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Salim HA, Huang S, Lakhani DA, Mei J, Balar A, Musmar B, Adeeb N, Hoseinyazdi M, Luna L, Deng F, Hyson NZ, Bahouth M, Dmytriw AA, Guenego A, Albers's GW, Lu H, Urrutia VC, Nael K, Marsh EB, Hillis AE, Llinas R, Wintermark M, Heit JJ, Faizy TD, Yedavalli V. Perfusion imaging predicts short-term clinical outcome in isolated posterior cerebral artery occlusion stroke. J Neuroimaging 2024. [PMID: 39223766 DOI: 10.1111/jon.13235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 08/21/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND AND PURPOSE Ischemic strokes due to isolated posterior cerebral artery (PCA) occlusions represent 5% of all strokes but have significant impacts on patients' quality of life, primarily due to visual deficits and thalamic involvement. Current guidelines for acute PCA occlusion management are sparse, and the prognostic value of perfusion imaging parameters remains underexplored. METHODS We conducted a retrospective analysis of 32 patients with isolated PCA occlusions treated at Johns Hopkins Medical Institutions between January 2017 and March 2023. Patients underwent pretreatment perfusion imaging, with perfusion parameters analyzed using RAPID software. The primary outcome was short-term clinical outcome as measured by the National Institutes of Health Stroke Scale (NIHSS) at discharge. RESULTS The median age of the cohort was 70 years, with 34% female and 66% male. Significant correlations were found between NIHSS at discharge and various perfusion parameters, including time-to-maximum (Tmax) >6 seconds (ρ = .55, p = .004), Tmax >8 seconds (ρ = .59, p = .002), Tmax >10 seconds (ρ = .6, p = .001), mismatch volume (ρ = .51, p = .008), and cerebral blood volume (CBV) < 34% (ρ = .59, p = .002). CONCLUSIONS Tmax and CBV volumes significantly correlated with discharge NIHSS with marginal superiority of Tmax >10 seconds and CBV <42% volumes. These findings suggest that CT and MR perfusion imaging can play a crucial role in the acute management of PCA strokes, though larger, standardized studies are needed to validate these results and refine imaging thresholds specific to posterior circulation infarcts.
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Affiliation(s)
- Hamza Adel Salim
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Shenwen Huang
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Dhairya A Lakhani
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Janet Mei
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Aneri Balar
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Basel Musmar
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Nimer Adeeb
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Meisam Hoseinyazdi
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Licia Luna
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Francis Deng
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Nathan Z Hyson
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Mona Bahouth
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Adrien Guenego
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Gregory W Albers's
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, California, USA
| | - Hanzhang Lu
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Victor C Urrutia
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Kambiz Nael
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Elisabeth B Marsh
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Argye E Hillis
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Raf Llinas
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Medical Center, Houston, Texas, USA
| | - Jeremy J Heit
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, California, USA
| | - Tobias D Faizy
- Department of Radiology, Neuroendovascular Program, Münster University Medical Center, Münster, Germany
| | - Vivek Yedavalli
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
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2
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Räty S, Nguyen TN, Nagel S, Puetz V, Alemseged F, Abdalkader M, Schonewille WJ, Strbian D. What Is the Evidence for Endovascular Thrombectomy in Posterior Circulation Stroke? Semin Neurol 2023; 43:345-355. [PMID: 37595603 DOI: 10.1055/s-0043-1771210] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Posterior circulation infarcts comprise approximately 25% of ischemic strokes but are less often treated with recanalization therapy and have longer treatment delays compared with anterior circulation strokes. Among posterior circulation strokes, basilar artery occlusion is associated with the most severe deficits and the worst prognosis. Endovascular thrombectomy is a standard of care for patients with anterior circulation large vessel occlusion, but not until recently were the first randomized controlled trials on endovascular thrombectomy in basilar artery occlusion published. Two of the trials were neutral, whereas two others showed better functional outcome after thrombectomy up to 24 hours of symptom onset compared with best medical treatment, which in most cases had low rates of intravenous thrombolysis. According to observational data, thrombectomy seems to be safe also in isolated posterior cerebral artery occlusions and might be an option for selected patients, even if its outcome benefit is yet to be demonstrated.
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Affiliation(s)
- Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen/Rhein, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Fana Alemseged
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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3
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Maulucci F, Disanto G, Bianco G, Pileggi M, Fischer U, Padlina G, Strambo D, Michel P, Kahles T, Nedeltchev K, Fisch U, Bonati L, Kägi G, Escribano Paredes JB, Carrera E, Nyffeler T, Bolognese M, Wegener S, Luft A, Schelosky L, Medlin F, von Reding A, Peters N, Renaud S, Mono ML, Remonda L, Machi P, Psychogios MN, Kaesmacher J, Mordasini P, Cereda CW. Endovascular therapy outcome in isolated posterior cerebral artery occlusion strokes: A multicenter analysis of the Swiss Stroke Registry. Eur Stroke J 2023; 8:575-580. [PMID: 37231695 PMCID: PMC10334166 DOI: 10.1177/23969873221150125] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
PURPOSE There is little data on the safety and efficacy of endovascular treatment (EVT) in comparison with intravenous thrombolysis (IVT) in acute ischemic stroke due to isolated posterior cerebral artery occlusion (IPCAO). We aimed to investigate the functional and safety outcomes of stroke patients with acute IPCAO treated with EVT (with or without prior bridging IVT) compared to IVT alone. METHODS We did a multicenter retrospective analysis of data from the Swiss Stroke Registry. The primary endpoint was overall functional outcome at 3 months in patients undergoing EVT alone or as part of bridging, compared with IVT alone (shift analysis). Safety endpoints were mortality and symptomatic intracranial hemorrhage. EVT and IVT patients were matched 1:1 using propensity scores. Differences in outcomes were examined using ordinal and logistic regression models. FINDINGS Out of 17,968 patients, 268 met the inclusion criteria and 136 were matched by propensity scores. The overall functional outcome at 3 months was comparable between the two groups (EVT vs IVT as reference category: OR = 1.42 for higher mRS, 95% CI = 0.78-2.57, p = 0.254). The proportion of patients independent at 3 months was 63.2% in EVT and 72.1% in IVT (OR = 0.67, 95% CI = 0.32-1.37, p = 0.272). Symptomatic intracranial hemorrhages were overall rare and present only in the IVT group (IVT = 5.9% vs EVT = 0%). Mortality at 3 months was also similar between the two groups (IVT = 0% vs EVT = 1.5%). CONCLUSION In this multicenter nested analysis, EVT and IVT in patients with acute ischemic stroke due to IPCAO were associated with similar overall good functional outcome and safety. Randomized studies are warranted.
