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Pop R, Finitsis SN, Marnat G, Derraz I, Cognard C, Calviere L, Caroff J, Clarençon F, Delvoye F, Consoli A, Lapergue B, Gory B. Cangrelor for emergent carotid stenting during stroke thrombectomy: a comparative analysis versus glycoprotein IIb/IIIa inhibitors or aspirin monotherapy. J Neurointerv Surg 2024:jnis-2024-022125. [PMID: 39242196 DOI: 10.1136/jnis-2024-022125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Accepted: 08/21/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Periprocedural antiplatelet treatment is a key determinant for the risk-benefit balance of emergent carotid artery stenting (eCAS) during stroke endovascular treatment (EVT). We aimed to assess the safety and efficacy profile of cangrelor compared with glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors or aspirin monotherapy. METHODS Data were extracted from the Endovascular Treatment in Ischemic Stroke (ETIS) registry, a prospective nationwide observational registry of stroke EVT in France. Included patients were treated with eCAS for anterior circulation tandem lesions between January 2015 and June 2023 and received periprocedural treatment with cangrelor, GPIIb/IIIa inhibitors or aspirin monotherapy. The primary outcome was functional outcome at 90 days, assessed by the modified Rankin Scale (mRS). Secondary outcomes included intracranial recanalization, hemorrhagic transformation and carotid stent patency at day 1. RESULTS Of the 1687 patients treated, 384 met the inclusion criteria: 91 received cangrelor, 77 received GPIIb/IIIa inhibitors and 216 aspirin monotherapy. Cangrelor was associated with a negative shift in the distribution of mRS scores compared with GPIIb/IIIa inhibitors (aOR 0.48, 95% CI 0.25 to 0.94, P=0.033). Compared with aspirin, cangrelor improved carotid stent patency at day 1 (aOR 4.00, 95% CI 1.19 to 14.29, P=0.025) but showed no significant differences in clinical outcomes. There were no differences in outcomes between full dose and low dose cangrelor. GPIIb/IIIa inhibitors demonstrated higher odds of functional independence (aOR 2.56, 95% CI 1.08 to 6.25, P=0.033) compared with aspirin. CONCLUSIONS This registry-based study indicates a potential trend towards lower odds of favorable clinical outcomes with cangrelor treatment compared with GPIIb/IIIa inhibitors. However, these findings should be interpreted with caution due to potential selection bias and warrant further research for validation.
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Affiliation(s)
- Raoul Pop
- Department of Interventional Neuroradiology, Strasbourg University Hospitals, Strasbourg, France
- Interventional Radiology, IHU Strasbourg, Strasbourg, France
- INSERM UMR_S1255, Etablissement Français du Sang, Strasbourg, France
| | | | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, France
| | - Imad Derraz
- Neuroradiology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Christophe Cognard
- Diagnostic and Therapeutic Neuroradiology, CHU Toulouse, Toulouse, France
| | | | - Jildaz Caroff
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Frédéric Clarençon
- Radiology, Sorbonne Universite, Paris, France
- Neuroradiology, Hopital Universitaire Pitie-Salpetriere, Paris, France
| | - François Delvoye
- Neurointerventional Radiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Hospital Foch, Suresnes, France
| | | | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
- Radiology, Université de Lorraine, Nancy, France
- IADI, INSERM U1254, Nancy, France
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Mendes GN, Jacquin G, Katsanos AH, Singh N, Stotts G, Ferguson DB, Yip S, Poppe AY. Safety of acute internal carotid artery stenting during endovascular thrombectomy in patients with acute ischemic stroke: a retrospective analysis of the OPTIMISE registry. J Neurointerv Surg 2024:jnis-2024-021915. [PMID: 38937083 DOI: 10.1136/jnis-2024-021915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 06/14/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The optimal management of tandem carotid lesions during endovascular thrombectomy (EVT) remains uncertain. The safety and efficacy of acute carotid artery stenting (aCAS) are debated, including safety concerns such as procedural complications and symptomatic intracerebral hemorrhage (sICH). We aimed to assess aCAS safety among EVT-treated patients using a large Canadian registry. METHODS We retrospectively analyzed the OPTIMISE registry and compared adult patients undergoing EVT and aCAS versus EVT only. The primary outcome was a composite of in-hospital death, long-term care facility destination at discharge, sICH, or any EVT-related procedural complications. Secondary outcomes included individual components of the primary outcome, EVT workflow times, final modified Thrombolysis in Cerebral Ischemia score and 90-day modified Rankin Scale score. Statistical significance was evaluated by a multivariate logistic regression model. RESULTS 4205 patients were included (330 with EVT-aCAS and 3875 with EVT-only). Both groups were similar with regard to baseline National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score and use of IV thrombolysis, but differed in age (EVT-aCAS group 67.2±12.1 years vs EVT-only group 71.3±14.1 years, P<0.001), proportion of women (28.2% vs 53.3%, P<0.001), and occlusion location (internal carotid artery terminus 44% vs 16%, P<0.001). The EVT-aCAS group showed a non-significant increase in odds of composite safety outcomes (adjusted OR 1.35 (95% CI 0.97 to 1.84), P=0.06) with a significantly higher proportion of procedural complications (10.0% vs 6.2%, P=0.002). CONCLUSION In a large national registry, EVT-aCAS was associated with a higher proportion of unfavorable safety outcomes, driven by more frequent procedural complications. Further research is needed to clarify the role of aCAS in tandem occlusion stroke.
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Affiliation(s)
- George Nilton Mendes
- Neurosciences Axis, Centre de Recherche du CHUM, Montreal, Quebec, Canada
- Neurosciences, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
| | - Grégory Jacquin
- Neurosciences Axis, Centre de Recherche du CHUM, Montreal, Quebec, Canada
- Neurosciences, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
| | - Aristeidis H Katsanos
- Medicine (Neurology), McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Nishita Singh
- Internal Medicine (Neurology), University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Grant Stotts
- Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Darren B Ferguson
- Diagnostic Radiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Samuel Yip
- Medicine (Neurology), The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexandre Y Poppe
- Neurosciences Axis, Centre de Recherche du CHUM, Montreal, Quebec, Canada
- Neurosciences, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
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Mujanovic A, Dobrocky T, Pfeilschifter W, Remonda L, Caroff J, Behme D, Seiffge DJ, Cereda CW, Kägi G, Leyon J, Piechowiak EI, Costalat V, Wagner J, Chabert E, Meinel TR, Jansen O, Alonso A, Loehr C, Liebeskind DS, Gralla J, Fischer U, Kaesmacher J. Value of intravenous alteplase before thrombectomy among patients with tandem lesions and emergent carotid artery stenting: A subgroup analysis of the SWIFT DIRECT trial. Eur J Neurol 2024; 31:e16256. [PMID: 38409874 PMCID: PMC11235868 DOI: 10.1111/ene.16256] [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: 11/21/2023] [Revised: 01/26/2024] [Accepted: 02/07/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND AND PURPOSE The value of intravenous thrombolysis (IVT) in eligible tandem lesion patients undergoing endovascular treatment (EVT) is unknown. We investigated treatment effect heterogeneity of EVT + IVT versus EVT-only in tandem lesion patients. Additional analyses were performed for patients undergoing emergent internal carotid artery (ICA) stenting. METHODS SWIFT DIRECT randomized IVT-eligible patients to either EVT + IVT or EVT-only. Primary outcome was 90-day functional independence (modified Rankin Scale score 0-2) after the index event. Secondary endpoints were reperfusion success, 24 h intracranial hemorrhage rate, and 90-day all-cause mortality. Interaction models were fitted for all predefined outcomes. RESULTS Among 408 included patients, 63 (15.4%) had a tandem lesion and 33 (52.4%) received IVT. In patients with tandem lesions, 20 had undergone emergent ICA stenting (EVT + IVT: 9/33, 27.3%; EVT: 11/30, 36.7%). Tandem lesion did not show treatment effect modification of IVT on rates of functional independence (tandem lesion EVT + IVT vs. EVT: 63.6% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 65.6% vs. 58.2%; p for interaction = 0.77). IVT also did not increase the risk of intracranial hemorrhage among tandem lesion patients (tandem lesion EVT + IVT vs. EVT: 34.4% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 33.5% vs. 26.3%; p for interaction = 0.15). No heterogeneity was noted for other endpoints (p for interaction > 0.05). CONCLUSIONS No treatment effect heterogeneity of EVT + IVT versus EVT-only was observed among tandem lesion patients. Administering IVT in patients with anticipated emergent ICA stenting seems safe, and the latter should not be a factor to consider when deciding to administer IVT before EVT.
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Affiliation(s)
- Adnan Mujanovic
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
| | - Waltraud Pfeilschifter
- Department of Neurology, University Hospital FrankfurtGoethe UniversityFrankfurt am MainGermany
| | - Luca Remonda
- Department of NeuroradiologyCantonal Hospital AarauAarauSwitzerland
| | - Jildaz Caroff
- Department of Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre HospitalParis‐Saclay UniversityLe Kremlin‐BicêtreFrance
| | - Daniel Behme
- Department for Neuroradiology, Otto von Guericke University Hospital MagdeburgUniversity of MagdeburgMagdeburgGermany
| | - David J. Seiffge
- Department of Neurology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
| | - Carlo W. Cereda
- Stroke Center, Neurology, Neurocenter of Southern Switzerland (EOC)LuganoSwitzerland
| | - Georg Kägi
- Department of NeurologyCantonal Hospital St. Gallen, University of St. GallenSt. GallenSwitzerland
| | - Joe Leyon
- Department of NeuroradiologySt. George's University HospitalLondonUK
| | - Eike I. Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
| | - Vincent Costalat
- Department of NeuroradiologyUniversity Hospital MontpellierMontpellierFrance
| | - Judith Wagner
- Department of NeurologyKepler University Hospital, Johannes Kepler University LinzLinzAustria
- Department of Neurology, Evangelisches Klinikum GelsenkirchenAcademic Hospital University Essen‐DuisburgGelsenkirchenGermany
| | - Emmanuel Chabert
- Department of NeuroradiologyUniversity Hospital Clermont‐FerrandClermont‐FerrandFrance
| | - Thomas R. Meinel
- Department of Neurology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
| | - Olav Jansen
- Department of Radiology and NeuroradiologyUniversity Hospital Schleswig‐Holstein, University of KielKielGermany
| | - Angelika Alonso
- Department of Neurology, Medical Faculty MannheimUniversity of HeidelbergMannheimGermany
| | - Christian Loehr
- Department of Radiology and NeuroradiologyKlinikum VestRecklinghausenGermany
| | - David S. Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of MedicineUniversity of California, Los AngelesLos AngelesUSA
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
- Department of NeurologyUniversity Hospital Basel, University of BaselBaselSwitzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
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Garayzade R, Berlis A, Schiele S, Ertl M, Schneider H, Müller G, Maurer CJ. Efficacy and Safety Outcomes for Acute Ischemic Stroke Patients Treated with Intravenous Infusion of Tirofiban After Emergent Carotid Artery Stenting. Clin Neuroradiol 2024; 34:163-172. [PMID: 37796321 PMCID: PMC10881598 DOI: 10.1007/s00062-023-01350-7] [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: 04/05/2023] [Accepted: 09/14/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Emergent stenting of the extracranial internal carotid artery (ICA) in stroke patients requires antiplatelet therapy to prevent in-stent thrombosis with a higher risk of intracranial haemorrhage. AIM OF THE STUDY Assess the efficacy and safety of emergent carotid stenting with intravenous tirofiban in acute ischemic stroke patients. METHODS Primary endpoint: symptomatic hemorrhage. Secondary endpoints: 90-day functional outcome and mortality. RESULTS Of the 62 patients, 21 (34%) received tirofiban as a single antiplatelet, and 41 (66%) received combined therapy. Premedication with anticoagulants and antiplatelets was significantly more frequent in the tirofiban-only group. The rate of symptomatic haemorrhage was significantly lower in the tirofiban-only group than in the combined group (4.8% vs. 27%, p = 0.046). The patients with tirofiban alone had a significantly better functional outcome at day 90 than the combined group (52% vs. 24%, p = 0.028). Mortality was equal (24%) in both groups. Pre-interventional NIHSS score (p = 0.003), significant blood pressure fluctuations (p = 0.012), tandem occlusion (p = 0.023), and thrombolysis (p = 0.044) showed relevant influence on the rate of symptomatic hemorrhage in the entire patient cohort. CONCLUSIONS A single antiplatelet therapy with tirofiban regardless of the premedication may improve the functional outcome in patients with stroke due to acute extracranial carotid lesion and emergent carotid stenting with lower rates of serious intracranial haemorrhage. For patients with high pre-interventional NIHSS score, tandem occlusion and after pre-interventional thrombolysis, caution is advised. Additionally, strict blood pressure monitoring should be conducted during the first 72 h after intervention.
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Affiliation(s)
- Rana Garayzade
- Department of diagnostic and interventional Radiology and Neuroradiology, Augsburg University Hospital, Augsburg, Germany.
| | - Ansgar Berlis
- Department of diagnostic and interventional Radiology and Neuroradiology, Augsburg University Hospital, Augsburg, Germany
| | - Stefan Schiele
- Institute of Mathematics, Augsburg University, Augsburg, Germany
| | - Michael Ertl
- Department of Neurology, Augsburg University Hospital, Augsburg, Germany
| | - Hauke Schneider
- Department of Neurology, Augsburg University Hospital, Augsburg, Germany
| | - Gernot Müller
- Institute of Mathematics, Augsburg University, Augsburg, Germany
| | - Christoph J Maurer
- Department of diagnostic and interventional Radiology and Neuroradiology, Augsburg University Hospital, Augsburg, Germany
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5
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Latacz P, Popiela T, Brzegowy P, Lasocha B, Kwiecień K, Simka M. Safety and Efficacy of Low-Dose Eptifibatide for Tandem Occlusions in Acute Ischemic Stroke. Neurol Int 2024; 16:253-262. [PMID: 38392958 PMCID: PMC10892545 DOI: 10.3390/neurolint16010017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVES The optimal treatment strategy for ischemic stroke in patients presenting with tandem occlusions of the internal carotid artery remains controversial. Several studies have demonstrated better clinical outcomes after eptifibatide, which is a short half-life antiplatelet agent. This retrospective analysis focused on the safety and efficacy of low-dose eptifibatide administration in stroke patients with tandem lesions. METHODS We evaluated the results of endovascular treatment in 148 stroke patients with tandem lesions. Patients in whom balloon angioplasty alone resulted in satisfactory cerebral flow did not receive eptifibatide (33 patients); others received this drug together with stent implantation (115 patients). Eptifibatide was given as an intravenous bolus of 180 μg/kg and then in a modified low dose of 1 μg/kg/min for 24 hours. RESULTS There were no statistically significant differences between both groups regarding 30-day mortality, frequency of thrombotic events, or hemorrhagic complications. An analysis of clinical status at 30-day follow-up revealed that the administration of eptifibatide was associated with a statistically significant better outcome: a higher rate of either no neurological symptoms or only mild symptoms (4 NIHSS points maximally). CONCLUSIONS The administration of eptifibatide in stroke patients presenting with tandem lesions is relatively safe. Moreover, treatment with this drug can improve clinical outcomes in these challenging patients.
