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Zidan M, Gronemann C, Lehnen NC, Bode F, Weller J, Petzold G, Radbruch A, Paech D, Dorn F. Stenting with dual-layer CGuard stent in acute sub-occlusive carotid artery stenosis and in tandem occlusions: a monocentric study. Neuroradiology 2024; 66:1635-1644. [PMID: 38844697 PMCID: PMC11322317 DOI: 10.1007/s00234-024-03397-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 06/01/2024] [Indexed: 08/16/2024]
Abstract
PURPOSE Double-layer design carotid stents have been cast in a negative light since several investigations reported high rates of in-stent occlusions, at least in the acute setting of tandem occlusions. CGuard is a new generation double-layered stent that was designed to prevent periinterventional embolic events. The aim of this study was to analyze the safety and efficacy of the CGuard in emergent CAS and for the acute treatment of tandem occlusions in comparison with the single-layer Carotid Wallstent (CWS) system. METHODS All patients who underwent CAS with CGuard or CWS after intracranial mechanical thrombectomy (MT) between 11/2018 and 12/2022 were identified from our local thrombectomy registry. Clinical, interventional and neuroimaging data were analyzed. Patency of the stent was assessed within 72 h. Intracranial hemorrhage and modified Rankin score (mRS) at discharge were the main endpoints. RESULTS In total, 86 stent procedures in 86 patients were included (CWS: 44, CGuard: 42). CGuard had a lower, but not statistically significant rate (p = 0.431) of in-stent occlusions (n = 2, 4.8%) when compared to the CWS (n = 4, 9.1%). Significant in-stent stenosis was found in one case in each group. There was no statistically significant difference in functional outcome at discharge between the two groups with a median mRS for CGuard of 2 (IQR:1-5) vs. CWS 3 (IQR:2-4). CONCLUSION In our series, the rate of in-stent occlusions after emergent CAS was lower with the dual-layer CGuard when compared to the monolayer CWS. Further data are needed to evaluate the potential benefit of the design in more detail.
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Affiliation(s)
- Mousa Zidan
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany.
| | - Christian Gronemann
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany
| | - Nils Christian Lehnen
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany
| | - Felix Bode
- Department of Neurology, Bonn University Hospital, Bonn, Germany
| | - Johannes Weller
- Department of Neurology, Bonn University Hospital, Bonn, Germany
| | - Gabor Petzold
- Department of Neurology, Bonn University Hospital, Bonn, Germany
| | - Alexander Radbruch
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany
| | - Daniel Paech
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany
- Department of Radiology, German Cancer Research Centre, Heidelberg, Germany
| | - Franziska Dorn
- Department of Neuroradiology, Bonn University Hospital, Venusberg-Campus1, Gebäude 81, 53127, Bonn, Germany
- Department of Neuroradiology, LMU-Klinikum der Universität München Medizinische Klinik und Poliklinik IV, Munich, Bayern, Germany
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Rodriguez MP, Taleb S, Lee JJH, Liebeskind DS, Saver JL. AC-ASPECTS, ACh-ASPECTS, and H-ASPECTS: new imaging scales to assess territorial and total cerebral hemispheric ischemic injury. Front Neurol 2024; 15:1397120. [PMID: 39022729 PMCID: PMC11252022 DOI: 10.3389/fneur.2024.1397120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 06/12/2024] [Indexed: 07/20/2024] Open
Abstract
Background The extent of ischemic injury in acute stroke is assessed in clinical practice using the Acute Stroke Prognosis Early CT Score (ASPECTS) rating system. However, current ASPECTS semi-quantitative topographic scales assess only the middle cerebral artery (MCA) (original ASPECTS) and posterior cerebral (PC-ASPECTS) territories. For treatment decision-making in patients with anterior cerebral artery (ACA) occlusions and internal carotid artery (ICA) occlusions with large ischemic cores, measures of all hemispheric regions are desirable. Methods In this cohort study, anatomic rating systems were developed for the anterior cerebral (AC-ASPECTS, 3 points) and anterior choroidal artery (ACh-ASPECTS, 1 point) territories. In addition, a total supratentorial hemisphere (H-ASPECTS, 16 points) score was calculated as the sum of the MCA ASPECTS (10 regions), supratentorial PC-ASPECTS (2 regions), AC-ASPECTS (3 regions), and ACh-ASPECTS (1 region). Three raters applied these scales to initial and 24 h CT and MR images in consecutive patients with ischemic stroke (IS) due to ICA, M1-MCA, and ACA occlusions. Results Imaging ratings were obtained for 96 scans in 50 consecutive patients with age 74.8 (±14.0), 60% female, NIHSS 15.5 (9.25-20), and occlusion locations ICA 34%; M1-MCA 58%; and ACA 8%. Treatments included endovascular thrombectomy +/- thrombolysis in 72%, thrombolysis alone in 8%, and hemicraniectomy in 4%. Among experienced clinicians, inter-rater reliability for AC-, ACh-, and H-ASPECTS scores was substantial (kappa values 0.61-0.80). AC-ASPECTS abnormality was present in 14% of patients, and ACh-ASPECTS abnormality in 2%. Among patients with ACA and ICA occlusions, H-ASPECTS scores compared with original ASPECTS scores were more strongly associated with disability level at discharge, ambulatory status at discharge, discharge destination, and combined inpatient mortality and hospice discharge. Conclusion AC-ASPECTS, ACh-ASPECTS, and H-ASPECTS expand the scope of acute IS imaging scores and increase correlation with functional outcomes. This additional information may enhance prognostication and decision-making, including endovascular thrombectomy and hemicraniectomy.
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Affiliation(s)
| | - Shayandokht Taleb
- Department of Neurology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, United States
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Jenny Ji-hyun Lee
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - David S. Liebeskind
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Jeffrey L. Saver
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Riegler C, von Rennenberg R, Bollweg K, Nguyen TN, Kleine JF, Tiedt S, Audebert HJ, Siebert E, Nolte CH. Endovascular therapy in patients with internal carotid artery occlusion and patent circle of Willis. J Neurointerv Surg 2024; 16:644-651. [PMID: 37491381 PMCID: PMC11228208 DOI: 10.1136/jnis-2023-020556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/24/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Occlusion of the internal carotid artery (ICA) may extend into the middle or anterior cerebral artery (ICA-T) or be confined to the intracranial (ICA-I) or extracranial segment (ICA-E). While there is excellent evidence for endovascular therapy (EVT) in ICA-T occlusions, studies on EVT in non-tandem ICA-I or ICA-E occlusions are scarce. OBJECTIVE To characterize EVT-treated patients with ICA-I- and ICA-E occlusion by comparing them with ICA-T occlusions. METHODS The German Stroke Registry (GSR), a national, multicenter, prospective registry was searched for EVT-treated patients with isolated ICA occlusion between June 2015 and December 2021. We stratified patients by ICA occlusion site: (a) ICA-T, (b) ICA-I, (c) ICA-E. Baseline factors, procedural variables, technical (modified Thrombolysis in Cerebral Infarction (mTICI)), and functional outcomes (modified Rankin scale score at 3 months) were analyzed. RESULTS Of 13 082 GSR patients, 2588 (19.8%) presented with an isolated ICA occlusion, thereof 1946 (75.2%) ICA-T, 366 (14.1%) ICA-I, and 276 (10.7%) ICA-E patients. The groups differed in age (77 vs 76 vs 74 years, Ptrend=0.02), sex (53.4 vs 48.9 vs 43.1% female, Ptrend<0.01), and stroke severity (median National Institutes of Health Stroke Scale score at admission 17 vs 14 vs 13 points, Ptrend<0.001). In comparison with ICA-T occlusions, both ICA-I and ICA-E occlusions had lower rates of successful recanalization (mTICI 2b/3: 85.4% vs 80.4% vs 76.3%; aOR (95% CI for ICA-I vs ICA-T 0.71 (0.53 to 0.95); aOR (95% CI) for ICA-E vs ICA-T 0.57 (0.42 to 0.78)). In adjusted analyses, ICA-E occlusion was associated with worse outcome when compared with ICA-T occlusion (mRS ordinal shift, cOR (95% CI) 0.70 (0.52 to 0.93)). CONCLUSION Patient characteristics and outcomes differ substantially between ICA-T, ICA-I, and ICA-E occlusions. These results warrant further studies on EVT in ICA-I and ICA-E patients.
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Affiliation(s)
- Christoph Riegler
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Regina von Rennenberg
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Kerstin Bollweg
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston, Massachusetts, USA
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Justus F Kleine
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | - Heinrich J Audebert
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
- Berlin Insititute of Health at Charité, Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany
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Qureshi AI, Lodhi A, Akhtar IN, Ma X, Kherani D, Kwok CS, Ford DE, Hanley DF, Hassan AE, Nguyen TN, Spiotta AM, Zaidi SF. Mechanical thrombectomy with intra-arterial thrombolysis versus mechanical thrombectomy alone in patients with acute ischemic stroke: A systematic review and meta-analysis. Int J Stroke 2024; 19:16-28. [PMID: 37306490 DOI: 10.1177/17474930231184369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND There is conflicting evidence as to whether intra-arterial thrombolysis (IAT) adds benefit in patients with acute stroke who undergo mechanical thrombectomy (MT). METHODS We conducted a systematic review to identify studies that evaluate IAT in patients with acute stroke who undergo MT. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until February 2023. Statistical pooling with random effects meta-analysis was undertaken to evaluate odds of functional independence, mortality, and near-complete or complete angiographic recanalization with IAT compared to no IAT. RESULTS A total of 18 studies were included (3 matched, 14 unmatched, and 1 randomized). The odds ratio (OR) for functional independence (modified Rankin Scale: 0-2) at 90 days was 1.14 (95% confidence interval (CI): 0.95-1.37, p = 0.17, 16 studies involving 7572 patients) with IAT with moderate between-study heterogeneity (I2 = 38.1%). The OR for functional independence with IAT was 1.28 (95% CI: 0.92-1.78, p = 0.15) in studies that were either matched or randomized and 1.24 (95% CI: 0.97-1.58, p = 0.08) in studies with the highest quality score. IAT was associated with higher odds of near-complete or complete angiographic recanalization (OR: 1.65, 95% CI: 1.03-2.65, p = 0.04) in studies that were either matched or of randomized comparisons. CONCLUSION Although the odds of functional independence appeared to be higher with IAT and MT compared with MT alone, none of the results were statistically significant. A prominent effect of the design and quality of the studies was observed on the association between IAT and functional independence at 90 days.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Abdullah Lodhi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Iqra N Akhtar
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Xiaoyu Ma
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Danish Kherani
- Department of Neurology, Houston Methodist Neurological Institute, Houston, TX, USA
| | - Chun Shing Kwok
- Department of Cardiology, University Hospitals of Birmingham NHS Trust, Birmingham, UK
| | - Daniel E Ford
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel F Hanley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ameer E Hassan
- Department of Neurology, The University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Syed F Zaidi
- Department of Neurology, The University of Toledo Medical Center, Toledo, OH, USA
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Klail T, Sedova P, Vinklarek JF, Kovacova I, Bar M, Cihlar F, Cernik D, Kočí L, Jura R, Herzig R, Husty J, Kocher M, Kovar M, Nevšímalová M, Raupach J, Rocek M, Sanak D, Sevcik P, Skoloudik D, Sramek M, Vanicek J, Vaško P, Vaclavik D, Tomek A, Mikulik R. Safety and Efficacy of Baseline Antiplatelet Treatment in Patients Undergoing Mechanical Thrombectomy for Ischemic Stroke: Antiplatelets Before Mechanical Thrombectomy. J Vasc Interv Radiol 2023; 34:1502-1510.e12. [PMID: 37192724 DOI: 10.1016/j.jvir.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/17/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023] Open
Abstract
PURPOSE To investigate the safety and efficacy of baseline antiplatelet treatment in patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT). MATERIALS AND METHODS Baseline use of antiplatelet medication before MT for (AIS) may provide benefit on reperfusion and clinical outcome but could also carry an increased risk of intracranial hemorrhage (ICH). All consecutive patients with AIS and treated with MT with and without intravenous thrombolysis (IVT) between January 2012 and December 2019 in all centers performing MT nationwide were reviewed. Data were prospectively collected in national registries (eg, SITS-TBY and RES-Q). Primary outcome was functional independence (modified Rankin Scale 0-2) at 3 months; secondary outcome was ICH. RESULTS Of the 4,351 patients who underwent MT, 1,750 (40%) and 666 (15%) were excluded owing to missing data from the functional independence and ICH outcome cohorts, respectively. In the functional independence cohort (n = 2,601), 771 (30%) patients received antiplatelets before MT. Favorable outcome did not differ in any antiplatelet, aspirin, and clopidogrel groups when compared with that in the no-antiplatelet group: odds ratio (OR), 1.00 (95% CI, 0.84-1.20); OR, 1.05 (95% CI, 0.86-1.27); and OR, 0.88 (95% CI, 0.55-1.41), respectively. In the ICH cohort (n = 3,685), 1095 (30%) patients received antiplatelets before MT. The rates of ICH did not increase in any treatment options (any antiplatelet, aspirin, clopidogrel, and dual antiplatelet groups) when compared with those in the no-antiplatelet group: OR, 1.03 (95% CI, 0.87-1.21); OR, 0.99 (95% CI, 0.83-1.18); OR, 1.10 (95% CI, 0.82-1.47); and OR, 1.43 (95% CI, 0.87-2.33), respectively. CONCLUSIONS Antiplatelet monotherapy before MT did not improve functional independence or increase the risk of ICH.