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Affiliation(s)
- F Maulucci
- Stroke Centre, Neurology Department, Neurocentre of Southern Switzerland, EOC, Lugano, Switzerland
| | - G Disanto
- Stroke Centre, Neurology Department, Neurocentre of Southern Switzerland, EOC, Lugano, Switzerland
| | - G Bianco
- Stroke Centre, Neurology Department, Neurocentre of Southern Switzerland, EOC, Lugano, Switzerland
| | - M Pileggi
- Stroke Centre, Interventional and Diagnostic Neuroradiology, Neurocentre of Southern Switzerland, EOC, Lugano, Switzerland
| | - U Fischer
- Department of Neurology, University Hospital Bern, Bern, Switzerland
- Department of Neurology and Stroke Centre, University Hospital Basel, Basel, Switzerland
| | - G Padlina
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - D Strambo
- Lausanne University Hospital, Stroke Centre, Neurology Service, Lausanne, Switzerland
| | - P Michel
- Lausanne University Hospital, Stroke Centre, Neurology Service, Lausanne, Switzerland
| | - T Kahles
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | - K Nedeltchev
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | - U Fisch
- Department of Neurology and Stroke Centre, University Hospital Basel, Basel, Switzerland
| | - L Bonati
- Department of Neurology and Stroke Centre, University Hospital Basel, Basel, Switzerland
| | - G Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | | | - E Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - T Nyffeler
- Luzerner Kantonsspital, Centre of Neurology and Neurorehabilitation, Luzern, Switzerland
| | - M Bolognese
- Luzerner Kantonsspital, Centre of Neurology and Neurorehabilitation, Luzern, Switzerland
| | - S Wegener
- Universitätsspital Zürich, Neurology, Zürich, Switzerland
| | - A Luft
- Universitätsspital Zürich, Neurology, Zürich, Switzerland
| | - L Schelosky
- Kantonsspital Münsterlingen, Division of Neurology, Münsterlingen, Switzerland
| | - F Medlin
- Stroke Unit, Division of Neurology, HFR Fribourg, Fribourg, Switzerland
| | - A von Reding
- Neurology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - N Peters
- Stroke Centre, Klinik Hirslanden, Zurich, Switzerland
| | - S Renaud
- Division of Neurology, Pourtalès Hospital, Neuchatel, Switzerland
| | - M-L Mono
- Stadtspital Waid und Triemli, Stroke Unit, Zürich, Switzerland
| | - L Remonda
- Department of Interventional Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - P Machi
- Department of Interventional Neuroradiology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - M-N Psychogios
- Department of Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - J Kaesmacher
- University Hospital Bern, Inselspital, Interventional Neuroradiology, Bern, Switzerland
| | - P Mordasini
- University Hospital Bern, Inselspital, Interventional Neuroradiology, Bern, Switzerland
| | - C W Cereda
- Stroke Centre, Neurology Department, Neurocentre of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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4
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Brouwer J, Ergezen S, Mulder MJHL, Lycklama A Nijeholt GJ, van Es ACGM, van der Lugt A, Dippel DWJ, Majoie CBLM, Roos YBWEM, Coutinho JM, Emmer BJ. Endovascular treatment for isolated posterior cerebral artery occlusion stroke in the MR CLEAN registry. J Neurointerv Surg 2023; 15:363-369. [PMID: 35292567 DOI: 10.1136/neurintsurg-2021-018505] [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: 12/01/2021] [Accepted: 02/17/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Endovascular treatment (EVT) is standard of care in anterior circulation large vessel occlusions. In posterior circulation occlusions, data on EVT in isolated posterior cerebral artery (PCA) occlusions are limited, although PCA occlusions can cause severe neurological deficit. OBJECTIVE To describe in a prospective study the clinical manifestations, outcomes, and safety of EVT in isolated PCA occlusions. METHODS We used data (2014-2017) from the MR CLEAN Registry, a nationwide, prospective cohort of EVT-treated patients in the Netherlands. We included patients with acute ischemic stroke (AIS) due to an isolated PCA occlusion on CT angiography. Patients with concurrent occlusion of the basilar artery were excluded. Outcomes included change in National Institutes of Health Stroke Scale (ΔNIHSS) score, modified Rankin Scale (mRS) score 0-3 after 90 days, mortality, expanded Thrombolysis in Cerebral Infarction (eTICI), and periprocedural complications. RESULTS Twenty (12%) of 162 patients with posterior circulation occlusions had an isolated PCA occlusion. Median age was 72 years; 13 (65%) were women. Median baseline NIHSS score was 13 (IQR 5-21). Six (30%) patients were comatose. Twelve patients (60%) received IVT. Median ΔNIHSS was -4 (IQR -11-+1). At follow-up, nine patients (45%) had mRS score 0-3. Seven (35%) died. eTICI 2b-3 was achieved in 13 patients (65%). Nine patients (45%) had periprocedural complications. No symptomatic intracranial hemorrhages (sICH) occurred. CONCLUSIONS EVT should be considered in selected patients with AIS with an isolated PCA occlusion, presenting with moderate-severe neurological deficits, as EVT was technically feasible in most of our patients and about half had good clinical outcome. In case of lower NIHSS score, a more conservative approach seems warranted, since periprocedural complications are not uncommon. Nonetheless, EVT seems reasonably safe considering the absence of sICH in our study.
