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Rodriguez-Calienes A, Siddiqui FM, Galecio-Castillo M, Mohammaden MH, Dolia JN, Grossberg JA, Pabaney A, Hassan AE, Tekle WG, Saei H, Miller S, Majidi S, T Fifi J, Valestin G, Siegler JE, Penckofer M, Zhang L, Sheth SA, Salazar-Marioni S, Iyyangar A, Nguyen TN, Abdalkader M, Linfante I, Dabus G, Mehta BP, Sessa J, Jumma MA, Sugg RM, Linares G, Nogueira RG, Liebeskind DS, Haussen DC, Ortega-Gutierrez S. Rescue Therapy for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: A Pooled Analysis of the Society of Vascular and Interventional Neurology Registry. Ann Neurol 2024; 96:343-355. [PMID: 38752428 DOI: 10.1002/ana.26967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE We aimed to evaluate the association between rescue therapy (RT) and functional outcomes compared to medical management (MM) in patients presenting after failed mechanical thrombectomy (MT). METHODS This cross-sectional study utilized prospectively collected and maintained data from the Society of Vascular and Interventional Neurology Registry, spanning from 2011 to 2021. The cohort comprised patients with large vessel occlusions (LVOs) with failed MT. The primary outcome was the shift in the degree of disability, as gauged by the modified Rankin Scale (mRS) at 90 days. Additional outcomes included functional independence (90-day mRS score of 0-2), symptomatic intracranial hemorrhage (sICH), and 90-day mortality. RESULTS Of a total of 7,018 patients, 958 presented failed MT and were included in the analysis. The RT group comprised 407 (42.4%) patients, and the MM group consisted of 551 (57.5%) patients. After adjusting for confounders, the RT group showed a favorable shift in the overall 90-day mRS distribution (adjusted common odds ratio = 1.79, 95% confidence interval [CI] = 1.32-2.45, p < 0.001) and higher rates of functional independence (RT: 28.8% vs MM: 15.7%, adjusted odds ratio [aOR] = 1.93, 95% CI = 1.21-3.07, p = 0.005) compared to the MM group. RT also showed lower rates of sICH (RT: 3.8% vs MM: 9.1%, aOR = 0.52, 95% CI = 0.28-0.97, p = 0.039) and 90-day mortality (RT: 33.4% vs MM: 45.5%, aOR = 0.61, 95% CI = 0.42-0.89, p = 0.009). INTERPRETATION Our findings advocate for the utilization of RT as a potential treatment strategy for cases of LVO resistant to first-line MT techniques. Prospective studies are warranted to validate these observations and optimize the endovascular approach for failed MT patients. ANN NEUROL 2024;96:343-355.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Neuroscience, Clinical Effectiveness, and Public Health Research Group, Universidad Cientifica del Sur, Lima, Peru
| | - Fazeel M Siddiqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Mahmoud H Mohammaden
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jaydevsinh N Dolia
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Aqueel Pabaney
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Wondwossen G Tekle
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Hamzah Saei
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Samantha Miller
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Shahram Majidi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johana T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gabrielle Valestin
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Mary Penckofer
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Linda Zhang
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Sunil A Sheth
- Department of Neurology, Radiology, University of Texas Health McGovern Medical School, Houston, TX, USA
| | - Sergio Salazar-Marioni
- Department of Neurology, Radiology, University of Texas Health McGovern Medical School, Houston, TX, USA
| | - Ananya Iyyangar
- Department of Neurology, Radiology, University of Texas Health McGovern Medical School, Houston, TX, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Mohamad Abdalkader
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Italo Linfante
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, FL, USA
| | - Guilherme Dabus
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, FL, USA
| | | | - Joy Sessa
- Memorial Neuroscience Institute, Pembroke Pines, FL, USA
| | | | - Rebecca M Sugg
- University of South Alabama Medical Center, Mobile, AL, USA
| | | | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Diogo C Haussen
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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Bae JW, Hyun DK. Endovascular Thrombectomy for Acute Ischemic Stroke : Current Concept in Management. J Korean Neurosurg Soc 2024; 67:397-410. [PMID: 38549263 PMCID: PMC11220414 DOI: 10.3340/jkns.2023.0181] [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: 08/28/2023] [Revised: 10/30/2023] [Accepted: 11/23/2023] [Indexed: 07/04/2024] Open
Abstract
Endovascular thrombectomy (EVT) has been established as the standard of care in the treatment of acute ischemic stroke (AIS) based on landmark randomized controlled trials. Nevertheless, while the strict eligibility of EVT for AIS patients restrict the wide application of EVT, a considerable population still undergoes off-label EVT. Besides, it is important to acknowledge that recanalization is not achieved in approximately 20% of procedures, and more than 50% of patients who undergo EVT still do not experience a favorable outcome. This article reviews the brief history of EVT trials and recent progressions in the treatment of AIS, with focusing on the expanding eligibility criteria, new target for EVT, and the evolution of EVT techniques.
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Affiliation(s)
- Jin Woo Bae
- Department of Neurosurgery, Inha University Hospital, Incheon, Korea
- Incheon Regional Cardio-cerebrovascular Disease Center, Incheon, Korea
| | - Dong Keun Hyun
- Department of Neurosurgery, Inha University Hospital, Incheon, Korea
- Incheon Regional Cardio-cerebrovascular Disease Center, Incheon, Korea
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3
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Ingleton A, Raseta M, Chung RE, Kow KJH, Weddell J, Nayak S, Jadun C, Hashim Z, Qayyum N, Ferdinand P, Natarajan I, Roffe C. Is intraprocedural intravenous aspirin safe for patients who require emergent extracranial stenting during mechanical thrombectomy? Stroke Vasc Neurol 2024; 9:279-288. [PMID: 37788913 PMCID: PMC11221300 DOI: 10.1136/svn-2022-002267] [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: 12/23/2022] [Accepted: 09/06/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Intraoperative antiplatelet therapy is recommended for emergent stenting during mechanical thrombectomy (MT). Most patients undergoing MT are also given thrombolysis. Antiplatelet agents are contraindicated within 24 hours of thrombolysis. We evaluated outcomes and complications of patients stented with and without intravenous aspirin during MT. METHODS All patients who underwent emergent extracranial stenting during MT at the Royal Stoke University Hospital, UK between 2010 and 2020, were included. Patients were thrombolysed before MT, unless contraindicated. Aspirin 500 mg intravenously was given intraoperatively at the discretion of the operator. Symptomatic intracranial haemorrhage (sICH) and the National Institutes for Health Stroke Scale score (NIHSS) were recorded at 7 days, and mortality and functional recovery (modified Rankin Scale: mRS ≤2) at 90 days. RESULTS Out of 565 patients treated by MT 102 patients (median age 67 IQR 57-72 years, baseline median NIHSS 18 IQR 13-23, 76 (75%) thrombolysed) had a stent placed. Of these 49 (48%) were given aspirin and 53 (52%) were not. Patients treated with aspirin had greater NIHSS improvement (median 8 IQR 1-16 vs median 3 IQR -9-8 points, p=0.003), but there were no significant differences in sICH (2/49 (4%) vs 9/53 (17%)), mRS ≤2 (25/49 (51%) vs 19/53 (36%)) and mortality (10/49 (20%) vs 12/53 (23%)) with and without aspirin. NIHSS improvement (median 12 IQR 4-18 vs median 7 IQR -7-10, p=0.01) was greater, and mortality was lower (4/33 (12%) vs 6/15 (40%), p=0.05) when aspirin was combined with thrombolysis, than for aspirin alone, with no increase in bleeding. CONCLUSION Our findings based on registry data derived from routine clinical care suggest that intraprocedural intravenous aspirin in patients undergoing emergent stenting during MT does not increase sICH and is associated with good clinical outcomes, even when combined with intravenous thrombolysis.
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Affiliation(s)
- Adam Ingleton
- Neurosciences, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Marko Raseta
- Statistics and Mathematical Modelling, Department of Molecular Genetics, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Rui-En Chung
- Radiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Kevin Jun Hui Kow
- Radiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Jake Weddell
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Sanjeev Nayak
- Interventional Radiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Changez Jadun
- Interventional Radiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Zafar Hashim
- Interventional Radiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Noman Qayyum
- Interventional Radiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Phillip Ferdinand
- Neurosciences, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Indira Natarajan
- Neurosciences, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Christine Roffe
- Neurosciences, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
- Stroke Research, Keele University, Keele, Staffordshire, UK
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4
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Jia B, Zhang L, Pan Y, Tong X, Zhang X, Mo D, Ma N, Luo G, Song L, Li X, Wang B, Nguyen TN, Gao F, Miao Z. Rescue angioplasty and/or stenting after mechanical thrombectomy: who can benefit? J Neurointerv Surg 2023:jnis-2023-020824. [PMID: 38050150 DOI: 10.1136/jnis-2023-020824] [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: 07/18/2023] [Accepted: 10/25/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Angioplasty and/or stenting is a rescue therapy for mechanical thrombectomy (MT) in acute intracranial large vessel occlusion. This study was undertaken to determine whether rescue angioplasty and/or stenting improves the outcome after MT and to investigate whether outcomes differ by subgroup of rescue indication. METHODS We performed propensity score matching (PSM) with data from a prospective multicenter registry of patients with acute large vessel occlusion receiving endovascular treatment. Patients were divided into the MT alone group and the MT with rescue therapy group. The primary outcome was functional independence (modified Rankin Scale score of 0-2) at 90 days. PSM was also performed in the failed MT (modified Thrombolysis In Cerebral Infarction (mTICI) 0-2a) and the residual severe stenosis (mTICI 2b-3) subgroups, respectively. RESULTS 326 patients of mean±SD age 62.7±12.0 years (90 women, 27.6%) were matched from 1274 patients. In the matched cohort, functional independence at 90 days was higher in the rescue therapy group than in the MT alone group (44.2% vs 29.5%; OR 1.90, 95% CI 1.18 to 3.06, P=0.008). In the failed MT subgroup with 66 matched pairs, more patients had functional independence in the rescue therapy group than in the MT alone group (39.0% vs 17.0%; OR 3.12, 95% CI 1.29 to 7.59, P=0.01). In the residual stenosis subgroup with 63 matched pairs, functional independence rates were similar in the rescue therapy and the MT alone groups (51.6% vs 55.7%; OR 0.85, 95% CI 0.42 to 1.72, P=0.65). CONCLUSION Rescue angioplasty and/or stenting could improve the clinical outcome in patients with acute large vessel occlusion with failed MT, while no benefit was seen in those with residual severe stenosis but substantial reperfusion.