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Affiliation(s)
- Tomas Klail
- Faculty of Medicine, Masaryk University, Brno, Czech Republic; University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | - Petra Sedova
- Department of Neurology, St Anne's University Hospital, Brno, Czech Republic; International Clinical Research Centre, Stroke Research Program, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Neurology, Mayo Clinic, Rochester, Minnesota; Department of Internal Medicine and Cardiology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Jan F Vinklarek
- Department of Neurology, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ingrid Kovacova
- International Clinical Research Centre, Stroke Research Program, St Anne's University Hospital, Brno, Czech Republic
| | - Michal Bar
- Department of Neurology, University Hospital, Ostrava, Czech Republic; Faculty of Medicine, Ostrava University, Ostrava, Czech Republic
| | - Filip Cihlar
- Department of Radiology, Masaryk's Hospital, Faculty of Health Studies, J.E. Purkinje University, KZ a.s., Ústí nad Labem, Czech Republic
| | - David Cernik
- Department of Radiology, Masaryk's Hospital, Faculty of Health Studies, J.E. Purkinje University, KZ a.s., Ústí nad Labem, Czech Republic
| | - Lubomir Kočí
- Neurocentre, Regional Hospital Liberec, Liberec, Czech Republic
| | - Rene Jura
- Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Neurology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Roman Herzig
- Department of Neurology, Comprehensive Stroke Centre, Charles University Faculty of Medicine and University Hospital in Hradec Králové, Hradec Králové, Czech Republic
| | - Jakub Husty
- Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Radiology and Nuclear Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Kocher
- Department of Radiology, Palacky University Medical School and Hospital, Olomouc, Czech Republic
| | - Martin Kovar
- Department of Neurology, Na Homolce Hospital, Prague, Czech Republic
| | - Miroslava Nevšímalová
- Department of Neurology, Hospital Ceske Budejovice, Ceske Budejovice, Czech Republic
| | - Jan Raupach
- Department of Radiology, University Hospital and Faculty of Medicine Hradec Králové, Charles University in Prague, Hradec Králové, Czech Republic
| | - Miloslav Rocek
- Department of Radiology, 2nd Medical School of Charles University and Motol University Hospital, Prague, Czech Republic
| | - Daniel Sanak
- Department of Neurology, Palacky Medical School and University Hospital, Comprehensive Stroke Center, Olomouc, Czech Republic
| | - Petr Sevcik
- Department of Neurology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - David Skoloudik
- Center for Health Research, Medical Faculty, Ostrava University, Ostrava, Czech Republic
| | - Martin Sramek
- Department of Neurosurgery and Neurooncology, 1st Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic; Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Jiri Vanicek
- Department of Medical Imaging, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Peter Vaško
- Department of Neurology, Faculty Hospital Kralovske Vinohrady and 3rd Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Daniel Vaclavik
- Neurology, Agel Research and Training Institute, Ostrava Vitkovice Hospital, Ostrava, Czech Republic; Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Ales Tomek
- Department of Neurology, 2nd Medical School of Charles University and Motol University Hospital, Prague, Czech Republic
| | - Robert Mikulik
- Department of Neurology, St Anne's University Hospital, Brno, Czech Republic; International Clinical Research Centre, Stroke Research Program, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Chang Y, Li YZ, Xue L. Adjuvant intra-arterial thrombolysis during mechanical thrombectomy is an effective means of improving outcomes for patients with large vessel occlusion stroke: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 232:107898. [PMID: 37473487 DOI: 10.1016/j.clineuro.2023.107898] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 06/30/2023] [Accepted: 07/15/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE It is unknown whether adjunctive intra-arterial thrombolysis (IAT) during mechanical thrombectomy (MT) improves outcomes in patients with large vessel occlusion (LVO) stroke. This systematic review and meta-analysis aimed to compare the safety and efficacy of MT with and without IAT for the treatment of LVO stroke. METHODS A systematic literature search of PubMed, Embase, and the Cochrane Library was conducted to identify studies that compared rates of 3-month functional independence (modified Rankin Scale score 0-2), successful revascularization, symptomatic intracranial hemorrhage, and 3-month mortality for MT+IAT and MT alone. Meta-analyses were performed using random effects models, and effect sizes were expressed as odds ratios (ORs) and 95% confidence intervals (CIs). Heterogeneity was assessed with Cochran's Q test and I2 statistic. RESULTS Twelve studies met eligibility criteria, comprising one randomized controlled trial and 11 observational cohort studies involving 2584 patients. Compared to MT alone, MT+IAT had a 43% higher odds of 3-month functional independence (OR 1.43, 95% CI 1.11-1.83; I2 =21%) and a 23% decrease in odds for 3-month mortality (OR 0.77, 95% CI 0.60-0.99; I2 =0%). There were no differences in successful revascularization (OR 1.39, 95% CI 0.89-2.17; I2 =57%) or symptomatic intracranial hemorrhage (OR 0.87, 95% CI 0.56-1.35; I2 =6%) between the two groups. CONCLUSIONS The present study has demonstrated that, compared with MT alone, the use of adjunct IAT during MT in patients with LVO stroke resulted in better functional outcomes and lower mortality.
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Affiliation(s)
- Yu Chang
- Department of Neurology, Suining Central Hospital, Sichuan, China.
| | - Yi-Zheng Li
- Department of Neurology, Qinghai Provincial People's Hospital, Qinghai, China
| | - Lin Xue
- Department of Neurology, The First Hospital of Jilin University, Jinlin, China
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7
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Elfil M, Ghozy S, Elmashad A, Ghaith HS, Aladawi M, Dicpinigaitis AJ, Mansour OY, Khandelwal P, Asif K, Nour M, Toth G, Al-Mufti F. Effect of intra-arterial thrombolysis following successful endovascular thrombectomy on functional outcomes in patients with large vessel occlusion acute ischemic stroke: A post-CHOICE meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107194. [PMID: 37216750 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 05/24/2023] Open
Abstract
INTRODUCTION Endovascular thrombectomy (EVT) is the standard treatment of acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Although > 70% of patients in the trials assessing EVT for AIS-LVO had successful recanalization, only a third ultimately achieved favorable outcomes. A "no-reflow" phenomenon due to distal microcirculation disruption might contribute to such suboptimal outcomes. Combining intra-arterial (IA) tissue plasminogen activator (tPA) and EVT to reduce the distal microthrombi burden was investigated in a few studies. We present a pooled-data meta-analysis of the existing evidence of this combinatorial treatment. METHODS We followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) recommendations. We aimed to include all original studies investigating EVT plus IA tPA in AIS-LVO patients. Using R software, we calculated pooled odds ratios (ORs) with corresponding 95% confidence intervals (CI). A fixed-effects model was adopted to evaluate pooled data. RESULTS Five studies satisfied the inclusion criteria. Successful recanalization was comparable between the IA tPA and control groups at 82.9% and 82.32% respectively. The 90-day functional independence was similar between both groups (OR= 1.25; 95% CI= 0.92-1.70; P= 0.154). Symptomatic intracranial hemorrhage (sICH) was also comparable between both groups (OR= 0.66; 95% CI= 0.34-1.26; P= 0.304). CONCLUSION Our current meta-analysis does not show significant differences between EVT alone and EVT plus IA tPA in terms of functional independence or sICH. However, with the limited number of studies and included patients, more randomized controlled trials (RCTs) are needed to further investigate the benefits and safety of combined EVT and IA tPA.
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Affiliation(s)
- Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Ahmed Elmashad
- Department of Neurology, University of Connecticut, Farmington, CT, USA
| | | | - Mohammad Aladawi
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Ossama Yassin Mansour
- Department of Neurology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Priyank Khandelwal
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Kaiz Asif
- Ascension Health and University of Illinois-Chicago, Chicago, IL, USA
| | - May Nour
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Gabor Toth
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, New York Medical College at Westchester Medical Center, Valhalla, NY, USA.
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Bilgin C, Kobeissi H, Ghozy S, Mohammed MA, Kadirvel R, Kallmes DF. First-line thrombectomy strategy for carotid terminus occlusions: A systematic review and meta-analysis. World Neurosurg X 2023; 19:100208. [PMID: 37213688 PMCID: PMC10193023 DOI: 10.1016/j.wnsx.2023.100208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 04/04/2023] [Accepted: 04/21/2023] [Indexed: 05/23/2023] Open
Abstract
Background Little research has focused on the performance of mechanical thrombectomy (MT) in carotid terminus occlusions (CTOs). Therefore, the best first-line thrombectomy strategy for CTOs remains unclear. Purpose To compare the safety and efficacy outcomes of three first-line thrombectomy techniques in CTOs. Methods A systematic literature search was conducted in Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, and Cochrane Central Register of Clinical Trials databases. Studies providing safety and efficacy outcomes for endovascular treatment of CTOs were included. Data regarding successful recanalization, functional independence, symptomatic intracranial hemorrhage (sICH), and first pass efficacy (FPE) were extracted from the included studies. A random-effects model was used to calculate prevalence rates and their corresponding 95% confidence intervals (CI), and subgroup analyses were performed to assess the impact of the initial MT technique on safety and efficacy outcomes. Results Six studies with 524 patients were included. The overall successful recanalization rate was 85.84% (95% CI = 77.96-94.52), and subgroup analysis did not show a significant difference among the three first-line MT techniques. Overall rates of functional independence and FPE were 39.73% (95% CI = 32.95-47.89) and 32.09% (95% CI = 22.93-44.92), respectively. The combined stent retriever (SR) and aspiration (ASP) technique achieved significantly higher first-pass efficacy rates compared to SR or ASP alone. The overall sICH rate was 9.89% (95% CI = 4.88-20.07), and subgroup analysis did not demonstrate a significant difference across groups. The sICH rates of SR, ASP, and SR + ASP were 8.49% (95% CI = 1.76-40.93), 6.8% (95% CI = 4.59-10.09), and 7.12% (95% CI = 0.27-100), respectively. Conclusions Our results support that MT is highly effective for CTOs with functional independence rates of 39%. Additionally, in our meta-analysis, the SR + ASP technique was associated significantly greater rates of FPE compared to SR or ASP alone, without an increase in sICH rates. Prospective, large-scale studies are necessary to determine the optimal first-line MT technique in the endovascular treatment of CTOs.
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Affiliation(s)
- Cem Bilgin
- Department of Radiology, Mayo Clinic Rochester, Minnesota, USA
- Corresponding author. 200 First St. SW, Rochester, MN, 55902, USA.
| | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic Rochester, Minnesota, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic Rochester, Minnesota, USA
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9
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Zhang Y, Zhang L, Zhang Y, Li Z, Zhang Y, Xing P, Chen W, Wang S, Li T, Yang P, Liu J. Endovascular Recanalization for Acute Internal Carotid Artery Terminus Occlusion: A Subgroup Analysis From the Direct-MT Trial. Neurosurgery 2022; 91:596-603. [PMID: 35856942 PMCID: PMC9447436 DOI: 10.1227/neu.0000000000002085] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/23/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The efficacy of endovascular recanalization for internal carotid artery (ICA) terminus occlusion has not been completely evaluated. OBJECTIVE To investigate the efficacy of endovascular recanalization for ICA terminus occlusion. METHODS Data from Direct-MT, a randomized controlled trial, were applied. ICA terminus occlusions were diagnosed with preprocedure computed tomography angiography by the core laboratory. We dichotomized the ICA terminus occlusions into 2 groups (non-T and T) and analyzed the differences between them. Single-factor analysis and multiple logistic regression were applied to detect independent factors for clinical outcomes and futile recanalization. RESULTS The rates of first-pass effect, successful recanalization, good clinical outcome, mortality, and futile recanalization were 22.3% (50 of 224), 83.0% (181 of 224), 24.6% (55 of 224), 26.7% (60 of 224), and 69.6% (126 of 181), respectively. Baseline National Institutes of Health Stroke Scale (negative factor; odds ratio [OR] 0.89; 95% CI 0.84-0.95; P < .001), hypertension (negative factor; OR 0.38; 95% CI 0.18-0.80; P = .010), Alberta Stroke Program Early CT Score ≥ 6 (OR 3.68; 95% CI 1.29-10.5; P = .014), tirofiban use (OR 2.46; 95% CI 1.16-5.19; P = .018), first-pass effect (OR 2.87; 95% CI 1.28-6.41; P = .010), and final extended thrombolysis in cerebral infarction ≥ 2b (OR, 3.50; 95% CI 1.17-10.4; P = .024) were independent factors for good clinical outcome. Baseline National Institutes of Health Stroke Scale (OR 1.12; 95% CI 1.05-1.20; P = .004), Alberta Stroke Program Early CT Score < 6 (OR 4.68; 95% CI 1.51-14.5; P = .007), tirofiban use (negative factor; OR 0.39; 95% CI 0.18-0.86; P = .020), and first-pass effect (negative factor; OR 0.44; 95% CI 0.19-0.99; P = .047) were independent factors for futile recanalization. CONCLUSION More efforts in modifiable factors should be made to improve the efficacy of endovascular recanalization for better clinical outcomes and less futile recanalization in ICA terminus occlusions.
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Affiliation(s)
- Yingying Zhang
- Department of Neurology, Fudan University Huadong Hospital, Shanghai, China
| | - Lei Zhang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongwei Zhang
- Department of Neurology, Naval Medical University Changhai Hospital, Shanghai, China
| | - Zifu Li
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongxin Zhang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Pengfei Xing
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Wenhuo Chen
- Department of Neurology, Fujian Medical University Zhangzhou Hospital, Zhangzhou, China
| | - Shouchun Wang
- Department of Neurology, Jilin University First affiliated Hospital, Changchun, China
| | - Tianxiao Li
- Department of Radiology, Zhenzhou University Henan Provincial People's Hospital, Zhenzhou, China
| | - Pengfei Yang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Jianmin Liu
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
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10
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Maus V, Hüsken S, Kalousek V, Karwacki GM, Nordmeyer H, Kleffner I, Weber W, Fischer S. Mechanical Thrombectomy in Acute Terminal Internal Carotid Artery Occlusions Using a Large Manually Expandable Stentretriever (Tiger XL Device): Multicenter Initial Experience. J Clin Med 2021; 10:jcm10173853. [PMID: 34501298 PMCID: PMC8432012 DOI: 10.3390/jcm10173853] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/27/2021] [Accepted: 08/24/2021] [Indexed: 12/16/2022] Open
Abstract
Background: The recently introduced Tigertriever XL Device for treatment of cerebral vessel occlusions combines manual adjustability and maximum length in one device. In this study, we report our initial experience with the Tigertriever XL in terminal ICA occlusions. Methods: Retrospective multicenter analysis of acute terminal ICA occlusions treated by mechanical thrombectomy using the Tigertriever XL Device. Results: 23 patients were treated using the Tigetriever XL due to an acute occlusion of the terminal ICA. The overall successful reperfusion rate after a median of two maneuvers using the Tigertriever XL Device was 78.3% (mTICI 2b-3). In 43.5% (10/23) additional smaller devices were applied to treat remaining occlusions in downstream territories, which resulted in a final successful reperfusion rate of 95.7%. Device related complications did not occur. Two symptomatic intracerebral hemorrhages (sICH) were observed. Conclusions: The Tigertriever XL Device might be a helpful tool in the treatment of ICA terminus occlusions with large clot burden resulting in high reperfusion rates. This is mainly related to the manual adjustability of the device combined with the maximum length.
