1
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McKenzie ED, Chaturvedi S, Peters SR. Basilar artery stenting in hyperacute stroke: A systematic review of published cases. Clin Neurol Neurosurg 2024; 242:108327. [PMID: 38761504 DOI: 10.1016/j.clineuro.2024.108327] [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: 07/13/2023] [Revised: 04/10/2024] [Accepted: 05/08/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND AND PURPOSE Basilar artery stenting is a rescue therapy in the management of hyperacute stroke. Published data on efficacy and safety are limited. METHODS A systematic review of published studies was performed in accordance with PRISMA guidelines. Inclusion criteria were adult patients with ischemic stroke with permanent basilar artery stent placement within 48 h of onset. Data were extracted by two independent reviewers. Additional cases from our institution were identified via a local stroke registry. RESULTS Of 212 screened articles, patient-level data was reported in 35 studies (87 individuals) and six additional patients were included from our registry. Patients (n = 93, 63 % male; median age 64) most often presented with mid-basilar occlusion (52 %) and 76 % received treatment within 12 hours of onset. Favorable angiographic results occurred in 67 %. The final modified Rankin Scale score (mRS) was 0-3 for 56 % of patients; mortality was 29 %. Those with complete flow post-procedure were more likely to have a final mRS of 0-3 (p = 0.05). CONCLUSIONS In 93 cases of basilar stenting in hyperacute stroke, favourable angiographic and functional outcomes were reported in 67 % and 56 % of patients, respectively. International multicenter registries are required to establish benefit and identify patient and technical factors that predict favorable outcomes.
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Affiliation(s)
- Erica D McKenzie
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Surbhi Chaturvedi
- Department of Neuroscience, Specialist Hospital, Bengaluru, Karnataka, India
| | - Steven R Peters
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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2
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Enomoto Y, Shoda K, Mizutani D, Matsubara H, Egashira Y, Iwama T. Platelet reactivity after clopidogrel loading in patients with acute ischemic stroke. Front Neurol 2022; 13:887243. [PMID: 36090856 PMCID: PMC9449631 DOI: 10.3389/fneur.2022.887243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveIt remains unclear when sufficient antiplatelet effect is achieved after administration of a loading dose of clopidogrel in patients with acute ischemic stroke (AIS). This study aimed to evaluate the clopidogrel response in patients with AIS identified by the platelet function test (PFT).MethodsP2Y12 reaction unit (PRU) values measured using VerifyNow at baseline and at 6, 24, and 72 h after administration of a loading dose (300 mg) of clopidogrel were compared between patients with AIS and those of other cerebrovascular diseases (CVD). The prevalence of clopidogrel abnormal response and its associated factors were examined.ResultsThe PRU value was significantly reduced with time in the other CVD group (p < 0.0001), and also in the AIS group (p = 0.0073). The PRU values were significantly higher in the AIS group than in the other CVD group (p < 0.0001 between the groups, baseline: 314 ± 53 vs. 284 ± 62, p = 0.35; 6 h: 290 ± 66 vs. 214 ± 71, p = 0.016; 24 h: 270 ± 75 vs. 190 ± 70, p < 0.0001; and 72 h: 231 ± 76 vs. 163 ± 93, p = 0.105). The prevalence of clopidogrel hypo-responder (PRU > 240 at 24 h after administration) was higher in the AIS group (79 vs. 33%, p < 0.0001) and associated with the baseline PRU value but not with the cytochrome P450 2C19 genotype or clinical ischemic events.ConclusionsResidual platelet reactivity at 24 h after clopidogrel loading was substantially higher in patients with AIS than in patients with other CVD. In addition, most patients with AIS were judged to be hypo-responders on PFT. This should be carefully interpreted in patients with AIS because of poor specificity for predicting clinical ischemic events.
