined as modified Rankin Scale (mRS) ≤ 2 at three months were better in the Cangrelor and Aspirin groups (66,7% and 58,1%, respectively) than in the Abciximab group (37,5%), as well as, the rate of any intracranial ICH (22,2% and 37,2% vs 62,5%). The rate of acute stent reocclusion was similar between groups. CONCLUSION When used as a rescue treatment during emergent stenting of EC-ICA, Cangrelor and Aspirin present a better safety profile than Abciximab, with less intracranial hemorrhages and a higher rate of good clinical outcome. Additional studies are needed to confirm these findings.
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Affiliation(s)
- François Delvoye
- Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France; Université de Liège, Belgique.
| | - Benjamin Maier
- Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France; Laboratory of Vascular Translational Science, U1148 INSERM, Université de Paris, 46 rue Henri Huchard 75018 Paris, France.
| | - Simon Escalard
- Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France.
| | - Julien Labreuche
- University of Lille, CHU Lille, EA 2694 - Santé Publique: Épidémiologie et Qualité des Soins, F-59000 Lille, France.
| | - Laurie-Anne Thion
- Anesthesiology Department, Rothschild Foundation Hospital, Paris, France.
| | - Soufiane Aknouche
- Clinical Research Unit, Rothschild Foundation Hospital, Paris, France.
| | - Solène Hebert
- Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France.
| | - Hocine Redjem
- Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France.
| | - Stanislas Smajda
- Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France.
| | - Gabriele Ciccio
- Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France.
| | - Julien Allard
- Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France.
| | - Candice Sabben
- Neurology Department, Rothschild Foundation Hospital, Paris, France.
| | - Michael Obadia
- Neurology Department, Rothschild Foundation Hospital, Paris, France.
| | | | | | - Raphael Blanc
- Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France; Laboratory of Vascular Translational Science, U1148 INSERM, Université de Paris, 46 rue Henri Huchard 75018 Paris, France.
| | - Michel Piotin
- Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France; Laboratory of Vascular Translational Science, U1148 INSERM, Université de Paris, 46 rue Henri Huchard 75018 Paris, France.
| | - Jean-Philippe Desilles
- Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France; Laboratory of Vascular Translational Science, U1148 INSERM, Université de Paris, 46 rue Henri Huchard 75018 Paris, France; Université de Paris, France.
| | - Mikael Mazighi
- Interventional Neuroradiology Department, Rothschild Foundation Hospital, Paris, France; Laboratory of Vascular Translational Science, U1148 INSERM, Université de Paris, 46 rue Henri Huchard 75018 Paris, France; Université de Paris, France; FHU Neurovasc, France.
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Cervo A, Ferrari F, Barchetti G, Quilici L, Piano M, Boccardi E, Pero G. Use of Cangrelor in Cervical and Intracranial Stenting for the Treatment of Acute Ischemic Stroke: A "Real Life" Single-Center Experience. AJNR Am J Neuroradiol 2020; 41:2094-2099. [PMID: 33033047 DOI: 10.3174/ajnr.a6785] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/07/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE In cases of large-vessel-occlusion strokes due to an underlying tandem internal carotid artery occlusion or intracranial atherosclerotic disease, concomitant stent placement may be needed. Immediate platelet inhibition is necessary, but to date, a standardized approach for antiplatelet inhibition in acute settings is still missing. Here we report our single-center experience about the safety and efficacy of periprocedural administration of cangrelor in patients with acute ischemic stroke due to intracranial or cervical artery occlusion undergoing stent placement. MATERIALS AND METHODS We retrospectively evaluated all cases of acute ischemic stroke that needed acute stent implantation and were treated with periprocedural administration of cangrelor between January 2019 and April 2020 at our institution. All patients who needed either extracranial or intracranial artery stent placement (in either the anterior or posterior circulation) were included. RESULTS We evaluated 38 patients in whom cangrelor was administered IV periprocedurally. Their mean age was 64 years (range, 26-85 years), with 25/38 male subjects and 13/38 female patients. In 26 patients (68.4%), a tandem occlusion was present and was treated with carotid artery stent placement, while 12 patients (31.6%) required an intracranial stent implantation. In 4 subjects (10.5%), an intracerebral hemorrhage occurred after the procedure. All patients in the series were alive 1 week after the procedure. CONCLUSIONS Although larger, multicentric randomized studies are strongly warranted, our results support the hypothesis of a possible role of cangrelor as a valuable therapeutic option in the management of platelet inhibition in acute ischemic stroke procedures after intra- or extracranial stent placement.