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Affiliation(s)
- BaiXue Jia
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Longhui Zhang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuelei Zhang
- Stroke Center, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gang Luo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ligang Song
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoqing Li
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bo Wang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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5
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Webb M, Essibayi MA, Al Kasab S, Maier IL, Psychogios MN, Grossberg JA, Alawieh A, Wolfe SQ, Arthur A, Dumont T, Kan P, Kim JT, De Leacy R, Osbun J, Rai A, Jabbour P, Park MS, Crosa R, Levitt MR, Polifka A, Yoshimura S, Matouk C, Williamson RW, Fragata I, Chowdhry SA, Starke RM, Samaniego EA, Cuellar H, Spiotta A, Mascitelli J. Predictors of Angiographic Outcome After Failed Thrombectomy for Large Vessel Occlusion: Insights from the Stroke Thrombectomy and Aneurysm Registry. Neurosurgery 2023; 93:1168-1179. [PMID: 37377425 DOI: 10.1227/neu.0000000000002560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 04/17/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Mechanical thrombectomy failure (MTF) occurs in approximately 15% of cases. OBJECTIVE To investigate factors that predict MTF. METHODS This was a retrospective review of prospectively collected data from the Stroke Thrombectomy and Aneurysm Registry. Patients who underwent mechanical thrombectomy (MT) for large vessel occlusion (LVO) were included. Patients were categorized by mechanical thrombectomy success (MTS) (≥mTICI 2b) or MTF ( RESULTS A total of 6780 patients were included, and 1001 experienced anterior circulation MTF. Patients in the MTF group were older (73 vs 72, P = .044) and had higher poor premorbid modified Rankin Scale (mRS) (10.8% vs 8.4%, P = .017). Onset to puncture time was greater in the MTF group (273 vs 260 min, P = .08). No significant differences were found between the access site, use of balloon guide catheter, frontline technique, or first-pass devices between the MTF and MTS groups. More complications occurred in the MTF group (14% vs 5.8%), including symptomatic intracerebral hemorrhage (9.4% vs 6.1%) and craniectomies (10% vs 2.8%) ( P < .001). On UVA, age, poor pretreatment mRS, increased number of passes, and increased procedure time were associated with MTF. Internal carotid artery, M1, and M2 occlusions had decreased odds of MTF. Poor preprocedure mRS, number of passes, and procedure time remained significant on MVA. A subgroup analysis of posterior circulation LVO revealed that number of passes and total procedure time correlated with increased odds of MTF ( P < .001) while rescue stenting was associated with less odds of MTF (odds ratio 0.20, 95% CI 0.06-0.63). Number of passes remained significant on MVA of posterior circulation occlusion subgroup analysis. CONCLUSION Anterior circulation MTF is associated with more complications and worse outcomes. No differences were found between techniques or devises used for the first pass during MT. Rescue intracranial stenting may decrease the likelihood of MTF for posterior circulation MT.
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Affiliation(s)
- Matthew Webb
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
| | | | - Sami Al Kasab
- Medical University of South Carolina, Charleston , South Carolina , USA
| | - Ilko L Maier
- University Medical Center Göttingen, Göttingen , Germany
| | | | | | | | | | - Adam Arthur
- University of Tennessee Health Science Center, Memphis , Tennessee , USA
| | - Travis Dumont
- Bannner University of Arizona Medical Center, Tucson , Arizona , USA
| | - Peter Kan
- University of Texas Medical Branch, Galveston , Texas , USA
| | - Joon-Tae Kim
- Chonnam National University Hospital, Gwangju , South Korea
| | | | - Joshua Osbun
- Washington University in St. Louis, St. Louis , Missouri , USA
| | - Ansaar Rai
- Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Pascal Jabbour
- Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Min S Park
- Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Roberto Crosa
- University of Virginia, Charlottesville , Virginia , USA
| | - Michael R Levitt
- Centro Endovascular Neurológico, Médica Uruguaya, Montevideo , Uruguay
| | - Adam Polifka
- University of Washington, Seattle , Washington , USA
| | | | | | | | - Isabel Fragata
- Allegheny General Hospital, Pittsburgh , Pennsylvania , USA
| | | | - Robert M Starke
- NorthShore University Health System, Evanston , Illinois , USA
| | | | | | - Alejandro Spiotta
- Medical University of South Carolina, Charleston , South Carolina , USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
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6
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Imam YZ, Akhtar N, Kamran S, Garcia-Bermejo P, Al Jerdi S, Zakaria A, Own A, Patro S. Rescue Stent Placement for Acute Ischemic Stroke with Large Vessel Occlusion Refractory to Mechanical Thrombectomy: A Multiethnic Middle Eastern/African/Asian Cohort. J Vasc Interv Radiol 2023; 34:1740-1748. [PMID: 37302471 DOI: 10.1016/j.jvir.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 05/20/2023] [Accepted: 06/04/2023] [Indexed: 06/13/2023] Open
Abstract
PURPOSE To investigate the safety and effectiveness of rescue stent placement in patients who experienced acute stroke in whom mechanical thrombectomy failed. METHODS This was a retrospective review of a multiethnic stroke database. After stent placement, an aggressive antiplatelet protocol was followed with glycoprotein IIb/IIIa infusion. The primary outcomes were incidence of intracerebral hemorrhage (ICH), recanalization score, and favorable prognosis (modified Rankin score ≤ 2) at 90 days. A comparison was made between patients from the Middle East and North Africa (MENA) region and those from other regions. RESULTS Fifty-five patients were included, with 87% being men. The mean age was 51.3 years (SD ±11.8); 32 patients (58%) were from South Asia, 12 (22%) from MENA, 9 (16%) from Southeast Asia, and 2 (4%) from elsewhere. Successful recanalization (modified Thrombolysis in Cerebral Infarction score = 2b/3) was achieved in 43 patients (78%), and symptomatic ICH occurred in 2 patients (4%). A favorable outcome at 90 days was seen in 26 of the 55 patients (47%). Apart from significantly older age-mean, 62.8 years (SD ±13; median, 69 years) versus 48.1 years (SD ±9.3; median, 49 years)-and coronary artery disease burden-4 (33%) versus 1 (2%) (P < .05), patients from MENA had risk factors, stroke severity, recanalization rates, ICH rates, and 90-day outcomes similar to those from South and Southeast Asia. CONCLUSION Rescue stent placement showed good outcomes and a low risk of clinically significant bleeding in a multiethnic cohort of patients from MENA and South and Southeast Asia, similar to that in published literature.
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Affiliation(s)
- Yahia Z Imam
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine-Qatar, Doha, Qatar.
| | - Naveed Akhtar
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Saadat Kamran
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | | | - Ayman Zakaria
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Own
- Neurosceince Institute, Hamad Medical Corporation, Doha, Qatar
| | - Satya Patro
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
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7
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Mohammaden MH, Tarek MA, Aboul Nour H, Haussen DC, Fifi JT, Matsoukas S, Farooqui M, Ortega-Gutierrez S, Zevallos CB, Galecio-Castillo M, Hassan AE, Tekle W, Al-Bayati AR, Salem MM, Burkhardt JK, Pukenas B, Cortez GM, Hanel RA, Aghaebrahim A, Sauvageau E, Hafeez M, Kan P, Tanweer O, Jumaa M, Zaidi SF, Oliver M, Sheth SA, Nahhas M, Salazar-Marioni S, Khaldi A, Li H, Kuybu O, Abdalkader M, Klein P, Peng S, Alaraj A, Nguyen TN, Nogueira RG. Rescue intracranial stenting for failed posterior circulation thrombectomy: analysis from the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study. J Neurointerv Surg 2023:jnis-2023-020676. [PMID: 37699704 DOI: 10.1136/jnis-2023-020676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/21/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUNDS Recent trials have shown improved outcomes after mechanical thrombectomy (MT) for vertebrobasilar occlusion (VBO) stroke. However, there is a paucity of data regarding safety and outcomes of rescue intracranial stenting (RS) after failed MT (FRRS+) for posterior circulation stroke. We sought to compare RS to failed reperfusion without RS (FRRS-). METHODS This is a retrospective analysis of the Stenting and Angioplasty in NeuroThrombectomy (SAINT) study, a multicenter collaboration involving prospectively collected databases. Patients were included if they had posterior circulation stroke and failed MT. The cohort was divided into two groups: FRRS+ and FRRS- (defined as modified Thrombolysis In Cerebral Infarction (mTICI) score 0-2a). The primary outcome was a shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included mRS 0-2 and mRS 0-3 at 90 days. Safety measures included rates of symptomatic intracranial hemorrhage (sICH), procedural complications, and 90-day mortality. Sensitivity and subgroup analyses were performed to identify outcomes in a matched cohort and in those with VBO, respectively. RESULTS A total of 152 failed thrombectomies were included in the analysis. FRRS+ (n=84) was associated with increased likelihood of lower disability (acOR 2.24, 95% CI 1.04 to 4.95, P=0.04), higher rates of mRS 0-2 (26.8% vs 12.5%, aOR 4.43, 95% CI 1.22 to 16.05, P=0.02) and mRS 0-3 (35.4% vs 18.8%, aOR 3.13, 95% CI 1.08 to 9.10, P=0.036), and lower mortality (42.7% vs 59.4%, aOR 0.40, 95% CI 0.17 to 0.97, P=0.04) at 90 days compared with FRRS- (n=68). The rates of sICH and procedural complications were comparable between the groups. Sensitivity and subgroup analyses showed similar results. CONCLUSION In patients with posterior circulation stroke who had failed MT, RS resulted in better functional outcomes with comparable safety profile to procedure termination.