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Affiliation(s)
- Josje Brouwer
- Department of Neurology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Saliha Ergezen
- Department of Intensive care/Neurosurgery, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | | | | | - Adriaan C G M van Es
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Aad van der Lugt
- Department of Radiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - J M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
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5
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Baig AA, Monteiro A, Waqas M, Cappuzzo JM, Siddiqi M, Doane J, Dossani RH, Almayman F, Khawar WI, Davies JM, Snyder KV, Levy EI, Siddiqui AH. Acute isolated posterior cerebral artery stroke treated with mechanical thrombectomy: A single-center experience and review of the literature. Interv Neuroradiol 2023; 29:10-19. [PMID: 35001703 PMCID: PMC9893240 DOI: 10.1177/15910199211070949] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/16/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Acute isolated posterior cerebral artery (PCA) occlusions account for 5-10% of all ischemic events. Due to peculiar patient presentation, the potential benefit of mechanical thrombectomy (MT) remains controversial. We evaluated the safety, feasibility, and effectiveness of MT in our patients and compared our results with the literature review conducted. METHODS Charts were reviewed retrospectively for consecutive patients diagnosed with acute PCA stroke who underwent MT. Demographics, procedural, and follow-up details were noted. For the literature review, a systematic search of PubMed, MEDLINE, and EMBASE databases was conducted for the keywords "posterior cerebral artery" and "thrombectomy" for articles published between January 1, 2010 and June 30, 2021. Estimated rates for recanalization, favorable outcomes (modified Rankin Scale [mRS] score 0-2), symptomatic intracerebral hemorrhage (sICH), and mortality were extracted. RESULTS Our cohort included 21 patients. Mean age was 71.2 years (standard deviation [SD] ± 10.2). Median National Institutes of Health Stroke Scale (NIHSS) presentation score was 9 (interquartile range [IQR] 5-15), with visual symptoms reported in 12(57.1%) patients. Overall, final modified thrombolysis in cerebral infarction (mTICI) 2b-3 was achieved in 17 patients (80.9%) with first-pass mTICI 2b-3 attained in 8 (38.1%). Postprocedure sICH occurred in 1 (4.8%) patient. Fifteen (71.4%) patients had a 0-2 mRS score at 90 days. Visual symptoms resolved in 10 of 12(83.3%) patients. Mortality occurred in 2 (9.5%) patients. For the systematic review, cohorts from 4 articles plus ours were included, totaling 222 patients. The estimated rate of successful recanalization was 85.25% (95% confidence interval[CI], 73.05%-97.45%), sICH was 3.60% (95% CI, 1.11%-6.09%), and mortality was 10.51% (95% CI, 5.88%-15.15%). CONCLUSION The results of our series and systematic review indicate MT as a potentially safe and effective treatment modality for acute PCA stroke. These results also indicate that patient selection and assessment may be the key in obtaining favorable outcomes.
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Affiliation(s)
- Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, NY, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, NY, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, NY, USA
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, NY, USA
| | - Manhal Siddiqi
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, NY, USA
| | - Jacob Doane
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, NY, USA
| | - Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, NY, USA
| | - Faisal Almayman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, NY, USA
| | - Wasiq I Khawar
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, NY, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, NY, USA
- Department of Bioinformatics, Jacobs School of Medicine and
Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo,
Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo,
Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo,
Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, NY, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida
Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo,
Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical
Sciences, University at Buffalo, Buffalo, NY, USA
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Altenbernd J, Forsting M, Weber W, Fischer S. Thrombectomy of symptomatic isolated occlusions of posterior cerebral arteries in segment P1 and P2 in acute stroke treatment. Acta Radiol 2022; 63:802-809. [PMID: 33940961 DOI: 10.1177/02841851211014191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Interventional stroke treatments for occlusions of the posterior circulation are established procedures. However, there are limited data on the treatment of isolated symptomatic P1 and P2 occlusions, which we have examined in this study. PURPOSE To investigate the mechanical thrombectomy of distal posterior occlusions. MATERIAL AND METHODS Retrospectively, data from patients with isolated P1 and P2 occlusions treated with MT were evaluated. Successful reperfusions have been defined as modified thrombolysis in cerebral infarct (mTICI) Grade 2b-3. A good clinical outcome was defined as a 90-day modified Rankin score 0-2. RESULTS All 79 treated patients were primarily aspirated. Stent retrievers were used secondarily in nine patients. Successful reperfusion was achieved in 95% of patients. Of the patients, 57% had a favorable clinical outcome after 90 days. CONCLUSION Mechanical thrombectomy with first line aspiration of symptomatic P1 and P2 occlusions is a safe and effective procedure.