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Affiliation(s)
- A Cervo
- From the Department of Neuroradiology (A.C., F.F., L.Q., M.P., E.B., G.P.), Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - F Ferrari
- From the Department of Neuroradiology (A.C., F.F., L.Q., M.P., E.B., G.P.), Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Biology and Biotecnology (F.F.), University of Pavia, Pavia, Italy
| | - G Barchetti
- Department of Neuroradiology (G.B.), Sapienza University, Rome, Italy
| | - L Quilici
- From the Department of Neuroradiology (A.C., F.F., L.Q., M.P., E.B., G.P.), Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - M Piano
- From the Department of Neuroradiology (A.C., F.F., L.Q., M.P., E.B., G.P.), Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - E Boccardi
- From the Department of Neuroradiology (A.C., F.F., L.Q., M.P., E.B., G.P.), Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - G Pero
- From the Department of Neuroradiology (A.C., F.F., L.Q., M.P., E.B., G.P.), Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Amuluru K, Sahlein D, Al-Mufti F, Payner T, Kulwin C, DeNardo A, Scott J. The Dilator-Dotter Technique: A Modified Method of Rapid Internal Carotid Artery Revascularization in Acute Ischemic Stroke. AJNR Am J Neuroradiol 2020; 41:1863-1868. [PMID: 32883663 DOI: 10.3174/ajnr.a6733] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/15/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Acute ischemic stroke due to tandem occlusive lesions involves high-grade ICA stenosis or occlusion with a distal intracranial occlusion. Several approaches and devices exist in the treatment of tandem occlusions; however, a consensus on the optimal technique does not exist. The Dotter technique is a method of catheter-based angioplasty to recanalize cervical ICA occlusions. We present a modified dilator-Dotter technique, which involves a polyethylene, tapered inner dilator to initially cross the occlusion, followed by guide catheterization and subsequent intracranial thrombectomy. The purpose of this study was to examine the safety and efficacy of this dilator-Dotter technique. MATERIALS AND METHODS We performed a retrospective review of patients with acute stroke due to tandem ICA intracranial occlusions, treated with our dilator-Dotter technique and thrombectomy between June 2018 and December 2019. We examined clinical, radiographic, and procedural data, as well as complications and outcomes. RESULTS Thirty-two patients were included. In 100% of cases, the dilator-Dotter technique resulted in ICA recanalization allowing successful thrombectomy. TICI 2b-3 revascularization was obtained in 31 patients (96%), within an average time of 25 minutes. The average preprocedural ICA stenosis was 98%, including 23 patients (72%) with complete occlusion. Following the dilator-Dotter technique, average ICA stenosis improved to 59%. There were no instances of death, iatrogenic dissection, emboli to new territory, or symptomatic intracranial hemorrhage. CONCLUSIONS The dilator-Dotter technique may be a safe and effective modification of the traditional Dotter technique in allowing rapid ICA recanalization in cases of acute ischemic stroke due to tandem occlusions.
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Affiliation(s)
- K Amuluru
- From the Division of Neurointerventional Radiology (K.A., D.S., A.D., J.S.) .,Division of Neurointerventional Radiology (K.A., D.S., A.D., J.S.)
| | - D Sahlein
- From the Division of Neurointerventional Radiology (K.A., D.S., A.D., J.S.).,Division of Neurointerventional Radiology (K.A., D.S., A.D., J.S.)
| | - F Al-Mufti
- Department of Neuroendovascular Surgery and Neurocritical Care (F.A.-M.), Westchester Medical Center at New York Medical College, Valhalla, New York
| | - T Payner
- Division of Cerebrovascular Neurosurgery (T.P., C.K.), Goodman Campbell Brain and Spine, Indianapolis, Indiana.,Division of Cerebrovascular Neurosurgery (T.P., C.K.), Ascension St. Vincent's Medical Center, Indianapolis, Indiana
| | - C Kulwin
- Division of Cerebrovascular Neurosurgery (T.P., C.K.), Goodman Campbell Brain and Spine, Indianapolis, Indiana.,Division of Cerebrovascular Neurosurgery (T.P., C.K.), Ascension St. Vincent's Medical Center, Indianapolis, Indiana
| | - A DeNardo
- From the Division of Neurointerventional Radiology (K.A., D.S., A.D., J.S.).,Division of Neurointerventional Radiology (K.A., D.S., A.D., J.S.)
