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Yue C, Deng W, Liu J, Luo X, Miao J, Liu J, Zheng B, Du J, Zhang Y, Yang S, Zi W, Li F. Endovascular treatment in patients with coma that developed secondary to acute basilar artery occlusion. J Neurosurg 2022; 137:1491-1500. [PMID: 35303706 DOI: 10.3171/2022.1.jns212967] [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: 12/29/2021] [Accepted: 01/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aimed to evaluate the efficacy of endovascular treatment (EVT) in patients with secondary coma following acute basilar artery occlusion (comatose patients) and to identify the impact of the Glasgow Coma Scale (GCS) score on medical decisions. METHODS Patients from the Endovascular Treatment for Acute Basilar Artery Occlusion study were divided into comatose and noncomatose cohorts. The primary outcome was favorable functional independence (modified Rankin Scale [mRS] scores 0-3). The safety outcome was 90-day mortality. Subgroup analysis was performed to identify populations best suited for EVT. Multivariate logistic regression was used to identify independent predictive factors of clinical outcomes. RESULTS Comatose patients who underwent EVT had more favorable functional outcomes and lower mortality compared with those who underwent standard medical treatment (functional outcomes: 15.98% vs 4.17%; mortality: 62.72% vs 82.29%). Moreover, EVT was associated with better outcomes in the cohort with GCS scores of 6-8 (mRS scores 0-3, 25.33% and mortality, 41.33%) than in the cohort with GCS scores of 3-5. Multivariate analysis indicated that EVT was an independent factor for favorable functional outcomes (adjusted OR 8.921, 95% CI 2.330-34.158) and mortality (adjusted OR 0.189, 95% CI 0.092-0.411) in comatose patients. The initial GCS score was an independent factor for favorable functional outcomes (adjusted OR 1.402, 95% CI 1.115-1.763) and mortality (adjusted OR 0.613, 95% CI 0.499-0.752) in comatose patients with EVT. CONCLUSIONS EVT significantly improved the prognosis of comatose patients, and patients with GCS scores of 6-8 were found to benefit more from EVT than those with GCS scores of 3-5. The initial GCS score was an independent predictive factor for prognosis in comatose patients.
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Affiliation(s)
- Chengsong Yue
- 1Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wei Deng
- 2Department of Neurology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | - Juan Liu
- 1Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Xiaojun Luo
- 3Department of Cerebrovascular Diseases, Guangyuan Central Hospital, Guangyuan, China
| | - Jian Miao
- 4Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang, China
| | - Jincheng Liu
- 5Department of Neurology, The First People's Hospital of Xiangyang, Hubei Medical University, Xiangyang, China
| | - Bo Zheng
- 6Department of Neurology, Ya'an People's Hospital, Ya'an, China
| | - Jie Du
- 7Department of Neurology, Kaizhou District People's Hospital, Chongqing, China
| | - Yuxian Zhang
- 8Department of Neurology, Danzhai County People's Hospital, Danzhai, China; and
| | - Shunyu Yang
- 9Department of Neurology, The First People's Hospital of Yunnan Province, Kunming, China
| | - Wenjie Zi
- 1Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Fengli Li
- 1Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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Wilseck ZM, Chaudhary N, Gemmete JJ. Commentary: Neuroendovascular Management of Acute Ischemic Basilar Strokes: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E348-E349. [PMID: 34245159 DOI: 10.1093/ons/opab251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/02/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Zachary M Wilseck
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Otorhinolaryngology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph J Gemmete
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Otorhinolaryngology, University of Michigan, Ann Arbor, Michigan, USA
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Ritvonen J, Sairanen T, Silvennoinen H, Virtanen P, Salonen O, Lindsberg PJ, Strbian D. Comatose With Basilar Artery Occlusion: Still Odds of Favorable Outcome With Recanalization Therapy. Front Neurol 2021; 12:665317. [PMID: 34017306 PMCID: PMC8130899 DOI: 10.3389/fneur.2021.665317] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/30/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Around 30–60% of patients with basilar artery occlusion (BAO) present with coma, which is often considered as a hallmark of poor prognosis. Aim: To examine factors that will help predict outcomes in patients with BAO comatose on admission. Methods: A total of 312 patients with angiography-proven BAO were analyzed. Comas were assessed as Glasgow Coma Scale (GCS) of ≤8 or impaired level of consciousness ascertained in the medical records. Outcomes were evaluated with the modified Rankin Scale (mRS) over a phone call at 3 months. In our study, 53 patients were excluded due to inadequate data on the level of consciousness. Results: In total, 103/259 (39.8%) of BAO patients were comatose on admission. Factors associated with acute coma were higher age, coronary artery disease, convulsions, extent of early ischemia by posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) < 8, absence of patent posterior collateral vasculature, and occlusion over multiple segments of BA. A total of 21/103 (20.4%) of comatose patients had a favorable outcome (mRS 0–3), and 12/103 (11.7%) had a good outcome (mRS 0–2). Factors associated with a favorable outcome in comatose BAO patients were younger age (p = 0.010), less extensive baseline ischemia (p = 0.027), recanalization (p = 0.013), and avoiding symptomatic intracranial hemorrhage (sICH) (p = 0.038). Factors associated with the poorest outcome or death (mRS 5–6) were older age (p = 0.001), diabetes (p = 0.022), atrial fibrillation (p = 0.016), lower median GCS [4 (IQR 3.6) vs. 6 (5–8); p = 0.006], pc-ASPECTS < 8 (p = 0.003), unsuccessful recanalization (p = 0.006), and sICH (p = 0.010). Futile recanalization (mRS 4–6) was significantly more common in comatose patients (49.4 vs. 18.5%, p < 0.001). Conclusions: One in five BAO patients with acute coma had a favorable outcome. Older patients with cardiovascular comorbidities and already existing ischemic lesions before reperfusion therapies tended to have a poor prognosis, especially if no recanalization is achieved and sICH occurred.
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Affiliation(s)
- Juhani Ritvonen
- Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Tiina Sairanen
- Clinical Neurosciences, University of Helsinki, Helsinki, Finland.,Neurological Research Unit, Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
| | - Heli Silvennoinen
- Helsinki Medical Imaging Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Pekka Virtanen
- Helsinki Medical Imaging Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Oili Salonen
- Helsinki Medical Imaging Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Perttu J Lindsberg
- Clinical Neurosciences, University of Helsinki, Helsinki, Finland.,Neurological Research Unit, Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
| | - Daniel Strbian
- Clinical Neurosciences, University of Helsinki, Helsinki, Finland.,Neurological Research Unit, Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
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Chang JY, Jung S, Jung C, Bae HJ, Kwon O, Han MK. Dominant vertebral artery status and functional outcome after endovascular therapy of symptomatic basilar artery occlusion. J Neuroradiol 2017; 44:151-157. [PMID: 28131432 DOI: 10.1016/j.neurad.2016.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 10/11/2016] [Accepted: 12/13/2016] [Indexed: 10/20/2022]
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5
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Levy E, Boulos A, Bendok B, Horowitz M, Kim S, Qureshi A, Guterman L, Hopkins L. Intracranial Stenting for Cerebrovascular Pathology. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/197140090301600118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
After reading this article, the participant should be able to: Describe the use of stent-assisted angioplasty for intracranial atherosclerotic disease. Recall the present status of stent-assisted managment of intracranial aneurysms. Describe the role of stenting and its technical aspects in the treatment of arteriovenous fistulae and acute stroke.
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Affiliation(s)
- E.I. Levy
- Dr. Levy is President, Department of Neurosurgery, University of Pittsburgh Medical Center-Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA 15213
| | - A.S. Boulos
- Dr. Boulos is Assistant Instructor of Clinical Neurosurgery
| | - B.R. Bendok
- Dr. Bendok is Assistant Professor of Neurosurgery
| | - M.B. Horowitz
- Dr. Horowitz is Associate Professor of Neurosurgery and Radiology, Departments of Neurological Surgery and Radiology, University of Pittsburgh Medical Center-Presbyterian University Hospital, 200 Lothrop Street, Pittsburgh PA 15213
| | - S.H. Kim
- Dr. Kim is Assistant Professor of Neurosurgery
| | - A.I. Qureshi
- Dr. Qureshi is Assistant Professor of Neurosurgery and Professor of Neurology
| | | | - L.N. Hopkins
- Dr. Hopkins is Director, Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Department of Neurosurgery, 3 Gates Circle, Buffalo NY 14209-1194
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Asadi H, Williams D, Thornton J. Changing Management of Acute Ischaemic Stroke: the New Treatments and Emerging Role of Endovascular Therapy. Curr Treat Options Neurol 2016; 18:20. [PMID: 27017832 DOI: 10.1007/s11940-016-0403-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OPINION STATEMENT Urgent reperfusion of the ischaemic brain is the aim of stroke treatment, and the last two decades have seen a rapid advancement in the medical and endovascular treatment of acute ischaemic stroke. Intravenous tissue plasminogen activator (tPA) was first introduced as a safe and effective thrombolytic agent followed by the introduction of newer thrombolytic agents as well as anticoagulant and antiplatelet agents, proposed as potentially safer drugs with more favourable interaction profiles. In addition to chemo-thrombolysis, other techniques including transcranial sonothrombolysis and microbubble cavitation have been introduced which are showing promising results, but await large-scale clinical trials. These developments in medical therapies which are undoubtedly of great importance due to their potential widespread and immediate availability are paralleled with gradual but steady improvements in endovascular recanalisation techniques which were initiated by the introduction of the MERCI (Mechanical Embolus Removal in Cerebral Ischemia) and Penumbra systems. The introduction of the Solitaire device was a significant achievement in reliable and safe endovascular recanalisation and was followed by further innovative stent retrievers. Initial trials failed to show a solid benefit in endovascular intervention compared with IV-tPA alone. These counterintuitive results did not last long, however, when a series of very well-designed randomised controlled trials, pioneered by MR-CLEAN, EXTEND-IA and ESCAPE, emerged, confirming the well-believed daily anecdotal evidence. There have now been seven positive trials of endovascular treatment for acute ischaemic stroke. Now that level I evidence regarding the superiority of endovascular recanalisation is abundantly available, the clinical challenge is how to select patients suitable for intervention and to familiarise and educate stroke care providers with this recent development in stroke care. It is important for the interventional services to be provided only in comprehensive stroke centres and endovascular interventions attempted by experienced well-trained operators, at this stage as an adjunct to the established medical treatment of IV-tPA, if there are no contraindications.