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Affiliation(s)
- Volker Maus
- Knappschaftskrankenhaus Bochum-Langendreer-Universitätsklinik, Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie, Nuklearmedizin, In der Schornau 23-25, 44892 Bochum, Germany; (V.M.); (S.H.); (W.W.)
| | - Sabeth Hüsken
- Knappschaftskrankenhaus Bochum-Langendreer-Universitätsklinik, Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie, Nuklearmedizin, In der Schornau 23-25, 44892 Bochum, Germany; (V.M.); (S.H.); (W.W.)
| | - Vladimir Kalousek
- Subdivision of Interventional Neuroradiology, Department of Radiology, Clinical Hospital Center Sisters of Mercy, 10000 Zagreb, Croatia;
| | - Grzegorz Marek Karwacki
- Luzerner Kantonsspital, Diagnostische und Interventionelle Neuroradiologie, Radiologie und Nuklearmedizin Spitalstrasse, 6000 Luzern, Switzerland;
| | - Hannes Nordmeyer
- Institut für Interventionelle Radiologie und Neuroradiologie, Neurozentrum Solingen, Radprax St. Lukas Hospital, 42697 Solingen, Germany;
- School of Medicine, Department of Health, Witten/Herdecke University, 58455 Witten, Germany
| | - Ilka Kleffner
- Knappschaftskrankenhaus Bochum-Langendreer-Universitätsklinik, Klinik für Neurologie, In der Schornau 23-25, 44829 Bochum, Germany;
| | - Werner Weber
- Knappschaftskrankenhaus Bochum-Langendreer-Universitätsklinik, Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie, Nuklearmedizin, In der Schornau 23-25, 44892 Bochum, Germany; (V.M.); (S.H.); (W.W.)
| | - Sebastian Fischer
- Knappschaftskrankenhaus Bochum-Langendreer-Universitätsklinik, Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie, Nuklearmedizin, In der Schornau 23-25, 44892 Bochum, Germany; (V.M.); (S.H.); (W.W.)
- Correspondence: ; Tel.: +49-234-2998-3803
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11
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Rajeev S, Katsumi T. Microsurgical Embolectomy in the Current Era of Pharmacological and Mechanical (Endovascular) Thrombolysis-A Reappraisal. Neurol India 2021; 69:567-572. [PMID: 34169843 DOI: 10.4103/0028-3886.319226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Microsurgical embolectomy though is the oldest known recanalization technique is being dismissed in favor of the latest mechanical endovascular techniques for the management of acute large vessel occlusion. Aim and Objective We aim to highlight the role of microsurgical embolectomy in the current era of pharmacological and mechanical (endovascular) thrombolysis. Methods An outline of the microsurgical embolectomy technique is described along with its current indications, advantages, and disadvantages. Results It carries higher complete (TICI 3) revascularization rates with lower risk of distal embolic events especially in cases with high clot burdens; but is more labor-intensive and has longer reperfusion time in comparison to endovascular methods along with the requirement of highly skilled neurovascular surgeons to perform it quickly. Conclusion Microsurgical embolectomy is an important indispensable recanalization technique in the armamentarium of vascular neurosurgeons.
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Affiliation(s)
- Sharma Rajeev
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Takizawa Katsumi
- Department of Neurosurgery, Japanese Red Cross Hospital, Asahikawa, Japan
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12
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Uyama A, Tsuto K, Matsumoto T, Takeuchi M. Effectiveness of Retrograde Angiography via the Contralateral Carotid Artery in Mechanical Thrombectomy for Carotid Non-T Occlusion by Dual Puncture Technique. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:747-754. [PMID: 37502263 PMCID: PMC10371003 DOI: 10.5797/jnet.tn.2020-0184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/20/2021] [Indexed: 07/29/2023]
Abstract
Objective We report the effectiveness of retrograde angiography via the contralateral carotid angiography using a dual puncture technique in mechanical thrombectomy (MT) for non-T occlusion in patients with acute internal carotid artery (ICA) occlusion not involving the ICA terminus. Case Presentation In the dual puncture technique, arterial puncture is performed at two sites: a balloon guiding catheter (BGC) is navigated to the ICA on the affected side and another catheter is navigated to the unaffected side. Thrombus retrieval is performed by manual aspiration through the BGC and MT using a stent retriever and/or aspiration device. Reperfusion is confirmed by retrograde angiography via the carotid artery on the unaffected side, with manual aspiration through the BGC on the affected side. Throughout the procedure, the BGC blocks the blood flow in the ICA on the affected side until reperfusion is confirmed. No distal embolization was occurred in our three patients treated using this technique. Conclusion Application of the dual puncture technique on MT is recommended for non-T occlusion to prevent distal embolization.
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Affiliation(s)
- Atsushi Uyama
- Department of Neurosurgery, Seisho Hospital, Odawara, Kanagawa, Japan
| | - Kazuma Tsuto
- Department of Neurosurgery, Seisho Hospital, Odawara, Kanagawa, Japan
| | - Takashi Matsumoto
- Department of Neurosurgery, Seisho Hospital, Odawara, Kanagawa, Japan
| | - Masataka Takeuchi
- Department of Neurosurgery, Seisho Hospital, Odawara, Kanagawa, Japan
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13
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Chen VHE, Lee GKH, Tan CH, Leow AST, Tan YK, Goh C, Gopinathan A, Yang C, Chan BPL, Sharma VK, Tan BYQ, Yeo LLL. Intra-Arterial Adjunctive Medications for Acute Ischemic Stroke During Mechanical Thrombectomy: A Meta-Analysis. Stroke 2021; 52:1192-1202. [PMID: 33611941 DOI: 10.1161/strokeaha.120.031738] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND PURPOSE In patients with acute ischemic stroke with large vessel occlusion, the role of intra-arterial adjunctive medications (IAMs), such as urokinase, tPA (tissue-type plasminogen activator), or glycoprotein IIb/IIIa inhibitors, during mechanical thrombectomy (MT) has not been clearly established. We aim to evaluate the efficacy and safety of concomitant or rescue IAM for acute ischemic stroke with large vessel occlusion patients undergoing MT. METHODS We searched Medline, Embase, and Cochrane Stroke Group Trials Register databases from inception until March 13, 2020. We analyzed all studies with patients diagnosed with acute ischemic stroke with large vessel occlusion in the anterior or posterior circulation that provided data for the two treatment arms, (1) MT+IAM and (2) MT only, and also reported on at least one of the following efficacy outcomes, recanalization and 90-day modified Rankin Scale, or safety outcomes, symptomatic intracranial hemorrhage and 90-day mortality. Data were collated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Sixteen nonrandomized observational studies with a total of 4581 patients were analyzed. MT only was performed in 3233 (70.6%) patients, while 1348 (29.4%) patients were treated with both MT and IAM. As compared with patients treated with MT alone, patients treated with combination therapy (MT+IAM) had a higher likelihood of achieving good functional outcome (risk ratio, 1.13 [95% CI, 1.03-1.24]) and a lower risk of 90-day mortality (risk ratio, 0.82 [95% CI, 0.72-0.94]). There was no significant difference in successful recanalization (risk ratio, 1.02 [95% CI, 0.99-1.06]) and symptomatic intracranial hemorrhage between the two groups (risk ratio, 1.13 [95% CI, 0.87-1.46]). CONCLUSIONS In acute ischemic stroke with large vessel occlusion, the use of IAM together with MT may achieve better functional outcomes and lower mortality rates. Randomized controlled trials are warranted to establish the safety and efficacy of IAM as adjunctive treatment to MT.
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Affiliation(s)
- Vanessa H E Chen
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.)
| | - Grace K H Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.)
| | - Choon-Han Tan
- Department of Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (C.-H.T.)
| | - Aloysius S T Leow
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.)
| | - Ying-Kiat Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.)
| | - Claire Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.)
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging (A.G., C.Y.), National University Health System, Singapore
| | - Cunli Yang
- Division of Interventional Radiology, Department of Diagnostic Imaging (A.G., C.Y.), National University Health System, Singapore
| | - Bernard P L Chan
- Division of Neurology, Department of Medicine (B.P.L.C., V.K.S., B.Y.Q.T., L.L.L.Y.), National University Health System, Singapore
| | - Vijay K Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.).,Division of Neurology, Department of Medicine (B.P.L.C., V.K.S., B.Y.Q.T., L.L.L.Y.), National University Health System, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.).,Division of Neurology, Department of Medicine (B.P.L.C., V.K.S., B.Y.Q.T., L.L.L.Y.), National University Health System, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.).,Division of Neurology, Department of Medicine (B.P.L.C., V.K.S., B.Y.Q.T., L.L.L.Y.), National University Health System, Singapore
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14
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Salehani A, Self D, Agee B, Refaey K, Elsayed GA, Chagoya G, Bernstock J, Stetler W. Impact of Anesthetic Variation in Endovascular Treatment of Acute Ischemic Stroke. Cureus 2020; 12:e11328. [PMID: 33304666 PMCID: PMC7719469 DOI: 10.7759/cureus.11328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Given recent technological advancements leading to better outcomes in endovascular therapy for acute ischemic stroke (AIS), updated guidelines recommend thrombectomy as the standard of care in acute large vessel occlusions. However, use of general anesthesia versus conscious sedation continues to be discussed. Two previous randomized trials have shown no significant difference between the use of conscious sedation compared with general anesthesia. Methods The authors performed a retrospective analysis of all consecutive patients with acute ischemia who underwent intra-arterial thrombectomy between September 2014 and May 2020 at a Level 1 stroke center. Patient characteristics along with clinical and operative data were extracted. Frequency distributions of selected characteristics were obtained and statistical significance of any differences according to the mode of anesthesia was assessed. Results A total of 480 patients were included in this study, 257 underwent general anesthesia and 223 underwent conscious sedation. Length of stay (LOS) in the ICU nor length of hospital stay was significantly different between groups. Change in National Institutes of Health Stroke Scale (NIHSS) score from admission to discharge, procedure times, and discharge disposition were not found to be significantly associated with either group although there was a trend towards longer door to puncture time with general anesthesia. Discharge disposition was found to be significantly associated with admission NIHSS (p=0.04). There was a trend towards longer hospital stay in patients with worse admission NIHSS (p=0.09). Success of thrombectomy was not significantly different between both anesthesia groups (p=0.37). Conclusions This large, single-center retrospective cohort study echoes the results of two previous randomized controlled trials in demonstrating non-inferiority of general anesthesia versus conscious sedation in cases of intra-arterial thrombectomy for AIS. These results contrast those of previously published retrospective studies.
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Affiliation(s)
- Arsalaan Salehani
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Dwight Self
- Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Bonita Agee
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Karim Refaey
- Neurological Surgery, Mayo Clinic, Jacksonville, USA
| | - Galal A Elsayed
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Gustavo Chagoya
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Joshua Bernstock
- Neurological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - William Stetler
- Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, USA
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15
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Li Z, Liu P, Zhang L, Zhang Y, Fang Y, Xing P, Huang Q, Yang P, Liu J. Y-Stent Rescue Technique for Failed Thrombectomy in Patients With Large Vessel Occlusion: A Case Series and Pooled Analysis. Front Neurol 2020; 11:924. [PMID: 32973671 PMCID: PMC7481477 DOI: 10.3389/fneur.2020.00924] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/17/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: Y-stent thrombectomy is a recent rescue technique for failed thrombectomy in patients with emergent large vessel occlusion. We presented case series of using Y-stent rescue technique at different sites and investigate its feasibility and safety through pooled analysis of collected case report or series. Methods: Twenty-eight cases were screened from stroke databank who underwent thrombectomy between January 2015 and June 2019. Clinical, procedural, and follow-up data were investigated and pooled analysis of published literature was analyzed. Results: The occlusion sites include carotid terminus in 14 patients; siphon segment in 3; middle cerebral artery (MCA) in 4; basilar terminus in 7. The overall recanalization rate reached 85.7% (arterial occlusive lesion score 2-3); and final reperfusion rate 85.7% (modified Thrombolysis in Cerebral Infarction 2b-3). After literature review, totally, 52 cases were included. Good clinical outcome was achieved in 26 (50%) and mortality in 7 (17.3%). There is no significant difference on the SAH complication at different sites. Literature review shows no difference between each site in the reperfusion and complication rate. Conclusion: Our case series results suggest that high recanalization rate can be effectively achieved with Y-stent rescue technique for patients with refractory emergent large vessel occlusion. The safety of using this technique at different sites needs further investigation for patients.
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Affiliation(s)
- Zifu Li
- Neurosurgery Department, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Peng Liu
- Neurosurgery Department, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Lei Zhang
- Neurosurgery Department, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yongwei Zhang
- Neurosurgery Department, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yibin Fang
- Neurosurgery Department, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Pengfei Xing
- Neurosurgery Department, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qinghai Huang
- Neurosurgery Department, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Pengfei Yang
- Neurosurgery Department, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jianmin Liu
- Neurosurgery Department, Changhai Hospital, Second Military Medical University, Shanghai, China
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16
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Singh R, Dekeyzer S, Reich A, Kotelis D, Gombert A, Wiesmann M, Nikoubashman O. Emergency Carotid Endarterectomy Instead of Carotid Artery Stenting Reduces Delayed Hemorrhage in Thrombectomy Stroke Patients. Clin Neuroradiol 2020; 31:737-744. [PMID: 32940724 PMCID: PMC8463364 DOI: 10.1007/s00062-020-00954-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/13/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Data in the literature suggest that thrombectomy with emergency carotid artery stenting (CAS) in acute stroke is associated with an increased hemorrhage rate. As we perform thrombectomy with the patient under general anesthesia, we avoid emergency CAS and perform emergency carotid endarterectomy (CEA) as an alternative to CAS in the same anesthesia session in our angiography suite whenever needed and possible. METHODS We compared 27 thrombectomy patients with emergency CEA and 62 thrombectomy patients with emergency CAS and glycoprotein (Gp) IIb/IIIa inhibitors and/or dual antiplatelet therapy (DAPT) in the same time span. RESULTS The symptomatic hemorrhage rate was 0% (0/27) in the CEA group and 8% (5/62) in the CAS group (p = 0.317). The parenchymal hemorrhage rate (PH2) was 7% (2/27) in the CEA group and 16% (10/62) in the CAS group (p = 0.333). Both cases of PH2 in the CEA group occurred during the intervention and were diagnosed on immediate postinterventional imaging, whereas in the CAS group only 2/10 cases of PH2 occurred during the intervention and the remaining 8 PH2 occurred within 3 days after the intervention (p = 0.048). Clinical outcome at 90 days was comparable with 39% of CEA and 51% of CAS patients achieving good clinical outcome (modified Rankin scale, mRS 0-2, p = 0.452). CONCLUSION The use of CEA is a feasible alternative to CAS in acute stroke and has the advantage that DAPT/GpIIb/IIIa inhibitors are not needed. All PH2 in CEA patients occurred during the intervention, implying that hemorrhage in this group is likely to be caused by reperfusion injury, whereas delayed hemorrhage is likely to be caused by DAPT/GpIIb/IIIa inhibitors.