| | - J Scott
- From the Division of Neurointerventional Radiology (K.A., D.S., A.D., J.S.).,Division of Neurointerventional Radiology (K.A., D.S., A.D., J.S.)
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10
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Zhang M, Hao JH, Lin K, Cui QK, Zhang LY. Combined surgical and interventional treatment of tandem carotid artery and middle cerebral artery embolus: A case report. World J Clin Cases 2020; 8:630-637. [PMID: 32110676 PMCID: PMC7031835 DOI: 10.12998/wjcc.v8.i3.630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 11/19/2019] [Accepted: 12/06/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The 2018 American Heart Association/American Stroke Association guidelines for early management of acute ischemic stroke recommend the use of retrievable stents for mechanical thrombectomy in patients with acute internal carotid artery or middle cerebral artery M1 occlusion that can be treated within 6 h from onset. For cases of carotid artery with ipsilateral middle cerebral artery tandem embolization, the operation is more complicated and challenging. We here report a case of a tandem embolism, and the anatomy of the aortic arch was complex. Direct carotid artery incision and thrombectomy can not only prevent the escape of the carotid embolus but also save time during establishment of the thrombectomy access.
CASE SUMMARY The patient was a 70-year-old man. He was admitted to hospital due to sudden inability to speak and inability to move his right limb for 3 h. Imaging confirmed a diagnosis of a tandem embolism in the left carotid artery with left M1 occlusion. Carotid artery incision thrombectomy combined with stent thrombectomy was performed. The operation was successful, and 24 h later the patient was conscious and mentally competent but had motor aphasia. His bilateral limb muscle strength level was 5, and his neurologic severity scores score was 2.
CONCLUSION Carotid artery incision thrombectomy combined with stenting for carotid artery plus cerebral artery tandem embolization is clinically feasible. For patients with a complicated aortic arch and an extremely tortuous carotid artery, carotid artery incision can be chosen to establish the interventional path.
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Affiliation(s)
- Meng Zhang
- Department of Neurosurgery, Liaocheng Brain Hospital, Liaocheng 252000, Shandong Province, China
| | - Ji-Heng Hao
- Department of Neurosurgery, Liaocheng Brain Hospital, Liaocheng 252000, Shandong Province, China
| | - Kai Lin
- Department of Neurosurgery, Liaocheng Brain Hospital, Liaocheng 252000, Shandong Province, China
| | - Qing-Ke Cui
- Department of Neurosurgery, Liaocheng Brain Hospital, Liaocheng 252000, Shandong Province, China
| | - Li-Yong Zhang
- Department of Neurosurgery, Liaocheng Brain Hospital, Liaocheng 252000, Shandong Province, China
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11
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Sun C, Li X, Zhao Z, Chen X, Huang C, Li X, Shan Y, Zou Y, Liu Y, Ibrahim M, Nyame L, Song B, Wang F, Zheng X, Hu J, Zhao Z, Zhou J, Zou J. Safety and Efficacy of Tirofiban Combined With Mechanical Thrombectomy Depend on Ischemic Stroke Etiology. Front Neurol 2019; 10:1100. [PMID: 31736848 PMCID: PMC6828979 DOI: 10.3389/fneur.2019.01100] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/01/2019] [Indexed: 01/01/2023] Open
Abstract
Background and Purpose: The clinical use of tirofiban for patients with acute ischemic stroke (AIS) who underwent mechanical thrombectomy (MT) remains controversial. We aimed to evaluate the safety and efficacy of tirofiban combined with MT in AIS patients. Methods: Patients with AIS who underwent MT from January 2014 to December 2018 were enrolled in three stroke units in China. Subgroup analyses were performed based on stroke etiology which was classified according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria. Safety outcomes were in-hospital intracerebral hemorrhage (ICH), symptomatic intracerebral hemorrhage (sICH) and mortality at 3-month. Efficacy outcomes were favorable functional outcome and functional independence at 3-month and neurological improvement at 24 h, 3 d and discharge. Results: In patients with large artery atherosclerosis (LAA) stroke, multivariate analyses revealed that tirofiban significantly decreased the odds of in-hospital ICH (adjusted OR = 0.382, 95% CI 0.180–0.809) and tended to increase the odds of favorable functional outcome at 3-month (adjusted OR = 3.050, 95% CI 0.969–9.598). By contrast, in patients with cardioembolism (CE) stroke, tirofiban was not associated with higher odds of favorable functional outcome at 3-month (adjusted OR = 0.719, 95% CI 0.107–4.807), but significantly decreased the odds of neurological improvement at 24 h and 3d (adjusted OR = 0.185, 95% CI 0.047–0.726; adjusted OR = 0.268, 95% CI 0.087–0.825). Conclusions: Tirofiban combined with MT appears to be safe and effective in LAA patients, but has no beneficial effect on CE patients.