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Affiliation(s)
- Hamed Asadi
- Neuroradiology and Neurointerventional Service, Department of Radiology, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland. .,School of Medicine, Faculty of Health, Deakin University, Pigdons Road, Waurn Ponds, VIC, 3216, Australia. .,Interventional Radiology Service, Department of Radiology, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland.
| | - David Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland and Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland
| | - John Thornton
- Neuroradiology and Neurointerventional Service, Department of Radiology, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland
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7
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Asadi H, Dowling R, Yan B, Wong S, Mitchell P. Advances in endovascular treatment of acute ischaemic stroke. Intern Med J 2015; 45:798-805. [DOI: 10.1111/imj.12652] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 11/19/2014] [Indexed: 11/27/2022]
Affiliation(s)
- H. Asadi
- Melbourne Brain Centre; Department of Medicine; Royal Melbourne Hospital; University of Melbourne; Melbourne Victoria Australia
| | - R. Dowling
- Melbourne Brain Centre; Department of Medicine; Royal Melbourne Hospital; University of Melbourne; Melbourne Victoria Australia
| | - B. Yan
- Melbourne Brain Centre; Department of Medicine; Royal Melbourne Hospital; University of Melbourne; Melbourne Victoria Australia
| | - S. Wong
- Radiology Department; Western Hospital; Melbourne Victoria Australia
| | - P. Mitchell
- Melbourne Brain Centre; Department of Medicine; Royal Melbourne Hospital; University of Melbourne; Melbourne Victoria Australia
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8
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Dornak T, Herzig R, Sanak D, Skoloudik D. Management of acute basilar artery occlusion: Should any treatment strategy prevail? Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2014; 158:528-34. [DOI: 10.5507/bp.2013.075] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 09/20/2013] [Indexed: 11/23/2022] Open
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Abstract
Objective:To identify predictors of good outcome in acute basilar artery occlusion (BAO).Background:Acute ischemic stroke (AIS) caused by BAO is often associated with a severe and persistent neurological deficit and a high mortality rate.Methods:The set consisted of 70 consecutive AIS patients (51 males; mean age 64.5±14.5 years) with BAO. The role of the following factors was assessed: baseline characteristics, stroke risk factors, pre-event antithrombotic treatment, neurological deficit at time of treatment, estimated time to therapy procedure initiation, treatment method, recanalization rate, change in neurological deficit, post-treatment imaging findings. 30- and 90-day outcome was assessed using the modified Rankin scale with a good outcome defined as a score of 0–3.Results:The following statistically significant differences were found between patients with good versus poor outcomes: mean age (54.2 vs. 68.9 years; p=0.0001), presence of arterial hypertension (52.4% vs. 83.7%; p=0.015), diabetes mellitus (9.5% vs. 55.1%; p=0.0004) and severe stroke (14.3% vs. 65.3%; p=0.0002), neurological deficit at time of treatment (14.0 vs. 24.0 median of National Institutes of Health Stroke Scale [NIHSS] points; p=0.001), successful recanalization (90.0% vs. 54.2%; p=0.005), change in neurological deficit (12.0 vs. 1.0 median difference of NIHSS points; p=0.005). Stepwise binary logistic regression analysis identified age (OR=0.932, 95% CI=0.882–0.984; p=0.012), presence of diabetes mellitus (OR=0.105, 95% CI=0.018–0.618; p=0.013) and severe stroke (OR=0.071, 95% CI=0.013–0.383; p=0.002) as significant independent negative predictors of good outcome.Conclusions:In the present study, higher age, presence of diabetes mellitus and severe stroke were identified as significant independent negative predictors of good outcome.
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10
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Beck O, Martin C, Alt F, Wingerter A, Staatz G, Schinzel H, Faber J. Massive pulmonary embolism in a young boy with T-cell leukaemia. Successful thrombolytic therapy by recombinant tissue plasminogen activator (rtPA). Hamostaseologie 2014; 34:233-6. [PMID: 24975773 DOI: 10.5482/hamo-14-03-0020] [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: 03/19/2014] [Accepted: 06/17/2014] [Indexed: 11/05/2022] Open
Abstract
Acute pulmonary embolism (PE) is a serious complication in association with malignant diseases. We describe the successful treatment of PE applying a systemic thrombolytic therapy in a 4-year-old boy with acute lymphoblastic leukaemia. The thrombolytic therapy with recombinant tissue plasminogen activator (rtPA) 0.1 mg/kg bodyweight per hour for six hours was continued for six days without important side effects. In particular no bleeding complications were observed. Computed tomography with contrast revealed a remarkable regression of the central PE. Without further delays the chemotherapy was resumed.
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Affiliation(s)
- O Beck
- Olaf Beck, MD, Children`s Hospital, Paediatric Haematology and Oncology, Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany, Tel. +49/(0)61 31/17 35 20, Fax +49/(0)61 31/17 64 69, E-mail:
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11
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Gawlitza M, Quäschling U, Hobohm C, Otto J, Voigt P, Hoffmann KT, Lobsien D. Hyperintense basilar artery on FLAIR MR imaging: diagnostic accuracy and clinical impact in patients with acute brain stem stroke. AJNR Am J Neuroradiol 2014; 35:1520-6. [PMID: 24812014 DOI: 10.3174/ajnr.a3961] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE FLAIR-hyperintense vessels are known to be a sign of sluggish collateral blood flow in hemispheric vessel occlusion. Additionally, they seem to have a prognostic implication. The aim of the current study was to evaluate the hyperintense configuration of the basilar artery (FLAIR-hyperintense basilar artery) as a marker of basilar artery occlusion and as a predictor of patient outcome. MATERIALS AND METHODS We retrospectively identified 20 patients with basilar artery occlusion who initially underwent MR imaging with subsequent DSA. The diagnostic accuracy of the FLAIR-hyperintense basilar artery sign was tested by 4 independent readers in a case-control design, and the relation among FLAIR-hyperintense basilar artery and DWI posterior circulation-ASPECTS, patient outcome, and patient survival was evaluated. To grade the extent of the FLAIR-hyperintense basilar artery sign, we generated a score by counting the number of sections from the basilar tip to the foramen magnum in which a hyperintense signal in the vessel lumen was present multiplied by the section thickness. RESULTS The FLAIR-hyperintense basilar artery sign showed moderate sensitivity (65%-95%) but very good specificity (95%-100%) and accuracy (85%-93%) for the detection of basilar artery occlusion. Substantial or excellent inter-reader agreement was observed (Cohen κ, 0.64-0.85). The FLAIR-hyperintense basilar artery inversely correlated with the posterior circulation-ASPECTS (r = -0.67, P = .01). Higher FLAIR-hyperintense basilar artery scores were associated with patient death (28.3 ± 13.7 versus 13.4 ± 11.1, P < .05). CONCLUSIONS The FLAIR-hyperintense basilar artery sign proved to be a valuable marker of vessel occlusion and may substantially support the diagnosis of basilar artery occlusion. The established FLAIR-hyperintense basilar artery score may be helpful for the prediction of individual patient survival.
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Affiliation(s)
- M Gawlitza
- From the Departments of Neuroradiology (M.G., U.Q., K.-T.H., D.L.)Diagnostic and Interventional Radiology (M.G., J.O., P.V.)
| | - U Quäschling
- From the Departments of Neuroradiology (M.G., U.Q., K.-T.H., D.L.)
| | - C Hobohm
- Neurology (C.H.), University Hospital Leipzig, Leipzig, Germany
| | - J Otto
- Diagnostic and Interventional Radiology (M.G., J.O., P.V.)
| | - P Voigt
- Diagnostic and Interventional Radiology (M.G., J.O., P.V.)
| | - K-T Hoffmann
- From the Departments of Neuroradiology (M.G., U.Q., K.-T.H., D.L.)
| | - D Lobsien
- From the Departments of Neuroradiology (M.G., U.Q., K.-T.H., D.L.)
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Machine learning for outcome prediction of acute ischemic stroke post intra-arterial therapy. PLoS One 2014; 9:e88225. [PMID: 24520356 PMCID: PMC3919736 DOI: 10.1371/journal.pone.0088225] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 01/03/2014] [Indexed: 12/14/2022] Open
Abstract
Introduction Stroke is a major cause of death and disability. Accurately predicting stroke outcome from a set of predictive variables may identify high-risk patients and guide treatment approaches, leading to decreased morbidity. Logistic regression models allow for the identification and validation of predictive variables. However, advanced machine learning algorithms offer an alternative, in particular, for large-scale multi-institutional data, with the advantage of easily incorporating newly available data to improve prediction performance. Our aim was to design and compare different machine learning methods, capable of predicting the outcome of endovascular intervention in acute anterior circulation ischaemic stroke. Method We conducted a retrospective study of a prospectively collected database of acute ischaemic stroke treated by endovascular intervention. Using SPSS®, MATLAB®, and Rapidminer®, classical statistics as well as artificial neural network and support vector algorithms were applied to design a supervised machine capable of classifying these predictors into potential good and poor outcomes. These algorithms were trained, validated and tested using randomly divided data. Results We included 107 consecutive acute anterior circulation ischaemic stroke patients treated by endovascular technique. Sixty-six were male and the mean age of 65.3. All the available demographic, procedural and clinical factors were included into the models. The final confusion matrix of the neural network, demonstrated an overall congruency of ∼80% between the target and output classes, with favourable receiving operative characteristics. However, after optimisation, the support vector machine had a relatively better performance, with a root mean squared error of 2.064 (SD: ±0.408). Discussion We showed promising accuracy of outcome prediction, using supervised machine learning algorithms, with potential for incorporation of larger multicenter datasets, likely further improving prediction. Finally, we propose that a robust machine learning system can potentially optimise the selection process for endovascular versus medical treatment in the management of acute stroke.