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3
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Jung WS, Kim SS, Lee KY, Suh SH. Usefulness of Self-Expandable Stent for Recanalization of Intracranial Atherosclerotic Disease: Preliminary Experience with Enterprise Stent. Neurointervention 2022; 17:37-44. [PMID: 35184435 PMCID: PMC8891589 DOI: 10.5469/neuroint.2022.00017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/10/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose The purpose of this preliminary study is to evaluate the efficacy and safety of the Enterprise stent for intracranial atherosclerotic disease (ICAD) in patients who presented with acute stroke due to vessel steno-occlusion and in patients with symptomatic disease despite optimum medical management. Materials and Methods A retrospective data analysis was performed on 15 consecutive patients who were treated with Enterprise stenting for recanalization of symptomatic intracranial steno-occlusive arteries due to underlying ICAD. Their clinical and radiological data were reviewed to evaluate procedural results, periprocedural and postprocedural complications, and clinical outcome. Results Enterprise stents were deployed as a rescue method in 15 patients for recanalization of steno-occlusion. All patients achieved final modified thrombolysis in cerebral infarction (mTICI) score improvement (53.3% with a mTICI score from 0 to 2b or 3, 46.7% with a mTICI score from 1 to 3). Two postprocedural complications (1 symptomatic intracranial hemorrhage and 1 severe brain edema, 13.3%) occurred among 15 patients. Among 12 patients with acute ischemic stroke (AIS), 6 patients (50%) had improvement in their National Institute of Health Stroke Scale of more than 4 at discharge. Seven patients (58.3%) had a good functional outcome with 3-month modified Rankin Score (mRS)≤2, and mortality occurred (mRS=6) in 2 patients (16.7%). None of the 10 AIS and 3 transient ischemic attack patients experienced further ischemic events attributable to the treated steno-occlusion during the follow-up period (ranged from 4 to 36 months, median 12 months). Conclusion This retrospective study suggests that Enterprise stenting can effectively and safely achieve recanalization in symptomatic steno-occlusive intracranial arteries.
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Affiliation(s)
- Woo Sang Jung
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Sam-Soo Kim
- Department of Radiology, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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4
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Maurer CJ, Dobrocky T, Joachimski F, Neuberger U, Demerath T, Brehm A, Cianfoni A, Gory B, Berlis A, Gralla J, Möhlenbruch MA, Blackham KA, Psychogios MN, Zickler P, Fischer S. Endovascular Thrombectomy of Calcified Emboli in Acute Ischemic Stroke: A Multicenter Study. AJNR Am J Neuroradiol 2020; 41:464-468. [PMID: 32029470 DOI: 10.3174/ajnr.a6412] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 12/23/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Large intracranial vessel occlusion due to calcified emboli is a rare cause of major stroke. We assessed the prevalence, imaging appearance, the effectiveness of mechanical thrombectomy, and clinical outcome of patients with large-vessel occlusion due to calcified emboli. MATERIALS AND METHODS We performed a retrospective analysis of clinical and procedural data of consecutive patients who underwent mechanical thrombectomy due to calcified emboli in 7 European stroke centers. RESULTS We screened 2969 patients, and 40 patients matched the inclusion criteria, accounting for a prevalence of 1.3%. The mean maximal density of the thrombus was 327 HU (range, 150-1200 HU), and the mean thrombus length was 9.2 mm (range, 4-20 mm). Four patients had multiple calcified emboli, and 2 patients had an embolic event during an endovascular intervention. A modified TICI score of ≥2b was achieved in 57.5% (23/40), with minimal-to-no reperfusion (modified TICI 0-1) in 32.5% (13/40) and incomplete reperfusion (modified TICI 2a) in 10% (4/40). Excellent outcome (mRS 0-1) was achieved in only 20.6%, functional independence (mRS 0-2) in 26.5% and 90-day mortality was 55.9%. CONCLUSIONS Acute ischemic stroke with large-vessel occlusion due to calcified emboli is a rare entity in patients undergoing thrombectomy, with considerably worse angiographic outcome and a higher mortality compared with patients with noncalcified thrombi. Good functional recovery at 3 months can still be achieved in about a quarter of patients.