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Affiliation(s)
- Paweł Latacz
- Department of Vascular Surgery and Angiology, Brothers of Mercy St. John of God Hospital, 31-061 Krakow, Poland; (P.L.); (K.K.)
| | - Tadeusz Popiela
- Chair of Radiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (T.P.); (P.B.)
| | - Paweł Brzegowy
- Chair of Radiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (T.P.); (P.B.)
| | | | - Krzysztof Kwiecień
- Department of Vascular Surgery and Angiology, Brothers of Mercy St. John of God Hospital, 31-061 Krakow, Poland; (P.L.); (K.K.)
| | - Marian Simka
- Institute of Medical Sciences, University of Opole, 45-040 Opole, Poland
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Baig AA, Waqas M, Turner RC, Kuo CC, Donnelly BM, Lai PMR, Raygor KP, Bouslama M, Lim J, Neumaier Bs J, Cappuzzo JM, Davies JM, Snyder KV, Siddiqui AH, Levy EI. A propensity score-matched comparative study of balloon guide catheters versus conventional guide catheters for concurrent mechanical thrombectomy with carotid stenting in tandem strokes: comparison of first pass effect, symptomatic intracranial hemorrhage, and 90-day functional outcomes. J Neurointerv Surg 2024; 16:124-130. [PMID: 37076277 DOI: 10.1136/jnis-2023-020114] [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: 01/19/2023] [Accepted: 03/22/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Extensive clot burden in tandem strokes accounts for poor mechanical thrombectomy (MT) outcomes. Several studies have shown the benefit of balloon guide catheters (BGCs) in MT and carotid artery stenting. OBJECTIVE In view of this potential benefit, to investigate the safety and effectiveness of proximal flow arrest using a BGC during concurrent MT and carotid revascularization for tandem stroke treatment in a comparative, propensity score-matched (PSM) study. METHODS Patients with a tandem stroke identified from our endovascular database were dichotomized into groups treated with BGCs versus conventional guide catheters. One-to-one PSM adjustment for baseline demographics and treatment selection bias using nearest-neighbor matching was performed. Patient demographics, presentation characteristics, and procedural details were recorded. Outcomes assessed were final modified Thrombolysis in Cerebral Infarction (mTICI) grade, periprocedural symptomatic intracranial hemorrhage (sICH) rate, in-hospital mortality, and 90-day modified Rankin Scale (mRS) score. Mann-Whitney U test and multivariate logistic regression were performed to compare procedural parameters and clinical outcomes. RESULTS Concurrent carotid revascularization (stenting with/without angioplasty) and MT was performed in 125 cases (BGC: 85; no BGC: 40). After PSM (40 patients/group), the BGC group had a significantly shorter procedure duration (77.9 vs 61.5 min; OR=0.996; P=0.006), lower discharge National Institutes of Health Stroke Scale score (8.0 vs 11.0; OR=0.987; P=0.042), and higher odds of 90-day mRS 0-2 score (52.3% vs 27.5%; OR=0.34; P=0.040). On multivariate regression, the BGC group had a significantly higher first pass effect rate (mTICI 2b or 3)(OR=1.115, 95% CI 1.015 to 1.432; P=0.013) and lower periprocedural sICH rate (OR=0.615, 95% CI 0.406 to 0.932; P=0.025). No difference in in-hospital mortality was observed (OR=1.591, 95% CI 0.976 to 2.593; P=0.067). CONCLUSION BGCs used for concurrent MT-carotid revascularization with flow arrest were safe and resulted in superior clinical and angiographic outcomes in patients with a tandem stroke.
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Affiliation(s)
- Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Ryan C Turner
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Brianna M Donnelly
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Pui Man Rosalind Lai
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Kunal P Raygor
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Mehdi Bouslama
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jenna Neumaier Bs
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Department Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Department Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
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7
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Zapata-Arriaza E, Medina-Rodríguez M, Moniche Álvarez F, de Albóniga-Chindurza A, Aguilar-Pérez M, Ainz-Gómez L, Baena-Palomino P, Zamora A, Pardo-Galiana B, Delgado-Acosta F, Valverde Moyano R, Jiménez-Gómez E, Bravo Rey I, Oteros Fernández R, Escudero-Martínez I, Vielba-Gomez I, Morales Caba L, Díaz Pérez J, García Molina E, Mosteiro S, Castellanos Rodrigo MDM, Amaya Pascasio L, Hidalgo C, Freijo Guerrero MDM, González Díaz E, Ramírez Moreno JM, Fernández Prudencio L, Terceño Izaga M, Bashir Viturro S, Gamero-García MÁ, Jiménez Jorge S, Rosso Fernández C, Montaner J, González García A. Statistical analysis plan for the multicenter, open, randomized controlled clinical trial to assess the efficacy and safety of intravenous tirofiban vs aspirin in acute ischemic stroke due to tandem lesion, undergoing recanalization therapy by endovascular treatment (ATILA trial). Trials 2024; 25:35. [PMID: 38195586 PMCID: PMC10775524 DOI: 10.1186/s13063-023-07817-9] [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: 07/12/2023] [Accepted: 11/21/2023] [Indexed: 01/11/2024] Open
Abstract
RATIONALE In-stent reocclusion after endovascular therapy has a negative impact on outcomes in acute ischemic stroke (AIS) due to tandem lesions (TL). Optimal antiplatelet therapy approach in these patients to avoid in-stent reocclusion is yet to be elucidated. AIMS To assess efficacy and safety of intravenous tirofiban versus intravenous aspirin in patients undergoing MT plus carotid stenting in the setting of AIS due to TL. SAMPLE SIZE ESTIMATES Two hundred forty patients will be enrolled, 120 in every treatment arm. METHODS AND DESIGN A multicenter, prospective, randomized, controlled (aspirin group), assessor-blinded clinical trial will be conducted. Patients fulfilling the inclusion criteria will be randomized at MT onset to the experimental or control group (1:1). Intravenous aspirin will be administered at a 500-mg single dose and tirofiban at a 500-mcg bolus followed by a 200-mcg/h infusion during the first 24 h. All patients will be followed for up to 3 months. STUDY OUTCOMES Primary efficacy outcome will be the proportion of patients with carotid in-stent thrombosis within the first 24 h after MT. Primary safety outcome will be the rate of symptomatic intracranial hemorrhage. DISCUSSION This will be the first clinical trial to assess the best antiplatelet therapy to avoid in-stent thrombosis after MT in patients with TL. TRIAL REGISTRATION The trial is registered as NCT05225961. February, 7th, 2022.
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Affiliation(s)
- Elena Zapata-Arriaza
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain.
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Neurovascular Research Laboratory, Institute of Biomedicine of Seville (IBIS), Av Manuel Siurot sn, Seville, 41013, Spain.
| | - Manuel Medina-Rodríguez
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Francisco Moniche Álvarez
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Asier de Albóniga-Chindurza
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Marta Aguilar-Pérez
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Neurovascular Research Laboratory, Institute of Biomedicine of Seville (IBIS), Av Manuel Siurot sn, Seville, 41013, Spain
| | - Leire Ainz-Gómez
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Pablo Baena-Palomino
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Aynara Zamora
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | - Blanca Pardo-Galiana
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | | | | | - Elvira Jiménez-Gómez
- Interventional Neuroradiology Department, Reina Sofía University Hospital, Córdoba, Spain
| | - Isabel Bravo Rey
- Interventional Neuroradiology Department, Reina Sofía University Hospital, Córdoba, Spain
| | | | | | - Isabel Vielba-Gomez
- Interventional Neuroradiology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Lluis Morales Caba
- Interventional Neuroradiology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Jose Díaz Pérez
- Interventional Neuroradiology Department, Virgen de la Arrixaca University Clinical Hospital, Murcia, Spain
| | | | - Sonia Mosteiro
- Interventional Neuroradiology Department, A Coruña University Hospital Complex, Coruña, Spain
| | | | | | - Carlos Hidalgo
- Interventional Neuroradiology Department, Torrecardenas University Hospital, Almería, Spain
| | | | - Eva González Díaz
- Interventional Neuroradiology Department, Cruces University Hospital, Vizcaya, Spain
| | | | | | - Mikel Terceño Izaga
- Department of Neurology, Doctor Josep Trueta Hospital, Girona, Spain
- Interventional Neuroradiology Unit, Doctor Josep Trueta Hospital, Girona, Spain
| | - Saima Bashir Viturro
- Department of Neurology, Doctor Josep Trueta Hospital, Girona, Spain
- Interventional Neuroradiology Unit, Doctor Josep Trueta Hospital, Girona, Spain
| | - Miguel Ángel Gamero-García
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen Macarena University Hospital, Seville, Spain
| | - Silvia Jiménez Jorge
- Clinical Research and Clinical Trials Unit (CTU), Virgen del Rocío Hospital, Seville, Spain
| | - Clara Rosso Fernández
- Clinical Research and Clinical Trials Unit (CTU), Virgen del Rocío Hospital, Seville, Spain
| | - Joan Montaner
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen Macarena University Hospital, Seville, Spain
| | - Alejandro González García
- Stroke Unit, Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Neurovascular Research Laboratory, Institute of Biomedicine of Seville (IBIS), Av Manuel Siurot sn, Seville, 41013, Spain
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8
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Pop R, Burel J, Finitsis SN, Papagiannaki C, Severac F, Mangin PH, Mihoc D, Leonard-Lorant I, Gheoca R, Wolff V, Chibbaro S, Sibon I, Richard S, Beaujeux R, Marnat G, Gory B. Comparison of three antithrombotic strategies for emergent carotid stenting during stroke thrombectomy: a multicenter study. J Neurointerv Surg 2023; 15:e388-e395. [PMID: 36759180 DOI: 10.1136/jnis-2022-019875] [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: 11/11/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Periprocedural antithrombotic treatment is a key determinant for the risk-benefit balance of emergent carotid artery stenting (eCAS) during stroke thrombectomy. We aimed to assess the safety and efficacy of three types of antithrombotic treatment. METHODS Retrospective review of prospectively collected endovascular databases in four comprehensive stroke centers, including consecutive cases of eCAS for tandem lesion strokes between January 2019 and July 2021. During this period, each center prospectively applied one of three periprocedural protocols: (a) two centers administered aspirin (250 mg IV); (b) one center administered aspirin and heparin (bolus+24 hours infusion); and (c) one center applied an aggressive antiplatelet strategy consisting of aspirin and clopidogrel (loading doses), with added intravenous tirofiban if in-stent thrombosis was observed during thrombectomy. Dichotomized comparisons of outcomes were performed between aggressive versus non-aggressive strategy (aspirin±heparin) and aspirin+heparin versus aspirin-alone groups. RESULTS Among 161 included patients, 62 received aspirin monotherapy, 38 aspirin+heparin, and 61 an aggressive treatment. Aggressive antiplatelet treatment was associated with an increased rate of excellent (modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3) recanalization and reduced carotid stent thrombosis at day 1 (3.5% vs 16.3%), compared with non-aggressive strategy. There were no significant differences in hemorrhagic transformation or 90-day mortality. There was a tendency towards better clinical outcome with aggressive treatment, without reaching statistical significance. Addition of heparin to aspirin was not associated with an increased rate of carotid stent patency. CONCLUSIONS Aggressive antiplatelet treatment was associated with improved intracranial recanalization and carotid stent patency, without safety concerns. These findings have implications for randomized trials and may be of utility for clinicians when making antithrombotic treatment choices.
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Affiliation(s)
- Raoul Pop
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
- Interventional Radiology, Institut de Chirurgie Guidée par l'Image, Strasbourg, France
- INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, F-67065, University of Strasbourg, Strasbourg, France
| | - Julien Burel
- Radiology, University Hospital Centre Rouen, Rouen, France
| | | | | | - Francois Severac
- Public Healthcare Department, University Hospitals Strasbourg, Strasbourg, France
| | - Pierre H Mangin
- INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, F-67065, University of Strasbourg, Strasbourg, France
| | - Dan Mihoc
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Ian Leonard-Lorant
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Roxana Gheoca
- Neurology, University Hospitals Strasbourg, Strasbourg, France
| | - Valerie Wolff
- Neurology, University Hospitals Strasbourg, Strasbourg, France
| | | | - Igor Sibon
- Neurology, University Hospital Center Bordeaux, Bordeaux, France
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Remy Beaujeux
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, University Hospital Centre Bordeaux, Bordeaux, France
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, Centre hospitalier regional universitaire de Nancy, Nancy, France
- Université de Lorraine, Nancy, France
- IADI, INSERM U1254, Nancy, France
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9
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van Elk T, Maes L, van der Meij A, Lemmens R, Uyttenboogaart M, de Borst GJ, Zeebregts CJ, Nederkoorn PJ. Immediate Carotid Artery Stenting or Deferred Treatment in Patients With Tandem Carotid Lesions Treated Endovascularly for Acute Ischaemic Stroke. EJVES Vasc Forum 2023; 61:31-35. [PMID: 38234597 PMCID: PMC10792755 DOI: 10.1016/j.ejvsvf.2023.12.002] [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: 10/23/2023] [Revised: 11/24/2023] [Accepted: 12/14/2023] [Indexed: 01/19/2024] Open
Abstract
Fifteen to 20% of patients with an acute ischaemic stroke have a tandem lesion defined by the combination of an intracranial large vessel thrombo-embolic occlusion and a high grade stenosis or occlusion of the ipsilateral internal carotid artery. These patients tend to have worse outcomes than patients with isolated intracranial occlusions, with higher rates of disability and death. The introduction of endovascular thrombectomy to treat the intracranial lesion clearly improved the outcome compared with treatment with intravenous thrombolysis alone. However, the best treatment strategy for managing the extracranial carotid artery lesion in patients with tandem lesions remains unknown. Current guidelines recommend carotid endarterectomy for patients with transient ischaemic attack or non-disabling stroke and moderate or severe stenosis of the internal carotid artery, within two weeks of the initial event, to prevent major stroke recurrence and death. Alternatively, the symptomatic carotid artery could be treated by endovascular placement of a stent during endovascular thrombectomy (EVT). This would negate the need for a second procedure, immediately reduce the risk of stroke recurrence, increase patient satisfaction, and could be cost effective. However, the administration of dual antiplatelet therapy could potentially increase the risk of symptomatic intracranial haemorrhage in patients with acute ischaemic stroke. Randomised controlled trials evaluating the efficacy and safety of immediate carotid artery stenting during EVT in acute stroke patients with tandem lesions are currently ongoing and will impact the current guidelines regarding the treatment of patients with acute ischaemic stroke due to these tandem lesions.
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Affiliation(s)
- Theodora van Elk
- Department of Neurology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Louise Maes
- Department of Neurology, University Hospital Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology, KULeuven - University of Leuven, Leuven, Belgium
| | - Anne van der Meij
- Department of Neurology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
- Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Robin Lemmens
- Department of Neurology, University Hospital Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology, KULeuven - University of Leuven, Leuven, Belgium
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Gert J. de Borst
- Department of Surgery (Division of Vascular Surgery), University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Clark J. Zeebregts
- Department of Surgery (Division of Vascular Surgery), University Medical Centre Groningen, Groningen, the Netherlands
| | - Paul J. Nederkoorn
- Department of Neurology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
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10
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Di Donna A, Muto G, Giordano F, Muto M, Guarnieri G, Servillo G, De Mase A, Spina E, Leone G. Diagnosis and management of tandem occlusion in acute ischemic stroke. Eur J Radiol Open 2023; 11:100513. [PMID: 37609048 PMCID: PMC10440394 DOI: 10.1016/j.ejro.2023.100513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023] Open
Abstract
Approximately 20-30% of patients with acute ischemic stroke, caused by large intracranial vessel occlusion, have a tandem lesion, defined as simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery. Patients with tandem lesions have usually worse outcomes than patients with single intracranial occlusions, and intravenous thrombolysis is less effective in these patients. Although endovascular thrombectomy is currently a cornerstone therapy in the management of acute ischemic stroke due to large vessel occlusion, the optimal management of extracranial carotid lesions in tandem occlusion remains controversial. Acute placement of a stent in the cervical carotid artery lesion is the most used therapeutic strategy compared with stented balloon angioplasty and thrombectomy alone without carotid artery revascularization; however, treatment strategies in these patients are often more complex than with single occlusion, so treatment decisions can change based on clinical and technical considerations. The aim of this review is to analyze the results of different studies and trials, investigating the periprocedural neurointerventional management of patients with tandem lesions and the safety, efficacy of the different technical strategies available as well as their impact on the clinical outcome in these patients, to strengthen current recommendations and thus optimize patient care.