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13
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Klimo P, Thompson CJ, Ragel BT, Boop FA. Methodology and reporting of meta-analyses in the neurosurgical literature. J Neurosurg 2014; 120:796-810. [PMID: 24460488 DOI: 10.3171/2013.11.jns13195] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECT Neurosurgeons are inundated with vast amounts of new clinical research on a daily basis, making it difficult and time-consuming to keep up with the latest literature. Meta-analysis is an extension of a systematic review that employs statistical techniques to pool the data from the literature in order to calculate a cumulative effect size. This is done to answer a clearly defined a priori question. Despite their increasing popularity in the neurosurgery literature, meta-analyses have not been scrutinized in terms of reporting and methodology. METHODS The authors performed a literature search using PubMed/MEDLINE to locate all meta-analyses that have been published in the JNS Publishing Group journals (Journal of Neurosurgery, Journal of Neurosurgery: Pediatrics, Journal of Neurosurgery: Spine, and Neurosurgical Focus) or Neurosurgery. Accepted checklists for reporting (PRISMA) and methodology (AMSTAR) were applied to each meta-analysis, and the number of items within each checklist that were satisfactorily fulfilled was recorded. The authors sought to answer 4 specific questions: Are meta-analyses improving 1) with time; 2) when the study met their definition of a meta-analysis; 3) when clinicians collaborated with a potential expert in meta-analysis; and 4) when the meta-analysis was the only focus of the paper? RESULTS Seventy-two meta-analyses were published in the JNS Publishing Group journals and Neurosurgery between 1990 and 2012. The number of published meta-analyses has increased dramatically in the last several years. The most common topics were vascular, and most were based on observational studies. Only 11 papers were prepared using an established checklist. The average AMSTAR and PRISMA scores (proportion of items satisfactorily fulfilled divided by the total number of eligible items in the respective instrument) were 31% and 55%, respectively. Major deficiencies were identified, including the lack of a comprehensive search strategy, study selection and data extraction, assessment of heterogeneity, publication bias, and study quality. Almost one-third of the papers did not meet our basic definition of a meta-analysis. The quality of reporting and methodology was better 1) when the study met our definition of a meta-analysis; 2) when one or more of the authors had experience or expertise in conducting a meta-analysis; 3) when the meta-analysis was not conducted alongside an evaluation of the authors' own data; and 4) in more recent studies. CONCLUSIONS Reporting and methodology of meta-analyses in the neurosurgery literature is excessively variable and overall poor. As these papers are being published with increasing frequency, neurosurgical journals need to adopt a clear definition of a meta-analysis and insist that they be created using checklists for both reporting and methodology. Standardization will ensure high-quality publications.
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Affiliation(s)
- Paul Klimo
- Semmes-Murphey Neurologic & Spine Institute
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14
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Lee WI, Mitchell P, Dowling R, Yan B. Clinical factors are significant predictors of outcome post intra-arterial therapy for acute ischaemic stroke: a review. J Neuroradiol 2013; 40:315-25. [PMID: 24239412 DOI: 10.1016/j.neurad.2013.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 08/16/2013] [Accepted: 09/17/2013] [Indexed: 11/28/2022]
Abstract
Intra-arterial therapy (IAT) provides superior recanalisation rates, approaching 80% for the current generation of endovascular devices. Furthermore, IAT may allow for an extended therapeutic window beyond that which is permissible for intravenous thrombolysis. However, the improved recanalisation rates are not matched by concordant clinical outcomes, leading to an invigorated search for predictors of clinical outcome. There is emerging evidence that younger age, mild-moderate stroke, and shorter vessel occlusion time are associated with better clinical outcome after IAT. This review aims to critically appraise current evidence that may inform changes in the selective inclusion of clinical factors in the future design and trial of IAT.
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Affiliation(s)
- Wei-I Lee
- Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia
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Abstract
Acute vertebrobasilar occlusion (VBO) remains a disease with a high mortality. Local intraarterial fibrinolysis (LIF) can reduce the mortality rate from about 90 to 60%. The combined therapy of i.v. Abciximab and i.a. rt-PA with additional PTA/stenting may improve neurological outcome and significantly reduce mortality, despite an increase of overall bleeding complications. Additional PTA/stenting is an important treatment factor in cases of atherothrombotic occlusion. In embolic occlusions, mechanical catheter devices, such as basket or snare devices or rheolytic systems, are promising therapies for the near future. This article describes diagnostic criteria and treatment factors in acute VBO. Different treatment strategies, such as i.v. and i.a. fibrinolysis, adjunctive application of GP IIb/IIIa inhibitors, PTA/stenting and mechanical embolectomy are addressed in detail.
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Affiliation(s)
- Bernd Eckert
- Allgemeines Krankenhaus Altona, Funktionsbereich Neuroradiologie, Hamburg, Germany.
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Miyagi T, Koga M, Shiokawa Y, Nakagawara J, Hasegawa Y, Furui E, Kimura K, Kario K, Okuda S, Yamagami H, Okada Y, Nezu T, Maeda K, Endo K, Minematsu K, Toyoda K. Intravenous alteplase at 0.6 mg/kg for acute stroke patients with basilar artery occlusion: the stroke acute management with urgent risk factor assessment and improvement (SAMURAI) Recombinant tissue plasminogen activator registry. J Stroke Cerebrovasc Dis 2012; 22:1098-106. [PMID: 23063059 DOI: 10.1016/j.jstrokecerebrovasdis.2012.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 08/03/2012] [Accepted: 08/22/2012] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The therapeutic efficacy of low-dose intravenous alteplase (0.6 mg/kg) for basilar artery occlusion (BAO) remains unknown. METHODS BAO patients enrolled from the Japanese multicenter registry involving 600 stroke patients treated with the low-dose intravenous alteplase were studied. RESULTS Twenty-five patients had BAO (8 women ranging from 32-92 years of age; mean baseline National Institutes of Health Stroke Scale [NIHSS] score 16). The stroke subtype was cardioembolic in 15 patients and atherothrombotic in 4 patients. BAO was recanalized during hospitalization in 18 (78%) of 23 patients undergoing follow-up angiography. Within the initial 24 hours, 14 patients (56%) had a ≥ 8-point decrease in the NIHSS score, being more common than 267 patients with middle cerebral artery occlusion (MCO) from the same registry (odds ratio [OR] 2.50; 95% confidence interval [CI] 1.06-5.97) after adjustment by sex, age, and baseline NIHSS score. In addition, 4 patients (16%) had a ≥ 4-point increase in the score, being marginally more common than MCO patients (OR 3.13; 95% CI 0.81-10.25). Symptomatic intracranial hemorrhage within the initial 36 hours (8% v 5%), independence at 3 months (modified Rankin Scale score ≤ 2, 48% v 52%), and mortality at 3 months (4% v 6%) were similar when comparing BAO and MCO patients. When compared with previous studies of BAO, vital and functional outcomes at 3 months were relatively better in our study. CONCLUSIONS The use of low-dose alteplase resulted in similar outcomes when comparing acute BAO and MCO patients.
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Affiliation(s)
- Tetsuya Miyagi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Inoue T, Tamura A, Tsutsumi K, Saito I, Saito N. Acute to subacute surgical revascularization for progressing stroke in atherosclerotic vertebrobasilar occlusion. Acta Neurochir (Wien) 2012; 154:1455-61; discussion 1461. [PMID: 22684374 DOI: 10.1007/s00701-012-1398-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Accepted: 05/15/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute vertebrobasilar artery (VBA) occlusion is catastrophic. For embolic occlusion, thrombolysis is reasonable. However, if the occlusion is atherosclerotic, the best therapeutic approach remains unclear. The aim of this study was to characterize the clinical course, case selection, techniques and complications associated with acute to subacute surgical revascularization in atherosclerotic vertebrobasilar occlusion under appropriate patient selection based on diffusion-weighted imaging (DWI) combined with careful evaluation of progressive neurological symptoms. METHODS We retrospectively reviewed nine consecutive patients who were scheduled to undergo acute to subacute surgical revascularization for progressing stroke in atherosclerotic VBA occlusion consisting of a relatively small DWI lesion. Clinical characteristics, radiological findings, results of revascularization, and 3-month outcomes (mRS) were assessed. RESULTS Seven patients underwent surgical revascularization (superficial temporal artery [STA]-superior cerebellar artery [SCA] bypass, n = 5; occipital artery [OA]-posterior inferior cerebellar artery [PICA] bypass, n = 1; vertebral endarterectomy, n = 1). Revascularization distal to the occlusion was successful in all seven patients. Two patients scheduled for STA-SCA bypass sustained irreversible confluent brainstem infarction before surgical intervention and died. The median time between admission and surgical treatment or irreversible coma was 20 h (range, 4-72 h). The modified Rankin Scale (mRS) at 3 months of seven patients who underwent surgical revascularization was good (mRS 0-2) in four patients, poor (mRS 3-6) in three patients. Mid- to long-term bypass patency was confirmed by magnetic resonance angiography (MRA) in the surviving five patients at a median follow-up of 7 months (range, 1-25 months). CONCLUSION Atherosclerotic vertebrobasilar artery (VBA) occlusion presented with stuttering onset of symptoms and patients developed worsening symptoms of vertebrobasilar insufficiency over hours to days. DWI was a useful modality to help guide the appropriate selection of patients for acute to subacute surgical revascularization for progressing stroke in atherosclerotic VBA occlusion. The surgical methods themselves were feasible. Poor outcomes were related to delay of treatment rather than surgical or technical failure.
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Affiliation(s)
- Tomohiro Inoue
- Department of Neurosurgery, Fuji Brain Institute and Hospital, 270-12 Sugita, Fujinomiya-shi, Shizuoka, 418-0021, Japan.
