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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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Nayak S, Grant L, Demetriou V, Raseta M. Development of a Novel Statistical Model for Predicting Clinical Outcomes in Stroke Patients With Tandem Occlusions After Endovascular Therapy. Cureus 2024; 16:e59703. [PMID: 38841049 PMCID: PMC11150731 DOI: 10.7759/cureus.59703] [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] [Accepted: 05/05/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Tandem occlusions are intracranial large vessel occlusions (LVOs) with a concomitant ipsilateral extracranial internal carotid artery occlusion and can cause more severe stroke symptoms. AIM To develop a simple, rigorously cross-validated novel tool to predict clinical outcomes following tandem occlusion in patients with acute LVO stroke, based on data that are easily available to clinicians. To have used machine learning approaches to utilize the available information from clinical and angiographic data to make predictive models able to distinguish between mortality versus survival and good (modified Rankin Scale (mRS) ≤ 2) versus unfavorable neurological outcomes (mRs ≥ 3) Materials and methods: Retrospective data from 87 consecutive patients with anterior circulation stroke and tandem occlusions who underwent mechanical thrombectomy and stenting between December 2009 and January 2020 were analyzed. Patients were stratified into three groups based on the location of their LVO, and these groups were compared using statistical tests. Predictive models were built and cross-validated 1000 times to estimate their predictive power, measured by accuracy and area under the receiver operating curve (AUROC). RESULTS For distinguishing good outcome (mRS ≤ 2) versus poor outcome (mRS ≥ 3), the model comprised age, initial National Institute of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early CT Score (ASPECTS), NIHSS at 24 hours, NIHSS at discharge and intracranial haemorrhage and yielded an accuracy of 83% and the AUROC of 0.91. For mortality prediction, the model comprised age, initial NIHSS, intravenous thrombolysis, NIHSS at 24 hours and NIHSS at discharge and yielded an accuracy of 91% and an AUROC of 0.94. CONCLUSIONS Models developed exhibit strong predictive performance and can distinguish between both the instances of survival versus mortality and good versus poor outcome with an aim to support clinicians in deciding on optimal management for these complex patients. The developed model will help identify those at risk of poorer outcomes and the prospective better selection of patients with acute ischaemic large vessel stroke secondary to tandem occlusions.
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Affiliation(s)
- Sanjeev Nayak
- Neuroradiology, Royal Stoke University Hospital, Stoke-on-Trent, GBR
| | - Lucy Grant
- Radiology, Newcastle Teaching Hospitals, Newcastle upon Tyne, GBR
| | - Vias Demetriou
- Neuroradiology, Newcastle Teaching Hospitals, Newcastle upon Tyne, GBR
| | - Marko Raseta
- Department of Molecular Genetics, Erasmus University Medical Center, Rotterdam, NLD
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3
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Ip B, Wang H, Yu SCH. Use of Tirofiban in Endovascular Thrombectomy: More Questions than Answers. Cardiovasc Intervent Radiol 2024; 47:216-217. [PMID: 38172252 DOI: 10.1007/s00270-023-03644-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Bonaventure Ip
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Hao Wang
- Department of Interventional Neurology, Linyi People's Hospital, Linyi, China
| | - Simon Chun Ho Yu
- Department of Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong, China.
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4
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Ifergan H, Dargazanli C, Ben Hassen W, Hak JF, Gory B, Ognard J, Premat K, Marnat G, Kerleroux B, Zhu F, Bellanger G, Sporns PB, Charbonnier G, Forestier G, Caroff J, Fauché C, Clarençon F, Janot K, Lapergue B, Boulouis G. Rescue intracranial permanent stenting for refractory occlusion following thrombectomy: a propensity matched analysis. J Neurointerv Surg 2024; 16:115-123. [PMID: 37080770 DOI: 10.1136/jnis-2022-020012] [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: 12/21/2022] [Accepted: 03/25/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Rescue intracranial stenting (RIS) can be used in refractory large vessel occlusion (LVO) after mechanical thrombectomy (MT). We aimed to assess the safety and efficacy of RIS versus a propensity matched sample of patients with persistent LVO. METHODS We retrospectively analysed a multicenter retrospective pooled cohort of patients with anterior LVO (2015-2021) treated with MT, and identified patients with at least three passes and a modified Thrombolysis In Cerebral Infarction (mTICI) score of 0 to 2a. Propensity score matching was used to account for determinants of outcome in patients with or without RIS. The study outcomes included 3 months modified Rankin Scale (mRS) and symptomatic hemorrhagic transformation (HT). RESULTS 420 patients with a refractory anterior occlusion were included, of which 101 were treated with RIS (mean age 69 years). Favorable outcome (mRS 0-2) was more frequent in patients with a patent stent at day 1 (53% vs 6%, P<0.001), which was independently associated with an early dual antiplatelet regimen (P<0.05). In the propensity matched sample, patients treated with RIS versus without RIS had similar rates of favorable outcomes (36.8% vs 30.3%, P=0.606). Patients with RIS showed a favorable shift in the overall mRS distributions (common adjusted OR 0.74, 95% CI 0.60 to 0.91, P=0.006). Symptomatic HT was marginally more frequent in the RIS group (9% vs 3%, P=0.07), and there was no difference in 3-month mortality. CONCLUSION In selected patients with a refractory intracranial occlusion despite at least three thrombectomy passes, RIS may be associated with an overall shift towards more favorable clinical outcome, and no significant increase in the odds of symptomatic HT or death.