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Affiliation(s)
- C J Maurer
- From the Departments of Diagnostic and Interventional Radiology and Neuroradiology (C.J.M., F.J., A.Berlis)
| | - T Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology (T.Dobrocky, J.G.), University of Bern, Inselspital, Bern, Switzerland
| | - F Joachimski
- From the Departments of Diagnostic and Interventional Radiology and Neuroradiology (C.J.M., F.J., A.Berlis)
| | - U Neuberger
- Department of Neuroradiology (U.N., M.A.M.), University of Heidelberg, Heidelberg, Germany
| | - T Demerath
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - A Brehm
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Neuroradiology (A.Brehm, M.N.P.), University Medical Center Göttingen, Göttingen, Germany
| | - A Cianfoni
- Department of Neuroradiology (A.C.), Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - B Gory
- Department of Diagnostic and Therapeutic Neuroradiology (B.G.), University Hospital of Nancy, Institut National de la Santé et de la Recherche Médicale U1254, Nancy, France
| | - A Berlis
- From the Departments of Diagnostic and Interventional Radiology and Neuroradiology (C.J.M., F.J., A.Berlis)
| | - J Gralla
- University Institute of Diagnostic and Interventional Neuroradiology (T.Dobrocky, J.G.), University of Bern, Inselspital, Bern, Switzerland
| | - M A Möhlenbruch
- Department of Neuroradiology (U.N., M.A.M.), University of Heidelberg, Heidelberg, Germany
| | - K A Blackham
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - M N Psychogios
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Neuroradiology (A.Brehm, M.N.P.), University Medical Center Göttingen, Göttingen, Germany
| | - P Zickler
- Neurology and Neurophysiology (P.Z.), Universitätsklinikum Augsburg, Augsburg, Germany
| | - S Fischer
- Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie (S.F.), Nuklearmedizin, Knappschaftskrankenhaus Bochum-Langendreer, Universitätsklinik, Bochum, Germany
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5
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Nakazaki M, Oka S, Sasaki M, Kataoka-Sasaki Y, Onodera R, Komatsu K, Iihoshi S, Hiroura M, Kawaguchi A, Kocsis JD, Honmou O. Prevention of neointimal hyperplasia induced by an endovascular stent via intravenous infusion of mesenchymal stem cells. J Neurosurg 2019; 133:1773-1785. [PMID: 31585431 DOI: 10.3171/2019.7.jns19575] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In-stent restenosis after percutaneous transluminal angioplasty and stenting (PTAS) due to neointimal hyperplasia is a potential cause of clinical complications, including repeated revascularization and ischemic events. Neointimal hyperplasia induced by an inflammatory response to the stent strut may be a possible mechanism of in-stent restenosis. Intravenous infusion of bone marrow-derived mesenchymal stem cells (MSCs) has been reported to show therapeutic efficacy for cerebral stroke, presumably by an antiinflammatory effect. This study aimed to determine whether MSCs can reduce or prevent neointimal hyperplasia induced by an endovascular stent. METHODS In this study, two types of bare metal stents were deployed using a porcine (mini-pig) model. One stent was implanted in the common carotid artery (CCA), which is considered quite similar to the human CCA, and the other was inserted in the superficial cervical artery (SCA), which is similar in size to the human middle cerebral artery. Angiographic images, intravascular ultrasound (IVUS) imaging, and microscopic images were used for analysis. RESULTS Angiographic images and IVUS studies revealed that intravenous infusion of MSCs immediately after deployment of stents prevented in-stent stenosis of the CCA and SCA. Histological analysis also confirmed that inflammatory responses around the stent struts were reduced in both the stented CCA and SCA in the mini-pig. CONCLUSIONS Intravenous infusion of MSCs inhibited the inflammatory reaction to an implanted stent strut, and prevented progressive neointimal hyperplasia in the stented CCA and SCA in a porcine model. Thus, MSC treatment could attenuate the recurrence of cerebral ischemic events after stenting.
