1
|
Sun X, Zhang H, Tong X, Gao F, Ma G, Miao Z. Effects of Periprocedural Tirofiban vs. Oral Antiplatelet Drug Therapy on Posterior Circulation Infarction in Patients With Acute Intracranial Atherosclerosis-Related Vertebrobasilar Artery Occlusion. Front Neurol 2020; 11:254. [PMID: 32351442 PMCID: PMC7174752 DOI: 10.3389/fneur.2020.00254] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 03/17/2020] [Indexed: 01/01/2023] Open
Abstract
Background and purpose: Tirofiban and oral antiplatelet drugs can be used to inhibit reocclusion and restore microvascular reperfusion during endovascular treatment (EVT). This study compared recanalization rates, symptomatic intracranial hemorrhage (SICH), 90 day mortality, and functional outcomes between periprocedural tirofiban and antiplatelet therapy in patients with acute intracranial atherosclerosis-related vertebrobasilar artery occlusion. Methods: A total of 105 consecutive patients with acute intracranial atherosclerosis-related vertebrobasilar artery occlusion who underwent EVT + tirofiban + oral antiplatelet or EVT + oral antiplatelet therapy at the Beijing Tiantan Hospital between January 2012 and July 2018 were included. Baseline characteristics, procedural parameters, and functional outcomes were assessed. Results: Among the 105 patients, 74 underwent EVT + tirofiban + oral antiplatelet therapy, while 31 underwent EVT + oral antiplatelet drug therapy. EVT + tirofiban + oral antiplatelet therapy resulted in higher recanalization rates compared to EVT + oral antiplatelet drug therapy (93.24% vs. 77.42%; p = 0.038), whereas the risk for SICH, 90 day mortality, and functional independence outcomes did not differ between the groups. Logistic regression analysis revealed that EVT + tirofiban + oral antiplatelet therapy had an increased probability of higher recanalization rates (OR 0.18 [95% confidence interval (CI) 1.24–24.39]; p = 0.025). There were no differences in SICH (OR 0.00 [95% CI 0.00–Inf]; p = 0.998), 90 day mortality (OR 1.19 [95% CI 0.17–4.05]; p = 0.826), or functional independence (modified Rankin score 0 to ≤ 2) (OR 1.43 [95% CI 0.23–2.17]; p = 0.538) between the groups. Conclusions: Ninety day functional outcomes of EVT + tirofiban + oral antiplatelet therapy were not superior to those of EVT + oral antiplatelet drug therapy; however, the recanalization rate was higher and the risks for SICH and 90 day mortality were lower.
Collapse
Affiliation(s)
- Xuan Sun
- Department of Interventional Neuroadiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huijun Zhang
- Department of Neurology, Tong Ren Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xu Tong
- Department of Interventional Neuroadiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroadiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaoting Ma
- Department of Interventional Neuroadiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroadiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
2
|
Asimos AW, Sassano DR, Jackson SC, Clemente JD, Rhoten JB, Chang B, Runyon MS. Assessment of Vessel Density on Non-Contrast Computed Tomography to Detect Basilar Artery Occlusion. West J Emerg Med 2020; 21:694-702. [PMID: 32421522 PMCID: PMC7234696 DOI: 10.5811/westjem.2019.12.45247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/06/2019] [Indexed: 12/03/2022] Open
Abstract
Introduction Basilar artery occlusion (BAO) may be clinically occult due to variable and non-specific symptomatology. We evaluated the qualitative and quantitative determination of a hyperdense basilar artery (HDBA) on non-contrast computed tomography (NCCT) brain for the diagnosis of BAO. Methods We conducted a case control study of patients with confirmed acute BAO vs a control group of suspected acute stroke patients without BAO. Two EM attending physicians, one third-year EM resident, and one medical student performed qualitative and quantitative assessments for the presence of a HDBA on axial NCCT images. Our primary outcome measures were sensitivity and specificity for BAO. Our secondary outcomes were inter-rater and intra-rater reliability of the qualitative and quantitative assessments. Results We included 60 BAO and 65 control patients in our analysis. Qualitative assessment of the hyperdense basilar artery sign was poorly sensitive (54%–72%) and specific (55%–89%). Quantitative measurement improved the specificity of hyperdense basilar artery assessment for diagnosing BAO, with a threshold of 61.0–63.8 Hounsfield units demonstrating relatively high specificity of 85%–94%. There was moderate inter-rater agreement for the qualitative assessment of HDBA (Fleiss’ kappa statistic 0.508, 95% confidence interval: 0.435–0.581). Agreement improved for quantitative assessments, but still fell in the moderate range (Shrout-Fleiss intraclass correlation coefficient: 0.635). Intra-rater reliability for the quantitative assessments of the two attending physician reviewers demonstrated substantial consistency. Conclusion Our results highlight the importance of carefully examining basilar artery density when interpreting the NCCT of patients with altered consciousness or other signs and symptoms concerning for an acute basilar artery occlusion. If the Hounsfield unit density of the basilar artery exceeds 61 Hounsfield units, BAO should be highly suspected.