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Yun JS, Kwak HS, Hwang SB, Chung GH. Endovascular management in patients with acute basilar artery obstruction: low-dose intra-arterial urokinase and mechanical clot disruption. Interv Neuroradiol 2011; 17:435-41. [PMID: 22192547 DOI: 10.1177/159101991101700407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Accepted: 10/01/2011] [Indexed: 11/15/2022] Open
Abstract
Mechanical clot disruption for the treatment of acute basilar artery occlusion (BAO) is known to provide a benefit. We aimed to determine the safety, recanalization rate and time-to-flow restoration of mechanical clot disruption and low dose urokinase (UK) infusions for the treatment of patients with acute BAO. Between June 2006 and June 2010, 21 patients with acute BAO underwent endovascular treatment that included angioplasty or stent placement. The time to treatment, duration of the procedure, dose of urokinase (UK), recanalization rates and symptomatic hemorrhages were analyzed. Clinical outcome measures were assessed at admission and at the time of discharge using the National Institutes of Health Stroke Scale (NIHSS) score and at three months after treatment using the modified Rankin Score (mRS). On admission, the median NIHSS score was 13.2. Median time from symptom onset to arrival at hospital was 356 minutes, and median time from symptom onset to intraarterial thrombolysis (IAT) was 49 minutes. We used the following interventional treatment regimens: Intra-arterial (IA) UK and a minimal mechanical procedure (n=14), IA UK with angioplasty (n=1), IA UK with angioplasty and stent placement (n=3) and IA UK with HyperForm (n=3). The recanalization (thrombolysis in cerebral ischemia grade II or III) rate was 90.5% (19/21). There was symptomatic hemorrhage in one patient (4.8%). The median NIHSS score at discharge was 6.3. The three-month outcome was favorable (mRS: 0-2) for 14 patients (66.7%) and poor (mRS: 3-6) for seven patients (33.3%). The overall mortality at three months was 14.3% (three patients died). Low-dose IAT with mechanical clot disruption is a safe and effective treatment for treatment for acute BAO.
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Affiliation(s)
- J S Yun
- Radiology Department, Chonbuk National University Medical School and Hospital, Jeonju, Jeonbuk, Korea
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19
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Bergui M, Cerrato P, Bradac GB. Stroke attributable to acute basilar occlusion. Curr Treat Options Neurol 2011; 9:126-35. [PMID: 17298773 DOI: 10.1007/s11940-007-0038-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute basilar artery occlusion carries a high risk of disabling stroke or death. Fast recanalization of the vessel is the mainstay of the therapy. Recanalization may be achieved by intravenous or intra-arterial administration of thrombolytics. These procedures are currently used as life-saving interventions, despite the low level of evidence supporting their efficacy, because of the bad prognosis of the disease. Intravenous thrombolysis may be started earlier, but it is less often used, mainly for historic reasons; intra-arterial measures are possibly more effective in achieving recanalization but require extra time before they can be started and demand a considerable amount of resources. The basilar artery does not recanalize in approximately one third of patients; this result has not been modified over the past two decades by these treatments and probably will not change. Combined mechanical and intra-arterial thrombolysis may be more efficient in achieving basilar artery recanalization, but the impact of this combined intervention on the final outcome has not been evaluated. Because time is critical, as in every stroke, implementation of a specific treatment protocol for this condition, including one of the aforementioned treatments, and eventual transfer to a secondary-care unit will save time and improve prognosis.
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Affiliation(s)
- Mauro Bergui
- Mauro Bergui, MD Neuroradiology, Neuroscience Department, University of Turin, Via Cherasco 15, 10126 Torino, Italy.
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20
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21
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Tortora F, Cirillo M, Ferrara M, Manto A, Briganti F, Cirillo S. DWI Reversibility after Intra-Arterial Thrombolysis. A Case Report and Literature Review. Neuroradiol J 2010; 23:752-62. [PMID: 24148733 DOI: 10.1177/197140091002300618] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Accepted: 11/05/2010] [Indexed: 11/16/2022] Open
Abstract
We report our case and review the literature on reversal DWI lesions, ADC thresholds and correlation between DWI lesion and outcome measured with clinical scales. A 30-years old woman was admitted to our hospital 18 hours after stroke onset. Considering the absence of alterations on CT and the worsening of symptomatology, the patient underwent MRI, which showed a slightly hyperintense signal in FLAIR images in the left portion of the pons and midbrain and a more evident bilateral DWI hyperintensity of the pons. The patient was treated with mechanical and pharmacological intra-arterial thrombolysis. The patient showed a rapid improvement of symptoms. Two weeks after the treatment her clinical conditions were characterized by a residual right hemiparesis and complete recovery of right motility, respiratory and swallowing difficulties. MR examination demonstrated a slight signal alteration of the pons left hemiportion and a disappearance of the mesencephalic signal alteration and of the right portion of the pons. DWI lesions represent irreversibly damaged tissue but new evidence suggests that DWI lesions may be reversible, especially with reperfusion, by now well demonstrated in animal models. Therefore acute DWI lesions probably contain not only irreversibly injured tissue but also parts of the penumbra. The debate on the capability of ADC maps to discriminate irreversibly from reversibly damaged tissue is a matter of controversy. ADC values in human stoke are not an independent indicator of tissue viability. The use of thresholds may improve reproducibility but not validity.
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Affiliation(s)
- F Tortora
- Department of Neuroradiology, II University School of Medicine; Naples, Italy -
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22
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Basilar artery thrombosis: imaging and endovascular therapy. Radiol Med 2010; 115:1219-33. [PMID: 20680500 DOI: 10.1007/s11547-010-0568-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 12/08/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE Basilar artery thrombosis represents a rare type of ischaemic stroke with a mortality rate of 80%-90% if not promptly treated. The aim of our study was to review our experience with computed tomography angiography (CTA) in the diagnosis of basilar artery thrombosis and its treatment with endovascular procedures. MATERIALS AND METHODS Our retrospective study is based upon 59 nontrauma patients with episodes of sudden loss of consciousness. Patients were investigated using unenhanced brain CT followed by intracranial CTA (16-slice CT) when no parenchymal haemorrhage was detected. Patients with a CTA diagnosis of basilar artery thrombosis were considered for endovascular treatment. CTA accuracy was evaluated by considering the 12 patients who underwent endovascular angiography (the gold standard). The success of endovascular therapy was evaluated by considering the degree of microcirculatory reperfusion. RESULTS After the exclusion of 33 patients affected by parenchymal or subarachnoid haemorrhage, the final study consisted of 26 patients who underwent CTA. Basilar artery thrombosis was diagnosed in 15 of them, and 12 were treated at our institution. The comparison between CTA and endovascular angiography showed 100% agreement in evaluating occlusion site and extension. Seven patients underwent intra-arterial lysis, and five underwent mechanical clot removal. CONCLUSIONS CTA, with its wide availability and rapid execution times, is the most indicated examination in the case of suspected basilar artery thrombosis. Although there is a lack of randomised controlled prospective studies suggesting the most appropriate therapeutic approach to basilar artery thrombosis, our study lends weight to the role of interventional neuroradiology in the treatment of this condition.
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Tan X, Guo Y. Hyperdense basilar artery sign diagnoses acute posterior circulation stroke and predicts short-term outcome. Neuroradiology 2010; 52:1071-8. [PMID: 20358365 DOI: 10.1007/s00234-010-0682-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2009] [Accepted: 03/09/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION It is well established that the hyperdense middle cerebral artery sign is a specific marker for early ischemia in anterior circulation. However, little is known about the hyperdense basilar artery sign (HDBA) in posterior circulation. Our aim was to determine whether the HDBA sign has utility in early diagnosis of acute posterior circulation stroke and prediction of short-term outcome. METHODS Three-blinded readers examined unenhanced computed tomography scans for the HDBA sign, and materials were classified into two groups according to this sign. Vascular risk factors, admission and discharge National Institute of Health Stroke Scale (NIHSS) scores, short-term outcome, and radiological findings between the two groups were compared. RESULTS One hundred and twenty-six cases of acute posterior circulation stroke (PCS) were included in the study. No statistically significant differences were found in risk factors of ischemic stroke, except atrial fibrillation (P=0.025). Admission and discharge NIHSS scores for the positive HDBA group were significantly higher than scores for the negative HDBA group (P=0.001, 0.002, respectively). The infarction territory for the positive HDBA group was mainly multi-region in nature (51.6%, P<0.001), while the negative HDBA group showed mainly middle territory infarction. Significant independent predictors of short-term outcome included the HDBA sign (P<0.001) and admission NIHSS scores (P<0.001). CONCLUSION Approximately half of the HDBA patients showed multi-region infarction and a serious neurological symptom. Based on our results, this sign might not only be helpful in early diagnosis of acute PCS but also be able to correlate with a poor short-term outcome.
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Affiliation(s)
- Xiaoping Tan
- Department of Neurology, Shengjing Hospital, Affiliated Hospital of China Medical University at Shenyang, 39 Hua Xiang Road, Tie Xi District, Shenyang, China
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24
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Tjoumakaris SI, Jabbour PM, Rosenwasser RH. Neuroendovascular management of acute ischemic stroke. Neurosurg Clin N Am 2010; 20:419-29. [PMID: 19853801 DOI: 10.1016/j.nec.2009.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Endovascular reperfusion therapy is evolving as a promising treatment in the setting of acute ischemic stroke. Careful patient selection and angiographic evaluation of the location and extent of occlusion are necessary for the successful management of stroke patients. Intra-arterial chemical thrombolysis, with such agents as alteplase and urokinase, has shown favorable results in the early management of cerebrovascular ischemia. Mechanical thrombolysis is becoming an adjunctive or alternative treatment therapy via novel clot dissolution and retrieval techniques. Existing and upcoming trials are investigating the safety and efficacy of neuroendovascular therapy while attempting to expand its indications in acute ischemic stroke.
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Affiliation(s)
- Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University, Jefferson Hospital for Neuroscience, 909 Walnut Street 3rd Floor, Philadelphia, PA 19107, USA.
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25
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Oster JM, Aggarwal P. Spontaneous recanalization of the basilar artery with conservative management months after symptom onset. Neurol Int 2009; 1:e17. [PMID: 21577354 PMCID: PMC3093223 DOI: 10.4081/ni.2009.e17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 10/19/2009] [Indexed: 11/23/2022] Open
Abstract
Basilar artery occlusion may be associated with a poor prognosis in the absence of recanalization. Choices in aggressive treatment for this potentially fatal condition vary from intra-arterial or intravenous thrombolysis, endovascular removal, or a combination of the two, with adjunct anti-coagulation therapy. These therapies have proven to be effective in recanalization, whereas conservative management with anti-coagulants alone has had more limited success in the literature. We report a case of basilar artery occlusion managed conservatively with unfractionated heparin, resulting in complete recanalization 3.5 months after symptom onset. Conservative management of basilar artery occlusion with unfractionated heparin was associated with complete recanalization long after symptom onset.