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Affiliation(s)
- Raveena Singh
- Department of Neuroradiology, University Hospital RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Sven Dekeyzer
- Department of Neuroradiology, University Hospital RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Drosos Kotelis
- Department of Vascular Surgery, University Hospital RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Alexander Gombert
- Department of Vascular Surgery, University Hospital RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
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17
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Mohammaden MH, Stapleton CJ, Brunozzi D, Hussein AE, Khedr EM, Atwal G, Alaraj A. Predictors of Poor Outcome Despite Successful Mechanical Thrombectomy of Anterior Circulation Large Vessel Occlusions Within 6 h of Symptom Onset. Front Neurol 2020; 11:907. [PMID: 33013629 PMCID: PMC7498572 DOI: 10.3389/fneur.2020.00907] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/14/2020] [Indexed: 11/26/2022] Open
Abstract
Background and Purpose: Successful reperfusion is a significant predictor of a good clinical outcome after mechanical thrombectomy (MT). However, some patients have a poor clinical outcome even with successful reperfusion. We aimed to study factors that predict a poor clinical outcome (90-day modified Rankin Scale ≥ 3) in patients with anterior circulation large vessel occlusion (LVO) treated by successful MT within 6 h of symptom onset. Methods: We performed a retrospective review of a prospectively maintained MT database of all patients who underwent MT within 6 h of symptom onset for an anterior circulation LVO at our institution from May 2016 to June 2018. Uni- and multivariable analyses were performed to identify predictors of poor outcome. Results: A total of 56 patients met the criteria for inclusion in this study. A poor outcome occurred in 31 (55.4%) patients. On univariate analysis, compared to patients with good clinical outcome, patients with poor outcome had higher mean baseline NIHSS scores (23.3 vs. 13.8, P < 0.001), were more likely to have internal carotid artery (ICA) occlusions (38.7 vs. 8%, P = 0.008), and had a higher incidence of distal clot migration (DCM) (48.4 vs. 8%, P = 0.028). Age, gender, other baseline clinical characteristics, MT technique, and incidence of hemorrhagic transformation did not differ between the two cohorts. On multivariable regression analysis, baseline NIHSS score [OR; 1.3, 95%CI [1.11–1.52], P = 0.001], site of occlusion (ICA) [OR; 8.9, 95%CI [1.3–60.9], P = 0.026], and DCM [OR; 5.77, 95%CI [1.09–30.69], P = 0.04] were independent predictors of poor outcome at 90-days. Conclusion: Baseline NIHSS score, ICA occlusion, and DCM are independent predictors of a poor outcome after MT for anterior circulation LVO performed within 6 h of symptoms onset.
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Affiliation(s)
- Mahmoud H Mohammaden
- Department of Neurology, South Valley University Qena Faculty of Medicine, Qena, Egypt.,Department of Neurology, Marcus Stroke and Neuroscience Center, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, United States
| | - Christopher J Stapleton
- Department of Neurosurgery, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Denise Brunozzi
- Department of Neurosurgery, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Ahmad E Hussein
- Department of Neurosurgery, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Eman M Khedr
- Department of Neurology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Gursant Atwal
- Department of Neurosurgery, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Ali Alaraj
- Department of Neurosurgery, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
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18
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Salehani A, Tabibian BE, Self DM, Agee B, Chagoya G, Stetler W, Fisher WS. An Observational Study Investigating the Need for Decompressive Hemicraniectomy after Thrombectomy in Acute Ischemic Stroke of the Middle Cerebral Artery Territory. Cureus 2020; 12:e9665. [PMID: 32944425 PMCID: PMC7488623 DOI: 10.7759/cureus.9665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The frequency incidence of decompressive hemicraniectomy following intra-arterial thrombectomy (IAT) in acute ischemic stroke (AIS) involving the middle cerebral artery (MCA) territory was assessed as a surrogate for morbidity. METHODS A single-institution retrospective chart review was conducted involving 209 consecutive patients between September 2014 and May 2017 with infarctions affecting the MCA territory and who subsequently underwent IAT. The outcomes of interest included the frequency of hemicraniectomy following IAT and the effects of intravenous tissue plasminogen activator (IV tPA) use and primary occlusion site on the Thrombolysis in Cerebral Infarction (TICI) score. RESULTS Thirty-one patients were excluded for infarctions not involving the MCA territory. A total of 178 patients were included in the study. Sixty-eight patients (38.6%) had infarctions of less than one-third of the MCA territory, 50 (28.4%) had infarctions between one-third and two-thirds, and 58 (33%) had infarctions involving greater than two-thirds with 54.3% suffering infarctions of the left side. Only four patients (2.2%) required a hemicraniectomy with no statistically significant association found between TICI score and hemicraniectomy (p=0.41) or between administration of IV tPA and hemicraniectomy (p=0.36). The primary occlusion site was found to influence TICI score (p=0.045). CONCLUSION A very small number of patients required hemicraniectomy after IAT as compared to previously published rates in the literature. However, several factors may prevent the patient from being an appropriate hemicraniectomy candidate in the first place and the small number of these patients in this study limits statistical analysis. The variables that determine a patient's candidacy for decompressive hemicraniectomy remains multi-factorial.
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Affiliation(s)
- Arsalaan Salehani
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Borna E Tabibian
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - D M Self
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Bonita Agee
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Gustavo Chagoya
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - William Stetler
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Winfield S Fisher
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
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19
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Murray NM, Wolman DN, Marks M, Dodd R, Do HM, Lee JT, Heit JJ. Endovascular Treatment of Acute Carotid Stent Occlusion: Aspiration Thrombectomy and Angioplasty. Cureus 2020; 12:e7997. [PMID: 32523851 PMCID: PMC7274505 DOI: 10.7759/cureus.7997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction Acute carotid stent occlusion (CSO) is a rare complication of endovascular carotid stent placement that requires emergent intervention. We describe angioplasty or combined angioplasty and aspiration thrombectomy as a new endovascular technique for CSO treatment. The technique is compared to others previously described in the literature. Methods We performed a retrospective cohort study of all patients who underwent endovascular treatment (ET) of acute symptomatic CSO from January 2008 to March 2018 at our neurovascular referral center. Patient demographics, endovascular treatment details, and outcome data were determined from the electronic medical record. Primary outcome was successful stent recanalization and cerebral reperfusion (modified thrombolysis in cerebral infarction (mTICI) score IIB-III). Secondary outcomes were National Institutes of Health Stroke Scale (NIHSS) shift from presentation to discharge, mortality, and modified Rankin Scale (mRS) score at 3 months. Additionally, a literature review (years 2008-2019) was performed to characterize other techniques for ET of CSO. Results Four patients who underwent ET of acute CSO were identified. ET treatment by angioplasty (n = 1) or combined aspiration thrombectomy and angioplasty (n = 3) resulted in carotid stent recanalization in all patients. Tandem intracranial occlusions were present in three patients (75%), and successful cerebral reperfusion was achieved in all patients. Patient symptoms improved (mean NIHSS shift -5.3 ± 7.2 at discharge). One patient died of a symptomatic reperfusion hemorrhage and another died of cardiac complications by 3-month follow-up. The mRS scores of the surviving patients were 1 and 3. Previously described studies (n = 14) using different and varied techniques had moderate recanalization rates and outcomes. Conclusion Combined aspiration thrombectomy and angioplasty for the neurointerventional treatment of acute CSO leads to high rates of stent recanalization and cerebral reperfusion. The recanalization rate here is improved compared to previously reported techniques. Further multicenter studies are required to risk-stratify patients for specific ET interventions.
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Affiliation(s)
| | | | | | - Robert Dodd
- Neurosurgery/ Cerebrovascular and Skull Base Surgery, Stanford University Medical Center, Palo Alto, USA
| | - Huy M Do
- Radiology, Stanford University School of Medicine, Stanford, USA
| | - Jason T Lee
- Vascular Surgery, Stanford University, Stanford, USA
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20
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Ospel JM, Kashani N N, Menon B, Almekhlafi M, Wilson A, Fischer U, Campbell B, Yoshimura S, Turjman F, Cherian M, Heo JH, Hill M, Saposnik G, Goyal M. Endovascular Treatment Decision Making in Octogenarians and Nonagenarians : Insights from UNMASK EVT an International Multidisciplinary Study. Clin Neuroradiol 2019; 30:45-50. [PMID: 31705154 DOI: 10.1007/s00062-019-00848-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 10/17/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Evidence for efficacy and safety in stroke patients ≥80 years is limited, since they were underrepresented in randomized thrombectomy trials. This study sought to explore how physicians approach endovascular therapy (EVT) decision making in octogenarians and nonagenarians under their current local resources under assumed ideal conditions, i.e. without external (monetary or infrastructural) limitations. METHODS In an international multidisciplinary survey, 607 physicians involved in acute stroke care were randomly assigned 10 out of a pool of 22 case scenarios with different evidence levels for EVT, 4 of which involved octogenarians and 2 nonagenarians, and asked how they would treat the patient in the given scenario A) under their current local resources and B) under assumed ideal conditions, i.e. with no external restraints. Decision rates were calculated and clustered multivariable regression analysis performed to determine adjusted measures of effect size for patient age. RESULTS In octogenarians, physicians decided in favor of EVT in 76.7% (all of which were level 2B evidence scenarios) under current local resources and in 80.2% under assumed ideal conditions. In nonagenarians, 74.0% decided in favor of EVT under current local resources (level 1A scenarios: 87.7%, level 2B scenarios: 60.3%) and 79.2% would offer EVT under assumed ideal conditions (level 1A scenarios: 91.3%, level 2B scenarios: 67.2%). Age was not a significant predictor for treatment decision under current local resources (adjusted odds ratio, OR: 0.99, confidence interval, CI: 0.96-1.02 per decile increase) and under assumed ideal conditions (adjusted OR: 1.00, CI 0.97-1.03 per decile increase). CONCLUSION The vast majority of physicians participating in this survey would offer EVT to acute ischemic stroke patients above 80 years.
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Affiliation(s)
- Johanna Maria Ospel
- Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland.,Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Nima Kashani N
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Bijoy Menon
- Department of Radiology, University of Calgary, Calgary, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Mohammed Almekhlafi
- Department of Radiology, University of Calgary, Calgary, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Alexis Wilson
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Urs Fischer
- University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Bruce Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine 1-1 Mukogawa, Nishinomiya, Hyogo, Japan
| | - Francis Turjman
- Department of Interventional Neuroradiology at Lyon University Hospital, University of Lyon, Lyon, France
| | - Mathew Cherian
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India
| | - Ji-Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea (Republic of)
| | - Michael Hill
- Department of Radiology, University of Calgary, Calgary, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Gustavo Saposnik
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Calgary, Canada. .,Department of Clinical Neurosciences, University of Calgary, Calgary, Canada. .,Departments of Radiology and Clinical Neurosciences, Foothills Medical Centre, University of Calgary, 1403 29th St. NW, T2N2T9, Calgary, AB, Canada.
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21
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Lamanna A, Maingard J, Barras CD, Kok HK, Handelman G, Chandra RV, Thijs V, Brooks DM, Asadi H. Carotid artery stenting: Current state of evidence and future directions. Acta Neurol Scand 2019; 139:318-333. [PMID: 30613950 DOI: 10.1111/ane.13062] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/18/2018] [Accepted: 01/03/2019] [Indexed: 11/29/2022]
Abstract
Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published long-term outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in-stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis.
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Affiliation(s)
- Anthony Lamanna
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
| | - Julian Maingard
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
| | - Christen D. Barras
- South Australian Health and Medical Research Institute Adelaide South Australia Australia
- The University of Adelaide Adelaide South Australia Australia
| | - Hong Kuan Kok
- Interventional Radiology ServiceNorthern Hospital Radiology Melbourne, Victoria Australia
- School of Medicine, Faculty of HealthDeakin University Waurn Ponds Victoria Australia
| | - Guy Handelman
- Education and Research CentreBeaumont Hospital Dublin Ireland
- Department of RadiologyRoyal Victoria Hospital Belfast UK
| | - Ronil V. Chandra
- Department of ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Unit, Monash ImagingMonash Health Melbourne Victoria Australia
| | - Vincent Thijs
- Stroke Division, The Florey Institute of Neuroscience & Mental HealthUniversity of Melbourne Melbourne Victoria Australia
- The University of Melbourne Melbourne Victoria Australia
- Department of NeurologyAustin Health Melbourne Victoria Australia
| | - Duncan Mark Brooks
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
- Interventional Neuroradiology Service, Department of RadiologyAustin Hospital Melbourne Victoria Australia
| | - Hamed Asadi
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
- School of Medicine, Faculty of HealthDeakin University Waurn Ponds Victoria Australia
- Department of ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Unit, Monash ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Service, Department of RadiologyAustin Hospital Melbourne Victoria Australia
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22
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Endovascular Therapy for Tandem Occlusion in Acute Ischemic Stroke: Intravenous Thrombolysis Improves Outcomes. J Clin Med 2019; 8:jcm8020228. [PMID: 30744174 PMCID: PMC6407107 DOI: 10.3390/jcm8020228] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/30/2019] [Accepted: 02/07/2019] [Indexed: 11/17/2022] Open
Abstract
Ischemic stroke related to tandem internal carotid and middle cerebral artery (TIM) occlusion is a challenging condition where endovascular treatment (EVT) is an emerging revascularization option. The identification of factors influencing clinical outcomes can assist in creating appropriate therapeutic algorithms for such patients. This study aimed to evaluate prognostic factors in the context of EVT for TIM occlusion. We performed a retrospective study of consecutive patients with TIM occlusion admitted within 6 h from symptom onset to two tertiary stroke centers. We recorded the etiology of stroke, clinical deficits at stroke onset and discharge, details of EVT, final infarct volume (FIV), in-hospital mortality, and outcome at three months. Among 73 patients with TIM occlusion, 53 were treated with EVT. The median age was 75.9 years (interquartile range (IQR) 64.6–82.6), with the most common etiology of cardioembolism (51.9%). Intravenous thrombolysis with tissue-plasminogen activator (t-PA) was performed in the majority (69.8%) of cases. EVT achieved successful recanalization with a thrombolysis in cerebral infarction (TICI) grade of 2b or 3 in 67.9%. A good outcome (modified Rankin score of 0–2 at three months) was observed in 37.7%. After adjustment for age, the National Institutes of Health Stroke Scale (NIHSS) at admission, and success of recanalization, smaller final infarct volume (odds ratio (OR) 0.021 for FIV above 25th percentile (95% CI 0.001–0.332, p = 0.005)) and administration of intravenous t-PA (OR 12.04 (95% CI 1.004–144.392, p = 0.049)) were associated with a good outcome at three months. Our study demonstrates that bridging with t-PA is associated with improved outcomes in the setting of tandem ICA and MCA occlusions treated with EVT and should therefore not be withheld in eligible patients.