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Affiliation(s)
- Masahito Nakazaki
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, and
- 4Department of Neurology, Yale University School of Medicine, New Haven, Connecticut; and
- 5Center for Neuroscience and Regeneration Research, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Shinichi Oka
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, and
| | - Masanori Sasaki
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, and
- 4Department of Neurology, Yale University School of Medicine, New Haven, Connecticut; and
- 5Center for Neuroscience and Regeneration Research, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Yuko Kataoka-Sasaki
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, and
| | - Rie Onodera
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, and
| | - Katsuya Komatsu
- 2Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido
| | - Satoshi Iihoshi
- 2Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Hokkaido
| | - Manabu Hiroura
- 3NIPRO Life Science Site, NIPRO Corporation, Kusatsu, Shiga, Japan
| | - Akira Kawaguchi
- 3NIPRO Life Science Site, NIPRO Corporation, Kusatsu, Shiga, Japan
| | - Jeffery D Kocsis
- 4Department of Neurology, Yale University School of Medicine, New Haven, Connecticut; and
- 5Center for Neuroscience and Regeneration Research, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Osamu Honmou
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, and
- 4Department of Neurology, Yale University School of Medicine, New Haven, Connecticut; and
- 5Center for Neuroscience and Regeneration Research, VA Connecticut Healthcare System, West Haven, Connecticut
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6
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Feng MT, Zhang HJ, Zhang YX, Xing PF, Zhang L, Zhang YW, Li ZF, Xu Y, Hong B, Huang QH, Yang PF, Liu JM. Stent Angioplasty for Acute Intracranial Atherosclerotic Occlusion After Failed Thrombectomy: A Single-Institution Series of 55 Patients. World Neurosurg 2019; 130:e444-e448. [DOI: 10.1016/j.wneu.2019.06.112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
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7
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Gross BA, Desai SM, Walker G, Jankowitz BT, Jadhav A, Jovin TG. Balloon-mounted stents for acute intracranial large vessel occlusion secondary to presumed atherosclerotic disease: evolution in an era of supple intermediate catheters. J Neurointerv Surg 2019; 11:975-978. [DOI: 10.1136/neurintsurg-2019-014877] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/18/2019] [Accepted: 04/23/2019] [Indexed: 11/03/2022]
Abstract
IntroductionTreatment of acute large vessel occlusion (LVO) stroke secondary to intracranial atherosclerotic disease (ICAD) is more nuanced with disparate and infrequently reported outcomes. The deployment of balloon-mounted stents presents an expedient approach with renewed feasibility in the modern era of supple intermediate catheters.MethodsA prospectively maintained endovascular stroke database was searched for patients undergoing intracranial stenting with balloon-mounted stents for acute LVO. Demographic, angiographic, and clinical data were extracted to determine procedural technique and success, measured both angiographically and clinically.ResultsSixty patients underwent stenting for acute LVO secondary to ICAD. Mean presenting National Institutes of Health Stroke Scale (NIHSS) score was 18 and 62% of treated sites were in the posterior circulation. Cases were performed under IV conscious sedation unless the patient was already intubated. Successful recanalization was achieved in 93% of cases (Thrombolysis in Cerebral Infarction (TICI) grade 2b in 48% and TICI grade 3 in 45%). Mean improvement in NIHSS score on post-procedure day 1 was 3.4. Good outcome (modified Rankin Scale score 0–2) at 3 months was 34% and the mortality rate was 34%. The rate of peri-procedural symptomatic hemorrhage was 8% and the rate of acute/subacute stent thrombosis was 7%. In this small cohort, patient age, sex, presenting NIHSS, comorbidities, smoking, tissue plasminogen activator administration, and stent location were not significant predictors of recanalization or good outcome.ConclusionTreatment of acute LVO stroke with balloon-mounted stents for ICAD has reperfusion rates and clinical outcomes comparable to thrombectomy, with higher rates of hemorrhage and mortality. Because stent placement was performed after attempted thrombectomy, a trial of primary stenting versus thrombectomy should be considered in patients suspected of underlying ICAD.