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Affiliation(s)
- Antonio Di Donna
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluca Muto
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Flavio Giordano
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Massimo Muto
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluigi Guarnieri
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giovanna Servillo
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Antonio De Mase
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Emanuele Spina
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giuseppe Leone
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
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11
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Liu C, Liu M, Yang X, Wang J, Li G. Efficacy and safety of bridging therapy versus direct thrombectomy for tandem lesions in acute stroke: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 234:108005. [PMID: 37837908 DOI: 10.1016/j.clineuro.2023.108005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Current studies have concluded that MT (Mechanical Thrombectomy) is safe and effective for tandem lesions (TL). However, The benefit of bridging therapy for TL is controversial. OBJECTIVE To compare efficacy and safety between bridging therapy and direct thrombectomy of tandem lesions. METHOD We conducted a systematic review and meta-analysis of studies comparing bridging therapy versus direct thrombectomy among TL patients with regards to symptomatic intracerebral hemorrhage(sICH), Parenchymal hemorrhage (PH), 3-month mortality, modified Rankin Scale (mRS) score within 3 months, successful reperfusion, and excellent reperfusion. The meta-analysis of proportions was conducted with a common effects model. RESULT Five studies (n = 1198 patients) were identified for the systematic review. For safety outcomes, the bridging group had no significant difference in the rate of symptomatic intracranial hemorrhage (OR = 0.78, 95% CI = 0.49-1.25, P = 0.31) and the rate of PH (OR = 0.67, 95% CI = 0.39-1.13, P = 0.13) but significantly lower rate of 3-month mortality (OR = 0.53, 95% CI = 0.37-0.75, P = 0.0004) compared to the direct thrombectomy group. In terms of efficacy outcomes, the bridging therapy group had a significantly higher rate of 3- month good functional outcome (mRS 0-2) (OR = 1.76, 95% CI = 1.38-2.24, P < 0.00001) and successful recanalization (OR = 1.69, 95% CI = 1.27-2.25, P = 0.0003) but no significant difference in the rate of excellent recanalization(OR = 1.21, 95% CI = 0.91-1.59, P = 0.19) in patients with TL compared to direct thrombectomy group. CONCLUSION Bridging therapy is effective in improving the 3-month functional prognosis and increasing the rate of arterial recanalization without increasing the risk of intracranial hemorrhage in patients with TL compared to direct thrombectomy. A large multicentre clinical RCT is expected, as are advanced intravenous thrombolysis and endovascular thrombectomy techniques.
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Affiliation(s)
- Chenxi Liu
- Department of Neurology, The Frist Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Mingsu Liu
- Department of Neurology, Zhongshan Hospital Affiliated to Fudan University, Shanghai 200032, China
| | - Xun Yang
- Department of Neurology, Hechuan District People's Hospital, Chongqing 401500, China
| | - Jinping Wang
- Department of Neurology, Chongqing University Central Hospital, Chongqing 400050, China
| | - Guangqin Li
- Department of Neurology, The Frist Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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12
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Sepp D, Berndt M, Mönch S, Ikenberg B, Wunderlich S, Maegerlein C, Zimmer C, Boeckh-Behrens T, Friedrich B. Outcome and risk of hemorrhage in patients with tandem lesions after endovascular treatment: A propensity score-matched case-control study. Heliyon 2023; 9:e14508. [PMID: 36942245 PMCID: PMC10024127 DOI: 10.1016/j.heliyon.2023.e14508] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 02/26/2023] [Accepted: 03/08/2023] [Indexed: 03/16/2023] Open
Abstract
Objectives Endovascular treatment of acute stroke patients with large vessel occlusions is well established. But tandem lesions of the internal carotid artery and the intracranial anterior circulation remain a challenge regarding the technical conditions and the putative higher risk of hemorrhage due to often required antiplatelet therapy.This study aims to evaluate the clinical outcome and the risk of hemorrhage after endovascular treatment of tandem lesions, with special regard to the periprocedural antiplatelet regimen. Materials and Methods In this retrospective study, we included 63 consecutive stroke patients with endovascular treated tandem lesions. One hundred eleven patients with a solitary intracranial occlusion were matched using a "propensity score-matched analysis" with the covariates sex, age, wake-up stroke, iv-thrombolysis and NIHSS. Results Rates of successful recanalization (mTICI 2b/3) and periprocedural complications were equal in both groups (P = 0.19; P = 0.35). The rate of good clinical outcome (mRS≤2) was similar, and the incidence of symptomatic hemorrhages was not significantly different (7.9% tandem lesions vs. 5.4% isolated intracranial occlusion, P = 0.51). Even intensified antiplatelet therapy in patients with tandem lesions did not increase the rate of symptomatic intracranial hemorrhages (P = 0.87). Conclusions Clinical outcome and symptomatic intracranial hemorrhages did not differ significantly between endovascular treated patients with tandem lesions and matched patients with solitary intracranial occlusions, regardless of the antiplatelet regimen. Therefore, the complex technical requirements for recanalization of a tandem lesion and the putative higher risk should not result in reluctant treatment that would decrease the chance of a good clinical outcome.
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Affiliation(s)
- Dominik Sepp
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- Corresponding author. Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Maria Berndt
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Sebastian Mönch
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Benno Ikenberg
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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13
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Yamashita S, Imahori T, Koyama J, Tanaka K, Okamura Y, Arai A, Iwahashi H, Mori T, Onobuchi K, Sasayama T. Endovascular Treatment of Tandem Atherosclerotic Cervical Internal Carotid Artery Occlusion in the Setting of Acute Ischemic Stroke. Vasc Endovascular Surg 2023; 57:137-148. [PMID: 36189731 DOI: 10.1177/15385744221130865] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Among tandem occlusions, atherosclerotic cervical internal carotid artery occlusion (ACICAO) can be technically challenging and associated with its unique complications. We evaluated our experience with endovascular treatment (EVT) of ACICAO in the setting of acute ischemic stroke. METHODS In total, 154 consecutive patients who underwent EVT for acute anterior circulation stroke at our institute were retrospectively reviewed. Patients with tandem ACICAO were analyzed in this study. Procedures, recanalization rates, complications, and prognoses were evaluated. RESULTS Ten patients (6%) of all 154 patients had ACICAO. In nine (90%) of the 10 patients, cervical lesions were successfully crossed and intervened upon. Four patients underwent stenting and five underwent angioplasty alone, followed by intracranial procedure. Eight patients (80%) achieved successful recanalization following mechanical thrombectomy for intracranial occlusion. However, one patient had massive subarachnoid hemorrhage during the procedure and another patient developed massive intracranial hemorrhage after EVT, both after stenting. Four of the five patients who initially underwent angioplasty alone subsequently underwent staged endarterectomy or stenting for residual stenosis on or after the next day. The single patient in whom the cervical lesion could not be crossed and another with reocclusion after EVT underwent a rescue bypass procedure due to persistent ischemic symptoms. After 90 days, four patients (40%) were functionally independent (modified Rankin scale score 0-2). CONCLUSIONS Our experience suggests that EVT for ACICAO is technically feasible; however, it involves the potential risk of several significant complications. To avoid serious hemorrhagic complications, cervical lesions may be better treated with angioplasty alone first.
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Affiliation(s)
- Shunsuke Yamashita
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan.,Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Taichiro Imahori
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan.,Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Junji Koyama
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Kazuhiro Tanaka
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan.,Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Yusuke Okamura
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Atsushi Arai
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | | | - Tatsuya Mori
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Kana Onobuchi
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Takashi Sasayama
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan
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14
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Medina-Rodríguez M, Moniche F, de Albóniga-Chindurza A, Ortega-Quintanilla J, Ainz-Gómez L, Pardo-Galiana B, Cabezas-Rodríguez JA, Aguilar-Pérez M, Zamora A, Delgado-Acosta F, Jiménez-Gómez E, Bravo Rey I, Oteros Fernández R, Freijo Guerrero MDM, González Díaz E, Escudero-Martínez I, Morales Caba L, Vielba-Gomez I, Mosteiro S, Castellanos Rodrigo MDM, Amaya Pascasio L, Hidalgo C, Fernandez Prudencio L, Ramirez Moreno JM, Díaz Pérez J, Sanz-Fernandez G, Baena-Palomino P, Gamero-García MÁ, Jiménez Jorge S, Rosso Fernández C, Montaner J, González García A, Zapata-Arriaza E. Safety and efficacy of tirofiban in acute ischemic stroke due to tandem lesions undergoing mechanical thrombectomy: A multicenter randomized clinical trial (ATILA) protocol. Eur Stroke J 2022; 8:380-386. [PMID: 37021200 PMCID: PMC10069213 DOI: 10.1177/23969873221146383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/22/2022] [Indexed: 12/30/2022] Open
Abstract
Background: In-stent thrombosis after mechanical thrombectomy (MT) worsen outcomes in acute ischemic stroke (AIS) due to tandem lesions (TL). Although an optimal antiplatelet therapy is needed, the best approach to avoid in-stent thrombosis is yet to be elucidated. Hypothesis: Low-dose intravenous tirofiban is superior to intravenous aspirin in avoiding in-stent thrombosis in patients undergoing MT plus carotid stenting in the setting of AIS due to TL. Methods: The ATILA-trial is a multicenter, prospective, phase IV, randomized, controlled (aspirin group as control), assessor-blinded clinical trial. Patients fulfilling inclusion criteria (AIS due to TL, ASPECTS ⩾ 6, pre-stroke modified Rankin Scale ⩽2 and onset <24 h) will be randomized (1:1) at MT onset to experimental (intravenous tirofiban) or control group (intravenous aspirin). Intravenous aspirin will be administered at a 500 mg single dose and tirofiban at a 500 µg bolus followed by a 200 µg/h infusion during first 22 h. All patients will be followed up to 3 months. Sample size estimated is 240 patients. Outcomes: The primary efficacy outcome is the proportion of patients with carotid in-stent thrombosis within the first 24 h after MT. The primary safety outcome is the rate of symptomatic intracranial hemorrhage. Secondary outcomes include functional independence defined as modified Rankin Scale 0–2, proportion of patients undergoing rescue therapy due to in-stent aggregation during MT and carotid reocclusion at 30 days. Discussion: ATILA-trial will be the first clinical trial regarding the best antiplatelet therapy to avoid in-stent thrombosis after MT in patients with TL. Trial registration: NCT0522596.
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Affiliation(s)
- Manuel Medina-Rodríguez
- Stroke Unit, Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | - Francisco Moniche
- Stroke Unit, Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | - Asier de Albóniga-Chindurza
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Joaquin Ortega-Quintanilla
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Leire Ainz-Gómez
- Stroke Unit, Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | - Blanca Pardo-Galiana
- Stroke Unit, Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | - Juan Antonio Cabezas-Rodríguez
- Stroke Unit, Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | - Marta Aguilar-Pérez
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Aynara Zamora
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | | | - Elvira Jiménez-Gómez
- Interventional Neuroradiology Department, Reina Sofía University Hospital, Córdoba, Spain
| | - Isabel Bravo Rey
- Interventional Neuroradiology Department, Reina Sofía University Hospital, Córdoba, Spain
| | | | | | - Eva González Díaz
- Interventional Neuroradiology Department, Cruces University Hospital, Vizcaya, Spain
| | | | - Lluis Morales Caba
- Interventional Neuroradiology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Isabel Vielba-Gomez
- Interventional Neuroradiology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Sonia Mosteiro
- Interventional Neuroradiology Department, A Coruña University Hospital Complex, A Coruña, Spain
| | | | | | - Carlos Hidalgo
- Interventional Neuroradiology Department, Torrecardenas University Hospital, Almería, Spain
| | | | | | - Jose Díaz Pérez
- Interventional Neuroradiology Department, Virgen de la Arrixaca University Clinical Hospital, Murcia, Spain
| | | | - Pablo Baena-Palomino
- Stroke Unit, Neurology Department, Virgen del Rocío University Hospital, Sevilla, Spain
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
| | - Miguel Ángel Gamero-García
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen Macarena University Hospital, Seville, Spain
| | - Silvia Jiménez Jorge
- Clinical Research and Clinical Trials Support Unit, Virgen del Rocio University Hospital, Sevilla, Spain
| | - Clara Rosso Fernández
- Clinical Research and Clinical Trials Support Unit, Virgen del Rocio University Hospital, Sevilla, Spain
| | - Joan Montaner
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Neurology Department, Virgen Macarena University Hospital, Seville, Spain
| | - Alejandro González García
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Elena Zapata-Arriaza
- Neurovascular Research Program, Seville Biomedical Research Institute, Seville, Spain
- Interventional Neuroradiology Department, Virgen del Rocío University Hospital, Sevilla, Spain
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15
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Widimsky P, Snyder K, Sulzenko J, Hopkins LN, Stetkarova I. Acute ischaemic stroke: recent advances in reperfusion treatment. Eur Heart J 2022; 44:1205-1215. [PMID: 36477996 PMCID: PMC10079392 DOI: 10.1093/eurheartj/ehac684] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/03/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022] Open
Abstract
Abstract
During the last 5–7 years, tremendous progress was achieved in the reperfusion treatment of acute ischaemic stroke during its first few hours from symptom onset. This review summarizes the latest evidence from randomized clinical trials and prospective registries with a focus on endovascular treatment using stent retrievers, aspiration catheters, thrombolytics, and (in selected patients) carotid stenting. Novel approaches in prehospital (mobile interventional stroke teams) and early hospital (direct transfer to angiography) management are described, and future perspectives (‘all-in-one’ laboratories with angiography and computed tomography integrated) are discussed. There is reasonable chance for patients with moderate-to-severe acute ischaemic stroke to survive without permanent sequelae when the large-vessel occlusion is removed by means of modern pharmaco-mechanic approach. Catheter thrombectomy is now the golden standard of acute stroke treatment. The role of cardiologists in stroke is expanding from diagnostic help (to reveal the cause of stroke) to acute therapy in those regions where such up-to-date Class I. A treatment is not yet available.
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Affiliation(s)
- Petr Widimsky
- Cardiocenter, Charles University and University Hospital Kralovske Vinohrady , Ruska 87, Prague 10 , Czech Republic
| | - Kenneth Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY , USA
| | - Jakub Sulzenko
- Cardiocenter, Charles University and University Hospital Kralovske Vinohrady , Ruska 87, Prague 10 , Czech Republic
| | - Leo Nelson Hopkins
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo , Buffalo, NY , USA
| | - Ivana Stetkarova
- Department of Neurology at the Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady , Ruska 87, Prague 10 , Czech Republic
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16
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Elfil M, Ghaith HS, Elsayed H, Aladawi M, Elmashad A, Patel N, Medicherla C, El-Ghanem M, Amuluru K, Al-Mufti F. Intravenous thrombolysis plus mechanical thrombectomy versus mechanical thrombectomy alone for acute ischemic stroke: A systematic review and updated meta-analysis of clinical trials. Interv Neuroradiol 2022:15910199221140276. [PMID: 36437809 DOI: 10.1177/15910199221140276] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the gold standard treatment for large vessel occlusion (LVO). A vital factor that might influence MT outcomes is the use of intravenous thrombolysis (IVT). A few clinical trials in this domain thus far have not yielded consistent outcomes. We conducted this meta-analysis to synthesize collective evidence in this regard. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guidelines were followed, and we performed a comprehensive literature search of four databases (PubMed, Scopus, Web of Science, Cochrane CENTRAL). For outcomes constituting continuous data, the mean difference (MD) and its standard deviation (SD) were pooled. For outcomes constituting dichotomous data, the frequency of events and the total number of patients were pooled as the risk ratio (RR). RESULTS Seven clinical trials with a total of 2317 patients are included in this meta-analysis. Six trials are randomized, and one trial was nonrandomized. No significant differences were found between MT plus IVT and MT alone in successful recanalization (RR 1.04, 95% Confidence Interval (CI) [0.92 to 1.17], P = 0.53), 90-day functional independence (RR 1.03, 95% CI [0.90 to 1.19], P = 0.65), symptomatic intracranial hemorrhage (sICH) (RR 1.22, 95% CI [0.84 to 1.75], P = 0.30), or mortality (RR 0.94, 95% CI [0.76 to 1.18], P = 0.61). CONCLUSION The current evidence does not favor either MT plus IVT or MT alone for LVO except for the procedural time. More trials are needed in this regard, and certain factors should be considered when comparing the two approaches.