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23
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Acute Occlusion of the Distal Internal Carotid Artery : Single Center Experience in 46 Consecutive Cases, review of the literature and proposal of a classification. Clin Neuroradiol 2018; 30:67-76. [PMID: 30426172 DOI: 10.1007/s00062-018-0743-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/27/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE The acute distal intracranial occlusion of the internal carotid artery (ICA) is a very complex heterogeneous pathology, characterized by various patterns. Aim of this work is to identify the different types and propose a classification. METHODS Among the patients admitted for stroke in the anterior circulation from august 2014 to October 2017, 46 (25%) presented with intracranial distal carotid artery occlusion. The mean age of the patients was 71 (SD 13.7), 65,2% female. The protocol included general and specific neurological examinations, CT, CT-Angiography with multiphase CTA, followed by Angiography. The occlusion was treated by aspiration device alone or associated with stent-retriever. NIHSS at the admission, at discharge and modified ranking Scale (mRS) at four months were examined. RESULTS The occlusions presented with various patterns. Depending on its site (located at the distal ICA bifurcation or more proximal at the level of the ophthalmic segment of ICA, with or without extent to ICA bifurcation) taking also into account the various involvement of the cerebral vessels and anatomic variations of Circle of Willis, three groups of occlusion types could be identified (T1, T2 and T3). The collateral circulation, and the possibilities of the endovascular revascularization important for the final outcome, were clearly connected with the type of occlusion. NIHSS at admission was 19.1 (Range from 8 to 30, SD 4.4). Good outcome defined as mRS 0-2 at for months was obtained in 17 patients (37%). CONCLUSIONS The proposed classification reproduces more precisely the complexity and heterogeneity of this pathology, being useful in the diagnosis and treatment of these patients.
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24
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Schubert J, Witte OW, Settmacher U, Mayer TE, Günther A, Zanow J, Klingner CM. Acute Stroke Treatment by Surgical Recanalization of Extracranial Internal Carotid Artery Occlusion: A Single Center Experience. Vasc Endovascular Surg 2018; 53:21-27. [PMID: 30301430 DOI: 10.1177/1538574418800131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Ischemic stroke due to an acute occlusion of the extracranial internal carotid artery (eICA) is associated with high morbidity and mortality. The best treatment option remains unclear. This study aims to increase the available therapeutic experience documented for surgical recanalization of acute eICA occlusions. We retrospectively reviewed all hospital records of the University Hospital Jena between 2006 and 2018 to identified patients with acute ischemic stroke due to an occlusion of the eICA who underwent emergent surgical recanalization. We analyzed clinical data, surgical reports, imaging data, and outpatient records. The primary outcome parameter was the modified Rankin Scale (mRS) at 3 months. During the survey, 12 patients (mean age: 62.3 ± 10.8 years; range: 35-87) underwent emergent surgical recanalization for an acutely symptomatic eICA occlusion. All patients presented with neurological deficits with a mean National Institutes of Health Stroke Scale score at admission of 15.0 ± 5.1 (range 2-23). Patients were selected for surgery mainly due to the extent of the perfusion mismatch, while stroke severity and age were also considered. The median time from symptom onset to surgery was 309 ± 122 minutes (range 112-650 minutes). Complete recanalization was obtained in all 12 patients. No patient deteriorated postoperatively, no intracranial hemorrhage was observed, and no patient died in the following 3 months. Favorable outcomes (mRS: 0-2) after 3 months were achieved in 7 of 12 patients. The current study adds support to previous findings that the surgical recanalization of acute eICA occlusions is a possible and safe treatment option. However, a critical patient selection based on mismatch size in perfusion imaging is crucially important for successful treatment.
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Affiliation(s)
- Julia Schubert
- 1 Hans Berger Department of Neurology, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
| | - Otto W Witte
- 1 Hans Berger Department of Neurology, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
| | - Utz Settmacher
- 2 Department of General, Visceral and Vascular Surgery, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
| | - Thomas E Mayer
- 3 Section Neuroradiology, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
| | - Albrecht Günther
- 1 Hans Berger Department of Neurology, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
| | - Jürgen Zanow
- 2 Department of General, Visceral and Vascular Surgery, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
| | - Carsten M Klingner
- 1 Hans Berger Department of Neurology, University Hospital Jena, Friedrich-Schiller University, Jena, Germany.,4 Biomagnetic Center, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
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25
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Marnat G, Bühlmann M, Eker OF, Gralla J, Machi P, Fischer U, Riquelme C, Arnold M, Bonafé A, Jung S, Costalat V, Mordasini P. Multicentric Experience in Distal-to-Proximal Revascularization of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection. AJNR Am J Neuroradiol 2018; 39:1093-1099. [PMID: 29700047 DOI: 10.3174/ajnr.a5640] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 02/07/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Internal carotid dissection is a frequent cause of ischemic stroke in young adults. It may cause tandem occlusions in which cervical carotid obstruction is associated with intracranial proximal vessel occlusion. To date, no consensus has emerged concerning endovascular treatment strategy. Our aim was to evaluate our endovascular "distal-to-proximal" strategy in the treatment of this stroke subtype in the first large multicentric cohort. MATERIALS AND METHODS Prospectively managed stroke data bases from 2 separate centers were retrospectively studied between 2009 and 2014 for records of tandem occlusions related to internal carotid dissection. Atheromatous tandem occlusions were excluded. The first step in the revascularization procedure was intracranial thrombectomy. Then, cervical carotid stent placement was performed depending on the functionality of the circle of Willis and the persistence of residual cervical ICA occlusion, severe stenosis, or thrombus apposition. Efficiency, complications, and radiologic and clinical outcomes were recorded. RESULTS Thirty-four patients presenting with tandem occlusion stroke secondary to internal carotid dissection were treated during the study period. The mean age was 52.5 years, the mean initial NIHSS score was 17.29 ± 6.23, and the mean delay between onset and groin puncture was 3.58 ± 1.1 hours. Recanalization TICI 2b/3 was obtained in 21 cases (62%). Fifteen patients underwent cervical carotid stent placement. There was no recurrence of ipsilateral stroke in the nonstented subgroup. Twenty-one patients (67.65%) had a favorable clinical outcome after 3 months. CONCLUSIONS Endovascular treatment of internal carotid dissection-related tandem occlusion stroke using the distal-to-proximal recanalization strategy appears to be feasible, with low complication rates and considerable rates of successful recanalization.
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Affiliation(s)
- G Marnat
- From the Interventional and Diagnostic Neuroradiology Department (G.M.), Bordeaux University Hospital, Bordeaux, France
| | - M Bühlmann
- University Institute of Diagnostic and Interventional Neuroradiology (J.G., P.M.)
| | - O F Eker
- Interventional and Diagnostic Neuroradiology Department (O.F.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - J Gralla
- University Institute of Diagnostic and Interventional Neuroradiology (J.G., P.M.)
| | - P Machi
- University Institute of Diagnostic and Interventional Neuroradiology (J.G., P.M.)
- Interventional and Diagnostic Neuroradiology Department (O.F.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - U Fischer
- University Institute of Diagnostic and Interventional Neuroradiology (J.G., P.M.)
| | - C Riquelme
- Interventional and Diagnostic Neuroradiology Department (O.F.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - M Arnold
- University Institute of Diagnostic and Interventional Neuroradiology (J.G., P.M.)
| | - A Bonafé
- Interventional and Diagnostic Neuroradiology Department (O.F.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - S Jung
- University Institute of Diagnostic and Interventional Neuroradiology (J.G., P.M.)
| | - V Costalat
- Interventional and Diagnostic Neuroradiology Department (O.F.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - P Mordasini
- From the Interventional and Diagnostic Neuroradiology Department (G.M.), Bordeaux University Hospital, Bordeaux, France
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26
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Impact of smoking on stroke outcome after endovascular treatment. PLoS One 2018; 13:e0194652. [PMID: 29718909 PMCID: PMC5931491 DOI: 10.1371/journal.pone.0194652] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 03/07/2018] [Indexed: 12/21/2022] Open
Abstract
Background Recent studies suggest a paradoxical association between smoking status and clinical outcome after intravenous thrombolysis (IVT). Little is known about relationship between smoking and stroke outcome after endovascular treatment (EVT). Methods We analyzed data of all stroke patients treated with EVT at the tertiary stroke centre of Berne between January 2005 and December 2015. Using uni- and multivariate modeling, we assessed whether smoking was independently associated with excellent clinical outcome (modified Rankin Scale (mRS) 0–1) and mortality at 3 months. In addition, we also measured the occurrence of symptomatic intracranial hemorrhage (sICH) and recanalization. Results Of 935 patients, 204 (21.8%) were smokers. They were younger (60.5 vs. 70.1 years of age, p<0.001), more often male (60.8% vs. 52.5%, p = 0.036), had less often from hypertension (56.4% vs. 69.6%, p<0.001) and were less often treated with antithrombotics (35.3% vs. 47.7%, p = 0.004) as compared to nonsmokers. In univariate analyses, smokers had higher rates of excellent clinical outcome (39.1% vs. 23.1%, p<0.001) and arterial recanalization (85.6% vs. 79.4%, p = 0.048), whereas mortality was lower (15.6% vs. 25%, p = 0.006) and frequency of sICH similar (4.4% vs. 4.1%, p = 0.86). After correcting for confounders, smoking still independently predicted excellent clinical outcome (OR 1.758, 95% CI 1.206–2.562; p<0.001). Conclusion Smoking in stroke patients may be a predictor of excellent clinical outcome after EVT. However, these data must not be misinterpreted as beneficial effect of smoking due to the observational study design. In view of deleterious effects of cigarette smoking on cardiovascular health, cessation of smoking should still be strongly recommended for stroke prevention.
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Iatrogenic Vessel Dissection in Endovascular Treatment of Acute Ischemic Stroke. Clin Neuroradiol 2017; 29:143-151. [PMID: 29098320 PMCID: PMC6394531 DOI: 10.1007/s00062-017-0639-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/04/2017] [Indexed: 11/30/2022]
Abstract
Purpose Knowledge about the localization and outcome of iatrogenic dissection (ID) during endovascular treatment of acute ischemic stroke (AIS) is limited. We aimed to determine the frequency, clinical aspects and morphology of ID in endovascular AIS treatment and to identify predictors of this complication. Methods Digital subtraction angiography (DSA) of ID carried out during endovascular treatment between January 2000 and March 2012 have been re-evaluated. The ID localization and morphology were analyzed and related to the interventional techniques. Baseline clinical and radiological findings, treatment modality and outcome were compared with patients without ID. Results Out of 866 patients 18 (2%) suffered an ID (44% female, median age 64 years). Localization was extracranial in 15 (83%, 14 internal carotid artery and 1 vertebral artery) and intracranial in 3 (17%; 1 vertebrobasilar dissection and 2 in the anterior circulation). Of the IDs 5 (28%) resulted in a high-degree, 3 (17%) in a moderate, 5 (28%) in a mild and 5 (28%) in no stenosis and 8 IDs were stented in the acute phase. At 3 months 7 (42%) patients had a favorable outcome (modified Rankin score mRS ≤ 2) and 6 (33%) patients had died. Patients with ID had a different stroke etiology (p = 0.041), were more likely to be smokers (44% versus 19%, p = 0.015) and were more likely to be treated with mechanical thrombectomy (100% versus 60%, p < 0.001). Although two ID patients had relevant complications, the outcome did not differ between the groups. Conclusion The occurrence of ID is a rare complication of endovascular AIS treatment associated with smoking and mechanical thrombectomy. Electronic supplementary material The online version of this article (10.1007/s00062-017-0639-z) contains supplementary material, which is available to authorized users.
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Simonsen CZ, Mikkelsen IK, Karabegovic S, Kristensen PK, Yoo AJ, Andersen G. Predictors of Infarct Growth in Patients with Large Vessel Occlusion Treated with Endovascular Therapy. Front Neurol 2017; 8:574. [PMID: 29163339 PMCID: PMC5670343 DOI: 10.3389/fneur.2017.00574] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 10/13/2017] [Indexed: 11/25/2022] Open
Abstract
Introduction Endovascular therapy (EVT) is now evidence based in anterior circulation stroke caused by large vessel occlusion. Outcome is related to infarct size, but data on predictors of infarct growth is limited. We analyzed our cohort of EVT treated patients primarily selected by magnetic resonance imaging (MRI) to examine predictors of infarct growth and the association between infarct size and outcome. Methods We identified 342 patients with anterior circulation stroke from 2004 to 2014 in our prospectively collected EVT database. Baseline infarct size was available for 281 (measured by MRI) while final infarct size was available for 312 patients. Functional outcome was defined by modified Rankin Score (mRS) after 90 days and good outcome was defined as mRS 0–2. Predictors of infarct growth were examined by regression analysis. Results Successful reperfusion [odds ratio (OR) 0.17, 95% confidence interval (CI) (0.09–0.33)] was the strongest predictor of reduction of infarct growth. Receiving intravenous thrombolysis and a short time span from symptom onset to scanning also reduced infarct growth. Occlusion of the internal carotid artery (ICA) intracranially predicted infarct growth (OR = 7.29, 95% CI: 2.36–22.53). EVT under general anesthesia and having a NIHSS between 10 and 15 were also associated with infarct growth. Discussion Failure of reperfusion resulted in an average infarct growth of approximately 50 ml. Lack of reperfusion generally results in a poor outcome likely due to infarct growth. Occlusion of the intracranial ICA and EVT under general anesthesia predicted infarct growth, while successful reperfusion, getting intraveneous thrombolysis, and a short time span from onset to scan protected against growth. A median infarct size of 52 ml best discriminates between a good and a bad outcome.