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8
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Wareham J, Flood R, Phan K, Crossley R, Mortimer A. A systematic review and meta-analysis of observational evidence for the use of bailout self-expandable stents following failed anterior circulation stroke thrombectomy. J Neurointerv Surg 2018; 11:675-682. [PMID: 30415225 DOI: 10.1136/neurintsurg-2018-014459] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 10/18/2018] [Accepted: 10/19/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND The crucial role of thrombectomy in the management of emergent large vessel occlusive stroke is not disputed but there is a technical failure rate in a significant minority of patients whose outcomes are often poor. Our objective was to perform a systematic review and meta-analysis to assess the safety and efficacy of permanent self-expandable stent deployment as a bailout procedure in cases of failed anterior circulation thrombectomy. METHODS Two independent reviewers searched the Pubmed (Medline) database for studies reporting outcomes following failed endovascular thrombectomy with subsequent rescue therapy employing self-expandable stents. RESULTS Eight studies (one prospective, seven retrospective) originating from Europe, Asia, and America comprising 160 patients met the inclusion criteria. Estimated baseline National Institutes of Health Stroke Scale score was 17.1 (95% CI 15.7 to 18.4). Following failed thrombetcomy and stent deployment, the rate of favorable outcome (modified Rankin Scale score 0-2) was 43% (95% CI 34% to 53%). Pooled mortality was 21% (95% CI 13% to 33%). Successful recanalization (Thrombolysis in Cerebral Infarction (TICI) 2b-3 or Thrombolysis in Myocardial Infarction (TIMI) 2-3) was 71% (95% CI 63% to 77%). Symptomatic intracerebral hemorrhage was seen in 12% (95% CI 7% to 18%). The Solitaire stent (Medtronic) was the most commonly deployed stent following failed thrombectomy attempts (66%; 95% CI 31% to 89%). Pre- or post-stent angioplasty was performed in 39%of patients (95% CI 29% to 48%). Glycoprotein IIb/IIIa inhibitors were used in 89% (95% CI 71% to 97%). 95% of patients received postprocedural antiplatelet therapy. CONCLUSION A rescue stent procedure seems reasonable as a last resort following failed thrombectomy but currently the level of evidence is limited. Prospective registries may aid in guiding future recommendations.
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Affiliation(s)
- James Wareham
- Department of Neuroradiology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Richard Flood
- Department of Neuroradiology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Neuro Spine Clinic, Sydney, New South Wales, Australia
| | - Robert Crossley
- Department of Neuroradiology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Alex Mortimer
- Department of Neuroradiology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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9
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Al-Mufti F, Cohen ER, Amuluru K, Patel V, El-Ghanem M, Nuoman R, Majmundar N, Dangayach NS, Meyers PM. Bailout Strategies and Complications Associated with the Use of Flow-Diverting Stents for Treating Intracranial Aneurysms. INTERVENTIONAL NEUROLOGY 2018; 8:38-54. [PMID: 32231694 DOI: 10.1159/000489016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 04/06/2018] [Indexed: 12/21/2022]
Abstract
Background Flow-diverting stents (FDS) have revolutionized the endovascular management of unruptured, complex, wide-necked, and giant aneurysms. There is no consensus on management of complications associated with the placement of these devices. This review focuses on the management of complications of FDS for the treatment of intracranial aneurysms. Summary We performed a systematic, qualitative review using electronic databases MEDLINE and Google Scholar. Complications of FDS placement generally occur during the perioperative period. Key Message Complications associated with FDS may be divided into periprocedural complications, immediate postprocedural complications, and delayed complications. We sought to review these complications and novel management strategies that have been reported in the literature.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA.,Departments of Neurology and Neurosurgery, Rutgers University - Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Eric R Cohen