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Affiliation(s)
- Chao Sun
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiang Li
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zheng Zhao
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiangliang Chen
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chaoping Huang
- Department of Neurology, Changsha Central Hospital, Changsha, China
| | - Xuemei Li
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Yajie Shan
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Yang Zou
- Faculty of Science, Melbourne University, Melbourne, VIC, Australia
| | - Yukai Liu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Mako Ibrahim
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Linda Nyame
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Baili Song
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Fusang Wang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaohan Zheng
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jue Hu
- Department of Neurology, Changsha Central Hospital, Changsha, China
| | - Zhihong Zhao
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jianjun Zou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
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Amuluru K, Al-Mufti F, Romero CE. Acute Ischemic Stroke due to Common Carotid Ostial Disease with Tandem Intracranial Occlusions Treated with Thrombectomy and Staged Retrograde Stenting. INTERVENTIONAL NEUROLOGY 2018; 7:445-451. [PMID: 30410523 DOI: 10.1159/000490584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 06/02/2018] [Indexed: 11/19/2022]
Abstract
Background Acute ischemic stroke due to tandem occlusive lesions of the anterior circulation involves an intracranial large vessel occlusion as well as a concurrent occlusion or high-grade stenosis of the proximal carotid system. The vast majority of proximal lesions in tandem occlusive cases involve the extracranial internal carotid artery, although the lesion can theoretically exist anywhere along the carotid artery pathway, including the common carotid ostium. Summary To the best of our knowledge, only 1 report describes common carotid artery ostial lesions in the setting of acute ischemic stroke due to tandem occlusions, in which the authors describe an anterograde treatment paradigm. We present the first 2 cases of acute ischemic stroke secondary to common carotid ostial disease with tandem intracranial occlusion, treated with intracranial thrombectomy followed by subsequent staged balloon-mounted stenting of the common carotid ostium. We review the pathophysiology of tandem occlusions, the controversy surrounding treatment techniques, and various approaches used in the treatment of ostial occlusive lesions. Key Message In certain situations where acute carotid stenting is not safe or technically possible, immediate intracranial thrombectomy with a subsequent staged balloon-mounted stenting of the ostial lesion may be a reasonable and safe option.