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Affiliation(s)
- Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Irene K Mikkelsen
- Center for Functionally Integrative Neuroscience, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Albert J Yoo
- Neuroendovascular Service, Texas Stroke Institute, Dallas, TX, United States
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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Broeg-Morvay A, Mordasini P, Slezak A, Liesirova K, Meisterernst J, Schroth G, Arnold M, Jung S, Mattle HP, Gralla J, Fischer U. Does Antiplatelet Therapy during Bridging Thrombolysis Increase Rates of Intracerebral Hemorrhage in Stroke Patients? PLoS One 2017; 12:e0170045. [PMID: 28095449 PMCID: PMC5240999 DOI: 10.1371/journal.pone.0170045] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 12/28/2016] [Indexed: 11/18/2022] Open
Abstract
Background Symptomatic intracerebral hemorrhage (sICH) after bridging thrombolysis for acute ischemic stroke is a devastating complication. We aimed to assess whether the additional administration of aspirin during endovascular intervention increases bleeding rates. Methods We retrospectively compared bleeding complications and outcome in stroke patients who received bridging thrombolysis with (tPA+ASA) and without (tPA-ASA) aspirin during endovascular intervention between November 2008 and March 2014. Furthermore, we analyzed bleeding complications and outcome in antiplatelet naïve patients with those with prior or acute antiplatelet therapy. Results Baseline characteristics, previous medication, and dosage of rtPA did not differ between 50 tPA+ASA (39 aspirin naïve, 11 preloaded) and 181 tPA-ASA patients (p>0.05). tPA+ASA patients had more often internal carotid artery (ICA) occlusion (p<0.001), large artery disease (p<0.001) and received more often acute stenting of the ICA (p<0.001). 10/180 (5.6%) tPA-ASA patients and 3/49 (6.1%) tPA+ASA patients suffered a sICH (p = 1.0). Rates of asymptomatic intracerebral hemorrhage, systemic bleeding complications and outcome did not differ between both groups (p>0.1). There were no differences in bleeding complications and mortality among 112 bridging patients with antiplatelet therapy (62 preloaded, 39 acute administration, 11 both) and 117 antiplatelet naïve patients. In a logistic regression analysis, aspirin administration during endovascular procedure was not a predictor of sICH. Conclusion Antiplatelet therapy before or during bridging thrombolysis in patients with acute ischemic stroke did not increase the risk of bleeding complications and had no impact on outcome. This finding has to be confirmed in larger studies.
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Affiliation(s)
- Anne Broeg-Morvay
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Agnieszka Slezak
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Kai Liesirova
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Julia Meisterernst
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Gerhard Schroth
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Heinrich P. Mattle
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- * E-mail:
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Steglich-Arnholm H, Holtmannspötter M, Gluud C, Krieger DW. Carotid artery stenting versus no stenting assisting thrombectomy for acute ischaemic stroke: protocol for a systematic review of randomised clinical trials with meta-analyses and trial sequential analyses. Syst Rev 2016; 5:208. [PMID: 27906117 PMCID: PMC5133765 DOI: 10.1186/s13643-016-0388-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 11/21/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND In patients with intracranial large vessel arterial occlusion, ipsilateral extracranial carotid artery occlusions or near-occlusions pose a significant hurdle in endovascular management of acute ischaemic stroke. Stenting of the carotid lesion may be beneficial in this situation to provide a stable access for introducing catheters through the carotid lesion into the intracranial vasculature and the target occlusion. Furthermore, carotid stenting may ensure ample blood flow for wash-out of clot material and reperfusion of the ischaemic penumbral tissue. However, antiplatelet therapy administered to prevent stent thrombosis and sudden increase in blood flow after reopening of the carotid lesion may increase the risk for intracranial haemorrhagic complications. This review aims to assess the benefits and harms of carotid stenting vs. no stenting assisting thrombectomy for acute ischaemic stroke. METHODS International and regional electronic databases will be searched to identify eligible randomised clinical trials. To identify further published, unpublished, or on-going and planned trials searches of Google Scholar, Worldwide Food and Drug Administrations, Worldwide Medicines Agencies, company homepages, reference lists, conference proceedings, and the Science Citation Index cited reference search index will be conducted. Manufacturers of relevant interventional equipment, authors, colleagues, and researchers active in the field will be contacted. No language restrictions will be applied to these searches. Randomised clinical trials will be included for assessing benefits and harms and quasi-randomised studies, and observational studies will be included for assessing harms of the intervention. Meta-analyses will be performed according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, and Trial Sequential Analyses will be conducted to control the risk of random errors and prevent premature statements of superiority of the experimental or control intervention or premature statement of futility. The quality of the evidence will be evaluated with the Grading of Recommendations Assessment, Development, and Evaluation. DISCUSSION This systematic review of carotid stenting in endovascular management of acute ischaemic stroke in patients with concomitant extracranial carotid lesions and intracranial embolism will assess benefits and harms of this intervention and assesses whether carotid stenting should be encouraged or avoided in acute ischaemic stroke and identify targets for further research. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016033346.
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Affiliation(s)
- Henrik Steglich-Arnholm
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, 2082, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Markus Holtmannspötter
- Department of Neuroradiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Derk Wolfgang Krieger
- Deptartment of Neurology Comprehensive Stroke Center, University Hospital, Zurich, Switzerland
- Deptartment of Neurology Mediclinic City Hospital, Stroke Unit, Dubai Health Care City, Dubai, United Arab Emirates
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Li W, Yin Q, Xu G, Liu X. Treatment Strategies for Acute Ischemic Stroke Caused by Carotid Artery Occlusion. INTERVENTIONAL NEUROLOGY 2016; 5:148-156. [PMID: 27781043 DOI: 10.1159/000445304] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Acute ischemic stroke caused by internal carotid artery (ICA) occlusion usually has a poor prognosis, especially the T occlusion cases without functional collaterals. The efficacy of intravenous (IV) or intra-arterial (IA) thrombolysis with recombinant tissue plasminogen activator (rt-PA) remains ambiguous in these patients. Eendovascular recanalization of the occluded carotid has been attempted in recent years as a potential strategy. However, the different etiologies of ICA occlusion pose a significant challenge to neurointerventionists. Recently, several endovascular evolvements have been reported in treating carotid occlusion-related stroke. This review summarizes the current status of treatment for acute ICA occlusion.
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Affiliation(s)
- Wei Li
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Qin Yin
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Gelin Xu
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Xinfeng Liu
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China
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Marnat G, Mourand I, Eker O, Machi P, Arquizan C, Riquelme C, Ayrignac X, Bonafé A, Costalat V. Endovascular Management of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection Using a Distal to Proximal Approach: Insight from the RECOST Study. AJNR Am J Neuroradiol 2016; 37:1281-8. [PMID: 26965467 DOI: 10.3174/ajnr.a4752] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 01/03/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Internal carotid artery dissection is a common cause of stroke in young adults. It may be responsible for tandem occlusion defined by a cervical steno-occlusive carotid wall hematoma associated with an intracranial large-vessel stroke. Intravenous thrombolysis is associated with a poor clinical outcome in these cases, and endovascular treatment has not been specifically evaluated to date. Our aim was to evaluate endovascular treatment technical and clinical efficiency in this specific occlusion topography, in comparison with treatment of isolated anterior circulation stroke. MATERIALS AND METHODS As part of our ongoing prospective stroke data base started in August 2009 (Prognostic Factors Related to Clinical Outcome Following Thrombectomy in Ischemic Stroke [RECOST] Study), we analyzed all carotid artery dissection tandem occlusion strokes and isolated anterior circulation occlusions. All patients were selected for endovascular treatment according to clinical-radiologic mismatch, NIHSS ≥ 7 and DWI-ASPECTS ≥5, within 6 hours after onset. For carotid artery dissection, the revascularization procedure consisted first of distal recanalization by a stent retriever in the intracranial vessel. Following assessment of the circle of Willis, internal carotid artery stent placement was only performed in case of insufficiency. Carotid artery dissection treatment efficacy, safety, and clinical outcome were compared with the results of the isolated anterior circulation occlusion cohort. RESULTS Two hundred fifty-eight patients with an anterior circulation stroke were analyzed, including 57 with tandem occlusions (22%); among them, 20 were carotid artery dissection-related occlusions (7.6%). The median age of patients with tandem occlusions with internal carotid dissection was 52.45 versus 66.85 years for isolated anterior circulation occlusion (P < .05); the mean initial NIHSS score was 17.53 ± 4.11 versus 17.55 ± 4.8 (P = .983). The median DWI-ASPECTS was 6.05 versus 6.64 (P = .098), and the average time from onset to puncture was 4.38 for tandem occlusions versus 4.53 hours in isolated anterior circulation occlusion (P = .704). Complication rates and symptomatic intracranial hemorrhage were comparable in both groups (5% versus 3%, P = .49). The duration of the procedure was significantly prolonged in case of tandem occlusion (80.69 versus 65.45 minutes, P = .030). Fourteen patients with carotid artery dissection (70%) had a 3-month mRS of ≤ 2, without a significant difference from patients with an isolated anterior circulation occlusion (44%, P = .2). Only 5 carotid artery dissections (25%) necessitated cervical stent placement. No early ipsilateral stroke recurrence was recorded, despite the absence of stent placement in 15 patients (75%) with carotid artery dissection. CONCLUSIONS Mechanical endovascular treatment of carotid artery dissection tandem occlusions is safe and effective compared with isolated anterior circulation occlusion stroke therapy. Hence, a more conservative approach with stent placement only in cases of circle of Willis insufficiency may be a reliable and safe strategy.
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Affiliation(s)
- G Marnat
- From the Department of Interventional and Diagnostic Neuroradiology (G.M.), Bordeaux University Hospital, Bordeaux, France
| | - I Mourand
- Departments of Neurology (I.M., C.A., X.A.)
| | - O Eker
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - P Machi
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - C Arquizan
- Departments of Neurology (I.M., C.A., X.A.)
| | - C Riquelme
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - X Ayrignac
- Departments of Neurology (I.M., C.A., X.A.)
| | - A Bonafé
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - V Costalat
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
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Schwaiger BJ, Kober F, Gersing AS, Kleine JF, Wunderlich S, Zimmer C, Poppert H, Prothmann S. The pREset Stent Retriever for Endovascular Treatment of Stroke Caused by MCA Occlusion: Safety and Clinical Outcome. Clin Neuroradiol 2016; 26:47-55. [PMID: 25112831 PMCID: PMC4833806 DOI: 10.1007/s00062-014-0329-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 07/29/2014] [Indexed: 01/19/2023]
Abstract
PURPOSE The purpose of this study was to analyze the safety and efficacy of the pREset device, a stent retriever system, for endovascular mechanical thrombectomy (MT) in acute ischemic stroke (AIS) after middle cerebral artery (MCA) occlusion. METHODS Retrospectively, 48 consecutive patients (mean age ± standard deviation, 71.0 ± 11.9 years; 24 women) treated for acute MCA occlusion using pREset solely or in combination with other MT devices were identified. Recanalization success was evaluated using the modified thrombolysis in cerebral infarction score (TICI), and complications were detected by 24-h follow-up computed tomography or magnetic resonance imaging. MCA anatomy was assessed in angiograms. Clinical outcome was evaluated with National Institutes of Health Stroke Scale (NIHSS) score at admission and discharge, and modified Rankin scale (mRS) score at discharge and follow-up. RESULTS Successful recanalization (TICI 2b/3) was achieved in 39 patients (81.3 %). Rate of procedure-related complications was 8.3 %. In four patients, a subarachnoid hemorrhage occurred (8.3 %), and parenchymal hematoma was detected in four patients (8.3 %). None of those events was associated with clinical deterioration. MCA curvature significantly influenced recanalization success (P < 0.005). Successful recanalization correlated significantly with lower NIHSS scores and favorable clinical outcome (mRS score 0-2) at discharge (P < 0.05). Mortality within 90 days was significantly lower in patients with TICI 2b/3 (P < 0.005). CONCLUSIONS High recanalization rates, low complication rates, and a significantly improved outcome after successful recanalization strongly suggest that MT with pREset is an adequate therapy for AIS after MCA occlusion. Vessel curvature is a significant determining factor for recanalization success.
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Affiliation(s)
- B J Schwaiger
- Abteilung für Neuroradiologie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - F Kober
- Abteilung für Neuroradiologie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - A S Gersing
- Abteilung für Neuroradiologie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - J F Kleine
- Abteilung für Neuroradiologie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - S Wunderlich
- Neurologische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - C Zimmer
- Abteilung für Neuroradiologie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - H Poppert
- Neurologische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - S Prothmann
- Abteilung für Neuroradiologie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany
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Lucena AFD, Castro-Afonso LHD, Monsignore LM, Nakiri GS, Fábio SRC, Pontes Neto O, Abud DG. Carotid artery stenting in the context of endovascular treatment of acute ischemic stroke. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:212-8. [PMID: 27050850 DOI: 10.1590/0004-282x20150213] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 11/09/2015] [Indexed: 11/22/2022]
Abstract
ABSTRACT Mechanical thrombectomy as an adjunctive to intravenous thrombolysis is now the standard treatment for acute ischemic stroke (AIS) due to large vessel occlusions. However, the best management of acute carotid tandem occlusions (CTO) remains controversial. Method Twenty patients underwent endovascular treatment of acute CTO. The primary endpoint was the composite rate of complete or partial recanalization without a symptomatic intracranial hemorrhage (sICH). Secondary endpoints were recanalization times, procedure times, and clinical outcomes at three months. Results The primary endpoint was reached in 17 (85%) patients. Recanalization rate was reached in 90% of patients (19/20) and sICH rate was 5% (1/20). At the 3-month follow-up we obtained a mRS ≤ 2 rate of 35% (7/20) and a mortality rate of 20% (4/20). Conclusion Carotid angioplasty stenting and endovascular treatment of AIS due to CTO appears effective with an acceptable rate of sICH.
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Broeg-Morvay A, Mordasini P, Bernasconi C, Bühlmann M, Pult F, Arnold M, Schroth G, Jung S, Mattle HP, Gralla J, Fischer U. Direct Mechanical Intervention Versus Combined Intravenous and Mechanical Intervention in Large Artery Anterior Circulation Stroke: A Matched-Pairs Analysis. Stroke 2016; 47:1037-44. [PMID: 26906917 DOI: 10.1161/strokeaha.115.011134] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 01/27/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Five randomized controlled trials have consistently shown that mechanical thrombectomy (MT) in addition to best medical treatment (±intravenous tissue-type plasminogen activator) improves outcome after acute ischemic stroke in patients with large artery anterior circulation stroke. Whether direct MT is equally effective as combined intravenous thrombolysis with MT (ie, bridging thrombolysis) remains unclear. METHODS We retrospectively compared clinical and radiological outcomes in 167 bridging patients with 255 patients receiving direct MT because of large artery anterior circulation stroke. We matched all patients from the direct MT group who would have qualified for intravenous tissue-type plasminogen activator with controls from the bridging group, using multivariate and propensity score analyses. Functional independence was defined as modified Rankin Scale score of 0 to 2. RESULTS From February 2009 to August 2014, 40 patients from the direct MT group would have qualified for bridging thrombolysis but were treated with MT only. Clinical and radiological characteristics did not differ from the bridging cohort, except for higher rates of hypercholesterolemia (P=0.019), coronary heart disease (P=0.039), and shorter intervals from symptom onset to endovascular intervention (P=0.01) in the direct MT group. Functional independence, mortality, and intracerebral hemorrhage rates did not differ (P>0.1). After multivariate matching analysis outcome in both groups did not differ, except for lower rates of asymptomatic intracerebral hemorrhage (P=0.023) and lower mortality (P=0.007) in the direct MT group. CONCLUSIONS In patients with large anterior circulation stroke, direct mechanical intervention seems to be equally effective as bridging thrombolysis. A randomized trial comparing direct MT with bridging therapy is warranted.