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, University of Pittsburgh-Hamot, Erie, Pennsylvania, USA
| | - Vikas Patel
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Mohammad El-Ghanem
- Department of Neurology and Medical Imaging, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Rolla Nuoman
- Department of Neurology, Rutgers University - New Jersey Medical School, Newark, New Jersey, USA
| | - Neil Majmundar
- Departments of Neurology and Neurosurgery, Rutgers University - Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Neha S Dangayach
- Departments of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Philip M Meyers
- Departments of Radiology and Neurosurgery and Columbia University Medical Center, New York, New York, New York, USA
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10
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Mocco J. Commentary on ’North American Solitaire Stent Retriever Acute Stroke registry: postmarketing revascularization and clinical outcome results'. J Neurointerv Surg 2018; 10:i44. [DOI: 10.1136/neurintsurg-2018-014098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2018] [Indexed: 11/03/2022]
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11
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Nappini S, Limbucci N, Leone G, Rosi A, Renieri L, Consoli A, Laiso A, Valente I, Rosella F, Rosati R, Mangiafico S. Bail-out intracranial stenting with Solitaire AB device after unsuccessful thrombectomy in acute ischemic stroke of anterior circulation. J Neuroradiol 2018; 46:141-147. [PMID: 29920349 DOI: 10.1016/j.neurad.2018.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 04/26/2018] [Accepted: 05/25/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Recent trials established the efficacy of mechanical stent-retriever thrombectomy for treatment of stroke patients with large vessel occlusion (LVO) in the anterior circulation. However, stent-retriever thrombectomy may not accomplish successful recanalization in all patients. The aim of this study is to report the role of bail-out permanent stenting after failure of mechanical thrombectomy. METHODS Among 430 patients included in a prospectively maintained database, we analysed 325 cases of anterior circulation LVO. Mechanical thrombectomy (mTICI 2b-3) was effective in 213/325 (65%) and failed in 112/325 (35%). Bail-out intracranial stenting was performed in 17/325 (5.2%) patients. In all cases a fully retrievable detachable stent was used (Solitaire AB, Medtronic). RESULTS No intraprocedural technical complications occurred. Successful reperfusion (mTICI 2b/3) was achieved in 12/17 patients (70.6%). Three (17.6%) patients died: one extensive infarction in the internal carotid artery territory, one large intracerebral haemorrhage, and one massive pulmonary embolism. Haemorrhagic conversion, both symptomatic and asymptomatic, occurred in 2/17 (11.7%). Good clinical outcome (mRS 0-2) at 3-months was achieved in 41.2% of patients. CONCLUSION Bail-out intracranial stenting after unsuccessful thrombectomy is technically feasible and the associated haemorrhagic risk seems acceptable in selected patients. We suggest that bail-out intracranial stenting, is safe and effective in selected patients with LVO stroke who failed to respond to thrombectomy.
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Affiliation(s)
- Sergio Nappini
- Neurovascular Interventional Unit, Careggi University Hospital, Florence. Largo P. Palagi, 1-50134 Florence, Italy.
| | - Nicola Limbucci
- Neurovascular Interventional Unit, Careggi University Hospital, Florence. Largo P. Palagi, 1-50134 Florence, Italy.
| | - Giuseppe Leone
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy.
| | - Andrea Rosi
- Neurovascular Interventional Unit, Careggi University Hospital, Florence. Largo P. Palagi, 1-50134 Florence, Italy.
| | - Leonardo Renieri
- Neurovascular Interventional Unit, Careggi University Hospital, Florence. Largo P. Palagi, 1-50134 Florence, Italy.