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Affiliation(s)
- Heloise Ifergan
- Diagnostic and Interventional Neuroradiology, University Hospital of Tours, Tours, Centre, France
| | - Cyril Dargazanli
- Diagnostic and Interventional Neuroradiology, University Hospital Centre Montpellier, Montpellier, Occitanie, France
| | - Wagih Ben Hassen
- Diagnostic and Interventional Neuroradiology, Saint Anne Hospital Centre, Paris, France
| | - Jean-Francois Hak
- Diagnostic and Interventional Neuroradiology, Hospital Timone, University Hospital of Marseille, Marseille, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, University of Lorraine, INSERM U1254, IADI, F-54000, University Hospital of Nancy, Nancy, France
| | - Julien Ognard
- Diagnostic and Interventional Neuroradiology, University and Regional Hospital Centre Brest, Brest, France
| | - Kevin Premat
- Diagnostic and Interventional Neuroradiology, University Hospital of Pitié Salpêtrière, APHP, Paris, France
| | - Gaultier Marnat
- Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Basile Kerleroux
- Diagnostic and Interventional Neuroradiology, Saint Anne Hospital Centre, Paris, France
| | - François Zhu
- Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Guillaume Bellanger
- Diagnostic and Interventional Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Peter B Sporns
- Diagnostic and Interventional Neuroradiology, University Hospital of Basel, Basel, Switzerland
| | - Guillaume Charbonnier
- Diagnostic and Interventional Neuroradiology, University Hospital of Besançon, Besancon, France
| | - Géraud Forestier
- Diagnostic and Interventional Neuroradiology, University Hospital of Limoges, Limoges, France
| | - Jildaz Caroff
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Cédric Fauché
- Diagnostic and Interventional Neuroradiology, University Hospital of Poitiers, Poitiers, France
| | - Frédéric Clarençon
- Diagnostic and Interventional Neuroradiology, University Hospital of Pitié Salpêtrière, APHP, Paris, France
| | - Kevin Janot
- Diagnostic and Interventional Neuroradiology, University Hospital of Tours, Tours, Centre, France
| | - Bertrand Lapergue
- Neurology, Stroke Center, University of Versailles and Saint Quentin en Yvelines, Foch Hospital, Suresnes, France
| | - Gregoire Boulouis
- Diagnostic and Interventional Neuroradiology, University Hospital of Tours, Tours, Centre, France
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Pinto CS, Ferreira F, Margarido I, Neves AL, Nunes JPL. Alkaline phosphatase and mortality in stroke patients: a systematic review. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:412. [PMID: 38213797 PMCID: PMC10777210 DOI: 10.21037/atm-23-1627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/18/2023] [Indexed: 01/13/2024]
Abstract
Background Increased plasma levels of alkaline phosphatase (ALP) have been associated to a worse prognosis in several types of diseases. In the present review, the authors aimed to study the relationship between plasma levels of ALP and overall mortality in patients with stroke. Methods A systematic review was carried out, searching two databases: Web of Science and Medline/PubMed. Results A total of nine studies that included data on overall mortality in stroke patients were selected. The selected studies were published between 2010 and 2022 and were predominantly from Asia. The articles reviewed quantified ALP levels through different methods: highest versus lowest quintiles of plasma ALP (three reports); highest versus lowest quartiles of plasma ALP (four reports); and plasma ALP levels in deceased versus in surviving patients (two reports). All selected studies showed an increased mortality associated to elevated ALP levels, irrespective of stroke type and length of follow-up, from a mean of 10 days to 2.5 years. The studies comparing the highest to the lowest ALP quintiles showed an aggregate value of 1.8 times greater risk of mortality for the former, when compared to the latter. Whereas, the studies comparing the highest to the lowest ALP quartiles showed an aggregate value of 2.4 times greater risk of mortality for the former, when compared to the latter. Conclusions Elevated ALP levels are associated with increased mortality in stroke patients and provide cost effective prognostic indicators of mortality in stroke.