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Affiliation(s)
- Mohamed Elfil
- Department of Neurological Sciences, 12284University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Hazem S Ghaith
- Faculty of Medicine, 68820Al-Azhar University, Cairo, Egypt
| | - Hanaa Elsayed
- Faculty of Medicine, 68799Zagazig University, Zagazig, Egypt
| | - Mohammad Aladawi
- Department of Neurological Sciences, 12284University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Ahmed Elmashad
- Department of Neurology, University of Connecticut, Farmington, Connecticut, USA
| | - Neisha Patel
- Department of Neurology, 8138Westchester Medical Center, Valhalla, New York, USA
| | - Chaitanya Medicherla
- Department of Neurology, 8138Westchester Medical Center, Valhalla, New York, USA
| | - Mohammad El-Ghanem
- Neuroendovascular Surgery, HCA Houston Northwest/University of Houston College of Medicine, Houston, Texas, USA
| | - Krishna Amuluru
- 178242Goodman Campbell Brain and Spine, Ascension St Vincent Medical Center, Carmel, Indiana, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, 8138Westchester Medical Center, Valhalla, New York, USA
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17
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Yu M, Miao X, Huang Y, Ma L, Yin L, Ren H, Wang Z. A clinical application study of a stent placement assessment. Medicine (Baltimore) 2022; 101:e31882. [PMID: 36451472 PMCID: PMC9704916 DOI: 10.1097/md.0000000000031882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Atherosclerotic acute carotid occlusion is a specific type of stroke, and controversy exists regarding the surgical strategy, that is, whether an internal carotid artery stent should be placed immediately after opening the occluded vessel. There is no objective evaluation system for this procedure. In a previous study, we summarized an evaluation decision system Emergent Carotid Artery Stent placement decision Evaluation System (ECASES) for emergency stent placement. STUDY DESIGN This is a prospective, single-center, randomized controlled trial. Patients with acute ischemic stroke caused by atherosclerotic carotid artery occlusion confirmed by imaging (computed tomography/magnetic resonance angiography/digital subtraction angiography) will be randomly divided into the study and control groups, with 101 patients in each group. The study group will undergo surgery according to the ECASES system and the control group will undergo surgery according to the operator's experience. The postoperative outcomes of the 2 groups will be compared. STUDY OUTCOMES Primary outcome: Neurological functional status (modified Rankin Scale and National Institutes of Health Stroke Scale scores) of patients 90 days postoperatively. Secondary outcomes: neurological function changes, hemorrhage events, cerebral edema, postoperative modified treatment in cerebral infarction grade, new cerebral infarction, and reocclusion of responsible vessels. DISCUSSION Currently, no prospective controlled data exist regarding the efficacy and safety of carotid stenting in the acute phase. Previously, we had developed an ECASES stent placement system for acute carotid artery occlusion. The present study will evaluate the efficacy and safety of ECASES in a randomized, double-blind prospective study and clarify its guiding significance in acute atherosclerotic carotid artery occlusion surgery.
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Affiliation(s)
- Mingsheng Yu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Xinglu Miao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Department of Neurosurgery, Jining No.1 People’s Hospital, Jining, Shandong Province, China
| | - Ying Huang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Lin Ma
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Long Yin
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Hecheng Ren
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
- * Correspondence: Hecheng Ren, Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, China (e-mail: ); Zengguang Wang, Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China (e-mail: )
| | - Zengguang Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- * Correspondence: Hecheng Ren, Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, China (e-mail: ); Zengguang Wang, Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China (e-mail: )
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18
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Bertog SC, Sievert K, Grunwald IQ, Sharma A, Hornung M, Kühn AL, Vaskelyte L, Hofmann I, Gafoor S, Reinartz M, Matic P, Sievert H. Acute Stroke Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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19
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Elder TA, Verhey LH, Schultz H, Smith ES, Adel JG. Cervical carotid occlusion in acute ischemic stroke: Should we give tPA? Surg Neurol Int 2022; 13:177. [PMID: 35509556 PMCID: PMC9063023 DOI: 10.25259/sni_176_2022] [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: 02/16/2022] [Accepted: 04/12/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Acute ischemic stroke (AIS) due to cervical internal carotid artery (cICA) occlusion is challenging to treat, with the lower revascularization rates, higher risk for complications, and poor response to thrombolytic therapy compared to isolated intracranial occlusions. While emergent revascularization through mechanical thrombectomy (MT) improves outcomes, the impact of tissue plasminogen activator (tPA) on outcomes in this subgroup of patients remains unclear. The objective of this study is to report our preliminary experience in treating AIS with cICA occlusions secondary to severe atherosclerotic stenosis and to establish the need for further clinical studies to determine the optimal intervention strategy for these lesions. Methods: Data were collected on patients who presented with acute cICA occlusion who underwent MT and either acute or staged carotid angioplasty and stenting. We compare patients who received tPA to those who did not, analyzing revascularization times, outcomes, and complications between the two populations, and discuss how this influenced our preferred treatment approach. Results: Twenty-one patients met inclusion criteria, seven of who received tPA and 14 did not receive tPA before surgical intervention. Procedural and functional outcomes were similar between the two populations. TPA administration correlated with a higher rate of vessel reocclusion in staged procedures and trended toward higher rates of symptomatic ICH and 90-day mortality. Conclusion: Emergent revascularization with acute cICA stenting carries advantages, but its safety is precluded by tPA administration. We suggest a trial which randomizes patients with cICA occlusions to receiving either tPA or dual antiplatelet therapy before surgical intervention, aiming to ultimately improved outcomes in these patients.
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Affiliation(s)
- Theresa A. Elder
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio,
| | - Leonard H. Verhey
- Department of Clinical Neurosciences, Spectrum Health, Michigan State University College of Human Medicine, Grand Rapids,
| | - Haritha Schultz
- Department of Internal Medicine, Central Michigan University College of Medicine,
| | - Eleanor S. Smith
- Department of Neurosurgery, Central Michigan University College of Medicine,
| | - Joseph G. Adel
- Department of Neuroscience, Ascension St Mary’s Hospital, Saginaw, Michigan, United States
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20
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Veunac L, Saliou G, Knebel JF, Bartolini B, Puccinelli F, Michel P, Hajdu SD. Revascularization of carotid artery occlusion using stenting versus non stenting in endovascular management of tandem occlusion stroke. J Clin Neurosci 2022; 98:15-20. [DOI: 10.1016/j.jocn.2022.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 12/19/2021] [Accepted: 01/25/2022] [Indexed: 10/19/2022]
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21
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Raynald, Sun D, Huo X, Jia B, Tong X, Ma G, Wang A, Mo D, Ma N, Gao F, Amin S, Ren Z, Miao Z. The Safety and Efficacy of Endovascular Treatment in Acute Ischemic Stroke Patients Caused by Large-Vessel Occlusion with Different Etiologies of Stroke: Data from ANGEL-ACT Registry. Neurotherapeutics 2022; 19:501-512. [PMID: 35243592 PMCID: PMC9226213 DOI: 10.1007/s13311-022-01189-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/25/2022] Open
Abstract
This study aimed to investigate the safety and efficacy of endovascular treatment (EVT) in acute ischemic stroke (AIS) patients caused by large-vessel occlusion (LVO) with different etiologies of stroke. A total of 928 AIS patients were assigned into intracranial atherosclerotic stenosis (ICAS)-LVO, cardioembolic (CE)-LVO, and artery to artery embolism (ATA)-LVO groups. The safety and efficacy endpoints were symptomatic intracranial hemorrhage (SICH) at 24 h after EVT, 90-day favorable outcomes (modified Rankin Scale (mRS) of 0-2), successful recanalization (modified thrombolysis in cerebral infarct (mTICI) 2b/3), and complete recanalization (mTICI 3). The logistic regression analysis was used to determine the associations between the safety and efficacy endpoints. There were 305 (32.9%), 535 (57.6%), and 88 (9.5%) patients in ICAS-LVO, CE-LVO, and ATA-LVO groups, respectively. No significant difference was found in the 90-day mRS and successful recanalization among the three groups. However, compared with the ICAS-LVO group, complete recanalization rate was higher in the CE-LVO (adjusted odds ratio, 4.50; 95% confidence interval (CI), 2.37-8.56) and ATA-LVO groups (aOR, 2.43; 95% CI, 1.16-5.10). The results of subgroup analysis showed a significant association between CE-LVO stroke etiology and complete recanalization in the age population < 65 years old (aOR, 14.33; 95% CI, 4.39-46.79, P = 0.019). Functional outcomes were similar among different etiologies of stroke. CE-LVO and ATA-LVO could be related to a higher rate of complete recanalization, and there was a trend of the increased risk of parenchymal hemorrhage in the CE-LVO group.
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Affiliation(s)
- Raynald
- Department of Interventional Neuroradiology, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Beijing, 100070, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Beijing, 100070, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Beijing, 100070, China.
| | - Baixue Jia
- Department of Interventional Neuroradiology, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Beijing, 100070, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Beijing, 100070, China
| | - Gaoting Ma
- Department of Interventional Neuroradiology, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Beijing, 100070, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Beijing, 100070, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Beijing, 100070, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Beijing, 100070, China
| | - Sheyar Amin
- Department of Neurology, University of South Florida, Tampa, FL, USA
| | - Zeguang Ren
- Department of Neurosurgery, Cleveland Clinic Martin Health, Port St. Lucie, FL, USA
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South 4th Ring West Road, Beijing, 100070, China.
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22
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Cucchiara BL, Kasner SE. Treatment of “Other” Stroke Etiologies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00058-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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23
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Al-Bayati AR, Nogueira RG, Haussen DC. Carotid Artery Stenting: Applications and Technical Considerations. Neurology 2021; 97:S137-S144. [PMID: 34785612 DOI: 10.1212/wnl.0000000000012802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 03/03/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW To examine current understanding of diverse etiologies of extracranial carotid disease, including clinical and imaging manifestations as well as treatment approaches. RECENT FINDINGS Increasing availability of advanced cerebrovascular imaging modalities continues to elucidate atherosclerotic and nonatherosclerotic carotid steno-occlusive disease as a common culprit of cerebral ischemia. Individualized treatment strategies targeting each etiologic subset would optimize preventive measures and minimize recurrence of cerebral ischemia. SUMMARY Ischemic stroke is a prominent cause of mortality and long-term disability worldwide. The magnified effect of carotid disease warrants constant and close inspection.
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Affiliation(s)
- Alhamza R Al-Bayati
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA.
| | - Raul G Nogueira
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
| | - Diogo C Haussen
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
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24
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Garg A, Farooqui M, Zevallos CB, Quispe-Orozco D, Mendez-Ruiz A, Zaidat O, Ortega-Gutierrez S. Carotid artery angioplasty versus stenting for management of acute tandem occlusions. J Neurol Sci 2021; 428:117588. [PMID: 34403954 DOI: 10.1016/j.jns.2021.117588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/16/2021] [Accepted: 07/23/2021] [Indexed: 10/20/2022]
Abstract
Background The optimal approach to treat the cervical carotid artery lesion during endovascular thrombectomy (EVT) for acute strokes with tandem occlusions is unclear. While carotid artery stenting (CAS) might be a more definitive recanalization method, the potential risk of intracranial hemorrhage (ICH) limits its routine usage. In this study, we aimed to evaluate the safety outcomes of CAS and carotid artery angioplasty (CAA) in patients with acute tandem occlusions. Methods In this retrospective cohort study, data were obtained from the Nationwide Readmissions Database 2016-2017. The primary safety outcome was a composite of ICH and all-cause in-hospital mortality. Logistic regression analysis was used to compare the in-hospital outcomes. Survival analysis was used to estimate the 30-day readmissions. Results We identified 2042 hospitalizations meeting the study inclusion criteria (median age: 66 years, female 31.3%). Of these, 1391 (68.1%) had undergone CAS and 651 (31.9%) CAA alone. Baseline characteristics between the two groups were similar, except patients with CAS were more likely to be on anti-thrombotic medications and were less likely to have received intravenous thrombolysis. There was no significant difference in the clinical outcomes including ICH, in-hospital mortality, gastrostomy tube placement, prolonged mechanical ventilation, length of stay, hospital charges, and 30-day readmissions between the two groups, however, patients with CAS were more likely to be discharged home after adjusting for the confounding variables [odds ratio (OR) 1.49, 95% confidence interval (CI) 1.05-2.12, P 0.025]. Conclusion The emergent CAS-EVT approach appears to be safe with no adverse outcomes compared to CAA alone.
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Affiliation(s)
- Aayushi Garg
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Cynthia B Zevallos
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Alan Mendez-Ruiz
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Osama Zaidat
- Department of Neurology, Mercy Health - St. Vincent Medical Center, Toledo, OH, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
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25
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Shi Z, Tian X, Tian B, Meddings Z, Zhang X, Li J, Saloner D, Liu Q, Teng Z, Lu J. Identification of high risk clinical and imaging features for intracranial artery dissection using high-resolution cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2021; 23:74. [PMID: 34120627 PMCID: PMC8201847 DOI: 10.1186/s12968-021-00766-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 04/28/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Intracranial artery dissection (IAD) often causes headache and cerebral vascular ischemic events. The imaging characteristics of IAD remain unclear. This study aims to characterize the appearance of culprit and non-culprit IAD using high-resolution cardiovascular magnetic resonance imaging (hrCMR) and quantify the incremental value of hrCMR in identifying higher risk lesions. METHODS Imaging data from patients who underwent intervention examination or treatment using digital subtraction angiography (DSA) and hrCMR using a 3 T CMR system within 30 days after the onset of neurological symptoms were collected. The CMR protocol included diffusion-weighted imaging (DWI), black blood T1-, T2- and contrast-enhanced T1-weighted sequences. Lesions were classified as culprit and non-culprit according to imaging findings and patient clinical presentations. Univariate and multivariate analyses were performed to assess the difference between culprit and non-culprit lesions and complementary value of hrCMR in identifying higher risk lesions. RESULTS In total, 75 patients were included in this study. According to the morphology, lesions could be classified into five types: Type I, classical dissection (n = 50); Type II, fusiform aneurysm (n = 1); Type III, long dissected aneurysm (n = 3); Type IV, dolichoectatic dissecting aneurysm (n = 9) and Type V, saccular aneurysm (n = 12). Regression analyses showed that age and hypertension were both associated with culprit lesions (age: OR, 0.83; 95% CI 0.75-0.92; p < 0.001 and hypertension: OR, 66.62; 95% CI 5.91-751.11; p = 0.001). Hematoma identified by hrCMR was significantly associated with culprit lesions (OR, 16.80; 95% CI 1.01-280.81; p = 0.037). Moreover, 17 cases (16 lesions were judged to be culprit) were diagnosed as IAD but not visible in DSA and 15 were Type I lesion. CONCLUSION hrCMR is helpful in visualizing and characterizing IAD. It provides a significant complementary value over DSA for the diagnosis of IAD.