| | - Arturo Consoli
- Neurovascular Interventional Unit, Careggi University Hospital, Florence. Largo P. Palagi, 1-50134 Florence, Italy.
| | - Antonio Laiso
- Neurovascular Interventional Unit, Careggi University Hospital, Florence. Largo P. Palagi, 1-50134 Florence, Italy.
| | - Iacopo Valente
- Department of Bioimaging and Radiological Sciences, Institute of Radiology, "A. Gemelli" Hospital-Catholic University, Rome, Italy.
| | - Francesco Rosella
- Department of Bioimaging and Radiological Sciences, Institute of Radiology, "A. Gemelli" Hospital-Catholic University, Rome, Italy.
| | - Riccardo Rosati
- Vascular and Interventional Radiology Unit, Department of Radiological, Oncological and Anatomo-pathological Sciences, Sapienza University of Rome, Rome, Italy.
| | - Salvatore Mangiafico
- Neurovascular Interventional Unit, Careggi University Hospital, Florence. Largo P. Palagi, 1-50134 Florence, Italy.
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Intracranial Stenting after Failure of Thrombectomy with the emboTrap ® Device. Clin Neuroradiol 2018; 29:677-683. [PMID: 29845367 PMCID: PMC6884426 DOI: 10.1007/s00062-018-0697-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/09/2018] [Indexed: 10/24/2022]
Abstract
BACKGROUND Approved alternatives in the guidelines for acute ischemic stroke patients who have failed intracranial thrombectomy are lacking. Primary permanent intracranial stenting was initially used in the era before thrombectomy and might still be a useful rescue treatment in acute stroke patients suffering from ongoing large vessel occlusion refractory to thrombectomy. METHODS The prospectively collected registry of patients with acute stroke caused by large vessel occlusions and treated with the emboTrap® device in Karolinska Hospital from October 2013 through March 2017 were retrospectively reviewed. Clinical outcome of non-recanalized patients with a thrombolysis in cerebral infarction (TICI) score of 0-1 after failed thrombectomy were compared with those who were treated with permanent intracranial stenting as rescue therapy. Favorable outcome was defined as modified Rankin scale 0-2. RESULTS The emboTrap® device was used in 201 patients. Persistent re-occlusions on withdrawal of the thrombectomy device were seen in 26 patients (13%) and of those, 12 individuals (46%) were treated with intracranial stenting. Baseline National Institutes of Health stroke scale (NIHSS), occlusion site, and onset-to-puncture time did not differ between the stenting group and the non-recanalized group. During the procedure half dose (5/12 patients) or full dose abciximab (6/12 patients), or aspirin (1/12 patient) was given intravenously immediately after stent placement. In 2 patients (17%) multiple stents were implanted. The stenting group had better functional outcomes at 3 months compared to the non-stenting group with 8/12 (66%) vs. 3/14 (21.4%, p < 0.05). Of the patients 5 (36%) in the non-stented group had died at 3 months follow-up, whereas mortality in the stenting cohort was 0% (p < 0.05) and no symptomatic intracranial hemorrhage (ICH) occurred in either group. CONCLUSION Intracranial stenting after failure of recanalization with thrombectomy led to a better rate of clinical outcome than leaving the patient non-recanalized. The required antiplatelet therapy, predominantly abciximab, did not lead to additional ICH.
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Bhaskar S, Stanwell P, Cordato D, Attia J, Levi C. Reperfusion therapy in acute ischemic stroke: dawn of a new era? BMC Neurol 2018; 18:8. [PMID: 29338750 PMCID: PMC5771207 DOI: 10.1186/s12883-017-1007-y] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 12/14/2017] [Indexed: 12/14/2022] Open
Abstract
Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging-based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes.