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Affiliation(s)
| | - Francisca Ferreira
- Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Neurology, University Hospital Center of São João, Porto, Portugal
| | - Inês Margarido
- Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Neurology, University Hospital Center of São João, Porto, Portugal
| | - Ana Lídia Neves
- Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Neurology, University Hospital Center of São João, Porto, Portugal
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6
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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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7
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Naftali J, Findler M, Perlow A, Barnea R, Brauner R, Auriel E, Raphaeli G. Intracranial stenting for large vessel intracranial atherosclerotic disease: Retrospective study. Interv Neuroradiol 2023:15910199231190685. [PMID: 37499212 DOI: 10.1177/15910199231190685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Intracranial atherosclerotic disease (ICAD) is a common cause for stroke and can be defined as symptomatic (stroke) or asymptomatic. Current guidelines recommend against intracranial stenting (ICS) for patients with ICAD; treatment of patients who failed the best medical therapy is still debatable. METHODS We introduce a preliminary retrospective analysis of our tertiary stroke center during 2018-2022 of patients that were treated with ICS either in acute phase or elective (eICS). Study endpoints were stroke, functional outcome (modified Rankin Score [mRS] at 3 months), and serious adverse events. RESULTS Thirty-three stents were implanted, 21 in acute group and 12 in the eICS group. Most patients (75%) were treated with a new generation self-expandible stent. One patient had peri-procedural stroke and four patients had transient ischemic event or stroke during follow-up. There were eight cases of death (all acute group patients, seven of which occurred in the posterior circulation). Fifteen patients (62%) had favorable clinical outcomes (mRS 0-2 for pre-stroke), of which 10/10 (100%) in the eICS, the other two eICS patients had pre-morbid mRS 3 with no clinical change. CONCLUSIONS The evolution of new devices for ICS and the accumulating interventional experience might open a new era. As no other effective alternative treatment options exist for preventing recurrent stroke, stenting is still common practice in many tertiary centers either urgently or as elective procedure for refractory cases.
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Affiliation(s)
- Jonathan Naftali
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Michael Findler
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Interventional Neuroradiology unit, Rabin Medical Center, Petach Tikva, Israel
| | - Alain Perlow
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Interventional Neuroradiology unit, Rabin Medical Center, Petach Tikva, Israel
| | - Rani Barnea
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ran Brauner
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Interventional Neuroradiology unit, Rabin Medical Center, Petach Tikva, Israel
| | - Eitan Auriel
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Guy Raphaeli
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Interventional Neuroradiology unit, Rabin Medical Center, Petach Tikva, Israel
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Šunde D, Ljevak J, Ozretić D, Perić I, Blažević N, Poljakovic Z. Young stroke patient with patent foramen ovale and intracranial stenosis-a case report. SAGE Open Med Case Rep 2023; 11:2050313X231187677. [PMID: 37465062 PMCID: PMC10350779 DOI: 10.1177/2050313x231187677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/26/2023] [Indexed: 07/20/2023] Open
Abstract
The prevalence of patent foramen ovale is approximately 20% in the global population. In patients under the age of 55 years, it has been proven as a cause of acute ischemic embolic stroke of otherwise undetermined source. We present a case of a 25-year-old patient who experienced an acute stroke of dominant hemisphere due to internal carotid artery occlusion.The patient underwent mechanical thrombectomy, followed by acute intracranial stenting due to persistent subocclusion of internal carotid artery. Further diagnostic investigations revealed a significant patent foramen ovale. During subsequent follow-up periods, the patient encountered multiple transient ischemic attacks despite receiving antithrombotic therapy. The indicated angiography examination revealed in-stent stenosis and thrombosis, which were resolved after optimal medical treatment. Following patent foramen ovale closure, the patient remained free from further neurological events during the subsequent two-year follow-up periods. This case emphasizes the necessity of comprehensive diagnostic evaluations in young individuals with stroke and underscores the importance of prudent slection of medical therapies.