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Affiliation(s)
- Mahmoud H Mohammaden
- Neurology, South Valley University Faculty of Medicine, Qena, Egypt
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Mohamed A Tarek
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Hassan Aboul Nour
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA
- Neurology and Neurosurgery, University of Kentucky, Lexington, Kentucky, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Neurology, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stavros Matsoukas
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mudassir Farooqui
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Santiago Ortega-Gutierrez
- Neuroloy, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | | | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | | | | | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bryan Pukenas
- Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Ricardo A Hanel
- Neurosurgery, Lyerly Neurosurgery, Jacksonville, Florida, USA
| | | | - Eric Sauvageau
- Neurosurgery, Lyerly Neurosurgery, Jacksonville, Florida, USA
| | - Muhammad Hafeez
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Omar Tanweer
- Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Mouhammad Jumaa
- Neurology, University of Toledo - Health Science Campus, Toledo, Ohio, USA
| | - Syed F Zaidi
- Neurology, University of Toledo - Health Science Campus, Toledo, Ohio, USA
| | - Marion Oliver
- Department of Neurology, University of Toledo - Health Science Campus, Toledo, Ohio, USA
| | - Sunil A Sheth
- Neurology, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Michael Nahhas
- Department of Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | | | - Ahmad Khaldi
- Neurosurgery, WellStar Health System, Marietta, Georgia, USA
| | - Hanzhou Li
- Department of Neurosciences, WellStar Health System, Marietta, Georgia, USA
| | - Okkes Kuybu
- Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Piers Klein
- Neurology, Radiology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sophia Peng
- Neurosurgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Ali Alaraj
- Neurosurgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Thanh N Nguyen
- Neurology, Boston University Medical Center, Boston, Massachusetts, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurology, Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
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8
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Huo X, Sun D, Chen W, Han H, Abdalkader M, Puetz V, Yi T, Wang H, Liu R, Tong X, Jia B, Ma N, Gao F, Mo D, Yan B, Mitchell PJ, Leung TW, Yavagal DR, Albers GW, Costalat V, Fiehler J, Zaidat OO, Jovin TG, Liebeskind DS, Nguyen TN, Miao Z. Endovascular Treatment for Acute Large Vessel Occlusion Due to Underlying Intracranial Atherosclerotic Disease. Semin Neurol 2023; 43:337-344. [PMID: 37549690 DOI: 10.1055/s-0043-1771207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Intracranial atherosclerotic disease (ICAD) is one of the most common causes of acute ischemic stroke worldwide. Patients with acute large vessel occlusion due to underlying ICAD (ICAD-LVO) often do not achieve successful recanalization when undergoing mechanical thrombectomy (MT) alone, requiring rescue treatment, including intra-arterial thrombolysis, balloon angioplasty, and stenting. Therefore, early detection of ICAD-LVO before the procedure is important to enable physicians to select the optimal treatment strategy for ICAD-LVO to improve clinical outcomes. Early diagnosis of ICAD-LVO is challenging in the absence of consensus diagnostic criteria on noninvasive imaging and early digital subtraction angiography. In this review, we summarize the clinical and diagnostic criteria, prediction of ICAD-LVO prior to the procedure, and EVT strategy of ICAD-LVO and provide recommendations according to the current literature.
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Affiliation(s)
- Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hongxing Han
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | | | - Volker Puetz
- Department of Neurology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hao Wang
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Raynald Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre, Melbourne, Australia
| | - Peter J Mitchell
- Department of Radiology, Melbourne Brain Centre, Melbourne, Australia
| | - Thomas W Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Dileep R Yavagal
- Departments of Neurology and Neurosurgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Güi-de-Chauliac, CHU de Montpellier, Montpellier, France
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Osama O Zaidat
- Department of Neuroscience, Mercy Saint Vincent Medical Center, Toledo, Ohio
| | - Tudor G Jovin
- Department of Neurology, Cooper University Hospital, Camden, New Jersey
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, California
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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9
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de Havenon A, Zaidat OO, Amin-Hanjani S, Nguyen TN, Bangad A, Abassi M, Anadani M, Almallouhi E, Chatterjee R, Mazighi M, Mistry E, Yaghi S, Derdeyn C, Hong KS, Kvernland A, Leslie-Mazwi T, Al Kasab S. Large Vessel Occlusion Stroke due to Intracranial Atherosclerotic Disease: Identification, Medical and Interventional Treatment, and Outcomes. Stroke 2023; 54:1695-1705. [PMID: 36938708 PMCID: PMC10202848 DOI: 10.1161/strokeaha.122.040008] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Large vessel occlusion stroke due to underlying intracranial atherosclerotic disease (ICAD-LVO) is prevalent in 10 to 30% of LVOs depending on patient factors such as vascular risk factors, race and ethnicity, and age. Patients with ICAD-LVO derive similar functional outcome benefit from endovascular thrombectomy as other mechanisms of LVO, but up to half of ICAD-LVO patients reocclude after revascularization. Therefore, early identification and treatment planning for ICAD-LVO are important given the unique considerations before, during, and after endovascular thrombectomy. In this review of ICAD-LVO, we propose a multistep approach to ICAD-LVO identification, pretreatment and endovascular thrombectomy considerations, adjunctive medications, and medical management. There have been no large-scale randomized controlled trials dedicated to studying ICAD-LVO, therefore this review focuses on observational studies.
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Affiliation(s)
| | | | | | | | | | | | | | - Eyad Almallouhi
- Neurology, Medical University of South Carolina, Charleston, SC
| | | | - Mikael Mazighi
- Neurology, Lariboisière hospital-APHP NORD, FHU Neurovasc, Paris Cité University, INSERM 1144, France
| | - Eva Mistry
- Neurology and Rehabilitation Medicine, University of Cincinnati, OH
| | - Shadi Yaghi
- Neurology, Warren Alpert Medical School of Brown University, Providence, RI
| | - Colin Derdeyn
- Neurosurgery, Carver College of Medicine, Iowa City, Iowa
| | - Keun-Sik Hong
- Neurology, Ilsan Paik Hospital, Inje University, Goyang, South Korea
| | | | | | - Sami Al Kasab
- Neurology, Medical University of South Carolina, Charleston, SC
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10
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Abdelrady M, Rodriguez J, Dargazanli C, Lefevre PH, Ognard J, Murias E, Chaviano J, Gentric JC, Ben Salem D, Mourand I, Arquizan C, Derraz I, Vega P, Costalat V. Angioplasty, stenting, or both - rescue maneuvers and reperfusion after endovascular therapy for intracranial atherosclerosis-related occlusion. Neuroradiology 2023; 65:775-784. [PMID: 36609714 DOI: 10.1007/s00234-022-03108-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/18/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE Data concerning reperfusion strategies of intracranial atherosclerosis-related occlusion (ICARO) and clinico-angiographic outcomes remain scarce, particularly in Caucasians. We aim to compare the reperfusion rate and functional outcome between reperfusion strategies in the setting of the ICARO. METHODS Retrospective analysis of prospectively maintained endovascular thrombectomy (EVT) registries at three high-volume stroke centers were retrospectively analyzed for consecutive ICARO patients from January 2015 to December 2019. We defined ICARO as any fixed high-degree (> 70%) focal narrowing or stenosis of any degree with a perpetual tendency for reocclusion. We categorized reperfusion strategies into four groups: EVT [group 1], balloon angioplasty [(BAp), group 2], placement of self-expandable stents [(SES), group 3], and BAp combined with implantation of SES; or direct placement of balloon mounted stents (BMS) [(BAp-SES/BMS), group 4]. We evaluated the association with the successful reperfusion [mTICI 2b - 3] and favorable outcome [mRS 0-2] with logistic regression analysis. RESULTS Out of 2550 EVT, 124 patients (median age, 70 (61-80) years; 76 men) with ICARO and 130 reperfusion attempts [36 EVT, 38 BAp, 17 SES, and 39 BAp + SES/BMS] were analyzed. SES implantation showed the highest frequency of post-procedural symptomatic intracranial hemorrhage [(18%, 3/17), p = .03]; however, we observed no significant differences in the mortality rate. Overall, we achieved successful reperfusion in 71% (92/130) and favorable outcomes in 42% (52/124) of the patients. BAp + SES/BMS was the only independent predictor of the final successful reperfusion [aOR, 4.488 (95% CI, 1.364-14.773); p = .01], which was significantly associated with the 90-day favorable outcome [aOR, 10.837 (95% CI, 3.609-32.541); p = < .001] after adjustment for confounding variables between the reperfusion strategies. CONCLUSION Among patients with ICARO, the rescue angioplasty stenting effectively contributed to higher odds of successful reperfusion with no increased risk for intracranial hemorrhage.
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Affiliation(s)
- Mohamed Abdelrady
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Hospital, Montpellier, France.
- Department of Neuroradiology, Hôpital Cavale Blanche, Brest University Hospital, Bd Tanguy Prigent, 29200, Brest, France.
- Department of Neuroradiology, El-Demerdash University Hospital, Cairo, Egypt.
| | - José Rodriguez
- Department of Radiology, Hospital Universitario Central de Asturias, Avda. Roma S/N 33011, Oviedo, Spain
| | - Cyril Dargazanli
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Hospital, Montpellier, France
| | - Pierre-Henri Lefevre
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Hospital, Montpellier, France
| | - Julien Ognard
- Department of Neuroradiology, Hôpital Cavale Blanche, Brest University Hospital, Bd Tanguy Prigent, 29200, Brest, France
| | - Eduardo Murias
- Department of Radiology, Hospital Universitario Central de Asturias, Avda. Roma S/N 33011, Oviedo, Spain
| | - Juan Chaviano
- Department of Radiology, Hospital Universitario Central de Asturias, Avda. Roma S/N 33011, Oviedo, Spain
| | - Jean-Christophe Gentric
- Department of Neuroradiology, Hôpital Cavale Blanche, Brest University Hospital, Bd Tanguy Prigent, 29200, Brest, France
| | - Douraied Ben Salem
- Department of Neuroradiology, Hôpital Cavale Blanche, Brest University Hospital, Bd Tanguy Prigent, 29200, Brest, France
| | - Isabelle Mourand
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Hospital, Montpellier, France
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Hospital, Montpellier, France
| | - Imad Derraz
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Hospital, Montpellier, France
| | - Pedro Vega
- Department of Radiology, Hospital Universitario Central de Asturias, Avda. Roma S/N 33011, Oviedo, Spain
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Hospital, Montpellier, France
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11
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Rodrigo-Gisbert M, Requena M, Rubiera M, Khalife J, Lozano P, De Dios Lascuevas M, García-Tornel Á, Olivé-Gadea M, Piñana C, Rizzo F, Boned S, Muchada M, Rodríguez-Villatoro N, Rodríguez-Luna D, Juega J, Pagola J, Hernández D, Molina CA, Tomasello A, Ribo M. Intracranial Artery Calcifications Profile as a Predictor of Recanalization Failure in Endovascular Stroke Treatment. Stroke 2023; 54:430-438. [PMID: 36689597 DOI: 10.1161/strokeaha.122.041257] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/12/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Acute ischemic stroke with large or medium-vessel occlusion associated with intracranial artery calcification (IAC) is an infrequent phenomenon presumably associated with intracranial atherosclerotic disease. We aimed to characterize IAC and its impact on endovascular treatment outcomes. METHODS We performed a retrospective cross-sectional study of consecutive patients with stroke treated with thrombectomy from January 2020 to July 2021 in our institution. We described IAC findings (length, density, and location pattern) on baseline noncontrast computed tomography. Patients were divided into 3 groups: IAC related to the occlusion location (symptomatic-IAC group), unrelated to the occlusion (asymptomatic-IAC group), and absence of any IAC (non-IAC group). We analyzed the association between the IAC profile and outcomes using logistic regression models. Intracranial angioplasty and stenting were considered rescue treatments. RESULTS Of the 393 patients included, 26 (6.6%) patients presented a symptomatic-IAC, 77 (19.6%) patients an asymptomatic-IAC, and in 290 (73.8%) patients no IAC was observed. The rate of failed recanalization (expanded Thrombolysis in Cerebral Infarction 0-2a) before rescue treatment was higher in symptomatic-IAC (65.4%) than in asymptomatic-IAC (15.6%; P<0.001) or non-IAC (13.4%; P<0.001). Rescue procedures were more frequently performed in symptomatic-IAC (26.9%) than in asymptomatic-IAC (1.3%; P<0.001) and non-IAC (4.1%; P<0.001). After adjusting for identifiable clinical and radiological confounders, symptomatic-IAC emerged as an independent predictor of failed recanalization (odds ratio, 11.89 [95% CI, 3.94-35.91]; P<0.001), adoption of rescue procedures (odds ratio, 12.38 [95% CI, 2.22-69.09]; P=0.004), and poor functional outcome (90-day modified Rankin Scale score ≥3; odds ratio, 3.51 [95% CI, 1.02-12.00]; P=0.046). CONCLUSIONS The presence of IAC related to the occlusion location is associated with worse angiographic and functional outcomes. Therefore, identification of symptomatic-IAC on baseline imaging may guide optimal endovascular treatment strategy, predicting the need for intracranial stenting and angioplasty.