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Affiliation(s)
- Sonu Bhaskar
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Peter Stanwell
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Dennis Cordato
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
| | - John Attia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
- Centre for Clinical Epidemiology & Biostatistics, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW Australia
| | - Christopher Levi
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
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Nappini S, Limbucci N, Leone G, Laiso A, Wlderk A, Mangiafico S. Trans-Anterior Communicating Artery Primary Stenting in Acute Tandem Middle Cerebral Artery–Internal Carotid Artery Occlusion Due to Thoracic Aortic Stent Graft. World Neurosurg 2017; 106:1050.e21-1050.e24. [DOI: 10.1016/j.wneu.2017.06.187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 06/28/2017] [Accepted: 06/30/2017] [Indexed: 11/25/2022]
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Wang X, Wang Z, Ji Y, Ding X, Zang Y, Wang C. Enterprise stent in recanalizing non-acute atherosclerotic intracranial internal carotid artery occlusion. Clin Neurol Neurosurg 2017; 162:47-52. [PMID: 28926782 DOI: 10.1016/j.clineuro.2017.06.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 06/19/2017] [Accepted: 06/24/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate the safety and effectiveness of recanalization in non-acute occlusion of intracranial internal carotid arteries using the flexible Enterprise self-expanding stent. PATIENTS AND METHODS From June 2014 to June 2016, 12 consecutive patients with non-acute occlusion of intracranial internal carotid arteries received endovascular recanalization with Enterprise stenting. All patients received medication for anti-platelet aggregation therapy before and after the operation. The perioperative complications and recanalization efficacy were evaluated with the modified Rankin scoring system and digital subtraction angiography (DSA) follow-up, respectively. RESULTS Endovascular recanalization was successfully performed in 10 out of 12 patients with Enterprise stenting. Stent implantation following balloon dilatation failed in one patient because the lumen diameter was too small. Another recanalization failed because the guide wire could not pass through the occlusion. No perioperative mortality was observed. One case of acute thrombosis and one case of intraoperative carotid spasm occurred, but these were resolved with thrombolytic therapy by microcatheter exposure treatment and antispasmodic medications, respectively. DSA follow-up in seven patients revealed no re-occlusion. One stroke event occurred in the 10 patients who completed the follow-up. A meaningful improvement in the modified Rankin score during follow-up was suggested by Wilcoxon signed-rank test results. CONCLUSION The Enterprise stent was shown to be safe and efficient in recanalizing non-acute atherosclerotic intracranial internal carotid artery occlusion. However, the long-term outcomes need to be further investigated.
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Affiliation(s)
- Xiaofei Wang
- Department of Neurosurgery, The Second Hospital of Shandong University, Jinan 250033, Shandong, China
| | - Zhigang Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Qingdao 266035, Shandong, China
| | - Yong Ji
- Department of Neurosurgery, The Second Hospital of Shandong University, Jinan 250033, Shandong, China
| | - Xuan Ding
- Department of Neurosurgery, The Second Hospital of Shandong University, Jinan 250033, Shandong, China
| | - Yizheng Zang
- Department of Neurosurgery, The Second Hospital of Shandong University, Jinan 250033, Shandong, China
| | - Chengwei Wang
- Department of Neurosurgery, The Second Hospital of Shandong University, Jinan 250033, Shandong, China.
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Delgado Acosta F, Jiménez Gómez E, Bravo Rey I, Bravo Rodríguez F, Ochoa Sepúlveda J, Oteros Fernández R. Intracranial stents in the endovascular treatment of acute ischemic stroke. RADIOLOGIA 2017. [DOI: 10.1016/j.rxeng.2017.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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17
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Delgado Acosta F, Jiménez Gómez E, Bravo Rey I, Bravo Rodríguez F, Ochoa Sepúlveda J, Oteros Fernández R. Uso del stent intracraneal en el tratamiento endovascular en agudo del ictus. RADIOLOGIA 2017; 59:218-225. [DOI: 10.1016/j.rx.2017.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 01/27/2017] [Accepted: 01/30/2017] [Indexed: 11/26/2022]
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