Collapse
Affiliation(s)
- Andrew W Asimos
- Atrium Health's Carolinas Medical Center, Department of Emergency Medicine, Charlotte, North Carolina
| | - D Richard Sassano
- Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Stephen C Jackson
- Atrium Health's Carolinas Medical Center, Department of Emergency Medicine, Charlotte, North Carolina
| | - Jonathan D Clemente
- Atrium Health's Carolinas Medical Center, Department of Radiology, Charlotte, North Carolina
| | - Jeremy B Rhoten
- Atrium Health's Carolinas Medical Center, Department of Neurosciences, Charlotte, North Carolina
| | - Brenda Chang
- Atrium Health, Information and Analytics Services, Charlotte, North Carolina
| | - Michael S Runyon
- Atrium Health's Carolinas Medical Center, Department of Emergency Medicine, Charlotte, North Carolina
| |
Collapse
|
3
|
Basilar artery thrombectomy: assessment of outcome and identification of prognostic factors. Acta Neurol Belg 2020; 120:99-105. [PMID: 31679149 DOI: 10.1007/s13760-019-01223-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 10/03/2019] [Indexed: 10/25/2022]
Abstract
Mechanical thrombectomy (MT) has been demonstrated as an effective treatment for acute ischemic stroke (AIS), thanks to large vessel occlusion (LVO), especially in case of anterior cerebral artery with many randomized clinical trials (RCTs) every year. On the other hand, there is a limited number of basilar artery occlusion (BAO)-related studies which have been conducted. The fact prompts our range of case studies, which furnish BAO understanding with our experience, results and some prognosis factors of MT. This retrospective and single-center study was conducted on 22 patients who were diagnosed with BAO and underwent the treatment of MT from October 2012 to January 2018. Clinical feature such as radiological imaging, procedure complications, and intracranial hemorrhage were all documented and evaluated. All the studies' results based on performance using modified Rankin scale score (mRS) and mortality at 90 days. The results from these BAO patients study indicated that the posterior circulation Acute Stroke Prognosis Early CT Score (pcASPECTS) recorded before the intervention was 7.7 ± 1.6, while the admission National Institutes of Health Stroke Scale (NIHSS) was 17.5 ± 5.4. 15/22 cases achieved successful recanalization (TICI, Thrombolysis in Cerebral Infarction scale, of 2b-3), accounting for 68.2%. The results highlighted 50% of the favorable outcome (mRS 0-2) occupying 11 out of 22 patients in total and the overall mortality was 36.4%. The intracranial hemorrhagic complication was detected in three cases (13.6%). Placing in juxtaposition the poor-outcome group and the favorable-outcome group, we could witness statistically significant difference (P < 0.05) suggesting both good baseline image (pc-ASPECTS ≥ 7) and recanalization (TICI 2b-3) were two good prognosis factors. Our case series showed that MT would be an effective and feasible treatment for BAO. The pre-procedural pcASPECTS ≥ 7 and post-procedural good recanalization (TICI 2b-3) were two important prognosis factors for predicting good clinical outcome.
Collapse
|
4
|
Shore TH, Harrington TJ, Faulder K, Steinfort B. Endovascular therapy in acute basilar artery occlusion: A retrospective single‐centre Australian analysis. J Med Imaging Radiat Oncol 2018; 63:33-39. [DOI: 10.1111/1754-9485.12825] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/07/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Timothy H Shore
- Department of Radiology Royal North Shore Hospital Sydney New South Wales Australia
| | - Timothy J Harrington
- Department of Radiology Royal North Shore Hospital Sydney New South Wales Australia
- Department of Neurosurgery Westmead Hospital Sydney New South Wales Australia
| | - Kenneth Faulder
- Department of Radiology Royal North Shore Hospital Sydney New South Wales Australia
- Department of Neurosurgery Westmead Hospital Sydney New South Wales Australia
| | - Brendan Steinfort
- Department of Radiology Royal North Shore Hospital Sydney New South Wales Australia
- Department of Neurosurgery Westmead Hospital Sydney New South Wales Australia
| |
Collapse
|
5
|
Hasan TF, Rabinstein AA, Middlebrooks EH, Haranhalli N, Silliman SL, Meschia JF, Tawk RG. Diagnosis and Management of Acute Ischemic Stroke. Mayo Clin Proc 2018; 93:523-538. [PMID: 29622098 DOI: 10.1016/j.mayocp.2018.02.013] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/25/2018] [Accepted: 02/16/2018] [Indexed: 10/17/2022]
Abstract
Acute ischemic stroke (AIS) is among the leading causes of death and long-term disability. Intravenous tissue plasminogen activator has been the mainstay of acute therapy. Recently, several prospective randomized trials documented the value of endovascular revascularization in selected patients with large-vessel occlusion within the anterior circulation. This finding has led to a paradigm shift in the management of AIS, including wide adoption of noninvasive neuroimaging to assess vessel patency and tissue viability, with the supplemental and independent use of intravenous tissue plasminogen activator to improve clinical outcomes. In this article, we review the landmark studies on management of AIS and the current position on the diagnosis and management of AIS. The review also highlights the importance of early stabilization and prompt initiation of therapeutic interventions before, during, and after the diagnosis of AIS within and outside of the hospital.