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Affiliation(s)
- Zhang Shi
- Department of Radiology, Changhai Hospital, Naval Medical University, 10 Building, 168 Changhai Road, Yangpu, Shanghai, 200433, China
- Department of Radiology, Addenbrooks' Hospital, University of Cambridge, Cambridge, UK
| | - Xia Tian
- Department of Radiology, Changhai Hospital, Naval Medical University, 10 Building, 168 Changhai Road, Yangpu, Shanghai, 200433, China
| | - Bing Tian
- Department of Radiology, Changhai Hospital, Naval Medical University, 10 Building, 168 Changhai Road, Yangpu, Shanghai, 200433, China.
| | - Zakaria Meddings
- Department of Radiology, Addenbrooks' Hospital, University of Cambridge, Cambridge, UK
| | - Xuefeng Zhang
- Department of Radiology, Changhai Hospital, Naval Medical University, 10 Building, 168 Changhai Road, Yangpu, Shanghai, 200433, China
| | - Jing Li
- Department of Radiology, Changhai Hospital, Naval Medical University, 10 Building, 168 Changhai Road, Yangpu, Shanghai, 200433, China
| | - David Saloner
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, USA
| | - Qi Liu
- Department of Radiology, Changhai Hospital, Naval Medical University, 10 Building, 168 Changhai Road, Yangpu, Shanghai, 200433, China
| | - Zhongzhao Teng
- Department of Radiology, Addenbrooks' Hospital, University of Cambridge, Cambridge, UK
- Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, China
| | - Jianping Lu
- Department of Radiology, Changhai Hospital, Naval Medical University, 10 Building, 168 Changhai Road, Yangpu, Shanghai, 200433, China.
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Marko M, Cimflova P, Poppe AY, Kashani N, Singh N, Ospel J, Mayank A, van Adel B, McTaggart RA, Nogueira RG, Demchuk AM, Rempel JL, Joshi M, Zerna C, Menon BK, Tymianski M, Hill MD, Goyal M, Almekhlafi MA. Management and outcome of patients with acute ischemic stroke and tandem carotid occlusion in the ESCAPE-NA1 trial. J Neurointerv Surg 2021; 14:neurintsurg-2021-017474. [PMID: 33947770 DOI: 10.1136/neurintsurg-2021-017474] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The optimal treatment and prognosis for stroke patients with tandem cervical carotid occlusion are unclear. We analyzed outcomes and treatment strategies of tandem occlusion patients in the ESCAPE-NA1 trial. METHODS ESCAPE-NA1 was a multicenter international randomized trial of nerinetide versus placebo in 1105 patients with acute ischemic stroke who underwent endovascular treatment. We defined tandem occlusions as complete occlusion of the cervical internal carotid artery (ICA) on catheter angiography, in addition to a proximal ipsilateral intracranial large vessel occlusion. Baseline characteristics and outcome parameters were compared between patients with tandem occlusions versus those without, and between patients with tandem occlusion who underwent ICA stenting versus those who did not. The influence of tandem occlusions on functional outcome was analyzed using multivariable regression modeling. RESULTS Among 115/1105 patients (10.4%) with tandem occlusions, 62 (53.9%) received stenting for the cervical ICA occlusion. Of these, 46 (74.2%) were stented after and 16 (25.8%) before the intracranial thrombectomy. A modified Rankin Score (mRS) of 0-2 at 90 days was achieved in 82/115 patients (71.3%) with tandem occlusions compared with 579/981 (59.5%) patients without tandem occlusions. Tandem occlusion did not impact functional outcome in the adjusted analysis (OR 1.5, 95% CI 0.95 to 2.4). Among the subgroup of patients with tandem occlusion, cervical carotid stenting was not associated with different outcomes compared with no stenting (mRS 0-2: 75.8% vs 66.0%, adjusted OR 2.0, 95% CI 0.8 to 5.1). CONCLUSIONS Tandem cervical carotid occlusion in patients with acute large vessel stroke did not lower the odds of good functional outcome in our study. Functional outcomes were similar irrespective of the management of the cervical ICA occlusion (stenting vs not stenting).
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Affiliation(s)
- Martha Marko
- Department of Neurology, Medical University of Vienna, Wien, Austria.,Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Petra Cimflova
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Alexandre Y Poppe
- Department of Neurosciences, Université de Montréal, Montreal, Québec, Canada.,Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada
| | - Nima Kashani
- Neuroradiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Nishita Singh
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Johanna Ospel
- Department of Radiology, University Hospital Basel, Basel, Switzerland.,University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Arnuv Mayank
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Brian van Adel
- Neurosurgery, McMaster University Department of Medicine, Hamilton, Ontario, Canada
| | - Ryan A McTaggart
- Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Raul G Nogueira
- Emory University School of Medicine, Grady Memorial Hospital Corp, Atlanta, Georgia, USA
| | - Andrew M Demchuk
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Jeremy L Rempel
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Manish Joshi
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Charlotte Zerna
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Bijoy K Menon
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | | | - Michael D Hill
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Pop R, Hasiu A, Mangin PH, Severac F, Mihoc D, Nistoran D, Manisor M, Simu M, Chibbaro S, Gheoca R, Quenardelle V, Rouyer O, Wolff V, Beaujeux R. Postprocedural Antiplatelet Treatment after Emergent Carotid Stenting in Tandem Lesions Stroke: Impact on Stent Patency beyond Day 1. AJNR Am J Neuroradiol 2021; 42:921-925. [PMID: 33602749 DOI: 10.3174/ajnr.a6993] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 11/10/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Postprocedural dual-antiplatelet therapy is frequently withheld after emergent carotid stent placement during stroke thrombectomy. We aimed to assess whether antiplatelet regimen variations increase the risk of stent thrombosis beyond postprocedural day 1. MATERIALS AND METHODS Retrospective review was undertaken of all consecutive thrombectomies for acute stroke with tandem lesions in the anterior circulation performed in a single comprehensive stroke center between January 9, 2011 and March 30, 2020. Patients were included if carotid stent patency was confirmed at day 1 postprocedure. The group of patients with continuous dual-antiplatelet therapy from day 1 was compared with the group of patients with absent/discontinued dual-antiplatelet therapy. RESULTS Of a total of 109 tandem lesion thrombectomies, 96 patients had patent carotid stents at the end of the procedure. The early postprocedural stent thrombosis rate during the first 24 hours was 14/96 (14.5%). Of 82 patients with patent stents at day 1, in 28 (34.1%), dual-antiplatelet therapy was either not initiated at day 1 or was discontinued thereafter. After exclusion of cases without further controls of stent patency, there was no significant difference in the rate of subacute/late stent thrombosis between the 2 groups: 1/50 (2%) in patients with continuous dual-antiplatelet therapy versus 0/22 (0%) in patients with absent/discontinued dual-antiplatelet therapy (P = 1.000). In total, we observed 88 patient days without any antiplatelet treatment and 471 patient days with single antiplatelet treatment. CONCLUSIONS Discontinuation of dual-antiplatelet therapy was not associated with an increased risk of stent thrombosis beyond postprocedural day 1. Further studies are warranted to better assess the additional benefit and optimal duration of dual-antiplatelet therapy after tandem lesion stroke thrombectomy.
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Affiliation(s)
- R Pop
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
- Institut de Chirurgie Minime Invasive Guidée par l'Image (R.P., R.B.), Strasbourg, France
| | - A Hasiu
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - P H Mangin
- Institut National de la Santé et de la Recherche Médicale (P.H.M.), University of Strasbourg, l'Établissement français du sang Grand-Est, BPPS UMR-S1255, Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
| | - F Severac
- Public Healthcare Department (F.S.), Strasbourg University Hospitals, Strasbourg, France
| | - D Mihoc
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - D Nistoran
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - M Manisor
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - M Simu
- Neurology Department (M.S.), Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - S Chibbaro
- Neurosurgery Department (S.C.), Strasbourg University Hospitals, Strasbourg, France
| | - R Gheoca
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - V Quenardelle
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - O Rouyer
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - V Wolff
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - R Beaujeux
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
- Institut de Chirurgie Minime Invasive Guidée par l'Image (R.P., R.B.), Strasbourg, France
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28
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Anadani M, Marnat G, Consoli A, Papanagiotou P, Nogueira RG, Spiotta AM, Bourcier R, Kyheng M, Labreuche J, Siddiqui AH, Ribo M, de Havenon A, Fischer U, Sibon I, Dargazanli C, Arquizan C, Cognard C, Olivot JM, Anxionnat R, Audibert G, Mazighi M, Blanc R, Lapergue B, Richard S, Gory B. Endovascular therapy with or without intravenous thrombolysis in acute stroke with tandem occlusion. J Neurointerv Surg 2021; 14:314-320. [PMID: 33911016 DOI: 10.1136/neurintsurg-2020-017202] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/12/2021] [Accepted: 04/14/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Endovascular therapy (EVT) is effective and safe in patients with tandem occlusion. The benefit of intravenous thrombolysis (IVT) prior to EVT in acute tandem occlusion is debatable. OBJECTIVE To compare EVT alone with EVT plus IVT in patients with acute ischemic stroke due to anterior circulation tandem occlusions. METHODS This is an individual patient pooled analysis of the Thrombectomy In TANdem lesions (TITAN) and Endovascular Treatment in Ischemic Stroke (ETIS) Registries. Patients were divided into two groups based on prior IVT treatment: (1) IVT+ group, which included patients who received IVT prior to EVT, (2) IVT- group, which included patients who did not receive IVT prior to EVT. Propensity score (inverse probability of treatment weighting (IPTW)) was used to reduce baseline between-group differences. The primary outcome was favorable outcome-that is, modified Rankin Scale (mRS) score 0 to 2 at 90 days. RESULTS Overall, 602 consecutive patients with an acute stroke with tandem occlusion were included (380 and 222 in the bridging therapy and EVT alone groups, respectively). Onset to imaging time was shorter in the IVT+ group (median 103 vs 140 min). In contrast, imaging to puncture time was longer in the IVT+ group (median 107 vs 91 min). In IPTW analysis, the IVT+ group had higher odds of favorable outcome, excellent outcome (90-day mRS score 0-1), and successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b/3 at the end of EVT). There was no difference in the risk of significant hemorrhagic complications between groups. In secondary analysis of patients treated with acute cervical internal carotid artery stenting, bridging therapy was associated with higher odds of favorable outcome and lower odds of mortality at 90 days. CONCLUSIONS Our results suggest that bridging therapy in patients with acute ischemic stroke due to anterior tandem occlusion is safe and may improve functional outcome, even in the setting of acute cervical internal carotid artery stenting during EVT.
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Affiliation(s)
- Mohammad Anadani
- Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA.,Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gaultier Marnat
- Department of Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Arturo Consoli
- Department of Diagnostic and Interventional Neuroradiology, Hospital Foch, Suresnes, France.,Interventional Neurovascular Unit, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | - Panagiotis Papanagiotou
- Klinikum Bremen-Mitte gGmbH, Bremen, Germany.,National and Kapodistrian University of Athens - Aretaiio Hospital, Athens, Greece
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Romain Bourcier
- Department of Neuroradiology, Nantes University Hospital, Nantes, France
| | - Maeva Kyheng
- Université Lille, CHU Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, Université de Lille, Lille, Hauts-de-France, France
| | - Julien Labreuche
- Université Lille, CHU Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, Université de Lille, Lille, Hauts-de-France, France
| | - Adnan H Siddiqui
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Marc Ribo
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Igor Sibon
- Department of Neurology, Stroke Unit, Bordeaux University Hospital, Bordeaux, France
| | - Cyril Dargazanli
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | | | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Jean Marc Olivot
- Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - René Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France.,Université de Lorraine, IADI, INSERM U1254, Nancy, France
| | - Gérard Audibert
- Department of Anesthesiology and Surgical Intensive Care, Université de Lorraine, CHRU-Nancy, Nancy, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Raphael Blanc
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Bertrand Lapergue
- Department of Neurology, Stroke Unit, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, Université de Lorraine, CHRU-Nancy, Nancy, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France .,Université de Lorraine, IADI, INSERM U1254, Nancy, France
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29
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Jost A, Roels C, Brown M, Janjua R, Heck D. Low-Dose Eptifibatide for Tandem Occlusion in Stroke: Safety and Carotid Artery Patency. AJNR Am J Neuroradiol 2021; 42:738-742. [PMID: 33541892 DOI: 10.3174/ajnr.a6985] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/21/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Maintaining carotid patency and avoiding symptomatic intracranial hemorrhage are competing concerns in tandem occlusions. This study provides data regarding the safety and efficacy of eptifibatide in stroke from tandem occlusion of the extracranial carotid artery and the intracranial carotid or middle cerebral artery. MATERIALS AND METHODS This is a retrospective analysis of 58 consecutive patients who received low-dose eptifibatide (135-mcg/kg bolus, 1-mcg/kg/min infusion) during treatment of tandem occlusions. Brain imaging and carotid sonography were performed at 24-36 hours. mRS was documented at 90 days, and carotid sonography, at 30-60 days. RESULTS The median age and NIHSS score were 64 years and 15, respectively. Twenty-five patients (43%) received tPA. ASPECTSs were 8-10 in 47 (81%) and 5-7 in 11 (19%) patients. Thirty-eight patients had angioplasty/stent placement acutely; 20 had angioplasty alone. Symptomatic intracranial hemorrhage occurred in 1 patient (2%). TICI 2b or higher was achieved in 56 patients (96%). Fifty-seven of 58 patients had clinical follow-up at 90 days (1 lost to follow up). The 90-day mRS was 0-2 in 42 patients (72%). There were 4/58 (7%) re-occlusions within 24-36 hours, all originally treated with stent placement. Forty-nine of 53 surviving patients had carotid sonography at 30-60 days, with 3 delayed re-occlusions, 2 with stents and 1 with angioplasty alone. The overall carotid patency at 30-60 days was 42/49 (86%). Carotid re-occlusion was not associated with clinical decline. CONCLUSIONS Low-dose eptifibatide seemed to be safe in tandem occlusions (symptomatic intracranial hemorrhage, 2%), although asymptomatic cervical carotid artery re-occlusions still occurred in 14% of patients.
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Affiliation(s)
- A Jost
- From the Wake Forest School of Medicine (A.J.), Winston Salem, North Carolina
| | - C Roels
- Departments of Pharmacy (C.R.)
| | - M Brown
- Triad Radiology Associates (M.B., D.H.), Forsyth Medical Center, Winston Salem, North Carolina
| | - R Janjua
- Neurosurgery (R.J.), Novant Health, Forsyth Medical Center, Winston Salem, North Carolina
| | - D Heck
- Triad Radiology Associates (M.B., D.H.), Forsyth Medical Center, Winston Salem, North Carolina
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30
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Nolan NM, Regenhardt RW, Koch MJ, Raymond SB, Stapleton CJ, Rabinov JD, Silverman SB, Leslie-Mazwi TM, Patel AB. Treatment Approaches and Outcomes for Acute Anterior Circulation Stroke Patients with Tandem Lesions. J Stroke Cerebrovasc Dis 2021; 30:105478. [PMID: 33248344 PMCID: PMC7855424 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105478] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/11/2020] [Accepted: 11/13/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Endovascular thrombectomy (EVT) has revolutionized stroke care for large vessel occlusions (LVOs). However, over half treated remain functionally disabled or die. Patients with tandem lesions, or severe stenosis/occlusion of the cervical internal carotid artery (ICA) with intracranial LVO, may have technical EVT challenges and worse outcomes. We sought to compare treatments and outcomes for patients with anterior circulation tandem lesions versus isolated LVOs. MATERIALS AND METHODS Consecutive tandem lesion and isolated intracranial LVO patients were identified at a single center. Demographics, medical history, presentations, treatments, and outcomes were collected and analyzed. RESULTS From 381 EVT patients, 62 had tandem lesions related to atherosclerosis (74%) or dissection (26%). Compared to isolated intracranial LVOs, they were younger (63 vs 70, p = 0.003), had less atrial fibrillation (13% vs 40%, p < 0.0001), less adequate reperfusion (TICI 2b-3, 58% vs 82%, p < 0.0001), more intracranial hemorrhage (ICH, 13% vs 5%, p = 0.037), but similar 90-day functional independence (mRS 0-2, 34% vs 43%, p = 0.181). The cervical ICA was treated before intracranial EVT (57%), after (13%), not acutely (22%), or was inaccessible (8%). Acute cervical ICA treatments were stenting (57%) or angioplasty alone (13%). Neither acute stenting nor order of treatment was associated with outcomes (TICI 2b-3, ICH, or 90-day mRS 0-2). Among acutely stented, neither alteplase nor antiplatelets were associated with outcomes or stent patency. CONCLUSIONS Tandem lesions were associated with less reperfusion, more ICH, but similar 90-day functional independence. No treatment approach was associated with outcomes. These data illustrate the technical challenges of tandem lesion treatment and underscore the importance of developing new approaches.