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Affiliation(s)
- Joel M Oster
- Department of Neurology, Lahey Clinic, Burlington, MA, USA
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26
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Eckert B. Acute Stroke Therapy 1981–2009*. Clin Neuroradiol 2009; 19:8-19. [DOI: 10.1007/s00062-009-8033-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Accepted: 11/03/2008] [Indexed: 11/25/2022]
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Nogueira RG, Yoo AJ, Buonanno FS, Hirsch JA. Endovascular approaches to acute stroke, part 2: a comprehensive review of studies and trials. AJNR Am J Neuroradiol 2009; 30:859-75. [PMID: 19386727 PMCID: PMC7051678 DOI: 10.3174/ajnr.a1604] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Reperfusion remains the mainstay of acute ischemic stroke treatment. Endovascular therapy has become a promising alternative for patients who are ineligible for or have failed intravenous (IV) thrombolysis. The conviction that recanalization of properly selected patients is essential for the achievement of good clinical outcomes has led to the rapid and widespread growth in the adoption of endovascular stroke therapies. However, comparisons of the recent reperfusion studies have brought into question the strength of the association between revascularization and improved clinical outcome. Despite higher rates of recanalization, the mechanical thrombectomy studies have demonstrated substantially lower rates of good outcomes compared with IV and/or intra-arterial thrombolytic trials. However, such analyses disregard important differences in clot location and burden, baseline stroke severity, time from stroke onset to treatment, and patient selection in these studies. Many clinical trials are testing novel devices and drugs as well as the paradigm of physiology-based stroke imaging as a treatment-selection tool. The objective of this article is to provide a comprehensive review of the relevant past, current, and upcoming data on endovascular stroke therapy with a special focus on the prospective studies and randomized clinical trials.
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Affiliation(s)
- R G Nogueira
- Endovascular Neurosurgery/Interventional Neuroradiology Section, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Kole M, Amin B, Marin H, Russman A, Sanders W. Intracranial angioplasty and stent placement for direct cerebral revascularization of nonacute intracranial occlusions and near occlusions. Neurosurg Focus 2009; 26:E3. [PMID: 19249959 DOI: 10.3171/2008.12.focus08269] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors reviewed their experience in 7 cases of nonacute intracranial occlusions and near occlusions in which the patients underwent intracranial angioplasty and stent implantation for direct cerebral revascularization. METHODS Between 2005 and 2008, 4 men and 3 women underwent direct cerebral revascularization of nonacute intracerebral occlusions or near occlusions. Five patients had chronic angiographically documented occlusion and 2 patients had chronic angiographically documented near occlusions. The locations of the treated vessels included 2 supraclinoid internal carotid arteries, 4 middle cerebral arteries, and 1 vertebral artery. Prior to intervention, all patients were symptomatic and experienced strokes ipsilateral to their occlusions. In addition, all patients had clinical or radiographic evidence of ongoing hemodynamic compromise. Five patients underwent successful intracranial angioplasty and stent placement and 2 patients underwent successful intracranial balloon angioplasty alone. The mean time from documented vessel occlusion to treatment was 35 days. All patients had successful revascularization determined using the Thrombolysis in Cerebral Infarction (TICI) scale: TICI Score 3, 2b, and 2a in 4, 2, and 1 patient, respectively, and the mean residual stenosis was 38%. RESULTS After uneventful technical procedures, 1 patient suffered a perforator vessel stroke and 1 patient suffered a fatal hemorrhage. Mean modified Rankin Scale score of 2 (range 1-5) and mean Glasgow Outcome Scale score of 4 (range 1-6) were achieved during a mean clinical follow-up period of 399 days (range 1-840 days). Asymptomatic restenosis was documented in 4 patients, 1 underwent bypass retreatment, and 1 patient received repeated balloon angioplasty. CONCLUSIONS Combined intracranial angioplasty and stent placement is a potential treatment option in selected patients for the direct revascularization of nonacute intracranial occlusions and near occlusions. Whether this represents a substantial risk reduction compared with the best medical therapy or a long-lasting treatment option is unknown.
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Affiliation(s)
- Max Kole
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan 48202, USA.
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Critical Care Management of Subarachnoid Hemorrhage and Ischemic Stroke. Clin Chest Med 2009; 30:103-22, viii-ix. [DOI: 10.1016/j.ccm.2008.11.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Nagel S, Schellinger PD, Hartmann M, Juettler E, Huttner HB, Ringleb P, Schwab S, Köhrmann M. Therapy of Acute Basilar Artery Occlusion. Stroke 2009; 40:140-6. [PMID: 18927446 DOI: 10.1161/strokeaha.108.526566] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
While intravenous recombinant tissue plasminogen activator (rt-PA) has been approved for acute stroke therapy within 3 hours, the optimum management of basilar artery occlusion (BAO) is still a matter of debate. We compared intraarterial thrombolysis with the combined bridging approach of intravenous abciximab and intraarterial thrombolysis with rt-PA (bridging therapy) in an observational, longitudinal, monocenter study.
Methods—
Between 1998 and 2006, information for 106 patients with acute BAO were prospectively entered into a local database. Patients eligible for treatment received either intraarterial thrombolysis with rt-PA alone (intraarterial thrombolysis) or were treated with intravenous abciximab and intraarterial rt-PA (bridging therapy). Outcome parameters were recanalization of the basilar artery according to Trial in Myocardial Infarction criteria, survival, and reduction of severe disability and death at 3 months. Logistic regression was used to identify independent predictors for recanalization, survival, and clinical outcome.
Results—
Of a total of 106 patients with confirmed BAO, 87 patients underwent subsequent angiography. Among those, 75 patients were identified who received the full treatment protocol. Patients in the bridging group had a better recanalization rate (83.7% vs 62.5%;
P
=0.03), a higher survival rate (58.1% vs 25%;
P
=0.01), and a better chance for an outcome with no or only mild to moderate disability (modified Rankin Scale score, 0–3; 34.9% vs 12.5%;
P
=0.02). Symptomatic intracerebral hemorrhage rates were comparable in both groups (14% in the bridging group vs 18.8%;
P
=0.41). Independent predictors for recanalization were age (OR, 0.95; 95% CI, 0.91–0.99), atrial fibrillation (OR, 6.53; 95% CI, 1.14–37.49), and bridging therapy (OR, 3.37; 95% CI, 1.02 to 11.18). Independent prognostic factors for outcome were Glasgow coma scale score at presentation (OR, 1.24; 95% CI, 1.03–1.45) and the combination of bridging therapy with successful recanalization (OR, 3.744; 95% CI, 1.04–13.43).
Conclusion—
Bridging therapy for acute BAO with intravenous abciximab and intraarterial rt-PA appears to be safe and yields higher recanalization and improved survival rates, as well as an overall improved chance for a better outcome.
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Affiliation(s)
- Simon Nagel
- From Department of Neurology (S.N., E.J., P.R.), University of Heidelberg, Medical School, Germany; Department of Neurology (P.D.S., H.B.H., S.S., M.K.), University of Erlangen, Medical School, Germany; Department of Neuroradiology (M.H., E.J.), University of Heidelberg, Medical School, Germany; Acute Stroke Programme (S.N.), Nuffield Department of Clinical Medicine, University of Oxford, UK
| | - Peter D. Schellinger
- From Department of Neurology (S.N., E.J., P.R.), University of Heidelberg, Medical School, Germany; Department of Neurology (P.D.S., H.B.H., S.S., M.K.), University of Erlangen, Medical School, Germany; Department of Neuroradiology (M.H., E.J.), University of Heidelberg, Medical School, Germany; Acute Stroke Programme (S.N.), Nuffield Department of Clinical Medicine, University of Oxford, UK
| | - Marius Hartmann
- From Department of Neurology (S.N., E.J., P.R.), University of Heidelberg, Medical School, Germany; Department of Neurology (P.D.S., H.B.H., S.S., M.K.), University of Erlangen, Medical School, Germany; Department of Neuroradiology (M.H., E.J.), University of Heidelberg, Medical School, Germany; Acute Stroke Programme (S.N.), Nuffield Department of Clinical Medicine, University of Oxford, UK
| | - Eric Juettler
- From Department of Neurology (S.N., E.J., P.R.), University of Heidelberg, Medical School, Germany; Department of Neurology (P.D.S., H.B.H., S.S., M.K.), University of Erlangen, Medical School, Germany; Department of Neuroradiology (M.H., E.J.), University of Heidelberg, Medical School, Germany; Acute Stroke Programme (S.N.), Nuffield Department of Clinical Medicine, University of Oxford, UK
| | - Hagen B. Huttner
- From Department of Neurology (S.N., E.J., P.R.), University of Heidelberg, Medical School, Germany; Department of Neurology (P.D.S., H.B.H., S.S., M.K.), University of Erlangen, Medical School, Germany; Department of Neuroradiology (M.H., E.J.), University of Heidelberg, Medical School, Germany; Acute Stroke Programme (S.N.), Nuffield Department of Clinical Medicine, University of Oxford, UK
| | - Peter Ringleb
- From Department of Neurology (S.N., E.J., P.R.), University of Heidelberg, Medical School, Germany; Department of Neurology (P.D.S., H.B.H., S.S., M.K.), University of Erlangen, Medical School, Germany; Department of Neuroradiology (M.H., E.J.), University of Heidelberg, Medical School, Germany; Acute Stroke Programme (S.N.), Nuffield Department of Clinical Medicine, University of Oxford, UK
| | - Stefan Schwab
- From Department of Neurology (S.N., E.J., P.R.), University of Heidelberg, Medical School, Germany; Department of Neurology (P.D.S., H.B.H., S.S., M.K.), University of Erlangen, Medical School, Germany; Department of Neuroradiology (M.H., E.J.), University of Heidelberg, Medical School, Germany; Acute Stroke Programme (S.N.), Nuffield Department of Clinical Medicine, University of Oxford, UK
| | - Martin Köhrmann
- From Department of Neurology (S.N., E.J., P.R.), University of Heidelberg, Medical School, Germany; Department of Neurology (P.D.S., H.B.H., S.S., M.K.), University of Erlangen, Medical School, Germany; Department of Neuroradiology (M.H., E.J.), University of Heidelberg, Medical School, Germany; Acute Stroke Programme (S.N.), Nuffield Department of Clinical Medicine, University of Oxford, UK
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Sauvageau E, Levy EI, Hopkins LN. Endovascular therapy for acute ischemic stroke. HANDBOOK OF CLINICAL NEUROLOGY 2009; 94:1225-1238. [PMID: 18793897 DOI: 10.1016/s0072-9752(08)94060-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Eric Sauvageau
- Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo NY 14209, USA
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Zavala-Alarcon E, Emmans L, Little R, Bant A. Percutaneous intervention for posterior fossa ischemia. A single center experience and review of the literature. Int J Cardiol 2008; 127:70-7. [PMID: 17651834 DOI: 10.1016/j.ijcard.2007.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Revised: 05/03/2007] [Accepted: 05/11/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of our study was to evaluate the results of endovascular treatment of symptomatic vertebro-basilar insufficiency (VBI) unresponsive to medical therapy. METHODS Cardiac patients regularly followed in our cardiology clinic with symptoms suggestive of posterior fossa ischemia diagnosed by the attending cardiologist, had diagnostic or suspicious findings of vertebral artery stenosis on ultrasound evaluation, with reversed vertebral flow on Doppler examination. These patients were referred for selective vertebral and subclavian artery angiography. All patients (17 men, 11 women; mean age of 64 years, range 54-87) had critical lesions (> 70% stenosis) in the vertebral or pre-vertebral subclavian arteries or both. After confirmation of the severity of the lesions and feasibility for revascularization, all these patients underwent percutaneous intervention and stent placement. All patients were followed-up through clinic visits for a mean of 14.2 months, (range 3.5-24.3). RESULTS In our 28 patients that were treated, 25 vertebral and 10 subclavian stents were placed. Success (< 20% residual diameter stenosis, without stroke or death) was achieved in 27 patients (96%). One patient undergoing intervention for an ostial subtotal occlusion of the left subclavian artery, developed a minor posterior fossa transient ischemic attack. At follow-up, 25 patients (89%) were alive and 22 (88%) of those had no further neurologic complaints. Three (11%) patients that had vertebral artery stents, died during follow-up from cardiac complications, unrelated to the neurovascular intervention. One patient (3.5%) had recurrent symptoms with in-stent restenosis at 6 months with successful balloon angioplasty and resolution of symptoms. The two other patients with persistent symptoms (only dizziness) had no evidence of restenosis and underwent further work-up that has not clarified the etiology. CONCLUSIONS Posterior fossa ischemia is an under-diagnosed condition that occurs with relative frequency in cardiac patients. Awareness of this condition and adequate non-invasive testing permits identification of these patients. Endovascular treatment using coronary wires and stents including drug eluting stents, seems to be the treatment of choice for vertebral artery revascularization due to the high technical success rate, low complication rate, and long-term durability.