Collapse
Affiliation(s)
- Tasneem F Hasan
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
| | | | | | - Neil Haranhalli
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
| | - Scott L Silliman
- Department of Neurology, University of Florida Health Science Center, Jacksonville, FL
| | | | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL.
| |
Collapse
|
6
|
Oselkin M, Satti SR, Sundararajan SH, Kung D, Hurst RW, Pukenas BA. Endovascular treatment for acute basilar thrombosis via a transradial approach: Initial experience and future considerations. Interv Neuroradiol 2018; 24:64-69. [PMID: 28956515 PMCID: PMC5772535 DOI: 10.1177/1591019917733709] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 09/02/2017] [Indexed: 11/17/2022] Open
Abstract
Acute basilar artery occlusion (BAO) secondary to emergent large vessel occlusion (ELVO) has an extremely poor natural history, with a reported mortality rate up to 95%. Mechanical thrombectomy in the setting of ELVO is generally performed via a transfemoral approach. However, radial access is increasingly being utilized as an alternative. We report our initial multi-institutional experience using primary radial access in the treatment of acute BAO in nine consecutive cases. Technical success defined as a TICI score of 2B or 3 was achieved in 89% of cases. Average puncture to revascularization time was 35.8 minutes. There were no complications related to radial artery catheterization. We contend radial access should potentially be considered as the first-line approach given inherent advantages over femoral access for mechanical thrombectomy for BAO.
Collapse
Affiliation(s)
- M Oselkin
- Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - SR Satti
- Department of Neurointerventional Surgery, Christiana Care Health System Newark, DE, USA
| | - SH Sundararajan
- Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - D Kung
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - RW Hurst
- Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - BA Pukenas
- Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
7
|
Lee YY, Yoon W, Kim SK, Baek BH, Kim GS, Kim JT, Park MS. Acute Basilar Artery Occlusion: Differences in Characteristics and Outcomes after Endovascular Therapy between Patients with and without Underlying Severe Atherosclerotic Stenosis. AJNR Am J Neuroradiol 2017; 38:1600-1604. [PMID: 28546252 DOI: 10.3174/ajnr.a5233] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 03/24/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Prediction of underlying intracranial atherosclerotic stenosis before endovascular therapy might be helpful for appropriate therapeutic planning in patients with acute ischemic stroke. This study aimed to compare the characteristics and treatment outcomes in patients with acute basilar artery occlusion relative to the existence or nonexistence of underlying intracranial atherosclerotic stenosis. MATERIALS AND METHODS Sixty-two patients with acute basilar artery occlusion underwent multimodal endovascular therapy. All patients underwent stent-retriever thrombectomy as a first-line endovascular therapy. Patients with underlying intracranial atherosclerotic stenosis underwent additional intracranial angioplasty and stent placement. The clinical and imaging characteristics and treatment outcomes were retrospectively analyzed and compared between patients with and without intracranial atherosclerotic stenosis. RESULTS Underlying intracranial atherosclerotic stenosis was identified at the occlusion site in 15 patients (24.1%). Occlusion in the proximal segment of the basilar artery was more common in patients with intracranial atherosclerotic stenosis (60% versus 6.4%, P < .001), whereas occlusion in the distal segment was more common in those without it (91.5% versus 26.7%, P < .001). Bilateral thalamic infarction on a pretreatment DWI was less common in patients with intracranial atherosclerotic stenosis (0% versus 27.7%, P = .027) compared with those without it. There were no significant differences in the rates of successful revascularization, favorable outcome, symptomatic hemorrhage, and mortality between the 2 groups. CONCLUSIONS Underlying intracranial atherosclerotic stenosis was not uncommon in patients with acute basilar artery occlusion. The occlusion segment of the basilar artery and the presence or absence of bilateral thalamic infarction on a pretreatment DWI might be helpful for predicting underlying intracranial atherosclerotic stenosis in patients with acute basilar artery occlusion. Patients with and without underlying intracranial atherosclerotic stenosis who underwent endovascular therapy had similar outcomes.