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Affiliation(s)
- Jens Altenbernd
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
- Department of Radiology and Neuroradiology, Gemeinschaftskrankenhaus Herdecke, Germany
| | - Michael Forsting
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Werner Weber
- Department of Radiology and Neuroradiology, Knappschaftskrankenhaus Bochum, Germany
| | - Sebastian Fischer
- Department of Radiology and Neuroradiology, Knappschaftskrankenhaus Bochum, Germany
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7
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Zhang G, Zhu Y, Ling Y, Chen P, Dai J, Wang C, Xu S, Shumadalova A, Shi H. Endovascular Treatment of Acute Ischemic Stroke Due to Isolated Proximal Posterior Artery Occlusion. Front Surg 2022; 9:919509. [PMID: 35693304 PMCID: PMC9174600 DOI: 10.3389/fsurg.2022.919509] [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: 04/13/2022] [Accepted: 05/05/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAcute ischemic stroke (AIS) due to isolated proximal posterior cerebral artery (PPCA) occlusion is rare but associated with high morbidity and mortality rates. However, the optimal treatment strategy for patients with AIS caused by PPCA remains unclear. We discuss our single-center experience with endovascular treatment (EVT) in patients with PPCA.MethodsData from patients with AIS due to PPCA occlusion were retrospectively analyzed. We analyzed procedural details, the degree of reperfusion, functional outcomes, and complications. Functional outcomes were determined using the modified Rankin Scale (mRS) at 90 days, and good outcome was defined as mRS 0–2 at 90 days. Successful reperfusion was defined as modified treatment in cerebral ischemia (mTICI) 2b−3 after endovascular therapy. Safety variables included symptomatic hemorrhage (defined as an increase of four or more points in the National Institute of Health Stroke Scale score), vessel perforation or dissection, and new ischemic stroke in different territories.ResultsSeven patients were included in this study. The mean age of the patients was 64 ± 12.4 years. Successful reperfusion was achieved in all seven patients (100%). Good outcomes were achieved at 90 days in 2 patients (28.6%), and favorable outcomes were observed in five patients (71.4%). One patient underwent angioplasty as rescue therapy after three attempts. One patient died because of severe gastrointestinal bleeding 24 h after EVT, which was probably a complication of intravenous alteplase. One patient had an embolism in the basilar artery and achieved complete reperfusion after rescue thrombectomy. Another patient had a complication of vessel dissection in the PPCA and underwent stent implantation as rescue therapy. We observed no recurrence of ischemic stroke or any intracranial hemorrhage on non-contrast computed tomography 24 h after the procedure.ConclusionEVT may represent an alternative treatment strategy for patients with acute ischemic stroke caused by PPCA.
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Affiliation(s)
- Guang Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yujing Zhu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yeping Ling
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Pingbo Chen
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiaxing Dai
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chunlei Wang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Shancai Xu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Alina Shumadalova
- Department of General Chemistry, Bashkir State Medical University, Ufa, Republic of Bashkortostan, Russia
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Correspondence: Huaizhang Shi
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Baik SH, Jung C, Kim BM, Kim DJ. Mechanical thrombectomy for acute posterior cerebral artery stroke; Feasibility and predictors of outcome. Neuroradiology 2022; 64:1419-1427. [PMID: 35133483 DOI: 10.1007/s00234-022-02910-3] [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: 10/05/2021] [Accepted: 01/25/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE The territorial involvement and the clinical benefit of endovascular therapy (EVT) of the posterior cerebral artery (PCA) occlusion may vary between patients. The purpose of this study was to investigate the feasibility of mechanical thrombectomy (MT) in isolated posterior cerebral artery occlusions (IPCAOs) and the prognostic factors of EVT. METHODS Forty-eight patients with acute PCA occlusion who underwent EVT between Mar 2008 and Apr 2021 from 2 tertiary centers were retrospectively analyzed. Clinical characteristics, imaging and perfusion abnormalities, and angiographic and clinical outcomes were analyzed. Ischemic changes were assessed with the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS). Perfusion abnormalities were assessed using automated software for Tmax volume measurement and identification of Tmax involved in PCA eloquent areas. RESULTS The IPCAO sites were P1 (n = 17) and P2 (n = 31). Overall successful recanalization (mTICI 2b/3) was achieved in 68.8% (33/48) and excellent outcome (90-day mRS 0-1) in 52.1% (25/48) of the patients. Excellent/non-excellent outcome was associated with male sex (p = 0.036), admission NIHSS (p = 0.002), pc-ASPECTS (p = 0.035), Tmax > 6 s involvement of the midbrain-thalamus (p = 0.008), first-line stent-retriever thrombectomy (p = 0.036), complete recanalization (p = 0.009), and modified first pass effect (FPE, p = 0.047). Tmax>6 s involvement of the midbrain-thalamus was an independent predictor for non-excellent outcome on multivariable analysis. CONCLUSION Acute stroke from IPCAO may be successfully treated with EVT. Tmax > 6 s involvement of the midbrain-thalamus on perfusion imaging may be a predictor for clinical outcome.
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Affiliation(s)
- Sung Hyun Baik
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Dong Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea.
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9
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Posterior Circulation Endovascular Thrombectomy for Large Vessels Occlusion in Patients Presenting with NIHSS Score ≤ 10. Life (Basel) 2021; 11:life11121423. [PMID: 34947955 PMCID: PMC8703711 DOI: 10.3390/life11121423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022] Open
Abstract
Mechanical thrombectomy (MT) is currently the gold standard treatment for ischemic stroke due to large vessel occlusion (LVO). However, the evidence of clinical usefulness of MT in posterior circulation LVO (pc-LVO) is still doubtful compared to the anterior circulation, especially in patients with mild neurological symptoms. The database of 10 high-volume stroke centers in Europe, including a period of three year and a half, was screened for patients with an acute basilar artery occlusion or a single dominant vertebral artery occlusion ("functional" BAO) presenting with a NIHSS ≤10, and with at least 3 months follow-up. A total of 63 patients were included. Multivariate analysis demonstrated that female gender (adjusted OR 0.04; 95% CI 0-0.84; p = 0.04) and combined technique (adj OR 0.001; 95% CI 0-0.81; p = 0.04) were predictors of worse outcome. Higher pc-ASPECTS (adj OR 4.75; 95% CI 1.33-16.94; p = 0.02) and higher Delta NIHSS (adj OR 2.06; 95% CI 1.16-3.65; p = 0.01) were predictors of better outcome. Delta NIHSS was the main predictor of good outcome at 90 days in patients with posterior circulation LVO presenting with NIHSS score ≤ 10.