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Affiliation(s)
- Marc Rodrigo-Gisbert
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Jane Khalife
- Department of Neurosurgery, Cooper University Health Care, Camden, NJ (J.K.)
| | - Prudencio Lozano
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marta De Dios Lascuevas
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Álvaro García-Tornel
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Carlos Piñana
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (C.P., D.H.)
| | - Federica Rizzo
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Sandra Boned
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marian Muchada
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Noelia Rodríguez-Villatoro
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - David Rodríguez-Luna
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Jesús Juega
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Jorge Pagola
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - David Hernández
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (C.P., D.H.)
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Alejandro Tomasello
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Departament de Medicina, Universitat Autònoma de Barcelona, Spain (M.R.-G., M. Requena, M. Rubiera, P.L., M.D.D.L., Á.G.-T., M.O.-G., F.R., S.B., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., A.T., M.R.)
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12
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Cai J, Xu H, Xiao R, Hu L, Xu P, Guo X, Xie Y, Pan M, Tang J, Gong Q, Liu Y, Su R, Deng J, Wang L. Rescue intracranial stenting for acute ischemic stroke after the failure of mechanical thrombectomy: A systematic review, meta-analysis, and trial sequential analysis. Front Neurol 2023; 14:1023089. [PMID: 36761342 PMCID: PMC9905111 DOI: 10.3389/fneur.2023.1023089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 01/06/2023] [Indexed: 01/26/2023] Open
Abstract
Background Intracranial rescue stenting (RS) might be an option for acute ischemic stroke after the failure of mechanical thrombectomy (MT). However, the findings were not consistent in previous systematic reviews, and whether the conclusion was supported by sufficient statistical power is unknown. Aim To examine the effect of RS on acute ischemic stroke after the failure of MT with a systematic review, meta-analysis, and trial sequential analysis (TSA). Methods We searched Ovid Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 15 June 2022, without any language restriction. Studies assessing the effect of RS for acute ischemia stroke after MT failure were included. Two reviewers independently screened the retrieved articles, extracted data, and evaluated the quality of the included studies through the New Ottawa Scale (NOS). The primary outcome was the recanalization rate after RS. Secondary outcomes included modified Rankin Scale (mRS) at 3 months after stroke, symptomatic intracranial hemorrhage (sICH), and mortality rate. We synthesized the data through a random-effects model and performed a TSA analysis. Results We included 15 studies (containing 1,595 participants) after screening 3,934 records. The pooled recanalization rate for rescue stenting was 82% (95% CI 77-87%). Compared with non-stenting, rescue stenting was associated with a higher proportion of patients with 0-2 mRS score (OR 3.96, 95% CI 2.69-5.84, p < 0.001) and a lower 90-day mortality rate (OR 0.46, 95% CI 0.32-0.65, p < 0.001), and stenting did not increase sICH rate (OR 0.63, 95% CI 0.39-1.04, p = 0.075). The TSA analysis showed that the meta-analysis of the mRS score had a sufficient sample size and statistical power. Conclusions Our study showed that rescue stenting was effective and safe for patients with acute ischemia stroke who also had a failed MT, and this result was confirmed in a TSA analysis.
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Affiliation(s)
- Junxiu Cai
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Hai Xu
- Department of Neurology, Ziyang People's Hospital, Ziyang, China
| | - Rongzhou Xiao
- Department of Radiology, Zigong Third People's Hospital, Zigong, China
| | - Liping Hu
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Ping Xu
- Clinical Laboratory, Zigong Third People's Hospital, Zigong, China
| | - Xianbin Guo
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Yu Xie
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Min Pan
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Jie Tang
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Qingtao Gong
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Yan Liu
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Rong Su
- Department of Neurology, Zigong Third People's Hospital, Zigong, China
| | - Jiahua Deng
- Department of Neurology, Huili People's Hospital, Huili, China,*Correspondence: Jiahua Deng ✉
| | - Li Wang
- Department of Neurology, Zigong Third People's Hospital, Zigong, China,Li Wang ✉
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13
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Guo S, Jin T, Xu C, Huang W, Shi Z, Geng Y. Rescue stenting after the failure of mechanical thrombectomy to treat acute intracranial atherosclerotic occlusion. Front Neurol 2023; 13:1001496. [PMID: 36703624 PMCID: PMC9873241 DOI: 10.3389/fneur.2022.1001496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023] Open
Abstract
Background Acute ischemic stroke (AIS) with intracranial large vessel occlusion (LVO) is refractory to reperfusion because of the underlying intracranial atherosclerosis (ICAS), and this condition often requires salvage methods such as balloon angioplasty and rescue stenting (RS). In this study, we investigated the short-term outcomes of RS after failed mechanical thrombectomy (MT) for the treatment of acute intracranial atherosclerotic occlusion. Methods We retrospectively evaluated the clinical data of 127 patients who underwent MT for acute intracranial atherosclerotic occlusion in our hospital between August 2018 and January 2022. The degree of recanalization was evaluated immediately after the treatment by Modified Thrombolysis in Cerebral Infarction (mTICI). The modified Rankin Scale (mRS) was used 90 days after treatment to evaluate the neurological functions. In addition, the incidence of symptomatic intracranial hemorrhage (sICH) and postoperative mortality within 90 days of treatment were calculated. Results Among the 127 patients, 86 patients (67.7%) had revascularization (mTICI 2b-3) immediately after MT (non-RS group), and RS was performed in 41 patients (32.3%) after MT failure (RS group). No difference in the sICH rate was observed between the two groups (17.1 vs. 16.3%, p = 0.91). There was a slightly higher mortality rate in the RS group (14.6 vs. 12.8%, p = 0.71); however, the difference was not significant. There was no difference in the proportion of patients in the RS and non-RS groups who had a 90-day mRS score of 0-2 (48.8 vs. 52.3%, p = 0.76). Conclusions Rescue stenting after MT failure might be a feasible rescue modality for treating acute intracranial atherosclerotic occlusion.
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Affiliation(s)
- Shunyuan Guo
- Department of Clinical Medicine, Medical College of Soochow University, Suzhou, Jiangsu, China,Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Tianyu Jin
- Department of Neurology, Zhejiang Chinese Medical University, Hangzhou, China
| | - Chao Xu
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Wei Huang
- Rheumatism and Immunity Research Institute, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Zongjie Shi
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,*Correspondence: Yu Geng ✉
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14
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Ni H, Hang Y, Wang CD, Liu S, Jia ZY, Shi HB, Zhao LB. Balloon Angioplasty Combined with Tirofiban as a First-Line Rescue Treatment After Failed Mechanical Thrombectomy for Middle Cerebral Artery Occlusion with Underlying Atherosclerosis. World Neurosurg 2022; 166:e306-e312. [PMID: 35809841 DOI: 10.1016/j.wneu.2022.07.001] [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] [Received: 03/14/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The standard rescue modality for patients with intracranial atherosclerotic stenosis after failed mechanical thrombectomy (MT) is not well established. We evaluated the safety and efficacy of balloon dilation in combination with tirofiban as the first-line salvage therapy when MT failed in these patients. METHODS We retrospectively analyzed the records of 47 patients admitted between January 2018 and June 2021, with middle cerebral artery atherosclerotic occlusion, who underwent balloon angioplasty in combination with tirofiban as the first-line salvage therapy after the failure of MT. The recanalization outcome, procedure-related complications, symptomatic intracranial hemorrhage, and functional outcome at 90 days were reviewed. RESULTS Recanalization with a modified Thrombolysis in Cerebral Infarction grade of 2b-3 was achieved in 41 (87.2%) of the 47 patients. Acute stents were deployed in another 6 patients who did not achieve successful re-perfusion after balloon angioplasty. Successful recanalization was achieved in 3 of them. One patient (2.1%, 1/47) experienced re-occlusion several days later due to the withdrawal of antiplatelet therapy for parenchymal hematoma. Seven patients (14.9%, 7/47) underwent stent angioplasty in the stable stage (range: 1-2 months) because severe residual stenosis was detected on follow-up imaging. There was only one event of periprocedural complication, namely ectopic migration of emboli. The good functional outcome rate was 55.3% (26/47), without the events of symptomatic intracranial hemorrhage and mortality. CONCLUSIONS Balloon angioplasty in combination with tirofiban is safe and effective for middle cerebral artery atherosclerotic occlusion after the failure of MT.
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Affiliation(s)
- Heng Ni
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yu Hang
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Chen-Dong Wang
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Sheng Liu
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Zhen-Yu Jia
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lin-Bo Zhao
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China.
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15
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Kim JH, Choi JI. Feasibility of rescue stenting technique in patients with acute ischemic stroke due to middle cerebral artery occlusion after failed thrombectomy: A single-center retrospective experience. PLoS One 2022; 17:e0274842. [PMID: 36166451 PMCID: PMC9514649 DOI: 10.1371/journal.pone.0274842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/02/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Despite remarkable advancements in intra-arterial mechanical thrombectomy (IAT), recanalization failure rates up to 24% have been reported. Recently, permanent stent placement (rescue stent, RS) during IAT has been suggested as an optional modality for better reperfusion and outcomes in these patients. However, previous studies were limited owing to non-standardized procedure protocols and small sample sizes. Here, we aimed to determine the efficacy and safety of RS in patients with acute ischemic stroke (AIS) with middle cerebral artery (MCA) occlusion.
Methods
Of the 243 patients in our IAT database (2015–2021), 183 were identified as having MCA occlusion alone. Among them, we extracted 53 patients in whom the IAT failed to show thrombolysis in cerebral ischemia (TICI) scores of 2A or worse. Intraoperatively, RS was deployed in 22 patients (RS group), whereas 31 patients (no-stent group) received IAT without stenting. The baseline characteristics and radiologic and clinical outcomes were reviewed. Comparisons between the groups and multivariate logistic analyses for recanalization and good functional outcomes (modified Rankin Scale 0–2) were performed.