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MESH Headings
- Aged
- Aged, 80 and over
- Carotid Artery, Internal, Dissection/diagnostic imaging
- Carotid Artery, Internal, Dissection/mortality
- Carotid Artery, Internal, Dissection/physiopathology
- Carotid Artery, Internal, Dissection/therapy
- Carotid Stenosis/diagnostic imaging
- Carotid Stenosis/mortality
- Carotid Stenosis/physiopathology
- Carotid Stenosis/therapy
- Cerebrovascular Circulation
- Databases, Factual
- Endovascular Procedures/adverse effects
- Endovascular Procedures/instrumentation
- Endovascular Procedures/mortality
- Female
- Functional Status
- Humans
- Intracranial Arteriosclerosis/diagnostic imaging
- Intracranial Arteriosclerosis/mortality
- Intracranial Arteriosclerosis/physiopathology
- Intracranial Arteriosclerosis/therapy
- Ischemic Stroke/diagnostic imaging
- Ischemic Stroke/mortality
- Ischemic Stroke/physiopathology
- Ischemic Stroke/therapy
- Male
- Middle Aged
- Recovery of Function
- Retrospective Studies
- Risk Factors
- Stents
- Thrombectomy/adverse effects
- Thrombectomy/mortality
- Thrombolytic Therapy/adverse effects
- Thrombolytic Therapy/mortality
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Neal M Nolan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Robert W Regenhardt
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
| | - Matthew J Koch
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Scott B Raymond
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Scott B Silverman
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
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Endovascular treatment of acute ischemic stroke due to tandem lesions of the anterior cerebral circulation: a multicentric Italian observational study. Radiol Med 2021; 126:804-817. [PMID: 33502665 PMCID: PMC8154792 DOI: 10.1007/s11547-020-01331-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/22/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Acute ischemic stroke (AIS) due to tandem lesions (TLs) of extracranial Internal Carotid Artery and Anterior Cerebral Circulation are challenging for endovascular treatment (EVT). This study aims to evaluate feasibility, safety and efficacy of EVT for TLs' AIS, with or without emergent carotid artery stenting (eCAS), in a real-life scenario. METHODS Retrospective review of prospectively collected non-randomized thrombectomy databases from five stroke centers between 2015 and 2019. Consecutive patients with TLs' AIS were selected. Clinical, neuroimage and procedure features, as well as antiplatelet therapy regimen, were evaluated. Primary outcome was 90-day mRS ≤ 2. Secondary outcomes included: mTICI score 2b-3, extracranial recanalization, procedural complications, symptomatic intracerebral hemorrhage (SICH) and 90-day mortality. RESULTS Two hundred twenty-seven patients were enrolled (67.8% males; mean age 65.9 ± 12.9 years). We obtained mTICI 2b-3 in 77.1%, extracranial recanalization in 86.8%, 90-day mRS (available in 201/227 cases) ≤ 2 in 49.8%. Procedural complications occurred in 16.7%, SICH in 9.7%; 90-day mortality rate (available in 201/227 cases) was 14.4%. The strongest predictors of good clinical outcome were young age (p < 0.0001), low baseline NIHSS (p = 0.008), high baseline ASPECTS (p < 0.0001), good collateral flow (p = 0.013) and extracranial recanalization (p = 0.001). The most significant predictors of SICH were low baseline ASPECTS (p < 0.0001), occurrence of complications (p < 0.0001) and eCAS (p = 0.002). CONCLUSION In our real-life series, the EVT for TLs' AIS was feasible, safe and effective in improving 90-day functional outcome with acceptable morbi-mortality rates. ECAS increased the risk of SICH, independently from the antiplatelet therapy regimen.
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32
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Zevallos CB, Farooqui M, Quispe-Orozco D, Mendez-Ruiz A, Patterson M, Below K, Martins SO, Mansour OY, Mont'Alverne F, Nguyen TN, Lemme L, Siddiqui AH, Fraser JF, Jadhav AP, Zaidat OO, Ortega-Gutierrez S. Proximal Internal Carotid artery Acute Stroke Secondary to tandem Occlusions (PICASSO) international survey. J Neurointerv Surg 2020; 13:1106-1110. [PMID: 33323501 DOI: 10.1136/neurintsurg-2020-017025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/19/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND While mechanical thrombectomy (MT) is the standard of care for large vessel occlusion strokes, the optimal management of tandem occlusions (TO) remains uncertain. We aimed to determine the current practice patterns among stroke physicians involved in the treatment of TO during MT. METHODS We distributed an online survey to neurovascular practitioners (stroke neurologists, neurointerventionalists, neurosurgeons, and radiologists), members of professional societies. After 2 months the site was closed and data were extracted and analyzed. We divided respondents into acute stenting and delayed treatment groups and responses were compared between the two groups. RESULTS We received 220 responses from North America (48%), Latin America (28%), Asia (15%), Europe (5%), and Africa (4%). Preferred timing for cervical revascularization varied among respondents; 51% preferred treatment in a subsequent procedure during the same hospitalization whereas 39% preferred to treat during MT. Angioplasty and stenting (41%) was the preferred technique, followed by balloon angioplasty and local aspiration (38%). The risk of intracerebral hemorrhage was the most compelling reason for not stenting acutely (68%). There were no significant differences among practice characteristics and timing groups. Most practitioners (70%) agreed that there is equipoise regarding the optimal endovascular treatment of cervical lesions in TO; hence, 77% would participate in a randomized controlled trial. CONCLUSIONS The PICASSO survey demonstrates multiple areas of uncertainty regarding the medical and endovascular management of TOs. Experts acknowledged the need for further evidence and their willingness to participate in a randomized controlled trial to evaluate the best treatment for the cervical TO lesion.
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Affiliation(s)
- Cynthia B Zevallos
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Alan Mendez-Ruiz
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mary Patterson
- Neurology, Mercy Health St Vincent Hospital, Toledo, Ohio, USA
| | - Kristine Below
- Neurology, Mercy Health St Vincent Hospital, Toledo, Ohio, USA
| | - Sheila O Martins
- Neurology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ossama Y Mansour
- Neurology, Stroke and NeuroInterventional Unit, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | | | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Luis Lemme
- Interventional Neuroradiology, Centro Endovascular Neurologico Buenos Aires, Buenos Aires, Argentina
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Justin F Fraser
- Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
| | | | - Osama O Zaidat
- Neuroscience, St Vincent Mercy Hospital, Toledo, Indiana, USA
| | - Santiago Ortega-Gutierrez
- Division of Neurointerventional Surgery-Interventional Neuroradiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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33
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Hellegering J, Uyttenboogaart M, Bokkers RPH, El Moumni M, Zeebregts CJ, van der Laan MJ. Treatment of the extracranial carotid artery in tandem lesions during endovascular treatment of acute ischemic stroke: a systematic review and meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1278. [PMID: 33178810 PMCID: PMC7607118 DOI: 10.21037/atm-2020-cass-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 05/10/2020] [Indexed: 01/01/2023]
Abstract
Endovascular treatment (EVT) is the standard treatment for patients with an acute ischemic stroke due to occlusion of large vessel occlusion (LVO). In 20% of patients, concomitant extracranial internal carotid artery (EICA) lesion is present. These tandem lesions (TL) offer a technical challenge. The treatment strategy for the treatment of the ipsilateral EICA is unclear. The aim of this review is to compare two treatment strategies for TL during EVT: balloon angioplasty (BA) only and immediate carotid artery stenting (iCAS). A systematic review and meta-analysis was performed. Data for each included study was extracted. For comparative studies a meta-analysis was performed. Functional outcome was expressed with the modified Rankin scale and safety endpoints were mortality and symptomatic intracranial hemorrhage (sICH). A total of 72 full text articles evaluating treatment of TL during EVT were screened. Sixteen iCAS and five comparative studies were included for meta-analysis. 53% of patients undergoing iCAS during EVT had good functional outcome in comparison to 45% of patients who underwent only BA. Mortality was comparable at 16% for both groups. The incidences of sICH were 8% and 4% for iCAS and BA respectively. In the meta-analysis, iCAS was associated with good functional outcome, with no significant differences in mortality and sICH with compared to BA. This study shows that treatment with iCAS of a simultaneously ipsilateral EICA lesion during EVT is associated with a favorable functional outcome compared to BA only with no significant difference in mortality or sICH. No conclusion could be drawn about the intracranial or extracranial first approach due to scarce of data. More studies are needed to determine long-term neurological outcomes, the necessity of re-interventions and optimal technical approach (intracranial or extracranial first).
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Affiliation(s)
- Joyce Hellegering
- Division of Vascular Surgery, Department of Surgery, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Reinoud P. H. Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mostafa El Moumni
- Division of Vascular Surgery, Department of Surgery, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J. Zeebregts
- Division of Vascular Surgery, Department of Surgery, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten J. van der Laan
- Division of Vascular Surgery, Department of Surgery, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Da Ros V, Scaggiante J, Sallustio F, Lattanzi S, Bandettini M, Sgreccia A, Rolla-Bigliani C, Lafe E, Sanfilippo G, Diomedi M, Ruggiero M, Haznedari N, Giannoni M, Finocchi C, Floris R. Carotid Stenting and Mechanical Thrombectomy in Patients with Acute Ischemic Stroke and Tandem Occlusions: Antithrombotic Treatment and Functional Outcome. AJNR Am J Neuroradiol 2020; 41:2088-2093. [PMID: 32972953 DOI: 10.3174/ajnr.a6768] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/07/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is no consensus on the optimal antithrombotic medication for patients with acute ischemic stroke with anterior circulation tandem occlusions treated with emergent carotid stent placement and mechanical thrombectomy. The identification of factors influencing hemorrhagic risks can assist in creating appropriate therapeutic algorithms for such patients. This study aimed to investigate the impact of medical therapy on functional and safety outcomes in patients treated with carotid stent placement and mechanical thrombectomy for tandem occlusions. MATERIALS AND METHODS A multicenter retrospective study on prospectively collected data was conducted. Only patients treated with carotid stent placement and mechanical thrombectomy for tandem occlusions of the anterior circulation were included. Univariate and multivariate analyses were performed on preprocedural, procedural, and postprocedural variables to assess factors influencing clinical outcome, symptomatic intracranial hemorrhage, stent patency, and successful intracranial vessel recanalization. RESULTS Ninety-five patients with acute ischemic stroke and tandem occlusions were included. Good clinical outcome (mRS ≤ 2) at 3 months was reached by 33 (39.3%) patients and was associated with baseline ASPECTS ≥ 8 (OR = 1.53; 95% CI, 1.16-2.00), ≤2 mechanical thrombectomy attempts (OR = 0.71; 95% CI, 0.55-0.99), and the absence of symptomatic intracranial hemorrhage (OR = 0.13; 95% CI , 0.03-0.51). Symptomatic intracranial hemorrhage was associated with a higher amount of intraprocedural heparin, ASPECTS ≤ 7, and ≥3 mechanical thrombectomy attempts. No relationships among types of acute antiplatelet regimen, intravenous thrombolysis, and symptomatic intracranial hemorrhage were observed. Patients receiving dual-antiplatelet therapy after hemorrhagic transformation had been ruled out on 24-hour CT were more likely to achieve functional independence and had a lower risk of symptomatic intracranial hemorrhage. CONCLUSIONS During carotid stent placement and mechanical thrombectomy for tandem occlusion treatment, higher intraprocedural heparin dosage (≥3000 IU) increased symptomatic intracranial hemorrhage risk when the initial ASPECTS was ≤7, and mechanical thrombectomy needs more than one passage for complete recanalization. Antiplatelets antiplatelets use were safe, and dual-antiaggregation therapy was related to better functional outcomes.
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Affiliation(s)
- V Da Ros
- From the Department of Biomedicine and Prevention (V.D.R., J.S., R.F.), Interventional Neuroradiology Unit
| | - J Scaggiante
- From the Department of Biomedicine and Prevention (V.D.R., J.S., R.F.), Interventional Neuroradiology Unit
| | - F Sallustio
- Comprehensive Stroke Center (F.S., M.D.), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - S Lattanzi
- Neurological Clinic (S.L.), Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | | | - A Sgreccia
- Department of Neurosciences and Interventional Neuroradiology Unit (A.S., E.L., G.S.), IRCCS Policlinico San Matteo, Pavia, Italy
| | - C Rolla-Bigliani
- Department of Diagnostic and Interventional Neuroradiology (C.R.-B.), Policlinico Universitario, San Martino, Italy
| | - E Lafe
- Department of Neurosciences and Interventional Neuroradiology Unit (A.S., E.L., G.S.), IRCCS Policlinico San Matteo, Pavia, Italy
| | - G Sanfilippo
- Department of Neurosciences and Interventional Neuroradiology Unit (A.S., E.L., G.S.), IRCCS Policlinico San Matteo, Pavia, Italy
| | - M Diomedi
- Comprehensive Stroke Center (F.S., M.D.), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - M Ruggiero
- Neuroradiology Unit (M.R., N.H.), AUSL Romagna, Cesena, Italy
| | - N Haznedari
- Neuroradiology Unit (M.R., N.H.), AUSL Romagna, Cesena, Italy
| | - M Giannoni
- Neuroradiological Clinic (M.G.), Department of Radiological Sciences, AOU Ospedali Riuniti, Ancona, Italy
| | | | - R Floris
- From the Department of Biomedicine and Prevention (V.D.R., J.S., R.F.), Interventional Neuroradiology Unit
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35
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Fernández Menéndez S, Murias Quintana E, Vega Valdés P, Morales Deza E, López-Cancio E, Benavente Fernández L, González Delgado M, Rico-Santos M, Calleja Puerta S, Larrosa Campo D. Efficacy and Safety of Endovascular Treatment in Acute Tandem Carotid Occlusions: Analysis of a Single-Center Cohort. Cerebrovasc Dis Extra 2020; 10:50-58. [PMID: 32580191 PMCID: PMC7383215 DOI: 10.1159/000507919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/14/2020] [Indexed: 01/11/2023] Open
Abstract
Introduction Acute ischemic strokes with tandem occlusions, which represent 10–20% of all ischemic strokes, have a particularly poor prognosis. Since emergent treatment of tandem lesions has not been specifically addressed in randomized trials, there is an absence of standardized management. Objective We sought to assess the efficacy and safety of acute endovascular treatment in stroke due to tandem occlusions in our center and compare the results with previous reports. Methods From a prospective registry we analyzed data of 99 consecutive patients (males: 77.7%, mean age ± SD: 67.5 ± 9.5 years) with stroke due to tandem occlusions who underwent treatment with emergent carotid stenting and intracranial mechanical thrombectomy. Successful recanalization was defined as a TICI score of 2b-3 and a good functional outcome was defined as a modified Rankin scale score ≤2 at 90 days. Symptomatic intracranial hemorrhage (sICH) was considered when associated with worsening on the National Institutes of Health Stroke Scale (≥4 points). Results A successful recanalization rate was achieved in 87.8 and 48.5% of the patients had a good functional outcome. sICH and mortality rates were 12.1 and 20.2%, respectively, and 21.2% of the patients received combined treatment with intravenous thrombolysis, which did not affect neither the prognosis nor the recanalization or sICH rates. The time from symptom onset to recanalization and the degree of recanalization were the main factors associated with prognosis and the occurrence of sICH. Conclusions Our results suggest that endovascular treatment with emergent carotid stenting and intracranial thrombectomy in patients with acute stroke due to tandem occlusions is an effective and safe procedure.