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Affiliation(s)
- Krishna Amuluru
- Department of Interventional Neuroradiology, University of Pittsburgh Medical Center Hamot, Erie, Pennsylvania, USA
| | - Fawaz Al-Mufti
- Neuroendovascular Surgery and Neurocritical Care, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Charles E Romero
- Department of Interventional Neuroradiology, University of Pittsburgh Medical Center Hamot, Erie, Pennsylvania, USA
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Wilson MP, Murad MH, Krings T, Pereira VM, O’Kelly C, Rempel J, Hilditch CA, Brinjikji W. Management of tandem occlusions in acute ischemic stroke – intracranial versus extracranial first and extracranial stenting versus angioplasty alone: a systematic review and meta-analysis. J Neurointerv Surg 2018. [DOI: 10.1136/neurintsurg-2017-013707] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BackgroundOptimal technical approaches of large-vessel anterior circulation acute ischemic strokes with concomitant extracranial internal carotid artery tandem occlusions is controversial.PurposeThis systematic review and meta-analysis evaluates: the overall outcomes of patients with tandem occlusions treated with second-generation mechanical thrombectomy devices; differences in outcomes of extracranial versus intracranial first approaches; and differences in outcomes of extracranial stenting at time of procedure versus angioplasty alone.MethodsMEDLINE, EMBASE, and the Web of Science was searched through September 2017 for studies evaluating patients presenting with acute tandem occlusions of the extracranial ICA and intracranial ICA, and/or proximal MCA treated with second-generation mechanical thrombectomy devices. Outcomes were pooled across studies using the random-effects model and expressed as cumulative incidence (event rate) and 95% CI.ResultsThirty-three studies were included in analysis. Overall mRS≤0–2 at 90 days was 47% (95% CI 42% to 51%). No statistical difference was seen in 90-day mRS≤0–2 for patients treated with extracranial versus intracranial first approaches, 53% (95% CI 44% to 61%) vs 49% (95% CI 44% to 57%) (P=0.58). No statistical difference was seen in 90-day mRS≤0–2 for patients treated with extracranial stenting versus angioplasty alone, 49% (95% CI 42% to 56%) vs 49% (95% CI 33% to 65%) (P=0.39). No other statistical differences in outcome or safety were identified.ConclusionsNearly half of all tandem occlusion patients treated with mechanical thrombectomy have good neurological outcomes. No statistical differences in outcome are identified between extracranial first versus intracranial first approaches, nor extracranial stenting versus angioplasty alone.
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Amuluru K, Romero CE, Pyle L, El-Ghanem M, Al-Mufti F. Mechanical Thrombectomy of Acute Middle Cerebral Artery Occlusion Using Trans-Anterior Communicating Artery Approach. World Neurosurg 2018; 112:46-52. [PMID: 29339323 DOI: 10.1016/j.wneu.2018.01.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/03/2018] [Accepted: 01/05/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND A cross-circulation technique involves gaining access to a cerebral vessel through a patent anterior or posterior communicating artery. This technique may be used in patients with emergent large-vessel occlusions and an unfavorable direct route to the occlusion. While few previous reports have demonstrated a successful cross-circulation technique for treatment of emergent large-vessel occlusions, we present the first 2 cases of transanterior communicating artery stent retriever thrombectomy. CASE DESCRIPTION Case #1: A 64-year-old female presented with acute right middle cerebral artery (MCA) occlusion. She demonstrated a "triple-tandem" brachiocephalic-internal carotid artery-middle cerebral artery occlusion, thus precluding direct access to the right MCA. Successful stent retriever mechanical thrombectomy was performed across the anterior communicating artery, using a left internal carotid artery approach. Case #2: A 70-year old female presented with acute occlusion of the left MCA and tandem occlusion of the cervical left internal carotid artery. Multiple attempts to catheterize the left common carotid artery were unsuccessful. She underwent successful stent retriever mechanical thrombectomy across a patent anterior communicating artery, using a right internal carotid artery approach. CONCLUSIONS Timely recanalization of an occluded artery plays a critical role in the prognosis of patients with acute ischemic stroke. Successful stent retriever mechanical thrombectomy of an occluded MCA is possible using a transanterior communicating artery approach in patients without a direct access route to the occluded intracranial vessel. We review the pathophysiology of tandem lesions, access routes to intracranial occlusions, and the literature on cross-circulation techniques to treat emergent large-vessel occlusions.
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Affiliation(s)
- Krishna Amuluru
- Department of Interventional Neuroradiology, University of Pittsburgh Medical Center-Hamot, Erie, Pennsylvania, USA.
| | - Charles E Romero
- Department of Interventional Neuroradiology, University of Pittsburgh Medical Center-Hamot, Erie, Pennsylvania, USA
| | - Logan Pyle
- Department of Interventional Neuroradiology, University of Pittsburgh Medical Center-Hamot, Erie, Pennsylvania, USA
| | - Mohammad El-Ghanem
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, New Jersey, USA
| | - Fawaz Al-Mufti
- Neurology-Division of Neuroendovascular Surgery and Neurocritical Care, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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