Results
No baseline differences were noted (RS vs. no-stent); however, the recanalization outcomes (59.1% vs. 25.8%, p = 0.15) and proportion of good modified Rankin Scale scores (45.5% vs. 19.4%, p = 0.041) were better in the RS group. The parameters of symptomatic ICH (9.7% vs. 9.4%) and mortality (6.5% vs. 5.7%) showed no significant difference. In the multivariate analyses, ‘hypertension’ and ‘RS deployment’ were identified as significantly associated factors with recanalization and good prognosis.
Conclusion
In select patients with MCA occlusion AIS after failed IAT, the RS technique can be an optional rescue treatment modality for acquiring better functional outcomes and delayed recanalization.
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Affiliation(s)
- Jang Hun Kim
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jong-Il Choi
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, Gyeonggi-do, Korea
- * E-mail:
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16
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Psychogios M, Brehm A, López-Cancio E, Marco De Marchis G, Meseguer E, Katsanos AH, Kremer C, Sporns P, Zedde M, Kobayashi A, Caroff J, Bos D, Lémeret S, Lal A, Arenillas JF. European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease. Eur Stroke J 2022; 7:III-IV. [PMID: 36082254 PMCID: PMC9446330 DOI: 10.1177/23969873221099715] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/22/2022] [Indexed: 07/22/2023] Open
Abstract
The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of patients with intracranial atherosclerotic disease (ICAD). The guidelines were prepared following the Standard Operational Procedure of the European Stroke Organisation guidelines and according to GRADE methodology. ICAD represents a major cause of ischemic stroke worldwide, and patients affected by this condition are exposed to a high risk for future strokes and other major cardiovascular events, despite best medical therapy available. We identified 11 relevant clinical problems affecting ICAD patients and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions. The first two questions refer to the asymptomatic stage of the disease, which is being increasingly detected thanks to the routine use of noninvasive vascular imaging. We were not able to provide evidence-based recommendations regarding the optimal detection strategy and management of asymptomatic ICAD, and further research in the field is encouraged as subclinical ICAD may represent a big opportunity to improve primary stroke prevention. The second block of PICOs (3-5) is dedicated to the management of acute large vessel occlusion (LVO) ischemic stroke caused by ICAD, a clinical presentation of this disease that is becoming increasingly relevant and problematic, since it is associated with more refractory endovascular reperfusion procedures. An operational definition of probable ICAD-related LVO is proposed in the guideline. Despite the challenging context, no dedicated randomized clinical trials (RCTs) were identified, and therefore the guideline can only provide with suggestions derived from observational studies and our expert consensus, such as the escalated use of glycoprotein IIb-IIIa inhibitors and angioplasty/stenting in cases of refractory thrombectomies due to underlying ICAD. The last block of PICOs is devoted to the secondary prevention of patients with symptomatic ICAD. Moderate-level evidence was found to recommend against the use of oral anticoagulation as preferred antithrombotic drug, in favor of antiplatelets. Low-level evidence based our recommendation in favor of double antiplatelet as the antithrombotic treatment of choice in symptomatic ICAD patients, which we suggest to maintain during 90 days as per our expert consensus. Endovascular therapy with intracranial angioplasty and or stenting is not recommended as a treatment of first choice in high-grade symptomatic ICAD (moderate-level evidence). Regarding neurosurgical interventions, the available evidence does not support their use as front line therapies in patients with high-grade ICAD. There is not enough evidence as to provide any specific recommendation regarding the use of remote ischemic conditioning in ICAD patients, and further RCTs are needed to shed light on the utility of this promising therapy. Finally, we dedicate the last PICO to the importance of aggressive vascular risk factor management in ICAD, although the evidence derived from RCTs specifically addressing this question is still scarce.
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Affiliation(s)
- Marios Psychogios
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
| | - Alex Brehm
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
| | - Elena López-Cancio
- Department of Neurology, Hospital
Universitario Central de Asturias, Oviedo, Spain
| | - Gian Marco De Marchis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Elena Meseguer
- Department of Neurology and Stroke
Center, Assistance Publique Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster
University and Population Health Research Institute, Hamilton, ON, Canada
| | - Christine Kremer
- Department of Neurology, Skåne
University Hospital, Malmö, Department of Clinical Sciences Lund University, Lund,
Sweden
| | - Peter Sporns
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
- Department of Neuroradiology,
University Clinic Hamburg Eppendorf, Hamburg, Germany
| | - Marialuisa Zedde
- Neurology Unit, Department of
Neuromotor Physiology, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio
Emilia, Italy
- Neurology Unit, Stroke Unit, Azienda
Unità Sanitaria Locale-IRCCS di Reggio Emilia, Italy
| | - Adam Kobayashi
- Department of Pharmacology and
Clinical Pharmacology, Institute of Medical Sciences, Faculty of Medicine –
Collegium Medicum Cardinal Stefan Wyszynski University in Warsaw, Poland
- Department of Neurology and Stroke
Unit, Mazovian Voivodeship Hospital in Siedlce, Poland
| | - Jildaz Caroff
- Department of Interventional
Neuroradiology – NEURI Brain Vascular Center, Bicêtre Hospital, Assistance Publique
Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Daniel Bos
- Department of Radiology and Nuclear
Medicine, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus
MC, Rotterdam, The Netherlands
| | | | - Avtar Lal
- European Stroke Organisation, Basel,
Switzerland
| | - Juan F Arenillas
- Stroke Program, Department of
Neurology, Hospital Clínico Universitario de Valladolid, Spain
- Clinical Neurosciences Research
Group, Department of Medicine, University of Valladolid, Spain
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17
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Mohammaden MH, Haussen DC, Al-Bayati AR, Hassan A, Tekle W, Fifi J, Matsoukas S, Kuybu O, Gross BA, Lang MJ, Narayanan S, Cortez GM, Hanel RA, Aghaebrahim A, Sauvageau E, Farooqui M, Ortega-Gutierrez S, Zevallos C, Galecio-Castillo M, Sheth SA, Nahhas M, Salazar-Marioni S, Nguyen TN, Abdalkader M, Klein P, Hafeez M, Kan P, Tanweer O, Khaldi A, Li H, Jumaa M, Zaidi S, Oliver M, Salem MM, Burkhardt JK, Pukenas BA, Alaraj A, Peng S, Kumar R, Lai M, Siegler J, Nogueira RG. Stenting and Angioplasty in Neurothrombectomy: Matched Analysis of Rescue Intracranial Stenting Versus Failed Thrombectomy. Stroke 2022; 53:2779-2788. [DOI: 10.1161/strokeaha.121.038248] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND:
Successful reperfusion is one of the strongest predictors of functional outcomes after mechanical thrombectomy (MT). Despite continuous advancements in MT technology and techniques, reperfusion failure still occurs in ≈15% to 30% of patients with large vessel occlusion strokes undergoing MT. We aim to evaluate the safety and efficacy of rescue intracranial stenting for large vessel occlusion stroke after failed MT.
METHODS:
The SAINT (Stenting and Angioplasty in Neurothrombectomy) Study is a retrospective analysis of prospectively collected data from 14 comprehensive stroke centers through January 2015 to December 2020. Patients were included if they had anterior circulation large vessel occlusion stroke due to intracranial internal carotid artery and middle cerebral artery-M1/M2 segments and failed MT. The cohort was divided into 2 groups: rescue intracranial stenting and failed recanalization (modified Thrombolysis in Cerebral Ischemia score 0–1). Propensity score matching was used to balance the 2 groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale at 90 days. Secondary outcomes included functional independence (90-day modified Rankin Scale score 0–2). Safety measures included symptomatic intracranial hemorrhage and 90-day mortality.
RESULTS:
A total of 499 patients were included in the analysis. Compared with the failed reperfusion group, rescue intracranial stenting had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 2.31 [95% CI, 1.61–3.32];
P
<0.001), higher rates of functional independence (35.1% versus 7%; adjusted odds ratio [aOR], 6.33 [95% CI, 3.14–12.76];
P
<0.001), and lower mortality (28% versus 46.5%; aOR, 0.55 [95% CI, 0.31–0.96];
P
=0.04) at 90 days. Rates of symptomatic intracerebral hemorrhage were comparable across both groups (7.1% versus 10.2%; aOR, 0.99 [95% CI, 0.42–2.34];
P
=0.98). The matched cohort analysis demonstrated similar results. Specifically, rescue intracranial stenting (n=107) had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 3.74 [95% CI, 2.16–6.57];
P
<0.001), higher rates of functional independence (34.6% versus 6.5%; aOR, 10.91 [95% CI, 4.11–28.92];
P
<0.001), and lower mortality (29.9% versus 43%; aOR, 0.49 [95% CI, 0.25–0.94];
P
=0.03) at 90 days with similar rates of symptomatic intracerebral hemorrhage (7.5% versus 11.2%; aOR, 0.87 [95% CI, 0.31–2.42];
P
=0.79) compared with patients who failed to reperfuse (n=107). There was no heterogeneity of treatment effect across the prespecified subgroups for improvement in functional outcomes.
CONCLUSIONS:
Acute intracranial stenting appears to be a safe and effective rescue strategy in patients with large vessel occlusion stroke who failed MT. Randomized multicenter trials are warranted.
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Affiliation(s)
- Mahmoud H. Mohammaden
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine-Atlanta, GA (M.H.M., D.C.H.)
| | - Diogo C. Haussen
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine-Atlanta, GA (M.H.M., D.C.H.)
| | - Alhamza R. Al-Bayati
- UPMC Stroke Institute, Departments of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, PA (A.R.A.-B., O.K., B.A.G., M.J.L., S.N., R.G.N.)
| | - Ameer Hassan
- Department of Neurology, Valley Baptist Medical Center, Harlingen, TX (A.H., W.T.)
| | - Wondwossen Tekle
- Department of Neurology, Valley Baptist Medical Center, Harlingen, TX (A.H., W.T.)
| | - Johanna Fifi
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York (J.F., S.M.)
| | - Stavros Matsoukas
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York (J.F., S.M.)
| | - Okkes Kuybu
- UPMC Stroke Institute, Departments of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, PA (A.R.A.-B., O.K., B.A.G., M.J.L., S.N., R.G.N.)
| | - Bradley A. Gross
- UPMC Stroke Institute, Departments of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, PA (A.R.A.-B., O.K., B.A.G., M.J.L., S.N., R.G.N.)
| | - Michael J. Lang
- UPMC Stroke Institute, Departments of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, PA (A.R.A.-B., O.K., B.A.G., M.J.L., S.N., R.G.N.)
| | - Sandra Narayanan
- UPMC Stroke Institute, Departments of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, PA (A.R.A.-B., O.K., B.A.G., M.J.L., S.N., R.G.N.)
| | - Gustavo M. Cortez
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, FL (G.M.C., R.A.H., A.A., E.S.)
| | - Ricardo A. Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, FL (G.M.C., R.A.H., A.A., E.S.)
| | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, FL (G.M.C., R.A.H., A.A., E.S.)