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Affiliation(s)
| | | | - Pedro Vega Valdés
- Service of Radiology, University Hospital "Central de Asturias" and ISPA, Oviedo, Spain
| | - Edison Morales Deza
- Service of Radiology, University Hospital "Central de Asturias" and ISPA, Oviedo, Spain
| | - Elena López-Cancio
- Service of Neurology, University Hospital "Central de Asturias" and ISPA, Oviedo, Spain
| | | | | | - Maria Rico-Santos
- Service of Neurology, University Hospital "Central de Asturias" and ISPA, Oviedo, Spain
| | - Sergio Calleja Puerta
- Service of Neurology, University Hospital "Central de Asturias" and ISPA, Oviedo, Spain
| | - Davinia Larrosa Campo
- Service of Neurology, University Hospital "Central de Asturias" and ISPA, Oviedo, Spain,
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36
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Osteraas ND, Crowley RW, Panos N, Dafer RM. Eptifibatide use following emergent carotid stenting in acute anterior circulation ischemic stroke with tandem occlusion. J Stroke Cerebrovasc Dis 2020; 29:105021. [PMID: 32807436 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Early revascularization of the extracranial internal carotid artery in acute anterior circulation ischemic stroke (ACIS) is feasible and may improve clinical outcome. When a stent is deployed, antithrombotic agents should be administered peri-procedurally to ensure stent patency. Our institution implemented a protocol for the use of eptifibatide as a means of maintaining stent patency in the treatment of ACIS associated with cervical internal carotid artery occlusion. METHODS Our internal database was queried for patients who received emergent endovascular therapy (ET) for ACIS with stent placement and eptifibatide administration between July 2016 and 2019. RESULTS Twenty nine patients met the study criteria. The etiology was large artery atherosclerosis in 26 cases. Two patients had a dissection (7%), and one had a carotid occlusion related to a recent carotid endarterectomy. Mean NIHSS was 14. Sixteen patients received IVrtPA. Extracranial-intracranial tandem occlusion (TO) was present in 21 of cases. All patients received an eptifibatide bolus followed by an infusion for approximately 24 hours post stent deployment. Head CT was obtained prior to initiation of oral dual antiplatelet therapy with aspirin and clopidogrel. Successful recanalization was achieved in all patients with no evidence of downstream embolization. Symptomatic intracerebral hemorrhage occurred in one patient. Stent occlusion occurred in two patients, only one of which was symptomatic. Favorable clinical outcome with mRS ≤ 2 at 3 months was achieved in seventeen patients. CONCLUSIONS The use of eptifibatide post procedure was associated with low risk of symptomatic intracranial hemorrhage, including in patients treated with rtPA.
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Affiliation(s)
- Nicholas D Osteraas
- Rush University Medical Center, 1725 W Harrison street Suite 1118, Chicago, IL 60605, United States.
| | - Richard W Crowley
- Rush University Medical Center, 1725 W Harrison street Suite 1118, Chicago, IL 60605, United States.
| | - Nicholas Panos
- Rush University Medical Center, 1725 W Harrison street Suite 1118, Chicago, IL 60605, United States.
| | - Rima M Dafer
- Rush University Medical Center, 1725 W Harrison street Suite 1118, Chicago, IL 60605, United States.
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37
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Zhu F, Hossu G, Soudant M, Richard S, Achit H, Beguinet M, Costalat V, Arquizan C, Consoli A, Lapergue B, Rouchaud A, Macian-Montoro F, Biondi A, Moulin T, Marnat G, Sibon I, Paya C, Vannier S, Cognard C, Viguier A, Mazighi M, Obadia M, Hassen WB, Turc G, Clarençon F, Samson Y, Dumas-Duport B, Preterre C, Barbier C, Boulanger M, Janot K, Annan M, Bricout N, Henon H, Soize S, Moulin S, Labeyrie MA, Reiner P, Pop R, Wolff V, Ognard J, Timsit S, Reyre A, Perot C, Papagiannaki C, Triquenot-Bagan A, Bracard S, Anxionnat R, Derelle AL, Tonnelet R, Liao L, Schmitt E, Planel S, Guillemin F, Gory B. Effect of emergent carotid stenting during endovascular therapy for acute anterior circulation stroke patients with tandem occlusion: A multicenter, randomized, clinical trial (TITAN) protocol. Int J Stroke 2020; 16:342-348. [DOI: 10.1177/1747493020929948] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and hypothesis There is no consensus on the optimal endovascular management of the extracranial internal carotid artery steno-occlusive lesion in patients with acute ischemic stroke due to tandem occlusion. We hypothesized that intracranial mechanical thrombectomy plus emergent internal carotid artery stenting (and at least one antiplatelet therapy) is superior to intracranial mechanical thrombectomy alone in patients with acute tandem occlusion. Study design TITAN is an investigator-initiated, multicenter, prospective, randomized, open-label, blinded-endpoint (PROBE) study. Eligibility requires a diagnosis of acute ischemic stroke, pre-stroke modified Rankin Scale (mRS)≤2 (no upper age limit), National Institutes of Health Stroke Scale (NIHSS)≥6, Alberta Stroke Program Early Computed Tomography Score (ASPECTS)≥6, and tandem occlusion on the initial catheter angiogram. Tandem occlusion is defined as large vessel occlusion (intracranial internal carotid artery , M1 and/or M2 segment) and extracranial severe internal carotid artery stenosis ≥90% (NASCET) or complete occlusion. Patients are randomized in two balanced parallel groups (1:1) to receive either intracranial mechanical thrombectomy plus internal carotid artery stenting (and at least one antiplatelet therapy) or intracranial mechanical thrombectomy alone within 8 h of stroke onset. Up to 432 patients are randomized after tandem occlusion confirmation on angiogram. Study outcomes The primary outcome measure is complete reperfusion rate at the end of endovascular procedure, assessed as a modified Thrombolysis in Cerebral Infarction (mTICI) 3, and ≥4 point decrease in NIHSS at 24 h. Secondary outcomes include infarct growth, recurrent clinical ischemic event in the ipsilateral carotid territory, type and dose of antiplatelet therapy used, mRS at 90 (±15) days and 12 (±1) months. Safety outcomes are procedural complications, stent patency, intracerebral hemorrhage, and death. Economics analysis includes health-related quality of life, and costs utility comparison, especially with the need or not of endarterectomy. Discussion TITAN is the first randomized trial directly comparing two types of treatment in patients with acute ischemic stroke due to anterior circulation tandem occlusion, and especially assessing the safety and efficacy of emergent internal carotid artery stenting associated with at least one antiplatelet therapy in the acute phase of stroke reperfusion. Trial registration ClinicalTrials.gov NCT03978988
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Affiliation(s)
- François Zhu
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
| | - Gabriela Hossu
- CIC 1433, Technological Innovation, IADI, INSERM U1254, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - Marc Soudant
- CIC 1433 Clinical Epidemiology, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - Sébastien Richard
- CIC 1433 Plurithematic, Nancy University Hospital, Université de Lorraine, Nancy, France
- Department of Neurology, Stroke Unit, Université de Lorraine, Nancy University Hospital, Nancy, France
| | - Hamza Achit
- CIC 1433 Clinical Epidemiology, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - Mélanie Beguinet
- CIC 1433 Clinical Epidemiology, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - Vincent Costalat
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | | | - Arturo Consoli
- Department of Diagnostic and Interventional Neuroradiology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Aymeric Rouchaud
- Department of Interventional Neuroradiology, CHU Dupuytren, Limoges, France
| | | | - Alessandra Biondi
- Department of Neuroradiology and Endovascular Therapy, Besançon University Hospital, Besancon, France
| | - Thierry Moulin
- Department of Neurology, Besançon University Hospital, Besancon, France
| | - Gaultier Marnat
- Department of Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Igor Sibon
- Department of Neurology, Stroke Center, University Hospital of Bordeaux, Bordeaux, France
| | - Christophe Paya
- Department of Neuroradiology, Rennes University Hospital, Rennes, France
| | - Stéphane Vannier
- Department of Neurology, Rennes University Hospital, Rennes, France
| | - Christophe Cognard
- Department of Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Alain Viguier
- Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Michael Obadia
- Department of Neurology, Stroke Unit, Rothschild Foundation Hospital, Paris, France
| | - Wagih B Hassen
- Department of Neuroradiology, Saint-Anne Hospital, Paris, France
| | - Guillaume Turc
- Department of Neurology, Stroke Unit, Saint-Anne Hospital, Paris, France
| | | | - Yves Samson
- Department of Neurology, Stroke Unit, Pitié-Salpêtrière Hospital, Paris, France
| | | | - Cécile Preterre
- Department of Neurology, Nantes University Hospital, Nantes, France
| | - Charlotte Barbier
- Department of Neuroradiology, Caen University Hospital, Caen, France
| | | | - Kevin Janot
- Department of Neuroradiology, Tours University Hospital, Lille, France
| | - Mariam Annan
- Department of Neurology, Tours University Hospital, Lille, France
| | - Nicolas Bricout
- Department of Neuroradiology, Lille University Hospital, Lille, France
| | - Hilde Henon
- Department of Neurology, Lille University Hospital, Lille, France
| | - Sébastien Soize
- Department of Neuroradiology, Reims University Hospital, Lille, France
| | - Solène Moulin
- Department of Neurology, Reims University Hospital, Lille, France
| | | | - Peggy Reiner
- Department of Neurology, Lariboisière Hospital, Paris, France
| | - Raoul Pop
- Department of Neuroradiology, Strasbourg University Hospital, Strasbourg, France
| | - Valérie Wolff
- Department of Neurology, Stroke Unit, Strasbourg University Hospital, Strasbourg, France
| | - Julien Ognard
- Department of Neuroradiology, Brest University Hospital, Brest, France
| | - Serge Timsit
- Department of Neurology, Brest University Hospital, Brest, France
| | - Anthony Reyre
- Department of Neuroradiology, Marseille University Hospital, Marseille, France
| | - Charline Perot
- Department of Neurology, Marseille University Hospital, Marseille, France
| | | | | | - Serge Bracard
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
- CIC 1433, Technological Innovation, IADI, INSERM U1254, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - René Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
- CIC 1433, Technological Innovation, IADI, INSERM U1254, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - Anne-Laure Derelle
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
| | - Romain Tonnelet
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
| | - Liang Liao
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
- CIC 1433, Technological Innovation, IADI, INSERM U1254, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - Emmanuelle Schmitt
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
| | - Sophie Planel
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
| | - Francis Guillemin
- CIC 1433 Clinical Epidemiology, Nancy University Hospital, Université de Lorraine, Nancy, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy University Hospital, Nancy, France
- CIC 1433, Technological Innovation, IADI, INSERM U1254, Nancy University Hospital, Université de Lorraine, Nancy, France
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38
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Poppe AY, Jacquin G, Roy D, Stapf C, Derex L. Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions. AJNR Am J Neuroradiol 2020; 41:1142-1148. [PMID: 32499251 DOI: 10.3174/ajnr.a6582] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 03/17/2020] [Indexed: 11/07/2022]
Abstract
Approximately 15% of patients undergoing endovascular thrombectomy for anterior circulation acute ischemic stroke have a tandem lesion, defined as a severe stenosis or occlusion of the cervical internal carotid artery ipsilateral to its intracranial occlusion. Patients with tandem lesions have worse outcomes than patients with isolated intracranial occlusions, but the optimal management of their carotid lesions during endovascular thrombectomy remains controversial. The main options commonly used in current practice include acute stent placement in the carotid lesion versus thrombectomy alone without definitive revascularization of the carotid artery. While treatment decisions for these patients are often complex and strategies vary according to clinical, anatomic, and technical considerations, only results from randomized trials comparing these approaches are likely to strengthen current recommendations and optimize patient care.
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Affiliation(s)
- A Y Poppe
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.) .,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - G Jacquin
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.).,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - D Roy
- Radiology (Neuroradiology) (D.R.), Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - C Stapf
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.).,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - L Derex
- Stroke Center (L.D.), Department of Neurology, Neurological Hospital, Hospices Civils de Lyon, Lyon, France.,EA 7425 HESPER (L.D.), Health Services and Performance Research, Claude Bernard Lyon 1 University, Lyon, France
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Wang D, Zhang L, Hu X, Zhu J, Tang X, Ding D, Wang H, Kong Y, Cai X, Lin L, Fang Q. Intravenous Thrombolysis Benefits Mild Stroke Patients With Large-Artery Atherosclerosis but No Tandem Steno-Occlusion. Front Neurol 2020; 11:340. [PMID: 32431662 PMCID: PMC7214684 DOI: 10.3389/fneur.2020.00340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/07/2020] [Indexed: 01/01/2023] Open
Abstract
At present, there is controversy regarding whether thrombolysis is beneficial for patients suffering from a mild stroke. In this study, we therefore sought to determine whether the therapeutic benefit of thrombolysis is dependent upon stroke subtype for those with mild stroke. We conducted a retrospective analysis of data from consecutive mild stroke patients (National Institutes of Health Stroke Scale ≤5) with and without recombinant tissue plasminogen activator (rt-PA) therapy. The TOAST (Trial of Org 10172 in acute stroke treatment) criteria was used to determine stroke subtypes. Patients suffering from large-artery atherosclerosis (LAA) were subdivided based upon whether or not they exhibited tandem steno-occlusion, as defined by the association of a proximal intracranial occlusion and a cervical internal carotid artery lesion (complete occlusion or severe stenosis ≥ 90%). For this study, favorable outcomes at 90 days of onset (modified Rankin Scale Score [mRS] of 0–1) were the primary measured outcome. Three hundred thirty-nine patients were included in the study. For patients with non-LAA, there were not statistically significant improvements in favorable outcomes for rt-PA treatment (p = 0.889, 0.929, 0.708; respectively). For patients with LAA, compared with non-treated group, rt-PA-treated patients had a significant in the rate of favorable outcomes at 90 days (82.8 vs. 64.9%; OR 2.59; 95%CI, 1.13–5.92; P = 0.024). Among LAA patients exhibiting tandem lesions, favorable outcomes were observed in 66.7% of rt-PA-treated patients, with no significant differences to those observed in untreated patients (OR 1.00; 95%CI, 0.23–4.28; p = 1.000). Among LAA patients without tandem lesions, compared with non-treated group, we found that rt-PA treatment was associated with a significant beneficial impact on favorable outcomes after 90 days (64.4 vs. 88.4%; OR 4.20; 95%CI, 1.43–12.30; p = 0.009). Our findings suggest that intravenous rt-PA is only beneficial in mild stroke patients with LAA-type strokes that do not exhibit tandem steno-occlusion.
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Affiliation(s)
- Dapeng Wang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Lulu Zhang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiaowei Hu
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Juehua Zhu
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiang Tang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Dongxue Ding
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Hui Wang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Yan Kong
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Xiuying Cai
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
| | - Longting Lin
- Hunter Medical Research Institute, University of Newcastle, New Lambton, NSW, Australia
| | - Qi Fang
- Department of Neurology, First Affliated Hospital of Soochow University, Suzhou, China
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40
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Zhu F, Anadani M, Labreuche J, Spiotta A, Turjman F, Piotin M, Steglich-Arnholm H, Holtmannspötter M, Taschner C, Eiden S, Haussen DC, Nogueira RG, Papanagiotou P, Boutchakova M, Siddiqui AH, Lapergue B, Dorn F, Cognard C, Killer-Oberpfalzer M, Mangiafico S, Ribo M, Psychogios MN, Labeyrie MA, Mazighi M, Biondi A, Anxionnat R, Bracard S, Richard S, Gory B, Grossberg JA, Guenego A, Darcourt J, Vukasinovic I, Pomero E, Davies J, Renieri L, Hecker C, Muchada MM, Consoli A, Rodesch G, Houdart E, Lockau J, Kastrup A, Blanc R, Redjem H, Behme D, Shallwani H, Christopher M, Mione G, Humbertjean L, Lacour JC, Riou-Comte N, Derelle AL, Tonnelet R, Liao L. Impact of Antiplatelet Therapy During Endovascular Therapy for Tandem Occlusions. Stroke 2020; 51:1522-1529. [DOI: 10.1161/strokeaha.119.028231] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Antiplatelet agents could be used in the setting of endovascular therapy for tandem occlusions to reduce the risk of de novo intracranial embolic migration, reocclusion of the extracranial internal carotid artery lesion, or in-stent thrombosis in case of carotid stent placement but have to be balanced with the intracerebral hemorrhagic transformation risk. In this study, we aim to investigate the impact of acute antiplatelet therapy administration on outcomes during endovascular therapy for anterior circulation tandem occlusions.