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Pfefferkorn T, Mayer TE, Opherk C, Peters N, Straube A, Pfister HW, Holtmannspötter M, Müller-Schunk S, Wiesmann M, Dichgans M. Staged Escalation Therapy in Acute Basilar Artery Occlusion. Stroke 2008; 39:1496-500. [PMID: 18323481 DOI: 10.1161/strokeaha.107.505123] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thomas Pfefferkorn
- From Department of Neurology (T.P., C.O., N.P., A.S., H.W.P., M.D.) and Department of Neuroradiology (T.E.M., M.H., S.M.-S., M.W.), Klinikum Grosshadern, University of Munich, Germany
| | - Thomas E. Mayer
- From Department of Neurology (T.P., C.O., N.P., A.S., H.W.P., M.D.) and Department of Neuroradiology (T.E.M., M.H., S.M.-S., M.W.), Klinikum Grosshadern, University of Munich, Germany
| | - Christian Opherk
- From Department of Neurology (T.P., C.O., N.P., A.S., H.W.P., M.D.) and Department of Neuroradiology (T.E.M., M.H., S.M.-S., M.W.), Klinikum Grosshadern, University of Munich, Germany
| | - Nils Peters
- From Department of Neurology (T.P., C.O., N.P., A.S., H.W.P., M.D.) and Department of Neuroradiology (T.E.M., M.H., S.M.-S., M.W.), Klinikum Grosshadern, University of Munich, Germany
| | - Andreas Straube
- From Department of Neurology (T.P., C.O., N.P., A.S., H.W.P., M.D.) and Department of Neuroradiology (T.E.M., M.H., S.M.-S., M.W.), Klinikum Grosshadern, University of Munich, Germany
| | - Hans-Walter Pfister
- From Department of Neurology (T.P., C.O., N.P., A.S., H.W.P., M.D.) and Department of Neuroradiology (T.E.M., M.H., S.M.-S., M.W.), Klinikum Grosshadern, University of Munich, Germany
| | - Markus Holtmannspötter
- From Department of Neurology (T.P., C.O., N.P., A.S., H.W.P., M.D.) and Department of Neuroradiology (T.E.M., M.H., S.M.-S., M.W.), Klinikum Grosshadern, University of Munich, Germany
| | - Stefanie Müller-Schunk
- From Department of Neurology (T.P., C.O., N.P., A.S., H.W.P., M.D.) and Department of Neuroradiology (T.E.M., M.H., S.M.-S., M.W.), Klinikum Grosshadern, University of Munich, Germany
| | - Martin Wiesmann
- From Department of Neurology (T.P., C.O., N.P., A.S., H.W.P., M.D.) and Department of Neuroradiology (T.E.M., M.H., S.M.-S., M.W.), Klinikum Grosshadern, University of Munich, Germany
| | - Martin Dichgans
- From Department of Neurology (T.P., C.O., N.P., A.S., H.W.P., M.D.) and Department of Neuroradiology (T.E.M., M.H., S.M.-S., M.W.), Klinikum Grosshadern, University of Munich, Germany
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Sylaja PN, Puetz V, Dzialowski I, Krol A, Hill MD, Demchuk AM. Prognostic value of CT angiography in patients with suspected vertebrobasilar ischemia. J Neuroimaging 2008; 18:46-9. [PMID: 18190495 DOI: 10.1111/j.1552-6569.2007.00174.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The outcome of vertebrobasilar ischemia depends on the clinical presentation and the presence or absence of vascular occlusion. The aim of our study was to analyze the CT angiography (CTA) predictors of outcome in patients with suspected vertebrobasilar ischemia. METHODS We studied patients with suspected acute vertebrobasilar ischemia between April 2002 and January 2006 and had CTA done within 24 hours of symptom onset. We reviewed the final diagnosis and 3-month follow-up and analyzed the clinical and CTA predictors of outcome. RESULTS Of the 133 patients, 21(15%), 18 (13%), and 16 (12%) had occlusion of basilar artery (BA), vertebral artery (VA), and posterior cerebral artery (PCA) respectively. The final diagnosis was stroke in 98 (73.6%), transient ischemic attack (TIA) in 10 (7.5%), and nonischemic in 25 (18.8%). No vascular occlusion was seen on CTA in patients with TIA and nonischemic diagnosis. At 3-month follow-up, we found a mortality rate of 10.6% and good functional outcome in 71.4%. The predictors of death in the multivariable analysis were the presence of BA occlusion (odds ratio[OR] 6.7, 95% CI, 1.4-30.6) and baseline National Institutes of Health Stroke Scale (NIHSS) (OR 1.14, 95% CI, 1.06-1.2). When patients with basilar occlusion were excluded, the presence of VA occlusion (OR 6.5, 95% CI, 1.34-31.4), age (OR 1.09, 95% CI, 1.03-1.14), and baseline NIHSS (OR 1.1, 95% CI, 1.03-1.18) predicted poorer outcome. CONCLUSIONS The presence or absence of a vascular occlusion is a critical factor for prognosis in suspected acute vertebrobasilar ischemia and is correlated with the location of occlusion.
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Affiliation(s)
- P N Sylaja
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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35
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Stroke. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50066-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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36
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Zavala-Alarcon E, Emmans L, Cecena F, Little R, Bant A. Percutaneous vertebral artery intervention: a necessary tool in every interventional cardiologist armamentarium. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2007; 8:107-13. [PMID: 17574170 DOI: 10.1016/j.carrev.2006.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2006] [Accepted: 11/17/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the results of endovascular treatment of symptomatic vertebrobasilar insufficiency unresponsive to medical therapy. METHODS Twenty-eight patients who were regularly followed up in our cardiology clinic with symptoms suggestive of posterior fossa ischemia and with diagnostic or suspicious findings on ultrasound evaluation were evaluated with selective vertebral and subclavian artery angiography. All patients (17 men, 11 women; mean age, 64 years; range, 54-87) had critical lesions (>70% stenosis) in the vertebral or subclavian arteries or both. Those lesions that were considered severe enough to explain the reported symptomatology underwent percutaneous intervention and stent placement. All patients were followed up through clinic visits for a mean of 14.2 months (range, 3.5-24.3). RESULTS In the 28 patients treated, 25 vertebral and 10 subclavian stents were placed. Success (<20% residual diameter stenosis, without stroke or death) was achieved in 27 patients (96%). One patient who had been undergoing intervention for a subtotal occlusion of the left subclavian artery developed a posterior fossa transient ischemic attack. At follow-up, 25 patients (89%) were alive, and 22 (88%) of those had no further neurological complaints. Three (11%) patients died during follow-up from cardiac complications. One (3.5%) patient had recurrent symptoms with in-stent restenosis at 6 months with successful balloon angioplasty and resolution of symptoms. CONCLUSIONS Posterior fossa ischemia is an underdiagnosed condition that occurs with relative frequency in the usual patient population that interventional cardiologists attend to. Endovascular treatment using coronary wires and stents including drug-eluting stents is the treatment of choice for vertebral artery revascularization due to its high technical success rate, low complication rate, and long-term durability.