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, FL (G.M.C., R.A.H., A.A., E.S.)
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.F., S.O.-G., C.Z., M.G.-C.)
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.F., S.O.-G., C.Z., M.G.-C.)
| | - Cynthia Zevallos
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.F., S.O.-G., C.Z., M.G.-C.)
| | - Milagros Galecio-Castillo
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.F., S.O.-G., C.Z., M.G.-C.)
| | - Sunil A. Sheth
- Department of Neurology, University of Texas, Houston (S.A.S., M.N., S.S.-M.)
| | - Michael Nahhas
- Department of Neurology, University of Texas, Houston (S.A.S., M.N., S.S.-M.)
| | | | - Thanh N. Nguyen
- Department of Neurology, Radiology, Boston University School of Medicine, MA (T.N.N., M.A., P.K.)
| | - Mohamad Abdalkader
- Department of Neurology, Radiology, Boston University School of Medicine, MA (T.N.N., M.A., P.K.)
| | - Piers Klein
- Department of Neurology, Radiology, Boston University School of Medicine, MA (T.N.N., M.A., P.K.)
| | - Muhammad Hafeez
- Department of Neurosurgery, Baylor School of Medicine, Houston, TX (M.H., P.K., O.T.)
| | - Peter Kan
- Department of Neurosurgery, Baylor School of Medicine, Houston, TX (M.H., P.K., O.T.)
| | - Omar Tanweer
- Department of Neurosurgery, Baylor School of Medicine, Houston, TX (M.H., P.K., O.T.)
| | - Ahmad Khaldi
- Department of Neurosciences, WellStar Health System, Atlanta, GA (A.K., H.L.)
| | - Hanzhou Li
- Department of Neurosciences, WellStar Health System, Atlanta, GA (A.K., H.L.)
| | - Mouhammad Jumaa
- Department of Neurology, University of Toledo, OH (M.J., S.Z., M.O.)
| | - Syed Zaidi
- Department of Neurology, University of Toledo, OH (M.J., S.Z., M.O.)
| | - Marion Oliver
- Department of Neurology, University of Toledo, OH (M.J., S.Z., M.O.)
| | - Mohamed M. Salem
- Department of Neurosurgery, University of Pennsylvania, Philadelphia (M.M.S., J.-K.B., B.A.P.)
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania, Philadelphia (M.M.S., J.-K.B., B.A.P.)
| | - Bryan A. Pukenas
- Department of Neurosurgery, University of Pennsylvania, Philadelphia (M.M.S., J.-K.B., B.A.P.)
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago (A.A., S.P.)
| | - Sophia Peng
- Department of Neurosurgery, University of Illinois at Chicago (A.A., S.P.)
| | - Rahul Kumar
- Department of Neurology, Cooper University Medical Center, Camden, NJ (R.K., M.L., J.S.)
| | - Michael Lai
- Department of Neurology, Cooper University Medical Center, Camden, NJ (R.K., M.L., J.S.)
| | - James Siegler
- Department of Neurology, Cooper University Medical Center, Camden, NJ (R.K., M.L., J.S.)
| | - Raul G. Nogueira
- UPMC Stroke Institute, Departments of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, PA (A.R.A.-B., O.K., B.A.G., M.J.L., S.N., R.G.N.)
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18
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Marnat G, Gory B, Sibon I, Kyheng M, Labreuche J, Boulouis G, Liegey JS, Caroff J, Eugène F, Naggara O, Consoli A, Mazighi M, Maier B, Richard S, Denier C, Turc G, Lapergue B, Bourcier R. Mechanical thrombectomy failure in anterior circulation strokes: Outcomes and predictors of favorable outcome. Eur J Neurol 2022; 29:2701-2707. [PMID: 35648445 PMCID: PMC9541042 DOI: 10.1111/ene.15429] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/18/2022] [Indexed: 12/01/2022]
Abstract
Background and purpose Despite continuous improvement and growing knowledge in the endovascular therapy of large vessel occlusion stroke (LVOS), mechanical thrombectomy (MT) still fails to obtain satisfying intracranial recanalization in 10% to 15% of cases. However, little is known regarding clinical and radiological outcomes among this singularly underexplored subpopulation undergoing failed MT. We aimed to investigate the outcome after failed MT and identify predictive factors of favorable outcome despite recanalization failure. Methods We conducted a retrospective analysis of consecutive patients prospectively included in the ongoing observational multicenter Endovascular Treatment in Ischemic Stroke registry from January 2015 to September 2020. Patients presenting with anterior circulation LVOS treated with MT but experiencing failed intracranial recanalization defined as final modified Thrombolysis In Cerebral Infarction (mTICI) score of 0, 1 and 2a were included. Clinical and radiological outcomes were assessed along with the exploration of predictive factors of Day‐90 favorable outcome. Results The study population comprised 533 patients. Mean age was 68.8 ± 16 years, and median admission National Institutes of Health Stroke Scale (NIHSS) and Alberta Stroke Program Early Computed Tomography Score (ASPECTS) were 17 (IQR 12–21) and 7 (IQR 5–8), respectively. Favorable outcomes were observed in 85 patients (18.2%) and 186 died (39.0%). The rate of symptomatic intracranial hemorrhage was 14.1%. In multivariable analysis, younger age (odds ratio [OR] 0.96, 95% CI 0.94–0.98, p < 0.001), a lower admission NIHSS (OR 0.87, 95% CI 0.83–0.91, p < 0.001), a lower number of MT passes (OR 0.77, 95% CI 0.77–0.87, p < 0.001), a lower delta ASPECTS between initial and Day‐1 imaging (OR 0.83, 95% CI 0.71–0.98, p = 0.026) and stroke etiology [significant difference among etiological subtypes (p = 0.024) with a tendency toward more favorable outcomes for dissection (OR 2.01, 95% CI 0.71–5.67)] were significantly associated with a 90‐day favorable outcome. Conclusions In this large retrospective analysis of a multicenter registry, we quantified the poor outcome after MT failure. We also identified factors associated with favorable outcome despite recanalization failure that might influence therapeutic management.
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Affiliation(s)
- Gaultier Marnat
- Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Benjamin Gory
- CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, Nancy, France.,IADI, INSERM-U1254, Université de Lorraine, Nancy, France
| | - Igor Sibon
- Neurology Department, Bordeaux University Hospital, Bordeaux, France
| | - Maeva Kyheng
- CHU Lille, Department of Biostatistics, Lille, France
| | | | | | | | - Jildaz Caroff
- Neuroradiolology Department, CHU Kremlin Bicêtre, Paris, France
| | - François Eugène
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Rennes, Rennes, France
| | - Olivier Naggara
- Department of Neuroradiology, GHU Paris, Centre Hospitalier Sainte-Anne, Université de Paris, INSERM-UMR-894, Paris, France
| | - Arturo Consoli
- Department of Stroke Center and Diagnostic and Interventional Neuroradiology, University of Versailles and Saint Quentin-en-Yvelines, Foch Hospital, Suresnes, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris, FHU-NeuroVASC, Paris, INSERM-1148, France
| | - Benjamin Maier
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris, FHU-NeuroVASC, Paris, INSERM-1148, France
| | | | | | - Guillaume Turc
- Department of Neurology, GHU Paris, Centre Hospitalier Sainte-Anne, Paris, France
| | - Bertrand Lapergue
- Department of Neurology, University of Versailles and Saint-Quentin-en-Yvelines, Foch Hospital, Suresnes, France
| | - Romain Bourcier
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nantes, Nantes, France
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19
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Marnat G, Finistis S, Delvoye F, Sibon I, Desilles JP, Mazighi M, Gariel F, Consoli A, Rosso C, Clarençon F, Elhorany M, Denier C, Chalumeau V, Caroff J, Veunac L, Bourdain F, Darcourt J, Olivot JM, Bourcier R, Dargazanli C, Arquizan C, Richard S, Lapergue B, Gory B. Safety and Efficacy of Cangrelor in Acute Stroke Treated with Mechanical Thrombectomy: Endovascular Treatment of Ischemic Stroke Registry and Meta-analysis. AJNR Am J Neuroradiol 2022; 43:410-415. [PMID: 35241418 PMCID: PMC8910798 DOI: 10.3174/ajnr.a7430] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/23/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Rescue therapies are increasingly used in the setting of endovascular therapy for large-vessel occlusion strokes. Among these, cangrelor, a new P2Y12 inhibitor, offers promising pharmacologic properties to join the reperfusion strategies in acute stroke. We assessed the safety and efficacy profiles of cangrelor combined with endovascular therapy in patients with large-vessel-occlusion stroke. MATERIALS AND METHODS We performed a retrospective patient data analysis in the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France from July 2018 to December 2020 and conducted a systematic review and meta-analysis using several data bases. Indications for cangrelor administration were rescue strategy in case of refractory intracranial occlusion with or without intracranial rescue stent placement, and cervical carotid artery stent placement in case of cervical occlusion (tandem occlusion or isolated cervical carotid occlusion). RESULTS In the clinical registry, 44 patients were included (median initial NIHSS score, 12; prior intravenous thrombolysis, 29.5%). Intracranial stent placement was performed in 54.5% (n = 24/44), and cervical stent placement, in 27.3% (n = 12/44). Adjunctive aspirin and heparin were administered in 75% (n = 33/44) and 40.9% (n = 18/44), respectively. Rates of symptomatic intracerebral hemorrhage, parenchymal hematoma, and 90-day mortality were 9.5% (n = 4/42), 9.5% (n = 4/42), and 24.4% (n = 10/41). Favorable outcome (90-day mRS, 0-2) was reached in 51.2% (n = 21/41), and successful reperfusion, in 90.9% (n = 40/44). The literature search identified 6 studies involving a total of 171 subjects. In the meta-analysis, including our series data, symptomatic intracerebral hemorrhage occurred in 8.6% of patients (95% CI, 5.0%-14.3%) and favorable outcome was reached in 47.6% of patients (95% CI, 27.4%-68.7%). The 90-day mortality rate was 22.6% (95% CI, 13.6%-35.2%). Day 1 artery patency was observed in 89.7% (95% CI, 81.4%-94.6%). CONCLUSIONS Cangrelor offers promising safety and efficacy profiles, especially considering the complex endovascular reperfusion procedures in which it is usually applied. Further large prospective data are required to confirm these findings.