Collapse
Affiliation(s)
- Y Y Lee
- From the Departments of Radiology (Y.Y.L., W.Y., S.K.K., B.H.B., G.S.K.)
| | - W Yoon
- From the Departments of Radiology (Y.Y.L., W.Y., S.K.K., B.H.B., G.S.K.)
| | - S K Kim
- From the Departments of Radiology (Y.Y.L., W.Y., S.K.K., B.H.B., G.S.K.)
| | - B H Baek
- From the Departments of Radiology (Y.Y.L., W.Y., S.K.K., B.H.B., G.S.K.)
| | - G S Kim
- From the Departments of Radiology (Y.Y.L., W.Y., S.K.K., B.H.B., G.S.K.)
| | - J T Kim
- Neurology (J.T.K., M.S.P.), Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - M S Park
- Neurology (J.T.K., M.S.P.), Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| |
Collapse
|
8
|
Abstract
Although stroke declined from the third to fifth most common cause of death in the United States, the annual incidence and overall prevalence continue to increase. Since the available US Food and Drug Administration-approved treatment options are time dependent, improving early stroke care may have more of a public health impact than any other phase of care. Timely and efficient stroke treatment should be a priority for emergency department and prehospital providers. This article discusses currently available and emerging treatment options in acute ischemic stroke focusing on the preservation of salvageable brain tissue, minimizing complications, and secondary prevention.
Collapse
Affiliation(s)
- Matthew S Siket
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 55 Claverick Street, 2nd Floor, Providence, RI 02903, USA.
| |
Collapse
|
9
|
Du S, Mao G, Li D, Qiu M, Nie Q, Zhu H, Yang Y, Zhang Y, Li Y, Wu Z. Mechanical thrombectomy with the Solitaire AB stent for treatment of acute basilar artery occlusion: A single-center experience. J Clin Neurosci 2016; 32:67-71. [PMID: 27312281 DOI: 10.1016/j.jocn.2016.01.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 01/01/2016] [Indexed: 10/21/2022]
Abstract
Basilar artery occlusion (BAO) remains one of the most devastating subtypes of ischemic stroke, and prognosis is poor if early recanalization is not achieved. The purpose of this study was to evaluate the safety and technical feasibility of mechanical thrombectomy with the Solitaire AB stent (Covidien, Irvine, CA, USA) for the treatment of acute BAO through a single-center experience. Twenty-one patients with acute BAO were treated with mechanical thrombectomy with the Solitaire AB stent device between 1st September 2011 and 1st December 2014. Recanalization was assessed using the Thrombolysis in Cerebral Infarction (TICI) scale system. Clinical outcome was established at discharge by The National Institute of Health Stroke Scale (NIHSS), and the mean time from symptom onset to recanalization determined. Authors had access to identifying information during or after data collection. The clinical status of patients on admission was severe, with a mean NIHSS score of 25.57±5.20 (range: 16-38), and the number of patients with TICI 2b or 3 was 0. The mean time from symptom onset to recanalization was 579.00±188.78min (range: 360-960min). At 3-month follow-up, eight (38.1%) patients had a good clinical outcome. At follow-up, the trial of ORG 10172 in acute stroke treatment (TOAST) classification was large-vessel atherosclerosis in 13 patients (61.9%), cardioembolic in seven patients (33.3%), and undetermined in one patient (4.8%). In our series, application of the Solitaire AB stent retriever in acute BAO resulted in a high recanalization rate without procedural complications, and with good clinical outcome. Further prospective trials are needed to confirm the potential clinical benefit of this treatment approach.
Collapse
Affiliation(s)
- Shiwei Du
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, 6 Tiantan Xili, Chongwen District, Beijing 100050, China
| | - Gengsheng Mao
- Department of Neurovascular Surgery, Chinese People's Armed Police Force General Hospital, Haidian, Beijing, China
| | - Dongmei Li
- Department of Neurovascular Surgery, Chinese People's Armed Police Force General Hospital, Haidian, Beijing, China
| | - Ming Qiu
- Department of Neurovascular Surgery, Chinese People's Armed Police Force General Hospital, Haidian, Beijing, China
| | - Qingbin Nie
- Department of Neurovascular Surgery, Chinese People's Armed Police Force General Hospital, Haidian, Beijing, China
| | - Haibo Zhu
- Department of Neurovascular Surgery, Chinese People's Armed Police Force General Hospital, Haidian, Beijing, China
| | - Yang Yang
- Department of Neurovascular Surgery, Chinese People's Armed Police Force General Hospital, Haidian, Beijing, China
| | - Youping Zhang
- Department of Neurovascular Surgery, Chinese People's Armed Police Force General Hospital, Haidian, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, 6 Tiantan Xili, Chongwen District, Beijing 100050, China
| | - Zhongxue Wu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, 6 Tiantan Xili, Chongwen District, Beijing 100050, China.
| |
Collapse
|