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37
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Veznedaroglu E, Levy EI. Endovascular Management of Acute Symptomatic Intracranial Arterial Occlusion. Neurosurgery 2006; 59:S242-50; discussion S3-13. [PMID: 17053609 DOI: 10.1227/01.neu.0000244419.91488.44] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
Acute ischemic stroke has reached epidemic proportions in the United States, affecting approximately 700,000 people annually. With the recent technological advancements in endovascular devices, clinicians now have tools capable of recanalizing acute intracranial occlusions. The combination of pharmacological thrombolysis and mechanical clot perturbation may result in increased rates of angiographic recanalization, which may lead to improvement in patient outcomes after acute stroke.
METHODS:
In this article, the various intra-arterial pharmacological and mechanical therapies used by interventionists to treat acute stroke are described. Strategies for using combinations of these therapies are discussed, as are preliminary radiographic and clinical outcomes. Techniques for complex mechanical stroke interventions are discussed in detail.
RESULTS:
Several advances in endovascular stroke technologies are becoming increasingly available.
CONCLUSION:
With proper patient selection, these therapies may lead to increased recanalization rates and better patient outcomes.
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Affiliation(s)
- Erol Veznedaroglu
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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38
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Mullen MT, McGarvey ML, Kasner SE. Safety and Efficacy of Thrombolytic Therapy in Postoperative Cerebral Infarctions. Neurol Clin 2006; 24:783-93. [PMID: 16935203 DOI: 10.1016/j.ncl.2006.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Acute ischemic stroke is a common and devastating complication of many surgical procedures. If diagnosed early, however, there are reasonably safe and effective treatment options. Although IV rtPA is the most well studied means of recanalization after ischemic stroke, it should be avoided within 14 days of a surgical procedure in favor of other locally directed techniques that carry a significantly lower risk of bleeding at the surgical site. Only in rare circumstances, when these newer modalities are not available and the surgery is minor, should IV rtPA be considered in postoperative patients. The treatment of choice for carefully selected patients with postoperative strokes is IAT with either rtPA or urokinase. IAT may be attempted up to 6 hours after an acute ischemic stroke and may be assisted by mechanical clot disruption/embolectomy in an attempt to improve recanalization rates. In patients who have had a recent craniotomy or any surgery where surgical site bleeding is expected to be massive or difficult to control or where small amounts of bleeding could be life threatening, IAT should be avoided. In these patients, and in patients who present greater than 6 hours but less than 8 hours after their stroke, mechanical thrombolysis/embolectomy may emerge as the only viable treatment option.
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Affiliation(s)
- Michael T Mullen
- Department of Neurology, University of Pennsylvania, Medical Center, 3 West Gates Building, 3400 Spruce Street, Philadelphia, PA 19104, USA
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39
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Parkinson RJ, Demers CP, Adel JG, Levy EI, Sauvageau E, Hanel RA, Shaibani A, Guterman LR, Hopkins LN, Batjer HH, Bendok BR. Use of heparin-coated stents in neurovascular interventional procedures: preliminary experience with 10 patients. Neurosurgery 2006; 59:812-21; discussion 821. [PMID: 17038945 DOI: 10.1227/01.neu.0000232836.66310.46] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Currently, there is minimal published data on the use of heparin-coated stents in the neurovasculature; however, these stents have a proven clinical record in the treatment of coronary disease. This article details our experience with the safety and technical aspects of stent deployment in the first 10 patients who had heparin-coated stents placed in the intracranial and cervical vasculature and the preliminary follow-up in most cases. METHODS We retrospectively reviewed the clinical history, intra- and periprocedural data, and imaging for the patients who received heparin-coated stents in the cervical and intracranial vasculature for cerebrovascular disease between October 2002 and October 2003. RESULTS Thirteen heparin-coated stents were placed in 10 patients. Seven out of the 10 patients had heparin-coated stents placed in the posterior circulation; the remaining three patients had stents placed in the anterior circulation. Four patients had stents placed intracranially. There was no acute or subacute in-stent thrombosis and no procedure-related complications. Follow-up was performed on most patients, with no clinical symptoms attributable to restenosis in any patient. CONCLUSION This small series suggests that heparin-coated stents are safe for use in the treatment of cervical and intracranial atherosclerotic disease. Longer-term follow-up is needed to study the heparin coating effect on in-stent restenosis rates and to assess the long-term durability and clinical efficacy of this stent. The use of drug-coated stents in the cerebrovascular circulation is an area that warrants further investigation.
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40
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Eberhardt O, Naegele T, Raygrotzki S, Weller M, Ernemann U. Stenting of vertebrobasilar arteries in symptomatic atherosclerotic disease and acute occlusion: case series and review of the literature. J Vasc Surg 2006; 43:1145-54. [PMID: 16765230 DOI: 10.1016/j.jvs.2006.02.027] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2005] [Accepted: 02/10/2006] [Indexed: 12/17/2022]
Abstract
PURPOSE Two of three patients with vertebrobasilar stroke harbor a stenosis of the vertebral or basilar arteries. The best treatment for secondary prophylaxis in vertebrobasilar occlusive disease has not been defined. In patients with high-grade stenoses, and especially those refractory to medication, stenting offers the chance to restore normal flow and prevent major strokes. METHODS We provide data regarding outcome and complications on 20 consecutive patients who underwent vertebrobasilar stenting at our institution (9 V0, 2V3, 5 V4, and 4 basilar artery lesions). Furthermore, we provide a comprehensive overview of the literature on >600 cases of vertebrobasilar stenting, including all published cases up to 2005. RESULTS Primary interventional success was achieved in all cases, with a mean residual stenosis of 3% +/- 4% in V0, 5% +/- 4% in V3/4, and 7% +/- 3% in basilar artery lesions. No peri-interventional neurologic complications and no transient ischemic attack or stroke at follow-up were noted in patients with vertebral ostial lesions, whereas two transient and three permanent clinical deteriorations occurred in patients with V4 or basilar artery lesions, some of which had presented with acute stroke. Patency rate was 100% at the last examination. According to published data on proximal vertebral artery stenting, mortality is 0.3%, the rate of neurologic complications is 5.5%, and the risk of posterior stroke at follow-up is 0.7%. Interventions for distal vertebral or basilar artery disease carry a 3.2% mortality risk, a 17.3% risk for neurologic complications and a 2% risk for stroke at follow-up. CONCLUSIONS Stenting of the vertebral origin can be performed safely and with a low rate of cerebral ischemic events at follow-up, although restenosis may occur. Larger comparative trials are needed. Treatment decisions in distal vertebrobasilar disease have been made on an individual basis.
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Affiliation(s)
- Olaf Eberhardt
- Department of General Neurology, Neurological Clinic, Center for Neurology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.
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Levy EI, Ecker RD, Horowitz MB, Gupta R, Hanel RA, Sauvageau E, Jovin TG, Guterman LR, Hopkins LN. Stent-assisted intracranial recanalization for acute stroke: early results. Neurosurgery 2006; 58:458-63; discussion 458-63. [PMID: 16528185 DOI: 10.1227/01.neu.0000199159.32210.e4] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE In patients who are not candidates for intravenous tissue plasminogen activator, intra-arterial (IA) therapy is an alternative. Current recanalization rates are 50 to 60% for IA thrombolysis. Stent-assisted recanalization in the setting of acute stroke after failed thrombolysis may improve recanalization rates. METHODS A retrospective analysis was performed of 19 patients treated at two institutions between July 2001 and March, 2005 with intracranial stenting of a vessel resistant to standard thrombolytic techniques. Demographics, clinical, and radiographic presentation and outcomes were studied. RESULTS Thirteen men and six women with a median baseline National Institutes of Health Stroke Scale (NIHSS) score of 16 (range, 15-22) were included. Eight lesions were located at the internal carotid artery terminus, seven in the M1/M2 segment, and four in the basilar artery. Average time-to-treatment was 210 +/- 160 minutes. Overall recanalization rate (Thrombolysis in Cerebral Infarction Grade 2 or 3) was 79%. There were six deaths: five due to progression of stroke and withdrawal of care at the family's request and one as the result of a delayed carotid injury after tracheostomy. One postoperative asymptomatic intracranial hemorrhage occurred without adverse affect on outcome. Median discharge NIHSS score of surviving patients was 5 (range, 2.5-11.5). Lesions at the internal carotid artery terminus (P < 0.009), older age (P < 0.003), and higher baseline NIHSS score (P < 0.009) were significant negative outcome predictors, as measured by >3 modified Rankin scale score at discharge. CONCLUSION Stent-assisted recanalization for acute stroke resulting from intracranial thrombotic occlusion is associated with a high recanalization rate and low intracranial hemorrhage rate. These initial results suggest that stenting may be an option for recalcitrant cerebral arterial occlusions.
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Affiliation(s)
- Elad I Levy
- Department of Neurosurgery, Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York 14209, USA
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Abstract
Background and Purpose—
Basilar artery occlusion (BAO) is an infrequent form of acute stroke, which invariably leads to death or long-term disability if not recanalized. A traditional recanalization approach based on historical controls and pathophysiological consideration is local intra-arterial thrombolysis (IAT) in eligible patients. This necessitates diagnostic evaluation and treatment in stroke centers equipped with an interventional neuroradiological service on a 24-hour basis, but its superiority to the technically simple intravenous thrombolysis (IVT) remains unproven.
Methods—
We analyzed systematically published case series of substantial size reporting the outcome of BAO after IAT or IVT.
Results—
In 420 BAO patients treated with IVT (76) and IAT (344), death or dependency were equally common: 78% (59 of 76) and 76% (260 of 344), respectively (
P
=0.82). Recanalization was achieved more frequently with IAT (225 of 344; 65%) than with IVT (40 of 76; 53%;
P
=0.05), but survival rates after IVT (38 of 76; 50%) and IAT (154 of 344; 45%) were equal (
P
=0.48). A total of 24% of patients treated with IAT and 22% treated with IVT reached good outcomes (
P
=0.82). Without recanalization, the likelihood of good outcome was close to nil (2%).
Conclusions—
Recanalization occurs in more than half of BAO patients treated with IAT or IVT, and 45% to 55% of survivors regain functional independence. Although improved therapy forms for BAO are necessary, hospitals not equipped for IAT may set up IVT protocols. The effect of IVT is probably not much different from the effect of IAT. IVT represents probably the best treatment that can be offered to victims of acute BAO in such hospitals.