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Affiliation(s)
- G. Marnat
- From the Department of Diagnostic and Interventional Neuroradiology (G.M., F.G.), University Hospital of Bordeaux, Bordeaux, France
| | - S. Finistis
- Aristotle University of Thessaloniki (S.F.), AhepaHospital, Thessaloniki, Greece
| | - F. Delvoye
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - I. Sibon
- Department of Neurology (I.S.), Stroke Center, University Hospital of Bordeaux, Bordeaux, France
| | - J.-P. Desilles
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - M. Mazighi
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - F. Gariel
- From the Department of Diagnostic and Interventional Neuroradiology (G.M., F.G.), University Hospital of Bordeaux, Bordeaux, France
| | - A. Consoli
- Department of Diagnostic and Interventional Neuroradiology (A.C.), Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | | | - F. Clarençon
- Neuroradiology (F.C., M.E.), Centre Hospitalier Universitaire Pitié Salpétrière Hospital, Paris, France
| | - M. Elhorany
- Neuroradiology (F.C., M.E.), Centre Hospitalier Universitaire Pitié Salpétrière Hospital, Paris, France
| | | | - V. Chalumeau
- Neuroradiolology (V.C., J.C.) Centre Hospitalier Universitaire Kremlin Bicêtre, Le Kremlin Bicêtre, France
| | - J. Caroff
- Neuroradiolology (V.C., J.C.) Centre Hospitalier Universitaire Kremlin Bicêtre, Le Kremlin Bicêtre, France
| | - L. Veunac
- Neuroradiolology (L.V.), Centre Hospitalier Cõte Basque, Bayonne, France
| | | | - J. Darcourt
- Neuroradiolology (J.D.), Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | | | - R. Bourcier
- Department of Neuroradiology (R.B.), University Hospital of Nantes, Nantes, France
| | - C. Dargazanli
- Departments of Interventional Neuroradiology (C. Dargazanli)
| | - C. Arquizan
- Neurology (C.A.), Centre Hospitalier Regional Universitaire Gui de Chauliac, Montpellier, France
| | - S. Richard
- Department of Neurology (S.R.), Université de Lorraine, Centre Hospitalier Regional Universitaire Nancy, Nancy, France
| | - B. Lapergue
- Department of Neurology (B.L.), Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - B. Gory
- Department of Diagnostic and Therapeutic Neuroradiology (B.G.), Université de Lorraine, Centre Hospitalier Regional Universitaire Nancy, Nancy, France,Université de Lorraine (B.G.), Imagerie Adaptative Diagnostique et Interventionnelle, Institut National de la Santé et de la Recherche Médicale U1254, Nancy, France
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20
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Lee JS, Lee SJ, Hong JM, Alverne FJAM, Lima FO, Nogueira RG. Endovascular Treatment of Large Vessel Occlusion Strokes Due to Intracranial Atherosclerotic Disease. J Stroke 2022; 24:3-20. [PMID: 35135056 PMCID: PMC8829471 DOI: 10.5853/jos.2021.01375] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 12/08/2021] [Indexed: 11/23/2022] Open
Abstract
Mechanical thrombectomy (MT) has become the gold-standard for patients with acute large vessel occlusion strokes (LVOS). MT is highly effective in the treatment of embolic occlusions; however, underlying intracranial atherosclerotic disease (ICAD) represents a therapeutic challenge, often requiring pharmacological and/or mechanical rescue treatment. Glycoprotein IIb/IIIa inhibitors have been suggested as the best initial approach, if reperfusion can be achieved after thrombectomy, with angioplasty and/or stenting being reserved for the more refractory cases. In this review, we focus on the therapeutic considerations surrounding the endovascular treatment of ICAD-related acute LVOS.
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Affiliation(s)
- Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Seong-Joon Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | | | | | - Raul G. Nogueira
- Department of Neurology and Neurosurgery, University of Pittsburg Medical Center, UPMC Stroke Institute, Pittsburg, PA, USA
- Correspondence: Raul G. Nogueira Department of Neurology and Neurosurgery, University of Pittsburg Medical Center, UPMC Stroke Institute, C-400 PUH, 200 Lothrop Street, Pittsburgh, PA 15213, USA Tel: +1-412-647-8080 Fax: +1-412-647-8445 E-mail:
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21
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Marnat G, Delvoye F, Finitsis S, Lapergue B, Gariel F, Consoli A, Desilles JP, Mazighi M, Dargazanli C, Bourcier R, Darcourt J, Chalumeau V, Elhorany M, Clarençon F, Richard S, Gory B, Sibon I. A Multicenter Preliminary Study of Cangrelor following Thrombectomy Failure for Refractory Proximal Intracranial Occlusions. AJNR Am J Neuroradiol 2021; 42:1452-1457. [PMID: 34117019 DOI: 10.3174/ajnr.a7180] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/09/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE Rescue endovascular and pharmacologic approaches are increasingly being adopted after recanalization failure of acute large-vessel occlusion strokes with mechanical thrombectomy, with encouraging results. The safety and efficacy of glycoprotein IIb/IIIa inhibitors in ischemic stroke have been investigated, though cangrelor, a recent intravenous P2Y12-receptor inhibitor with a rapid onset/offset of action and a short half-life, may be a valuable option. We compared the safety and efficacy of cangrelor with those of glycoprotein IIb/IIIa inhibitors for refractory occlusions. MATERIALS AND METHODS We performed a retrospective analysis of the ongoing prospective, multicenter, observational Endovascular Treatment in Ischemic Stroke Registry in France between May 2012 and February 2020. Refractory intracranial occlusions of the anterior and posterior circulation were included and defined as recanalization failure of large-vessel occlusion stroke, perioperative target artery reocclusion, or high risk of early reocclusion related to an arterial wall lesion. The primary end point was a favorable outcome, defined as a 90-day mRS of 0-2. Secondary end points were reperfusion, intracranial hemorrhage, and procedural complications. RESULTS Among 69 patients, 15 were treated with cangrelor, and 54, with glycoprotein IIb/IIIa inhibitors. The favorable outcome (adjusted OR = 2.22; 95% CI, 0.42-11.75; P = .348) and mortality (adjusted OR = 0.44; 95% CI, 0.06-3.16; P = .411) rates were similar in both groups. There was no difference in the rates of any intracranial hemorrhage (adjusted OR = 0.40; 95% CI, 0.08-2.09; P = .280), symptomatic intracranial hemorrhage (6.7% versus 0.0%, P = .058), or procedural complications (6.7% versus 20.4%, P = .215). Reperfusion rates were higher in the cangrelor group, though the difference did not reach statistical significance (93.3% versus 75.0% for modified TICI 2b-3; adjusted OR =10.88; 95% CI, 0.96-123.84; P = .054). CONCLUSIONS Cangrelor seems to be as safe as glycoprotein IIb/IIIa inhibitors for managing refractory intracranial occlusion and leads to satisfactory brain reperfusion. Cangrelor is a promising agent in this setting, and additional studies are warranted to confirm our findings.
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Affiliation(s)
- G Marnat
- Neuroradiology Department (G.M., F.G.) and Neurology (I.S.), Bordeaux University Hospital, Bordeaux, France
| | - F Delvoye
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - S Finitsis
- Aristotle University of Thessaloniki (S.F.), Ahepa Hospital, Thessaloniki, Greece
| | - B Lapergue
- Department of Neurology (B.L.), Foch Hospital, Versailles Saint-Quentin-en-Yvelines University, Suresnes, France
| | - F Gariel
- Neuroradiology Department (G.M., F.G.) and Neurology (I.S.), Bordeaux University Hospital, Bordeaux, France
| | - A Consoli
- Department s of Neuroradiology (A.C.) and Neurology (B.L.), Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - J-P Desilles
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - M Mazighi
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - C Dargazanli
- Department of Neuroradiology (C.D.), Centre Hospitalier Régional Universitaire Gui de Chauliac, Montpellier, France
| | - R Bourcier
- Department of Neuroradiology (R.B.), University Hospital of Nantes, Nantes, France
| | - J Darcourt
- Department of Neuroradiology (J.D.), University Hospital of Toulouse, Toulouse, France
| | - V Chalumeau
- Department of Neuroradiology (M.E., F.C.), Pitié-Salpêtrière Hospital, Paris, France
| | - M Elhorany
- Department of Neuroradiology (M.E., F.C.), Pitié-Salpêtrière Hospital, Paris, France
| | - F Clarençon
- Department of Neuroradiology (M.E., F.C.), Pitié-Salpêtrière Hospital, Paris, France
| | - S Richard
- Department of Neurology (S.R.), Université de Lorraine, Centre Hospitalier Régional Universitaire-Nancy, Stroke Unit, Nancy, France
- Institut national de la santé et de la recherche médicale U1116 (S.R.), Centre Hospitalier Régional Universitaire-Nancy, Nancy, France
| | - B Gory
- Department of Diagnostic and Therapeutic Neuroradiology (B.G.), Université de Lorraine, CHRU-Nancy, Nancy, France
- Institut National de la Santé et de la Recherche Mmédicale U1254 (B.G.), Université de Lorraine, Imagerie Adaptative Diagnostique et Interventionnelle, Nancy, France
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22
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Pagiola I, Frudit ME, Caldas JGMP. Atlas condemned to hold up the celestial heavens and bailout the mechanical thrombectomy failures in stroke? ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:261-263. [PMID: 33886803 DOI: 10.1590/0004-282x-anp-2020-0279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/24/2020] [Indexed: 11/22/2022]
Affiliation(s)
- Igor Pagiola
- Universidade Federal de São Paulo, Disciplina de Neurorradiologia Intervencionista, São Paulo SP, Brazil.,Hospital Sírio-Libanês, Neurorradiologia Intervencionista, São Paulo SP, Brazil.,Hospital Estadual Central, Disciplina de Neurorradiologia Intervencionista, Vitória ES, Brazil
| | - Michel Eli Frudit
- Hospital Sírio-Libanês, Neurorradiologia Intervencionista, São Paulo SP, Brazil.,Universidade Federal de São Paulo, Disciplina de Neurorradiologia Intervencionista, São Paulo SP, Brazil
| | - José Guilherme Mendes Pereira Caldas
- Universidade de São Paulo, Faculdade de Medicina, Disciplina de Neurorradiologia Intervencionista, São Paulo SP, Brazil.,Hospital Sírio-Libanês, Setor de Neurorradiologia Intervencionista, São Paulo SP, Brazil
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23
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Zha M, Wu M, Huang X, Zhang X, Huang K, Yang Q, Cai H, Ji Y, Lv Q, Yang D, Dai Q, Liu R, Liu X. A Pre-Interventional Scale to Predict in situ Atherosclerotic Thrombosis in Acute Vertebrobasilar Artery Occlusion Patients. Front Neurol 2021; 12:648081. [PMID: 33897603 PMCID: PMC8058399 DOI: 10.3389/fneur.2021.648081] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Determining the occlusion mechanism before endovascular treatment (EVT) is of great significance for acute large vessel occlusion patients. We aimed to develop and validate a simple pre-EVT scale with readily available variables for predicting in situ atherosclerotic thrombosis (ISAT) in acute vertebrobasilar artery occlusion (VBAO) patients. Materials and Methods: Consecutive patients were retrieved from Nanjing Stroke Registry Program between January 2014 and December 2019 as a derivation cohort. Anonymous data of consecutive patients between January 2014 and December 2019 were collected from another comprehensive stroke center as an external validation cohort. Demographics, medical histories, and clinical characteristics were collected. ISAT was defined according to the following criteria: (a) detection of moderate to severe (≥50%) stenosis or stenosis with significant distal flow impairment at the occluded segment when successful reperfusion was achieved; (b) transient visualization of eccentric plaque contour or a recurrent re-occlusion tendency when reperfusion was unsuccessful. Logistic regression was taken to develop a predictive scale. The performance of the scale was assessed by area under the receiver operating characteristic curve (AUC) and Hosmer–Lemeshow test. Results: ISAT was observed in 41 of 95 (43.2%) patients included in the derivation cohort. The ISAT predictive scale consisted of three pre-interventional predictors, including the history of hypertension, atrial fibrillation rhythm, and baseline serum glucose level ≥7.55 mmol/L. The model depicted acceptable calibration (Hosmer–Lemeshow test, P = 0.554) and good discrimination (AUC, 0.853; 95% confidence interval, 0.775–0.930). The optimal cutoff value of the ISAT scale was 1 point with 95.1% sensitivity, 64.8% specificity, and 77.9% accuracy. In the validation cohort, the discrimination ability was still promising with an AUC value of 0.800 (0.682–0.918). Conclusion: The three-item scale comprised of the history of hypertension, atrial fibrillation rhythm, and dichotomous serum glucose level had a promising predictive value for ISAT before EVT in acute VBAO patients.