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10
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Cunha B, Baptista M, Pamplona J, Carvalho R, da Câmara CP, Alves M, Papoila AL, Nunes AP, Reis J, Fragata I. Acute Treatment of Isolated Posterior Cerebral Artery Occlusion: Single Center Experience. J Stroke Cerebrovasc Dis 2021; 31:106239. [PMID: 34910987 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106239] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/17/2021] [Accepted: 11/20/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Randomized trials for mechanical thrombectomy (MT) excluded patients with ischemic strokes due to isolated posterior cerebral artery occlusion (IPCAO), and there is no evidence for best acute treatment strategy in these patients. We aimed to assess the effectiveness and safety of MT in acute IPCAO. METHODS We retrospectively analyzed consecutive patients with acute stroke due to IPCAO submitted to MT and/or intravenous thrombolysis (IVT), between 2015-2019. Effectiveness outcomes (recanalization rate, first-pass effect, NIHSS 24h improvement and 3-month Modified Ranking Scale - mRS) and safety outcomes (complications, symptomatic intracranial hemorrhage (SICH) and 3-month mortality) were described and compared between groups. RESULTS A total of 38 patients were included, 25 underwent MT and 13 had IVT alone. Successful and complete recanalization were achieved in 68% and 52% of MT patients, respectively. NIHSS improvement at 24h was found in 56% of MT patients versus 30.8% of patients submitted to IVT alone (OR [95% CI]=2.86 [0.69-11.82]) and excellent functional outcome at 3 months (mRS≤1) was achieved in 54.2% of MT patients versus 38.5% in the IVT group (OR [95% CI]=1.60 [0.41-6.32]). Complications occurred in 3 (12%) procedures and there were no SICH. Mortality at 3 months was 20% in the MT group and 15.4% in patients submitted to IVT alone. CONCLUSIONS Our results reflect a real-world scenario in a single center and seem to support the recently growing literature showing that MT is a feasible and safe treatment in IPCAO, with favorable effectiveness.
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Affiliation(s)
- Bruno Cunha
- Neuroradiology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal.
| | - Mariana Baptista
- Neuroradiology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Jaime Pamplona
- Neuroradiology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Rui Carvalho
- Neuroradiology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Catarina Perry da Câmara
- Neuroradiology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Marta Alves
- NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal; Epidemiology and Statistics Unit, Research Centre, Centro Hospitalar Universitário de Lisboa Central; Center of Statistics and it's Applications, University of Lisbon, Lisbon, Portugal
| | - Ana Luísa Papoila
- NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal; Epidemiology and Statistics Unit, Research Centre, Centro Hospitalar Universitário de Lisboa Central; Center of Statistics and it's Applications, University of Lisbon, Lisbon, Portugal
| | - Ana Paiva Nunes
- Stroke Unit, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - João Reis
- Neuroradiology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Isabel Fragata
- Neuroradiology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
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11
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Maus V, Rogozinski S, Borggrefe J, Barnikol UB, Saklak M, Mpotsaris A. Clinical presentation of posterior cerebral artery occlusions - Clinical rationale for a more aggressive therapeutic strategy? eNeurologicalSci 2021; 25:100368. [PMID: 34765752 PMCID: PMC8571698 DOI: 10.1016/j.ensci.2021.100368] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/12/2021] [Accepted: 09/02/2021] [Indexed: 01/19/2023] Open
Abstract
Introduction A proximal occlusion of the posterior cerebral artery (PCA) can affect patients severely and clinical outcome might be poor. Aim of this paper is to describe clinical presentation, diagnostic findings and outcome of patients suffering from ischemia in the PCA territory. Methods We conducted a retrospective analysis of clinically affected patients with imaging-based evidence of ischemia within in the PCA territory at a comprehensive stroke center over a six-year period. Clinical (including demographics, National Institutes of Health Stroke Scale, NIHSS, modified Rankin Sclae, mRS), imaging (including occlusion site and brain infarction) and therapeutic data were evaluated. A favorable outcome was defined as an mRS ≤2. Results Two hundred thirty-five patients were clinically affected with evidence of PCA ischemia detected by cross-sectional imaging. One-hundred fourty-five patients demonstrated an occlusion of the PCA including 43/145 (30%) with P1 occlusion, 80/145 (55%) with P2 and 22/145 (15%) with P3 occlusion. The most frequent symptom was hemi−/ quadrantanopsia (181/235, 77%). Sixty-eight patients (29%) suffered from hemiparesis. The occurrence of a hemiparesis was associated with a P1 occlusion (27/43, 63% vs. 41/192, 21%; p < 0.0001). Hemi−/quadrantanopsia was less frequently associated with a P1 occlusion (26/43, 61% vs. 155/192, 81%; p = 0.0043). P1 occlusions more frequently showed thalamic infarction (28/43, 65% vs. 65/192, 34%; p < 0.0001). At discharge, patients with P1 occlusion more often showed a poor outcome (mRS > 2, 30/43, 70% vs. 55/192, 29%; p < 0.0001). Conclusion Hemiparesis due to P1 occlusion is a common phenomenon in stroke patients and associated with a poor clinical outcome. Hemiparesis in patients with a proximal PCA occlusion is a frequent event. Proximal PCA occlusions are associated with thalamic infarction. The clinical outcome in patients with proximal PCA occlusion is poor.