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Affiliation(s)
- Anne Broeg-Morvay
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Corrado Bernasconi
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Monika Bühlmann
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Frauke Pult
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Gerhard Schroth
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Simon Jung
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Heinrich P Mattle
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jan Gralla
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Urs Fischer
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
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Yoon W, Kim BM, Kim DJ, Kim DI, Kim SK. Outcomes and prognostic factors after emergent carotid artery stenting for hyperacute stroke within 6 hours of symptom onset. Neurosurgery 2015; 76:321-9. [PMID: 25599209 DOI: 10.1227/neu.0000000000000610] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The optimal treatment for hyperacute stroke attributable to cervical internal carotid artery (C-ICA) occlusion remains controversial. OBJECTIVE This study sought to evaluate clinical outcomes and prognostic factors after carotid artery stenting (CAS) in patients with hyperacute stroke within 6 hours of onset. METHODS Forty-seven patients with hyperacute stroke attributable to atherosclerotic C-ICA occlusion underwent emergent CAS. Forty-two patients (89.4%) had tandem intracranial artery occlusion (TIO). When patients showed remnant M1 or proximal M2 occlusions after CAS, intracranial recanalization therapy was performed by using pharmacologic thrombolysis and mechanical thrombectomy with a Solitaire stent. Clinical and radiologic data were compared between patients with favorable (modified Rankin scale, 0-2) and unfavorable outcomes. Binary logistic regression analysis was used to find independent prognostic factors. RESULTS Emergent CAS was successful in all but 1 patient. Seven (16.7%) of 42 patients with TIO did not need further treatment, because thrombolysis in cerebral ischemia ≥2b was achieved immediately after CAS. Of the 35 patients who underwent intracranial recanalization therapy for remnant TIO, thrombolysis in cerebral ischemia ≥2b was achieved in 71.4% (25 of 35). Twenty-six patients (55.3%) had favorable outcomes, and mortality was 6.4% at 3 months. Time from symptom onset to carotid recanalization was inversely and independently associated with a favorable outcome for all patients and for those with TIO (P < .05). CONCLUSION In our patient group, emergent CAS for hyperacute stroke caused by atherosclerotic C-ICA occlusion seemed to be effective and safe. Time to carotid recanalization was inversely and independently associated with a favorable outcome.
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Affiliation(s)
- Woong Yoon
- *Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea; ‡Department of Radiology, Severance Stroke Center, Yonsei University College of Medicine Severance Hospital, Seoul, South Korea
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Park S, Park ES, Kwak JH, Lee DG, Suh DC, Kwon SU, Lee DH. Endovascular Management of Long-Segmental Petrocavernous Internal Carotid Artery (Carotid S) Occlusion. J Stroke 2015; 17:336-43. [PMID: 26437999 PMCID: PMC4635712 DOI: 10.5853/jos.2015.17.3.336] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/05/2015] [Accepted: 07/06/2015] [Indexed: 11/25/2022] Open
Abstract
Background and Purpose Long-segmental thrombotic occlusion of the distal internal carotid artery (ICA) sparing the cervical segment proximally and the supraclinoid segment distally, which could be termed ’Carotid S occlusion’, has an unusual clinical presentation. However, endovascular management of this lesion is challenging. The purpose of our study is to report our endovascular treatment clinical experience of the disease. Methods From March 2008 to June 2013, we could identify 14 patients (average age: 62.1, median age: 62, range: 50-79) with ‘Carotid S occlusion’, who underwent endovascular recanalization procedures. Patient’s clinical presentations were collected and the imaging findings also analyzed. The technical success rate, 24-hour and follow-up imaging outcome, and the clinical outcome using the 90-day mRS (modified Rankin scale) score were evaluated. Results Patients presented with gradually progressing (n = 8), fluctuating (n = 3), transient ischemic attack (n = 2) and stationary (n = 1) symptoms. DWI showed internal and external border-zone lesions in six patients, only internal ICA border-zone lesions in three patients, and only external border-zone lesions in two patients. Underlying distal ICA stenosis was noted in 12 patients. The technical success rate was 92.8% (13/14). Luminal patency was noted in all patients (100%) after 24 hours and in nine of 10 (90%) on long-term follow-up (median: 6.5, average: 15.1, range: 1-39 months). A 90-day, good functional outcome (mRS ≤ 2) was noted in 13 of 14 patients (92.8%). Conclusions ‘Carotid S occlusion’ usually presented with border-zone infarction and endovascular management of the lesions was feasible. A relatively successful clinical outcome could be achieved after successful revascularization.
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Affiliation(s)
- Soonchan Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea ; Department of Radiology, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Eun Suk Park
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jae Hyuk Kwak
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong-Geun Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dae Chul Suh
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sun U Kwon
- Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Deok Hee Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Steglich-Arnholm H, Krieger DW. Carotid stent-assisted thrombectomy in acute ischemic stroke. Future Cardiol 2015; 11:615-32. [PMID: 26406551 DOI: 10.2217/fca.15.54] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Acute carotid occlusion or near-occlusion with concomitant intracranial embolism cause severe acute ischemic strokes in patients. These concomitant occlusions have suggested poor response to intravenous thrombolysis and complicate endovascular treatment. Nevertheless, endovascular stent-assisted thrombectomy may improve outcome in patients but the treatment is not without concerns. Required antiplatelet therapy to prevent stent thrombosis may increase the rate of intracranial hemorrhage, especially after recent thrombolysis. Furthermore, technical difficulties in access of the intracranial vasculature may cause adverse events, even in the hands of experienced interventionalists. These concerns currently defy the treatment in being recommended for general use and only on a compassionate basis. However, recent patient series have suggested reasonable safety and efficacy for carotid stent-assisted thrombectomy.
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Affiliation(s)
| | - Derk W Krieger
- Department of Neurology, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark.,Faculty of Health & Medical Science, University of Copenhagen, Blegdamsvej 3B, København N 2200, Denmark
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Behme D, Mpotsaris A, Zeyen P, Psychogios MN, Kowoll A, Maurer CJ, Joachimski F, Liman J, Wasser K, Kabbasch C, Berlis A, Knauth M, Liebig T, Weber W. Emergency Stenting of the Extracranial Internal Carotid Artery in Combination with Anterior Circulation Thrombectomy in Acute Ischemic Stroke: A Retrospective Multicenter Study. AJNR Am J Neuroradiol 2015; 36:2340-5. [PMID: 26294652 DOI: 10.3174/ajnr.a4459] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 05/13/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Several small case series reported a favorable clinical outcome for emergency stent placement in the extracranial internal carotid artery combined with mechanical thrombectomy in acute stroke. The rate of postinterventional symptomatic intracranial hemorrhages was reported to be as high as 20%. Therefore, we investigated the safety and efficacy of this technique in a large multicentric cohort. MATERIALS AND METHODS The data bases of 4 German stroke centers were screened for all patients who received emergency stent placement of the extracranial internal carotid artery in combination with mechanical thrombectomy of the anterior circulation between 2007 and 2014. The primary outcome measure was the rate of symptomatic intracranial hemorrhage according to the European Cooperative Acute Stroke Study III criteria; secondary outcome measures included the angiographic revascularization results and clinical outcome. RESULTS One hundred seventy patients with a median age of 64 years (range, 25-88 years) were treated. They presented after a median of 98 minutes (range, 52-160 minutes) with a median NIHSS score of 15 (range, 12-19). Symptomatic intracranial hemorrhages occurred in 15/170 (9%) patients; there was no statistically significant difference among groups pertaining to age, sex, intravenous rtPA, procedural timings, and the rate of successful recanalization. In 130/170 (77%) patients, a TICI score of ≥ 2b could be achieved. The in-hospital mortality rate was 19%, and 36% of patients had a favorable outcome at follow-up. CONCLUSIONS Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is effective and safe. It is not associated with a significantly higher risk of symptomatic intracranial hemorrhage compared with published series for mechanical thrombectomy alone.
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Affiliation(s)
- D Behme
- From the Departments of Neuroradiology (D.B., M.N.P., M.K.)
| | - A Mpotsaris
- Department of Radiology and Neuroradiology (A.M., P.Z., C.K., T.L.), University Cologne, University Hospital Cologne, Cologne, Germany
| | - P Zeyen
- Department of Radiology and Neuroradiology (A.M., P.Z., C.K., T.L.), University Cologne, University Hospital Cologne, Cologne, Germany
| | - M N Psychogios
- From the Departments of Neuroradiology (D.B., M.N.P., M.K.)
| | - A Kowoll
- Department of Radiology and Neuroradiology (A.K., W.W.), Ruhr-University-Bochum, University Medical Center Langendreer, Bochum, Germany
| | - C J Maurer
- Departments of Radiology and Neuroradiology (C.J.M., A.B.)
| | - F Joachimski
- Neurology (F.J.), Klinikum Augsburg, Augsburg, Germany
| | - J Liman
- Neurology (J.L., K.W.), Georg-August-University Göttingen, University Medical Center, Göttingen, Germany
| | - K Wasser
- Neurology (J.L., K.W.), Georg-August-University Göttingen, University Medical Center, Göttingen, Germany
| | - C Kabbasch
- Department of Radiology and Neuroradiology (A.M., P.Z., C.K., T.L.), University Cologne, University Hospital Cologne, Cologne, Germany
| | - A Berlis
- Departments of Radiology and Neuroradiology (C.J.M., A.B.)
| | - M Knauth
- From the Departments of Neuroradiology (D.B., M.N.P., M.K.)
| | - T Liebig
- Department of Radiology and Neuroradiology (A.M., P.Z., C.K., T.L.), University Cologne, University Hospital Cologne, Cologne, Germany
| | - W Weber
- Department of Radiology and Neuroradiology (A.K., W.W.), Ruhr-University-Bochum, University Medical Center Langendreer, Bochum, Germany
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Abstract
Carotid occlusion is a disease that presents a difficult decision for the treating provider. Traditionally, many providers would opt for expectant management with risk factor reduction and supportive therapy. There is a growing body of literature however pointing to possible improved outcomes of more aggressive treatments, including reopening of the occluded carotid. In this review, we discuss the difficulties involved in diagnosing a patient presenting with symptomatic carotid occlusion, the natural history of the disease, and the emerging treatment options and paradigms of different institutions based on recent literature.
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Endovascular Treatment of Acute Stroke: Evolution and Selection of Techniques and Instruments Based on Thrombus Imaging. Clin Neuroradiol 2015. [PMID: 26216652 DOI: 10.1007/s00062-015-0435-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Mechanical thrombectomy provides higher recanalization rates than intravenous or intra-arterial thrombolysis. Finally this has been shown to translate into improved clinical outcome in six multicentric randomized controlled trials. However, within cohorts the clinical outcomes may vary, depending on the endovascular techniques applied. Systems aiming mainly for thrombus fragmentation and lacking a protection against distal embolization have shown disappointing results when compared to recent stent-retriever studies or even to historical data on local arterial fibrinolysis. Procedure-related embolic events are usually graded as adverse events in interventional neuroradiology. In stroke, however, the clinical consequences of secondary emboli have so far mostly been neglected and attributed to progression of the stroke itself. We summarize the evolution of instruments and techniques for endovascular, image-guided, microneurosurgical recanalization in acute stroke, and discuss how to avoid procedure-related embolic complications.
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Heldner MR, Jung S, Zubler C, Mordasini P, Weck A, Mono ML, Ozdoba C, El-Koussy M, Mattle HP, Schroth G, Gralla J, Arnold M, Fischer U. Outcome of patients with occlusions of the internal carotid artery or the main stem of the middle cerebral artery with NIHSS score of less than 5: comparison between thrombolysed and non-thrombolysed patients. J Neurol Neurosurg Psychiatry 2015; 86:755-60. [PMID: 25266203 DOI: 10.1136/jnnp-2014-308401] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 08/24/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE The use of thrombolysis in patients with minor neurological deficits and large vessel occlusion is controversial. METHODS We compared the outcome of patients with low National Institutes of Health Stroke Scale (NIHSS) scores and large vessel occlusions between thrombolysed and non-thrombolysed patients. RESULTS 88 (1.7%) of 5312 consecutive patients with acute (within 24 h) ischaemic stroke had occlusions of the internal carotid or the main stem of the middle cerebral artery and baseline NIHSS scores ≤5.47 (53.4%) were treated without thrombolysis, and 41 (46.6%) received intravenous thrombolysis, endovascular therapy or both. Successful recanalisation on MR or CT angiography at 24 h was more often observed in thrombolysed than in non-thrombolysed patients (78.9% versus 10.5%; p<0.001). Neurological deterioration (increase of NIHSS score ≥1 compared to baseline) was observed in 22.7% of non-thrombolysed versus 10.3% of thrombolysed after 24 h (p=0.002), in 33.3% versus 12.5% at hospital discharge (p=0.015) and in 41.4% versus 15% at 3 months (p<0.001). Symptomatic intracerebral haemorrhage occurred in two (asymptomatic in five) thrombolysed and in none (asymptomatic in three) non-thrombolysed. Thrombolysis was an independent predictor of favourable outcome (p=0.030) but not survival (p=0.606) at 3 months. CONCLUSIONS Non-thrombolysed patients with mild deficits and large vessel occlusion deteriorated significantly more often within 3 months than thrombolysed patients. Symptomatic intracerebral haemorrhages occurred in less than 5% of patients in both groups. These data suggest that thrombolysis is safe and effective in these patients. Therefore, randomised trials in patients with large vessel occlusions and mild or rapidly improving symptoms are needed.