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Affiliation(s)
- Perttu J Lindsberg
- Department of Neurology, Neurosciences Program, Biomedicum Helsinki, Helsinki, Finland.
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43
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Boy S, Isenhardt K, Gardill K, Kapp B, Schneider R, Berkefeld J. [Interventional endovascular therapy (stenting) for residual stenosis after lysis of the basilar artery]. DER NERVENARZT 2005; 76:1488, 1490-2, 1494. [PMID: 16047137 DOI: 10.1007/s00115-005-1958-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Despite the introduction of local thrombolytic therapy, there is still a very high mortality rate in basilar thrombosis. We report three cases of successful intra-arterial thrombolysis of acute basilar artery occlusion and consecutive interventional endovascular therapy. In all cases, the acute thrombosis of the basilar artery probably developed from preexisting atherosclerotic stenoses. The clinical outcomes were excellent. We discuss early consecutive stenting as a possible therapeutic option in cases of residual stenosis after successful intra-arterial lysis of basilar artery occlusion.
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Affiliation(s)
- S Boy
- Neurologische Klinik, Klinikum Aschaffenburg
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44
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Pfefferkorn T, Mayer TE, Schulte-Altedorneburg G, Brückmann H, Hamann GF, Dichgans M. [Diagnosis and therapy of basilar artery occlusion]. DER NERVENARZT 2005; 77:416-22. [PMID: 16228158 DOI: 10.1007/s00115-005-2007-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In view of the poor prognosis for untreated patients with basilar artery occlusion, rapid delivery of effective treatment has the highest priority. Early recanalization by intra-arterial thrombolysis can improve the outcome in some patients. Apart from this method, specialized centers are increasingly using mechanical devices and glycoprotein IIb/IIIa inhibitors to achieve recanalization. This review focuses on current developments in the diagnosis and treatment of acute basilar artery occlusion.
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Affiliation(s)
- T Pfefferkorn
- Neurologische Klinik, Klinikum Grosshadern, Ludwigs-Maximilians-Universität München.
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45
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Horowitz M, Jovin T, Levy E, Anderson W. Emergent Basilar Artery and Bilateral Posterior Cerebral Artery Angioplasty, Urokinase Thrombolysis, and Stenting for Acute Basilar Artery Occlusion Secondary to Diagnostic Cardiac Catheterization: Case Presentation. J Neuroimaging 2005. [DOI: 10.1111/j.1552-6569.2005.tb00329.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Schonewille WJ, Algra A, Serena J, Molina CA, Kappelle LJ. Outcome in patients with basilar artery occlusion treated conventionally. J Neurol Neurosurg Psychiatry 2005; 76:1238-41. [PMID: 16107358 PMCID: PMC1739786 DOI: 10.1136/jnnp.2004.049924] [Citation(s) in RCA: 159] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Most data on the outcome of basilar artery occlusion are from recent case series of patients treated with intra-arterial thrombolysis. The limited knowledge on the outcome after a conventional treatment approach comes from a few small case series of highly selected patients. OBJECTIVE To provide more data on the outcome of conventional treatment. METHODS Data were analysed on patients from three centres with symptomatic basilar artery occlusion treated conventionally. Conventional therapy was defined as treatment with antiplatelets, anticoagulation, or both. RESULTS Data were available on 82 patients. The case fatality was 40%. Among survivors, 65% remained dependent (Rankin score 4-5). Patients younger than 60 years (odds ratio = 3.1 (95% confidence interval, 1.0 to 9.5)) and those with a minor stroke (OR = 3.1 (1.0 to 9.6)) were more likely to have a good outcome (Rankin score 0-3). Patients with a progressive stroke were less likely to have a good outcome (OR = 0.3 (0.08 to 1.2)) than patients with a maximum deficit at onset or fluctuating symptoms at presentation. CONCLUSIONS Conventional treatment of symptomatic basilar artery occlusion is associated with a poor outcome in almost 80% of patients, which emphasises the importance of the search for a more effective treatment approach.
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Affiliation(s)
- W J Schonewille
- University Medical Centre Utrecht, Department of Neurology, HP G 03.228, PO Box 85500, 3508 GA Utrecht, Netherlands.
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Eckert B, Koch C, Thomalla G, Kucinski T, Grzyska U, Roether J, Alfke K, Jansen O, Zeumer H. Aggressive Therapy With Intravenous Abciximab and Intra-Arterial rtPA and Additional PTA/Stenting Improves Clinical Outcome in Acute Vertebrobasilar Occlusion. Stroke 2005; 36:1160-5. [PMID: 15890988 DOI: 10.1161/01.str.0000165918.80812.1e] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
A combined therapy of local recombinant tissue plasminogen activator (rtPA) fibrinolysis and intravenous Abciximab platelet inhibition with additional percutaneous transluminal angioplasty (PTA)/stenting may improve recanalization and neurological outcome in patients with acute vertebrobasilar occlusion.
MethodsCombined FAST therapy consisted on intravenous bolus of Abciximab (0.25 mg/kg) followed by a 12-hour infusion therapy (0.125 μg/kg per minute) and low-dose intra-arterial rtPA (median dosage: 20 mg, FAST cohort: N=47). The results were compared with a retrospective cohort, treated by intraarterial rtPA monotherapy (median dosage: 40 mg, rtPA cohort, N=41). Additional PTA/stenting was performed in case of severe residual stenosis. Recanalization success was classified according to the Trials in Myocardial Infarction (TIMI) criteria: TIMI0/1, failed recanalization; TIMI2/3, successful recanalization. Bleeding complications were evaluated according to severe extracerebral hemorrhage (ECH), asymptomatic intracerebral hemorrhage (AIH), and symptomatic intracerebral hemorrhage (SIH).
Results—
Overall bleeding rate was higher under the combined therapy, but the SIH rate did not differ (FAST versus rtPA: ECH, 3% versus 0%; AIH, 32% versus 22%; SIH 13% versus 12%). Additional PTA/stenting was performed in 14 (FAST) versus 5 (rtPA) patients. TIMI2/3 recanalization rate was similar (FAST, 72%; rtPA, 68%), but TIMI3 rate was remarkably higher under combined therapy (FAST, 45%; rtPA, N=22%). Neurologic outcome appeared better under combined therapy (FAST versus rtPA: favorable outcome rate: 34% versus 17%) with a significantly lower mortality rate (FAST versus rtPA: 38% versus 68%;
P
=0.006). These results were consistent for embolic and atherothrombotic occlusions.
Conclusion—
Combined therapy of intravenous Abciximab and half dose intra-arterial rtPA with additional PTA/stenting appears to improve neurologic outcome in acute vertebrobasilar occlusion despite an increase of overall bleeding complications.
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Affiliation(s)
- Bernd Eckert
- Department of Neuroradiology, University Hospital Hamburg-Eppendorf, Germany.
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48
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Grunwald IQ, Struffert T, Roth C, Papanagiotou P, Scheuermann J, Voges M, Reith W. Thrombolyse der A. basilaris: Ergebnisse im Saarland über einen Zeitraum von 5 Jahren. Radiologe 2005; 45:448-54. [PMID: 15871003 DOI: 10.1007/s00117-005-1221-2] [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: 10/25/2022]
Abstract
Acute thrombosis of the basilar artery has a fatal outcome if left untreated. The relatively good prognosis with intra-arterial thrombolysis makes it the therapy of choice for acute basilar thrombosis. In the Saarland stroke registry, we analyzed 47 patients with angiographically proven basilar artery thrombosis within the last 5 years. We observed a better outcome in patients with good income, with recanalization, and a short time between onset of symptoms and start of thrombolysis. The complications, such as intracerebral bleedings, occurred only in the group treated with rt-PA. Intra-arterial thrombolysis with urokinase or rt-PA is a relatively safe therapy, but should be performed in neuroradiological centers. With progressing symptoms the therapeutic window can be stretched up to 12 h, but coma lasting for more than 4 h is related to a bad outcome.
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Affiliation(s)
- I Q Grunwald
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum des Saarlandes Homburg, Homburg/Saar.
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49
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Lindsberg PJ, Soinne L, Roine RO, Tatlisumak T. Options for Recanalization Therapy in Basilar Artery Occlusion. Stroke 2005; 36:203-4. [PMID: 15637313 DOI: 10.1161/01.str.0000153796.49137.e8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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50
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Koebbe CJ, Horowitz MB, Levy EI, Dutton K, Jungries CC, Purdy PD. Intraarterial thrombolysis for thromboemboli associated with endovascular aneurysm coiling. Report of five cases. Interv Neuroradiol 2004; 8:151-8. [PMID: 20594524 DOI: 10.1177/159101990200800207] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2002] [Accepted: 05/09/2002] [Indexed: 11/16/2022] Open
Abstract
SUMMARY With the rapidly developing applications of GDC endovascular aneurysm embolization, the recognition and treatment of potential intra-procedural complications is crucial to reducing the morbidity and mortality of this procedure. Thromboembolic complications occur with an incidence of 2-11% with endovascular aneurysm coiling. We describe five cases in which the intraarterial use of thrombolytics was applied to disrupt a fresh clot and recanalize the occluded vessels with variable angiographic and clinical success. Five cases are presented in which thromboembolic complications occurred during or shortly after GDC endovascular aneurysm occlusion. The complication was recognized while depositing coils in two cases, on post-embolization angiogram in one, and a few hours following embolization in two cases in which a new neurologic deficit developed in the ICU. In those cases recognized while the microcatheter was near the aneurysm site, immediate thrombolysis was performed at the site of occlusion. The patients who developed a new neurologic deficit were returned to the endovascular suite and the site of occlusion was noted to be distal to the coiled aneurysm. Clot disruption was performed with the microcatheter before delivering intraarterial thrombolytics. Thromboembolic complications of GDC aneurysm embolization are fortunately rare and can be managed with delivery of thrombolytic therapy at the site of occlusion. Intraarterial thrombolysis of fresh clot caused by GDC aneurysm occlusion can successfully open the occluded vessels but not without serious risk of hemorrhage.
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Affiliation(s)
- C J Koebbe
- Department of Neurological Surgery, University of Pittsburgh Medical Center; Pittsburgh; Pennsylvania, USA
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