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Affiliation(s)
- Mingming Zha
- Department of Neurology, Jinling Hospital, Medical School of Southeast University, Nanjing, China
| | - Min Wu
- Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Xianjun Huang
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Xiaohao Zhang
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Kangmo Huang
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Qingwen Yang
- Department of Neurology, Jinling Hospital, Medical School of Southeast University, Nanjing, China
| | - Haodi Cai
- Department of Neurology, Jinling Hospital, Medical School of Southeast University, Nanjing, China
| | - Yachen Ji
- Department of Neurology, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Qiushi Lv
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Dong Yang
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Qiliang Dai
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Rui Liu
- Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
| | - Xinfeng Liu
- Department of Neurology, Jinling Hospital, Medical School of Southeast University, Nanjing, China.,Department of Neurology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China.,Department of Neurology, Jinling Hospital, Affiliated Medical School of Nanjing University, Nanjing, China
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24
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Narsinh KH, Kilbride BF, Mueller K, Murph D, Copelan A, Massachi J, Vitt J, Sun CH, Bhat H, Amans MR, Dowd CF, Halbach VV, Higashida RT, Moore T, Wilson MW, Cooke DL, Hetts SW. Combined Use of X-ray Angiography and Intraprocedural MRI Enables Tissue-based Decision Making Regarding Revascularization during Acute Ischemic Stroke Intervention. Radiology 2021; 299:167-176. [PMID: 33560189 DOI: 10.1148/radiol.2021202750] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background For patients with acute ischemic stroke undergoing endovascular mechanical thrombectomy with x-ray angiography, the use of adjuncts to maintain vessel patency, such as stents or antiplatelet medications, can increase risk of periprocedural complications. Criteria for using these adjuncts are not well defined. Purpose To evaluate use of MRI to guide critical decision making by using a combined biplane x-ray neuroangiography 3.0-T MRI suite during acute ischemic stroke intervention. Materials and Methods This retrospective observational study evaluated consecutive patients undergoing endovascular intervention for acute ischemic stroke between July 2019 and May 2020 who underwent either angiography with MRI or angiography alone. Cerebral tissue viability was assessed by using MRI as the reference standard. For statistical analysis, Fisher exact test and Student t test were used to compare groups. Results Of 47 patients undergoing acute stroke intervention, 12 patients (median age, 69 years; interquartile range, 60-77 years; nine men) underwent x-ray angiography with MRI whereas the remaining 35 patients (median age, 80 years; interquartile range, 68-86 years; 22 men) underwent angiography alone. MRI results influenced clinical decision making in one of three ways: whether or not to perform initial or additional mechanical thrombectomy, whether or not to place an intracranial stent, and administration of antithrombotic or blood pressure medications. In this initial experience, decision making during endovascular acute stroke intervention in the combined angiography-MRI suite was better informed at MRI, such that therapy was guided in real time by the viability of the at-risk cerebral tissue. Conclusion Integrating intraprocedural 3.0-T MRI into acute ischemic stroke treatment was feasible and guided decisions of whether or not to continue thrombectomy, to place stents, or to administer antithrombotic medication or provide blood pressure medications. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Lev and Leslie-Mazwi in this issue.
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Affiliation(s)
- Kazim H Narsinh
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Bridget F Kilbride
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Kerstin Mueller
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Daniel Murph
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Alexander Copelan
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Jonathan Massachi
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Jeffrey Vitt
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Chung-Huan Sun
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Himanshu Bhat
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Matthew R Amans
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Christopher F Dowd
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Van V Halbach
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Randall T Higashida
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Terilyn Moore
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Mark W Wilson
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Daniel L Cooke
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
| | - Steven W Hetts
- From the Department of Radiology & Biomedical Imaging, Division of Interventional Neuroradiology (K.H.N., B.F.K., D.M., A.C., J.M., M.R.A., C.F.D., V.V.H., R.T.H., T.M., M.W.W., D.L.C., S.W.H.), and Department of Neurology (J.V., C.H.S.), University of California San Francisco, 505 Parnassus Ave, L-351, San Francisco, CA 94143-0628; and Siemens Medical Solutions, Malvern, Pa (K.M., H.B.)
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Zhang P, Xing Y, Li H, Yao Q, Shen J, Liu Y, Wei Y, Guo Y. Efficacy and safety of rescue angioplasty and/or stenting for acute large artery occlusion with underlying intracranial atherosclerosis: A systematic review and meta-analysis. Clin Neurol Neurosurg 2021; 203:106538. [PMID: 33607582 DOI: 10.1016/j.clineuro.2021.106538] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Intracranial angioplasty and/or stenting implantation is an important rescue treatment for the management of intracranial atherosclerosis-related occlusion (ICAS-O) after mechanical thrombectomy failure, but its safety and efficacy remain unclear. We investigated the safety and efficacy of rescue intracranial angioplasty and/or stenting for emergent large artery occlusion (LAO) with underlying ICAS. METHODS We searched for relevant full-text articles in EMBASE, PubMed and the Cochrane Central Register of Controlled Trials from inception to March 1, 2020. We calculated the odds ratios (ORs) using random-effects models for symptomatic intracranial hemorrhage (sICH), mortality, recanalization rate and favorable clinical outcome at 90 days between ICAS-O group treated by rescue therapy and Non ICAS-O group. RStudio software 1.3.959 was used to perform this meta-analysis. RESULTS Ten studies were included with a total of 1639 patients, of which 450 (27.5 %) were in the ICAS-O group treated with intracranial angioplasty and/or stenting, and 1189 (72.5 %) were in the Non ICAS-O group. Overall, intracranial angioplasty and/or stenting did not improve the recanalization rate (OR, 0.67 [0.26-1.76]; p = 0.419) or favorable functional outcome (OR, 1.01 [0.64-1.58]; p = 0.97) in patients with underlying ICAS-O, and the risk of sICH (OR, 0.99 [0.59-1.68]; p = 0.983) and mortality (OR, 1.26 [0.87-1.83]; p = 0.225) did not significantly differ between ICAS-O and Non ICAS-O. CONCLUSIONS From these observational study results, rescue intracranial angioplasty and/or stenting seems safe in patients with emergent LAO after attempted thrombectomy, but further rigorous studies are warranted to confirm its efficacy.
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Affiliation(s)
- Pengfei Zhang
- Department of Neurosurgery, Beichen Traditional Chinese Medical Hospital Tianjin, Tianjin, 300400, China
| | - Yongguo Xing
- Department of Neurosurgery, Beichen Traditional Chinese Medical Hospital Tianjin, Tianjin, 300400, China
| | - Hongbin Li
- Department of Neurology, Beichen Traditional Chinese Medical Hospital Tianjin, Tianjin, 300400, China
| | - Qingping Yao
- Department of Neurology, Beichen Traditional Chinese Medical Hospital Tianjin, Tianjin, 300400, China
| | - Jie Shen
- Department of Neurology, Beichen Traditional Chinese Medical Hospital Tianjin, Tianjin, 300400, China
| | - Yi Liu
- Department of Neurology, Beichen Traditional Chinese Medical Hospital Tianjin, Tianjin, 300400, China
| | - Ying Wei
- Department of Neurology, Beichen Traditional Chinese Medical Hospital Tianjin, Tianjin, 300400, China
| | - Yanting Guo
- Department of Pediatrics, Tianjin First Central Hospital, Tianjin, 300192, China.
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26
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Rescue stenting versus medical care alone in refractory large vessel occlusions: a systematic review and meta-analysis. Neuroradiology 2020; 62:629-637. [PMID: 31927615 DOI: 10.1007/s00234-020-02360-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/02/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Mechanical thrombectomy (MT) failure is associated with very poor prognosis. Permanent intracranial stenting (PIS) may be useful in such refractory occlusions. However, this strategy requires an aggressive antithrombotic regimen that may be harmful in extended strokes. The aim of this study was to compare clinical outcomes between patients with refractory acute large vessel occlusions (LVOs) treated by PIS versus patients for whom the procedure was stopped without recanalization. METHODS We conducted a systematic review by searching for articles in PubMed, the Cochrane Library, and ClinicalTrials.gov from January 2015 to September 2019. Two reviewers independently selected studies comparing PIS after failed MT in addition to usual care versus usual care only. A comparative meta-analysis was performed using random-effects models to estimate odds ratios of favorable clinical outcome at 90 days, defined as a modified Rankin scale 0-2, mortality and symptomatic intracranial hemorrhage (SICH). RESULTS Four comparative studies were included for a total of 352 patients: 149 in the PIS group versus 203 in the control group. PIS was associated with significantly higher rates of 90-day favorable clinical outcome (odds ratio [OR], 2.87 [95% confidence interval (95% CI), 1.77-4.66]; p < 0.001; I2, 0%) and lower mortality (OR, 0.39 [0.16-0.93]; p = 0.03; I2, 43%), whereas SICH rates did not significantly differ (OR, 0.68 [0.37-1.27]; p = 0.23; I2, 0%). CONCLUSION From observational study results, attempting PIS after failed MT seems to improve clinical outcomes without increasing the risk of intracranial bleeding. Randomized trials are needed to confirm these results.
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