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Affiliation(s)
- Mirjam R Heldner
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Christoph Zubler
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Anja Weck
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marie-Luise Mono
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Christoph Ozdoba
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marwan El-Koussy
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Heinrich P Mattle
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Gerhard Schroth
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
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Liebeskind DS, Flint AC, Budzik RF, Xiang B, Smith WS, Duckwiler GR, Nogueira RG. Carotid I's, L's and T's: collaterals shape the outcome of intracranial carotid occlusion in acute ischemic stroke. J Neurointerv Surg 2015; 7:402-7. [PMID: 24789707 PMCID: PMC4216639 DOI: 10.1136/neurintsurg-2014-011231] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 04/13/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Collaterals may affect revascularization, ischemic severity, and clinical outcomes in acute stroke owing to internal carotid artery (ICA) occlusion. OBJECTIVE To examine the hypothesis that morphology of occlusive thrombus and collateral flow patterns may influence the outcome of ICA occlusions after mechanical thrombectomy. METHODS Pooled analyses of ICA occlusions in the MERCI and Multi-MERCI trials employed central angiography review readings to categorize lesions as I, L, or T clots and functional lesions based on collateral flow patterns. Demographic variables, procedural details, and clinical outcomes were compared across ICA lesion types. RESULTS A total of 72 subjects (mean age 67 years (SD 16), 51% female, median National Institutes of Health Stroke Scale 20 (range 8-35)) were included, with 90-day modified Rankin score ≤2 in 28% and 51% mortality. Clots were categorized as an I lesion in 9/72 (12.5%), L lesion in 12/72 (16.7%), and T lesion in 51/72 (70.8%). Based on collateral flow patterns, cases were categorized as having a functional I lesion in 7/72 (9.7%), functional L in 38/72 (52.8%), and functional T in only 27/72 (37.5%). Multivariate analyses showed that a functional T lesion, with insufficient collateral flow to ipsilateral anterior cerebral arteries via the contralateral ICA, was a strong predictor of both revascularization success and subsequent clinical outcomes. CONCLUSIONS Collateral flow patterns distinguish the nature and impact of ICA occlusions on expected revascularization and subsequent clinical outcomes in acute ischemic stroke. The nomenclature of terminal ICA occlusions introduced here (carotid I's, L's, and T's) may enhance future endovascular trials targeting such proximal occlusions. TRIAL REGISTRATION NUMBER NCT00318071 (http://clinicaltrials.gov). MERCI was not registered because enrollment began before July 1, 2005.
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Affiliation(s)
- David S Liebeskind
- Department of Neurology, UCLA Stroke Center, Los Angeles, California, USA
| | | | | | - Bin Xiang
- Prospect Analytical, San Jose, California, USA
| | - Wade S Smith
- University of California San Francisco, San Francisco, California, USA
| | - Gary R Duckwiler
- Department of Neurology, UCLA Stroke Center, Los Angeles, California, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
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Surgical embolectomy for internal carotid artery terminus occlusion. Neurosurg Rev 2015; 38:661-9. [PMID: 25962555 DOI: 10.1007/s10143-015-0640-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 11/17/2014] [Accepted: 01/19/2015] [Indexed: 10/23/2022]
Abstract
The aim of this study was to assess the efficacy and safety of surgical embolectomy for internal carotid artery terminus (ICA-T) occlusion. Twenty-five consecutive patients with acute ischemic stroke attributed to embolic ICA-T occlusion who underwent surgical embolectomy were retrospectively reviewed. Twenty-four patients were examined based on magnetic resonance imaging, with one patient included based on a computed tomography scan. Recanalization rate, recanalization time, complications, National Institutes of Health Stroke Scale (NIHSS) score improvement at 1 month, and modified Rankin Scale (mRS) at 3 months were evaluated. Final recanalization status was Thrombolysis in Myocardial Infarction (TIMI) 3 in 24 patients (96 %). Median recanalization time from symptom onset and from start of surgery was 281 and 79 min, respectively. Two patients (8 %) had major hemorrhagic complications related to surgery. Seventeen patients (68 %) demonstrated NIHSS score improvement of more than 10 points at 1 month. At 3 months, eight patients (32 %) were mRS 0-2, five patients (20 %) were mRS 3, and three patients (12 %) had died. Surgical embolectomy for ICA-T occlusion demonstrated a high complete recanalization rate and should be reconsidered as an additional therapeutic strategy to overcome this devastating situation.
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Song D, Heo JH, Kim DI, Kim DJ, Kim BM, Lee K, Yoo J, Lee HS, Nam HS, Kim YD. Impact of temporary opening using a stent retriever on clinical outcome in acute ischemic stroke. PLoS One 2015; 10:e0124551. [PMID: 25879929 PMCID: PMC4399833 DOI: 10.1371/journal.pone.0124551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 03/15/2015] [Indexed: 01/19/2023] Open
Abstract
Background Stent retriever has a distinct ability to restore blood flow temporarily before achieving final reperfusion. There has been a limited report regarding the clinical impact of it. We investigated if temporary opening of occluded vessels using a stent retriever before final reperfusion might improve clinical outcome in acute ischemic stroke patients who received the endovascular reperfusion treatment. Methods We enrolled consecutive ischemic stroke patients who had an initial occlusive lesion in the anterior circulation and achieved final reperfusion (Thrombolysis In Cerebral Infarction [TICI] ≥2) by endovascular treatment. Temporary opening was defined as the presence of ante grade flow (TICI≥2) during deployment of a stent retriever. Favorable outcome was defined as a modified Rankin scale score≤2 at 90 day. Results A total of 98 patients were included in the study and temporary opening was achieved in 49 (50%). Temporary opening was associated with favorable outcome (odds ratio, 7.825; 95% confidence interval, 1.592–38.461; p = 0.011) in the multivariate analysis. The probability of having a favorable outcome tended to decrease as time from onset to final reperfusion increased in patients without temporary opening. However, this trend was not evident in the patient with temporary opening. The beneficial effect of temporary opening on clinical outcome seemed to be present in patients with good collaterals but not in patients with poor collaterals. Conclusions Temporary opening of occluded vessel using a stent retriever may be beneficial for improving clinical outcome in acute ischemic stroke patients.
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Affiliation(s)
- Dongbeom Song
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ik Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Kijeong Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Joonsang Yoo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- * E-mail:
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Hasegawa H, Inoue T, Tamura A, Saito I. Emergent intracranial surgical embolectomy in conjunction with carotid endarterectomy for acute internal carotid artery terminus embolic occlusion and tandem occlusion of the cervical carotid artery due to plaque rupture. J Neurosurg 2015; 122:939-47. [DOI: 10.3171/2014.11.jns132855] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute internal carotid artery (ICA) terminus occlusion is associated with extremely poor functional outcomes or mortality, especially when it is caused by plaque rupture of the cervical ICA with engrafted thrombus that elongates and extends into the ICA terminus. The goal of this study was to evaluate the efficacy and safety of surgical embolectomy in conjunction with carotid endarterectomy (CEA) for acute ICA terminus occlusion associated with cervical plaque rupture resulting in tandem occlusion. A retrospective review of medical records was performed. Clinical and radiographic characteristics were evaluated, including details of surgical technique, recanalization grade, recanalization time, complications, modified Rankin Scale (mRS) score at 3 months, and National Institutes of Health Stroke Scale (NIHSS) score improvement at 1 month. Three patients (mean age 77.3 years; median presenting NIHSS Score 22, range 19–26) presented with abrupt tandem occlusion of the cervical ICA and ICA terminus and were selected for surgery after confirmation of embolic high-density signal at the ICA terminus on CT and diffusion-weighted imaging (DWI)/magnetic resonance angiography (MRA) mismatch. All patients underwent craniotomy for surgical embolectomy of the ICA terminus embolus followed by cervical exposure, aspiration of long residual proximal embolus ranging from the cervical to cavernous ICA, and removal of ruptured unstable plaque by CEA. Postoperative MRA demonstrated Thrombolysis In Myocardial Infarction (TIMI) 3 recanalization in all patients (100%) without evidence of additional infarction according to DWI. Mean recanalization time from hospital arrival was 234 minutes and from start of surgery, 151 minutes. Serial postoperative CT and MRI studies showed no symptomatic hemorrhage, brain edema, or progression of infarction. The patients' mRS scores at 3 months were 3, 3, and 1. All 3 patients demonstrated marked improvements in NIHSS scores (median 17 points; range 13–23 points) at 1 month. Considering the dismal prognosis associated with ICA terminus occlusion, especially when accompanied by cervical plaque rupture, emergent surgical embolectomy in conjunction with CEA might be an effective and decisive treatment option with a high complete recanalization rate and acceptable safety profile.
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Acute stroke patients treated with stent retrievers in carotid "T" occlusions have improved recanalization and outcome. Can J Neurol Sci 2014; 41:709-13. [PMID: 25410249 DOI: 10.1017/cjn.2014.109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Recanalization rates and patient outcomes in acute occlusion of the carotid terminus have previously been poor. The use of stent-retrievers has resulted in better recanalization and patient outcomes. We sought to compare outcomes in patients treated with stent-retrievers to outcomes in older techniques. METHODS We retrospectively compared a stent-retriever cohort to a historical cohort. We evaluated recanalization rates and good outcomes (defined as mRS < 2 at 30 days or 10 point drop in NIHSS). RESULTS There were twenty patients treated with stent-retrievers versus nine without. The recanalization rate in patients treated with stent retrievers was significantly higher than that of other modalities (90% vs 33%, p=0.004). Good outcomes were significantly higher in the stent retriever cohort (70% vs 22%, p=0.041). CONCLUSION The use of stent-retrievers in patients with carotid "T" occlusions shows promise in comparison to older techniques. A randomized trial comparing stent-retriever therapy to IV thrombolysis is warranted to determine the efficacy of this new generation of devices.
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Lockau H, Liebig T, Henning T, Neuschmelting V, Stetefeld H, Kabbasch C, Dorn F. Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results. Neuroradiology 2014; 57:589-98. [PMID: 25404414 DOI: 10.1007/s00234-014-1465-5] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 11/04/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Acute tandem occlusions of the cervical and distal internal carotid artery (ICA) or middle cerebral artery (MCA) are associated with major stroke with intravenous (i.v.) thrombolysis alone in approximately 90 % of patients. The data on endovascular management of tandem occlusions is still limited. The purpose of this study was to review technical aspects and the current state of the literature on acute ICA stenting in combination with stent retriever-based intracranial thrombectomy. METHODS We retrospectively reviewed the data of 37 consecutive patients with tandem occlusions including clinical parameters, angiographic results, procedural aspects, complications, and hemorrhages. RESULTS Median National Institutes of Health Stroke Scale (NIHSS) on admission was 17 (3-30). Intracranial thrombectomy was performed prior to ICA stenting in 25/37 (67.6 %) and after stenting in 12/37 (32.4 %) patients. ICA stenting was successful in all cases, and a thrombolysis in cerebral infarction (TICI) scale 2b/3 result was achieved in 27/37 (73 %) cases. The mean angiography time was significantly shorter in the "thrombectomy first" group (43.1 ± 30.8 vs. 110.8 ± 43.0 min, p < 0.001), and more patients had favorable outcomes after 3 months (13/25 = 52.0 vs. 4/12 = 33.3 %, p = 0.319). In this group, intermediate catheters were used and successfully prevented embolism to unaffected territories in all cases. CONCLUSION Acute stenting of the cervical ICA in combination with intracranial thrombectomy was technically feasible and safe in our series. Thrombectomy prior to proximal stenting was associated with shorter reperfusion times and a tendency towards better clinical outcome leading to a good outcome in about 50 % of the patients. Therefore, we recommend this approach in tandem occlusion requiring stent angioplasty.
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Affiliation(s)
- H Lockau
- Department of Radiology, University Hospital of Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
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Affiliation(s)
- A H V Schapira
- Department of Clinical Neurosciences, UCL Institute of Neurology, London, UK.
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Hsieh K, Verma RK, Schroth G, Gratz PP, Kellner-Weldon F, Gralla J, Zubler C, Mordasini P, Jung S, Mattle HP, El-Koussy M. Multimodal 3 Tesla MRI Confirms Intact Arterial Wall in Acute Stroke Patients After Stent-Retriever Thrombectomy. Stroke 2014; 45:3430-2. [DOI: 10.1161/strokeaha.114.006665] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kety Hsieh
- From the Department of Diagnostic and Interventional Neuroradiology (K.H., R.K.V., G.S., P.P.G., F.K.-W., J.G., C.Z., P.M., M.E.-K.), and Department of Neurology (S.J., H.P.M.), University Hospital Bern, Switzerland
| | - Rajeev K. Verma
- From the Department of Diagnostic and Interventional Neuroradiology (K.H., R.K.V., G.S., P.P.G., F.K.-W., J.G., C.Z., P.M., M.E.-K.), and Department of Neurology (S.J., H.P.M.), University Hospital Bern, Switzerland
| | - Gerhard Schroth
- From the Department of Diagnostic and Interventional Neuroradiology (K.H., R.K.V., G.S., P.P.G., F.K.-W., J.G., C.Z., P.M., M.E.-K.), and Department of Neurology (S.J., H.P.M.), University Hospital Bern, Switzerland
| | - Pascal P. Gratz
- From the Department of Diagnostic and Interventional Neuroradiology (K.H., R.K.V., G.S., P.P.G., F.K.-W., J.G., C.Z., P.M., M.E.-K.), and Department of Neurology (S.J., H.P.M.), University Hospital Bern, Switzerland
| | - Frauke Kellner-Weldon
- From the Department of Diagnostic and Interventional Neuroradiology (K.H., R.K.V., G.S., P.P.G., F.K.-W., J.G., C.Z., P.M., M.E.-K.), and Department of Neurology (S.J., H.P.M.), University Hospital Bern, Switzerland
| | - Jan Gralla
- From the Department of Diagnostic and Interventional Neuroradiology (K.H., R.K.V., G.S., P.P.G., F.K.-W., J.G., C.Z., P.M., M.E.-K.), and Department of Neurology (S.J., H.P.M.), University Hospital Bern, Switzerland
| | - Christoph Zubler
- From the Department of Diagnostic and Interventional Neuroradiology (K.H., R.K.V., G.S., P.P.G., F.K.-W., J.G., C.Z., P.M., M.E.-K.), and Department of Neurology (S.J., H.P.M.), University Hospital Bern, Switzerland
| | - Pasquale Mordasini
- From the Department of Diagnostic and Interventional Neuroradiology (K.H., R.K.V., G.S., P.P.G., F.K.-W., J.G., C.Z., P.M., M.E.-K.), and Department of Neurology (S.J., H.P.M.), University Hospital Bern, Switzerland
| | - Simon Jung
- From the Department of Diagnostic and Interventional Neuroradiology (K.H., R.K.V., G.S., P.P.G., F.K.-W., J.G., C.Z., P.M., M.E.-K.), and Department of Neurology (S.J., H.P.M.), University Hospital Bern, Switzerland
| | - Heinrich P. Mattle
- From the Department of Diagnostic and Interventional Neuroradiology (K.H., R.K.V., G.S., P.P.G., F.K.-W., J.G., C.Z., P.M., M.E.-K.), and Department of Neurology (S.J., H.P.M.), University Hospital Bern, Switzerland
| | - Marwan El-Koussy
- From the Department of Diagnostic and Interventional Neuroradiology (K.H., R.K.V., G.S., P.P.G., F.K.-W., J.G., C.Z., P.M., M.E.-K.), and Department of Neurology (S.J., H.P.M.), University Hospital Bern, Switzerland
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