Methods—
This is a retrospective analysis of a collaborative pooled analysis of 11 prospective databases from the multicenter observational TITAN registry (Thrombectomy in Tandem Lesions). Patients were divided into groups based on the number of antiplatelet administered during endovascular therapy. The primary outcome was favorable outcome, defined as a modified Rankin Scale score of 0 to 2 at 90 days.
Results—
This study included a total of 369 patients; 145 (39.3%) did not receive any antiplatelet agent and 224 (60.7%) received at least 1 antiplatelet agent during the procedure. Rate of favorable outcome was nonsignificantly higher in patients treated with antiplatelet therapy (58.3%) compared with those treated without antiplatelet (46.0%; adjusted odds ratio, 1.38 [95% CI, 0.78–2.43];
P
=0.26). Rate of 90-day mortality was significantly lower in patients treated with antiplatelet therapy (11.2% versus 18.7%; adjusted odds ratio, 0.47 [95% CI, 0.22–0.98];
P
=0.042), without increasing the risk of any intracerebral hemorrhage. Successful reperfusion (modified Thrombolysis in Cerebral Ischemia score 2b-3) rate was significantly better in the antiplatelet therapy group (83.9% versus 71.0%; adjusted odds ratio, 1.89 [95% CI, 1.01–3.64];
P
=0.045).
Conclusions—
Administration of antiplatelet therapy during endovascular therapy for anterior circulation tandem occlusions was safe and was associated with a lower 90-day mortality. Optimal antiplatelet therapy remains to be assessed, especially when emergent carotid artery stenting is performed. Further randomized controlled trials are needed.
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Affiliation(s)
- François Zhu
- From the Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, France (F.Z., R.A., S.B., B.G.)
| | - Mohammad Anadani
- Department of Neurology, Washington University School of Medicine, St. Louis, MO (M.A.)
- Department of Neurosurgery, Medical University of South Carolina, Charleston (A.S., M.A.)
| | - Julien Labreuche
- Department of Biostatistics, EA 2694–Santé Publique: Epidémiologie et Qualité des Soins, University of Lille, CHU Lille, France (J.L.)
| | - Alejandro Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston (A.S., M.A.)
| | - Francis Turjman
- Department of Interventional Neuroradiology, Hospices Civils de Lyon, France (F.T.)
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (M.P., M.M.)
| | | | | | - Christian Taschner
- Department of Neuroradiology, Medical Center-University of Freiburg, Germany (C.T., S.E.)
| | - Sebastian Eiden
- Department of Neuroradiology, Medical Center-University of Freiburg, Germany (C.T., S.E.)
| | - Diogo C. Haussen
- Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA (D.C.H, R.G.N.)
| | - Raul G. Nogueira
- Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA (D.C.H, R.G.N.)
| | - Panagiotis Papanagiotou
- Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte/Bremen-Ost, Deutschland (P.P., M.B.)
| | - Maria Boutchakova
- Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte/Bremen-Ost, Deutschland (P.P., M.B.)
| | - Adnan H. Siddiqui
- Department of Neurosurgery, State University of New York, Buffalo (A.H.S.)
| | - Bertrand Lapergue
- Department of Neurology Stroke Center, Foch Hospital, Suresnes, France (B.L.)
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital of Munich, Germany (F.D.)
| | - Christophe Cognard
- Department of Neuroradiology, University Hospital of Toulouse, France (C.C.)
| | | | - Salvatore Mangiafico
- Department of Interventional Neuroradiology, Careggi University Hospital, Florence, Italy (S.M.)
| | - Marc Ribo
- Department of Neurology, Hospital Vall D’Hebron, Barcelona, Spain (M.R.)
| | - Marios N. Psychogios
- Department of Neuroradiology, University Medical Center Göttingen, Germany (M.N.P.)
| | - Marc-Antoine Labeyrie
- Department of Interventional Neuroradiology, Lariboisière Hospital, Paris, France (M.-A.L.)
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (M.P., M.M.)
| | - Alessandra Biondi
- Department of Neuroradiology, University Hospital of Besançon, France (A.B.)
| | - René Anxionnat
- From the Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, France (F.Z., R.A., S.B., B.G.)
- INSERM U1254, IADI, F-5400, Université de Lorraine, Nancy, France (R.A., S.B., B.G.)
| | - Serge Bracard
- From the Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, France (F.Z., R.A., S.B., B.G.)
- INSERM U1254, IADI, F-5400, Université de Lorraine, Nancy, France (R.A., S.B., B.G.)
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, Unversity Hospital of Nancy, Centre d’Investigation Clinique Plurithématique, CIC-P 1433, INSERM U1116, Université de Lorraine, Nancy, France (S.R.)
| | - Benjamin Gory
- From the Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, France (F.Z., R.A., S.B., B.G.)
- INSERM U1254, IADI, F-5400, Université de Lorraine, Nancy, France (R.A., S.B., B.G.)
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41
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Byrne D, Walsh JP, Sugrue G, Nicolaou S, Rohr A. CT Imaging of Acute Ischemic Stroke [Formula: see text]. Can Assoc Radiol J 2020; 71:266-280. [PMID: 32157894 DOI: 10.1177/0846537120902068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Although acute ischemic stroke remains one of the most common causes of death and disability worldwide, it is a potentially treatable condition if appropriately managed in a timely manner. The goals of acute stroke imaging include establishing a diagnosis as fast as possible with (1) accurate infarct quantification, (2) intracranial and cervical vasculature assessment, and (3) brain perfusion analysis for detection of infarct core and potentially salvageable penumbra allowing optimal patient selection for appropriate therapy. Given the extensive number of images generated from acute stroke imaging studies and as "time is brain," this article aims to highlight a logical approach for the radiologist in acute stroke computed tomography imaging in order to accurately interpret and communicate results in a timely manner.
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Affiliation(s)
- D Byrne
- Division of Neuroradiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,University of British Columbia, Vancouver, British Columbia, Canada
| | - J P Walsh
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Emergency Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - G Sugrue
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Emergency Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - S Nicolaou
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Emergency Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - A Rohr
- Division of Neuroradiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,University of British Columbia, Vancouver, British Columbia, Canada
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42
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Simultaneous Angioplasty and Mechanical Thrombectomy in Tandem Carotid Occlusions. Incidence of Reocclusions and Prognostic Predictors. J Stroke Cerebrovasc Dis 2020; 29:104578. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/07/2019] [Accepted: 11/26/2019] [Indexed: 11/22/2022] Open
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43
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Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344-e418. [PMID: 31662037 DOI: 10.1161/str.0000000000000211] [Citation(s) in RCA: 3341] [Impact Index Per Article: 668.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
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44
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Abstract
CLINICAL ISSUE Acute strokes caused by tandem occlusions include an atherosclerotic or dissective stenosis/occlusion of the extracranial internal carotid artery (eICA) in combination with an intracranial vessel occlusion. STANDARD TREATMENT Endovascular treatment can be technically challenging but is definitely superior to intravenous thrombolysis alone and achieves good clinical results comparable to those from solitary intracranial occlusions. LATEST STUDY RESULTS Although there are still no prospectively randomized studies on endovascular treatment for tandem occlusions, currently available data favor acute stenting of the eACI followed by intracranial thrombectomy. PURPOSE OF THE ARTICLE This review discusses endovascular treatment options for tandem occlusions based on currently available data.
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45
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Pursuing the Optimal Treatment Strategy for Acute Ischemic Stroke Patients with Tandem Occlusions. World Neurosurg 2019; 130:559-560. [PMID: 31439499 DOI: 10.1016/j.wneu.2019.07.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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46
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Tian F, Abi-Aad KR, Bendok BR, Krishna C. Thrombectomy for a Patient with Concomitant Acute Cervical Internal Carotid and Middle Cerebral Artery Occlusion: Video Case. Neurosurgery 2019; 85:S74-S75. [PMID: 31197341 DOI: 10.1093/neuros/nyz084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 03/24/2019] [Indexed: 11/12/2022] Open
Abstract
We present the case of a 62-yr-old female who presented with ground-level fall and new onset of left-sided weakness of 30 min duration. CT angiogram revealed right ICA pseudo-occlusion and thrombus filling the right proximal M1 segment of the right MCA. On detailed neurological exam patient was noted to have NIHSS of 25. Patient was started on IV TPA infusion and was taken to interventional angiography suite after an informed consent was obtained. Diagnostic angiography was performed which demonstrated critical stenosis of the right proximal internal carotid artery. Right carotid artery stenting and balloon angioplasty of the carotid stent with distal embolic protection device was performed. Post carotid stent angiogram once again confirmed proximal right M1 pseudo-occlusion in the right MCA distribution. The clot was removed using a stent retriever, thus achieving complete recanalization (TICI 3) of the right cerebral hemisphere. The patient returned to baseline neurological status and a 1 mo follow-up diagnostic angiogram revealed patent carotid stent. Following the case presentation, we present the nuances of acute ischemic stroke management of large vessel occlusion with an emphasis on technical nuances, recent published guidelines1 and the literature.2-8.
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Affiliation(s)
- Fucheng Tian
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Karl R Abi-Aad
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona.,Department of Radiology, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Chandan Krishna
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
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47
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van der Zijden T, Mondelaers A, Yperzeele L, Voormolen M, Parizel PM. Current concepts in imaging and endovascular treatment of acute ischemic stroke: implications for the clinician. Insights Imaging 2019; 10:64. [PMID: 31197499 PMCID: PMC6565797 DOI: 10.1186/s13244-019-0744-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/02/2019] [Indexed: 12/16/2022] Open
Abstract
During the last decade, the management of acute ischemic stroke has changed dramatically, from an expectant bedside "wait and see" attitude towards active treatment, thanks to the continuous improvement of new therapeutic options. In addition to the use of intravenous (IV) thrombolysis in emergent large vessel occlusion (ELVO), endovascular therapy (EVT) has proven to be very efficient in selected acute stroke patients. The indications for EVT have progressed from the era of thrombolysis to individual patient profiling. Recently, several indication parameters, e.g., "treatment time window" or "more distal vessel occlusion," are under debate for adjustment. In this article, we review the imaging strategies in acute stroke and discuss several EVT indication dogmas, which are subject to change.
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Affiliation(s)
- Thijs van der Zijden
- Department of Radiology, Antwerp University Hospital & University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium.
| | - Annelies Mondelaers
- Department of Radiology, Antwerp University Hospital & University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium
| | - Laetitia Yperzeele
- Department of Neurology, Antwerp University Hospital & University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium
- Department Translational Neurosciences, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Maurits Voormolen
- Department of Radiology, Antwerp University Hospital & University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
| | - Paul M Parizel
- Department of Radiology, Antwerp University Hospital & University of Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium
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48
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Periprocedural Heparin During Endovascular Treatment of Tandem Lesions in Patients with Acute Ischemic Stroke: A Propensity Score Analysis from TITAN Registry. Cardiovasc Intervent Radiol 2019; 42:1160-1167. [DOI: 10.1007/s00270-019-02251-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/21/2019] [Indexed: 11/30/2022]
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49
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Epidemiology, aetiology, and management of ischaemic stroke in young adults. Lancet Neurol 2019; 17:790-801. [PMID: 30129475 DOI: 10.1016/s1474-4422(18)30233-3] [Citation(s) in RCA: 214] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 06/01/2018] [Accepted: 06/05/2018] [Indexed: 01/15/2023]
Abstract
Epidemiological evidence suggests that the incidence of ischaemic stroke in young adults (18-50 years) has increased substantially. These patients have a long life expectancy after stroke, and the costs of long-term care pose huge challenges to health-care systems. Although the current recommendations for treatment of young and old (>50 years) patients with stroke are similar, the optimal management of young adult patients with stroke is unknown. They are usually not included in trials, and specific subanalyses limited to young adult patients with stroke are usually not done, owing to lower incidence of stroke and lower prevalence of vascular risk factors in young adults. Progress has been made in identifying patients with a considerable risk of stroke occurrence, such as those with patent foramen ovale. Future prevention studies might result in a decrease in the incidence of stroke and its sequelae in young adults. The development of guidelines specifically devoted to the management of stroke in young adults will be an important step in achieving this aim.
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50
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Zhu F, Bracard S, Anxionnat R, Derelle AL, Tonnelet R, Liao L, Mione G, Humbertjean L, Lacour JC, Hossu G, Anadani M, Richard S, Gory B. Impact of Emergent Cervical Carotid Stenting in Tandem Occlusion Strokes Treated by Thrombectomy: A Review of the TITAN Collaboration. Front Neurol 2019; 10:206. [PMID: 30915023 PMCID: PMC6421313 DOI: 10.3389/fneur.2019.00206] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 02/18/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction: Endovascular therapy has been shown to be an effective and safe treatment for tandem occlusion. The endovascular therapeutic strategies for tandem occlusions strokes have not been adequately evaluated and the best approach is still controversial. The TITAN (Thrombectomy in TANdem occlusions) registry was a result of a collaborative effort to identify the best therapeutic approach for acute ischemic stroke due to tandem lesion. In this review, we aim to summarize the main findings of the TITAN study and discuss the challenges of treatment for tandem occlusion in the era of endovascular thrombectomy. Methods: A review of the data from the multicenter international observational and non-randomized TITAN registry was performed. The TITAN registry included acute ischemic stroke patients with tandem lesions (proximal intracranial occlusion and cervical carotid artery occlusion or stenosis>90%) who were treated with thrombectomy with or without carotid artery stenting. Results: Prior intravenous thrombolysis and emergent cervical carotid stenting were associated with higher reperfusion (mTICI 2b-3 and mTICI 3) rates at the end of the intervention. Poor outcome did not occur more frequently after stenting than after conservative treatment of the cervical carotid lesion. Emergent carotid stenting with antithrombotic agents and intracranial thrombectomy yielded higher reperfusion rate and good outcome (90 day mRS 0-2) compared to other strategies (carotid artery stenting and thrombectomy without antithrombotic, angioplasty and thrombectomy, or thrombectomy alone). Pretreatment intravenous thrombolysis was not associated with increased risk of hemorrhagic complications. Likewise, periprocedural unfractionated heparin did not modify the efficacy and safety results. Etiology of carotid artery lesion (atherosclerosis vs. dissection) did not emerge as predictor of outcome or recanalization. Conclusion: Emergent stenting of the cervical carotid lesion with antithrombotic agents in conjunction to thrombectomy appears to be the best treatment strategy for acute ischemic strokes with tandem lesions. These findings will be further investigated in the ongoing randomized controlled TITAN trial.
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Affiliation(s)
- François Zhu
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Serge Bracard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
- INSERM U1254, IADI, University of Lorraine, Nancy, France
| | - René Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
- INSERM U1254, IADI, University of Lorraine, Nancy, France
| | - Anne-Laure Derelle
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Romain Tonnelet
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Liang Liao
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Gioia Mione
- Department of Neurology, Stroke Unit, University Hospital of Nancy, Nancy, France
| | - Lisa Humbertjean
- Department of Neurology, Stroke Unit, University Hospital of Nancy, Nancy, France
| | | | - Gabriela Hossu
- INSERM U1254, IADI, University of Lorraine, Nancy, France
| | - Mohammad Anadani
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, University Hospital of Nancy, Nancy, France
- Centre d'Investigation Clinique Plurithématique, INSERM U1116, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
- INSERM U1254, IADI, University of Lorraine, Nancy, France
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