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Affiliation(s)
- Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Langendreer, Ruhr-University Bochum, Bochum, Germany
| | - Sophia Rogozinski
- Department of Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany.,Department of Neurology, University Hospital Hannover, Hannover, Germany
| | - Jan Borggrefe
- Department of Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling Klinikum Minden, Minden, Germany
| | - Utako Birgit Barnikol
- Department of Child and Adolescence Psychiatry, Research Unit Ethics in Translational Oncology Clinic1 of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Muharrem Saklak
- Department of Surgery, DRK Hospital Berlin-Mitte, Berlin, Germany
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12
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Monteiro A, Khan S, Waqas M, Dossani RH, Ruggiero N, Siddiqi NM, Baig AA, Rai HH, Cappuzzo JM, Levy EI, Siddiqui AH. Mechanical thrombectomy versus intravenous alteplase alone in acute isolated posterior cerebral artery occlusion: a systematic review. J Neurointerv Surg 2021; 14:564-567. [PMID: 34728545 DOI: 10.1136/neurintsurg-2021-018017] [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: 07/10/2021] [Accepted: 09/20/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Acute isolated posterior cerebral artery occlusions (aPCAOs) were excluded or under-represented in major randomized trials of mechanical thrombectomy (MT). The benefit of MT in comparison to intravenous tissue plasminogen activator (alteplase; IV-tPA) alone in these patients remains controversial and uncertain. METHODS We performed a systematic search of PubMed, MEDLINE, and EMBASE databases for articles comparing MT with or without bridging IV-tPA and IV-tPA alone for aPCAO using keywords ('posterior cerebral artery', 'thrombolysis' and 'thrombectomy') with Boolean operators. Extracted data from patients reported in the studies were pooled into groups (MT vs IV-tPA alone) for comparison. Estimated rates for favorable outcome (modified Rankin scale score 0-2), symptomatic intracranial hemorrhage (sICH), and mortality were extracted. RESULTS Seven articles (201 MT patients, 64 IV-tPA) were included, all retrospective. There was no statistically significant difference between pooled groups in median age, median presentation National Institutes of Health Stroke Scale (NIHSS) score, PCAO segment, and median time from symptom onset to puncture or needle. The recanalization rate was significantly higher in the MT group than the IV-tPA group (85.6% vs 53.1%, p<0.00001). Odds ratios for favorable outcome (OR 1.5, 95% CI 0.8 to 2.5), sICH (OR 1.1, 95% CI 0.2 to 5.5), and mortality (OR 1.4, 95% CI 0.5 to 3.6) did not significantly favor any modality. CONCLUSIONS We found no significant differences in odds of favorable outcome, sICH, and mortality in MT and IV-tPA in comparable aPCAO patients, despite superior MT recanalization rates. Equipoise remains regarding the optimal treatment modality for these patients.
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Affiliation(s)
- Andre Monteiro
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Slah Khan
- Medical Student, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Muhammad Waqas
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Rimal H Dossani
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Nicco Ruggiero
- Medical Student, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Nehaal M Siddiqi
- Medical Student, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Ammad A Baig
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Hamid H Rai
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Justin M Cappuzzo
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Elad I Levy
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA.,Neurosurgery and Radiology and Canon Stroke and Vascular Research Center and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA .,Neurosurgery and Radiology and Canon Stroke and Vascular Research Center and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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13
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Herweh C, Abdalkader M, Nguyen TN, Puetz V, Schöne D, Kaiser D, Chen CH, Jeng JS, Möhlenbruch MA, Ringleb PA, Nagel S. Mechanical Thrombectomy in Isolated Occlusion of the Proximal Posterior Cerebral Artery. Front Neurol 2021; 12:697348. [PMID: 34393977 PMCID: PMC8358070 DOI: 10.3389/fneur.2021.697348] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/24/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction: Endovascular therapy (EVT) is established as first-line treatment for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in the anterior circulation. For basilar artery occlusion, recent randomized clinical trials demonstrated not only equipoise but also advantages for EVT under particular circumstances. It remains unclear whether EVT offers an advantage over best medical management (BMM) including thrombolysis (IVT) in isolated occlusion of the proximal posterior cerebral artery (PCAO). Methods: Patients with AIS due to PCAO proven by CT or MR angiography were retrospectively identified from local databases at four comprehensive stroke centers in Germany, USA, and Taiwan between 2012 and 2020. Demographic and clinical data were collected, and imaging characteristics including pretherapeutic, interventional, and follow-up imaging were reviewed locally at each center. Patients were grouped according to therapy, i.e., BMM including IVT alone vs. BMM and EVT. Efficacy endpoints were early neurological improvement (ENI) after 24 h or at discharge, good outcome (modified Rankin scale 0–2) after 3 months, as well as hemorrhagic complications and in-house deaths as safety endpoints. Results: We included 130 patients of whom 23 (17.7%) received EVT. EVT patients had more proximal occlusions (69.9 vs. 43%, p = 0.023) and had a better premorbid function [premorbid mRS, 0 (0–4) vs. 1 (0–3), p < 0.01] when compared to BMM patients. IVT showed a trend toward being less performed in the EVT group (21.7 vs. 41.1%, p = 0.1), while other baseline parameters were balanced. Successful reperfusion was achieved in 52% of EVT patients. ENI was more frequent in the EVT group (61 vs. 35.5%, p = 0.034). Good outcome at 90 days and safety endpoints did not differ. In a bivariate analysis, ENI was independently predicted by the use of EVT (OR, 2.76; CI, 1.055–7.04) and the baseline National Institutes of Health Stroke Scale (NIHSS) (OR, 1.082; CI, 1.027–1.141 per point increase). Discussion: EVT in isolated PCAO appears safe and feasible. Positive effects on clinical outcome are primarily on ENI but also depend on the initial stroke severity. Further prospective or randomized studies are needed to better describe the potential long-term clinical benefits of EVT for PCAO as compared with best medical management.
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Affiliation(s)
- Christian Herweh
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Mohamad Abdalkader
- Division of Interventional Neurology/Neuroradiology, Boston Medical Center, Boston, MA, United States
| | - Thanh N Nguyen
- Division of Interventional Neurology/Neuroradiology, Boston Medical Center, Boston, MA, United States
| | - Volker Puetz
- Department of Neurology, Dresden University Hospital, Dresden, Germany
| | - Daniela Schöne
- Department of Neurology, Dresden University Hospital, Dresden, Germany
| | - Daniel Kaiser
- Institute of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Chih-Hao Chen
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter A Ringleb
- Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simon Nagel
- Neurology, Heidelberg University Hospital, Heidelberg, Germany
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14
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Mechanical thrombectomy of acute distal posterior cerebral artery occlusions. J Clin Neurosci 2021; 88:57-62. [PMID: 33992205 DOI: 10.1016/j.jocn.2021.03.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/22/2021] [Accepted: 03/16/2021] [Indexed: 11/20/2022]
Abstract
To describe our experience with mechanical thrombectomy (MTE) of acute distal posterior cerebral artery (PCA) occlusions, either isolated or in combination with more proximal vessel occlusions regarding recanalization rates, MTE techniques, and procedural safety. From the prospectively maintained stroke thrombectomy databases of two institutions, all consecutive patients subjected to MTE of acute distal PCA occlusion (P2 and 3 segments) between July 2013 and May 2020 were retrospectively identified. Imaging data and angiographic features, as well as patients' demographic and clinical data were evaluated. 35 consecutive patients were included in the study. In 17 patients MTE of isolated acute distal PCA occlusion was performed. 9 patients had combined basilar artery (BA) and distal PCA occlusion on stroke imaging and 3 had embolic distal PCA occlusion following MTE for BA occlusion. 6 patients harbored distal PCA occlusions in combination with carotid-T occlusion and a dominant posterior communicating artery. The median NIHSS at presentation was 14 (IQR 8 - 27). 25 patients (71.4%) had occlusions of the P2 and 10 patients (28.6%) of the P3 segment. Successful recanalization (TICI 2b/3) was achieved in 31 patients (88.6%). 10 patients (28.6%) were treated with a direct contact aspiration technique, while a stent retriever was used in 25 patients (71.4%). No complication attributable to distal PCA MTE occurred. Good outcome (mRS ≤ 2) was achieved in 14 patients (46.7%) and mortality was 22.9%. MTE for acute distal PCA occlusion in the setting of different occlusion patterns appears both safe and angiographically effective. Yet, clinical effectiveness remains to be determined.
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15
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Abbasi M, Liu Y, Fitzgerald S, Mereuta OM, Arturo Larco JL, Rizvi A, Kadirvel R, Savastano L, Brinjikji W, Kallmes DF. Systematic review and meta-analysis of current rates of first pass effect by thrombectomy technique and associations with clinical outcomes. J Neurointerv Surg 2021; 13:212-216. [PMID: 33441394 DOI: 10.1136/neurintsurg-2020-016869] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/16/2020] [Accepted: 11/20/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND First pass effect (FPE) in mechanical thrombectomy is thought to be associated with good clinical outcomes. OBJECTIVE To determine FPE rates as a function of thrombectomy technique and to compare clinical outcomes between patients with and without FPE. METHODS In July 2020, a literature search on FPE (defined as modified Thrombolysis in Cerebral Infarction (TICI) 2c-3 after a single pass) and modified FPE (mFPE, defined as TICI 2b-3 after a single pass) and mechanical thrombectomy for stroke was performed. Using a random-effects meta-analysis, we evaluated the following outcomes for both FPE and mFPE: overall rates, rates by thrombectomy technique, rates of good neurologic outcome (modified Rankin Scale score ≤2 at day 90), mortality, and symptomatic intracerebral hemorrhage (sICH) rate. RESULTS Sixty-seven studies comprising 16 870 patients were included. Overall rates of FPE and mFPE were 28% and 45%, respectively. Thrombectomy techniques shared similar FPE (p=0.17) and mFPE (p=0.20) rates. Higher odds of good neurologic outcome were found when we compared FPE with non-FPE (56% vs 41%, OR=1.78) and mFPE with non-mFPE (57% vs 44%, OR=1.73). FPE had a lower mortality rate (17% vs 25%, OR=0.62) than non-FPE. FPE and mFPE were not associated with lower sICH rate compared with non-FPE and non-mFPE (4% vs 18%, OR=0.41 for FPE; 5% vs 7%, OR=0.98 for mFPE). CONCLUSIONS Our findings suggest that approximately one-third of patients achieve FPE and around half of patients achieve mFPE, with equivalent results throughout thrombectomy techniques. FPE and mFPE are associated with better clinical outcomes.
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Affiliation(s)
- Mehdi Abbasi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yang Liu
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Seán Fitzgerald
- CÚRAM-SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland.,Physiology Department, National University of Ireland Galway, Galway, Ireland
| | - Oana Madalina Mereuta
- CÚRAM-SFI Research Centre for Medical Devices, National University of Ireland Galway, Galway, Ireland.,Physiology Department, National University of Ireland Galway, Galway, Ireland
| | | | - Asim Rizvi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Luis Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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16
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Memon MZ, Kushnirsky M, Brunet MC, Saini V, Koch S, Yavagal DR. Mechanical thrombectomy in isolated large vessel posterior cerebral artery occlusions. Neuroradiology 2020; 63:111-116. [PMID: 32748080 DOI: 10.1007/s00234-020-02505-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 07/28/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Mechanical thrombectomy (MT) in posterior circulation large vessel occlusion (LVO), including posterior cerebral artery (PCA), has not been validated since all five major MT trials excluded such patients. To evaluate the feasibility and preliminary safety and efficacy of MT in isolated PCA occlusion stroke patients with new-generation MT devices. METHODS Endovascularly treated acute ischemic stroke (AIS) patients were identified from a prospectively collected database and their baseline characteristics were noted. Clinical outcomes were angiographic recanalization, a favorable clinical outcome at 3 months on modified Rankin Scale (mRS) and visual field (VF) deficit improvement on confrontation test, rate of intracranial hemorrhage (ICH), and mortality at 3 months. RESULTS A total of 355 AIS patients underwent MT from January 2018 to December 2019. Isolated PCA MT was performed in 15 consecutive patients. The mean age was 64 ± 17 years, and 9(60%) were women. Median presentation NIHSS was 9 (interquartile range 5-15). MT devices used were stent retrievers in 6 patients and combined aspiration and stent retriever in 9 patients. Complete revascularization (TICI 2c or 3) was achieved in 12/15 patients. 3-month VF normalization was seen in 7/12 of the patients. Post-procedure symptomatic ICH occurred in 1/15 of patients. mRS score of 0-2 was achieved in 9/15 of patients but one patient was dead at 3 months post procedure. CONCLUSION MT is feasible and can achieve successful reperfusion in isolated PCA occlusions and resulted in favorable motor and visual outcomes in this small series of ischemic stroke patients.
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Affiliation(s)
- Muhammad Zeeshan Memon
- Departments of Neurology and Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine Miami, FL, Miami, USA.
| | - Marina Kushnirsky
- Departments of Neurology and Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine Miami, FL, Miami, USA
| | - Marie Christine Brunet
- Departments of Neurology and Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine Miami, FL, Miami, USA
| | - Vasu Saini
- Departments of Neurology and Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine Miami, FL, Miami, USA
| | - Sebastian Koch
- Departments of Neurology and Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine Miami, FL, Miami, USA
| | - Dileep R Yavagal
- Departments of Neurology and Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine Miami, FL, Miami, USA
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17
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Two Cases of Posterior Cerebral Artery P2 Segment Occlusion with Motor Weakness Improved by Acute Mechanical Thrombectomy. World Neurosurg 2020; 142:13-16. [PMID: 32562904 DOI: 10.1016/j.wneu.2020.06.085] [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: 05/19/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Clinical evidence to support the use of mechanical thrombectomy (MT) for posterior cerebral artery P2 segment occlusion (P2O) has not been established, and hemiplegia due to P2O improved by MT to our knowledge has not yet been reported. We report 2 cases of P2O with hemiplegia improved by MT. CASE DESCRIPTION In case 1, a 68-year-old man was admitted with right hemiplegia and dysesthesia (National Institutes of Health Stroke Scale score 14). Head magnetic resonance imaging showed acute ischemia in the left inferolateral thalamus and posterior limb of the internal capsule. Angiography showed left P2O, which was recanalized after MT. Hemiplegia improved immediately following recanalization, and modified Rankin Scale score at discharge was 0. In case 2, a 69-year-old man was admitted with left hemiplegia and dysesthesia (National Institutes of Health Stroke Scale score 8). Head magnetic resonance imaging showed acute ischemia in the right inferolateral thalamus and posterior limb of the internal capsule. Angiography showed right P2O, which was recanalized after MT, as in case 1. His symptoms resolved completely. CONCLUSIONS P2O may cause severe motor deficit. In such cases, MT may contribute to safely improving patients' deficits.
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Meyer L, Papanagiotou P, Politi M, Kastrup A, Kraemer C, Hanning U, Kniep H, Broocks G, Pilgram-Pastor SM, Wallocha M, Chapot R, Fiehler J, Stracke CP, Leischner H. Feasibility and safety of thrombectomy for isolated occlusions of the posterior cerebral artery: a multicenter experience and systematic literature review. J Neurointerv Surg 2020; 13:217-220. [PMID: 32527938 DOI: 10.1136/neurintsurg-2020-016059] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Substantial clinical evidence supporting the benefit of mechanical thrombectomy (MT) for distal occlusions within the posterior circulation is still missing. This study aims to investigate the procedural feasibility and safety of MT for isolated occlusions of the posterior cerebral artery. METHODS We retrospectively reviewed patients from three stroke centers with acute ischemic stroke attributed to isolated posterior cerebral artery occlusion (IPCAOs) who underwent MT between January 2014 and December 2019. Procedural and safety assessment included successful recanalization rates (defined as Thrombolysis in Cerebral Infarction Scale (TICI) ≥2b), number of MT attempts and first-pass effect (TICI 3), intracranial hemorrhage (ICH), mortality, and intervention-related serious adverse events. Treatment effects were evaluated by the rate of early neurological improvement (ENI) and early functional outcome was assessed with the modified Rankin Scale (mRS) at discharge. A systematic literature review was conducted to identify and summarize previous reports on MT for IPCAOs. RESULTS Forty-three patients with IPCAOs located in the P1 (55.8%, 24/43), P2 (37.2%, 16/43), and P3 segment (7%, 3/43) were analyzed. The overall rate of successful recanalization (TICI ≥2b) was 86% (37/43), including a first pass-effect of 48.8% (21/43) leading to TICI 3. sICH occurred in 7% (3/43) and there were two cases with iatrogenic vessel dissection and one perforation. ENI was observed in 59% (23/39) and excellent functional outcome (mRS ≤1) in 46.2% (18/39) of patients who were discharged. The in-hospital mortality rate was 9.3% (4/43). CONCLUSION Our study suggests the technical feasibility and safety of thrombectomy for IPCAOs. Further studies are needed to investigate safety and long-term functional outcomes with posterior circulation stroke-adjusted outcome assessment.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany.,Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Politi
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Mitte, Bremen, Germany
| | | | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Marta Wallocha
- Department of Intracranial Endovascular Therapy, Alfried-Krupp Krankenhaus, Essen, Germany
| | - René Chapot
- Department of Intracranial Endovascular Therapy, Alfried-Krupp Krankenhaus, Essen, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Paul Stracke
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Intracranial Endovascular Therapy, Alfried-Krupp Krankenhaus, Essen, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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