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Affiliation(s)
- Domagoj Šunde
- Medical School Zagreb, Zagreb, Croatia
- University Hospital Zagreb, Zagreb, Croatia
| | | | - David Ozretić
- Medical School Zagreb, Zagreb, Croatia
- University Hospital Zagreb, Zagreb, Croatia
| | - Ivan Perić
- University Hospital Zagreb, Zagreb, Croatia
| | | | - Zdravka Poljakovic
- Medical School Zagreb, Zagreb, Croatia
- University Hospital Zagreb, Zagreb, Croatia
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9
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Juega J, Li J, Palacio-Garcia C, Rodriguez M, Tiberi R, Piñana C, Rodriguez-Luna D, Requena M, García-Tornel Á, Rodriguez-Villatoro N, Rubiera M, Muchada M, Olivé-Gadea M, Rizzo F, Hernandez D, Dios-Lascuevas M, Hernandez-Perez M, Dorado L, Quesada H, Cardona P, De La Torre C, Gallur L, Camacho J, Ramon-Y-Cajal S, Tomasello A, Ribó M, Molina CA, Pagola J. Granulocytes-Rich Thrombi in Cerebral Large Vessel Occlusion Are Associated with Increased Stiffness and Poorer Revascularization Outcomes. Neurotherapeutics 2023; 20:1167-1176. [PMID: 37212981 PMCID: PMC10457261 DOI: 10.1007/s13311-023-01385-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/23/2023] Open
Abstract
We aim to identify a profile of intracranial thrombus resistant to recanalization by mechanical thrombectomy (MT) in acute stroke treatment. The first extracted clot of each MT was analyzed by flow cytometry obtaining the composition of the main leukocyte populations: granulocytes, monocytes, and lymphocytes. Demographics, reperfusion treatment, and grade of recanalization were registered. MT failure (MTF) was defined as final thrombolysis in cerebral infarction score IIa or lower and/or need of permanent intracranial stenting as a rescue therapy. To explore the relationship between stiffness of intracranial clots and cellular composition, unconfined compression tests were performed in other cohorts of cases. Thrombi obtained in 225 patients were analyzed. MTF were observed in 30 cases (13%). MTF was associated with atherosclerosis etiology (33.3% vs. 15.9%; p = 0.021) and higher number of passes (3 vs. 2; p < 0.001). Clot analysis of MTF showed higher percentage of granulocytes [82.46 vs. 68.90% p < 0.001] and lower percentage of monocytes [9.18% vs.17.34%, p < 0.001] in comparison to successful MT cases. The proportion of clot granulocytes (aOR 1.07; 95% CI 1.01-1.14) remained an independent marker of MTF. Among thirty-eight clots mechanically tested, there was a positive correlation between granulocyte proportion and thrombi stiffness (Pearson's r = 0.35, p = 0.032), with a median clot stiffness of 30.2 (IQR, 18.9-42.7) kPa. Granulocytes-rich thrombi are harder to capture by mechanical thrombectomy due to increased stiffness, so a proportion of intracranial granulocytes might be useful to guide personalized endovascular procedures in acute stroke treatment.
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Affiliation(s)
- Jesús Juega
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Jiahui Li
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | | | - Maite Rodriguez
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Riccardo Tiberi
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Carlos Piñana
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - David Rodriguez-Luna
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Álvaro García-Tornel
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Noelia Rodriguez-Villatoro
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Marian Muchada
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Federica Rizzo
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - David Hernandez
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marta Dios-Lascuevas
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Laura Dorado
- Department of Neurology, Germans Trias I Pujol University Hospital, Badalona, Spain
| | - Helena Quesada
- Department of Neurology, Bellvitge University Hospital, Hospitalet de Llobregat, Spain
| | - Pere Cardona
- Department of Neurology, Bellvitge University Hospital, Hospitalet de Llobregat, Spain
| | - Carolina De La Torre
- Proteomics Unit, Josep Carreras Leukaemia Research Institute (IJC), Badalona, Spain
| | - Laura Gallur
- Hematology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Jessica Camacho
- Department of Pathology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Alejandro Tomasello
- Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain.
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Jorge Pagola
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute. Universitat Autonoma de Barcelona, Passeig de la Vall d'Hebron, 119-129, Barcelona, 08035, Spain
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10
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Khachatryan T, Shafie M, Abcede H, Shah J, Nagamine M, Granstein J, Yuki I, Golshani K, Suzuki S, Yu W. Rescue therapy after thrombectomy for large vessel occlusion due to underlying atherosclerosis: review of literature. Front Neurol 2023; 14:1181295. [PMID: 37396754 PMCID: PMC10313123 DOI: 10.3389/fneur.2023.1181295] [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: 03/13/2023] [Accepted: 05/24/2023] [Indexed: 07/04/2023] Open
Abstract
In this review article, we summarized the current advances in rescue management for reperfusion therapy of acute ischemic stroke from large vessel occlusion due to underlying intracranial atherosclerotic stenosis (ICAS). It is estimated that 24-47% of patients with acute vertebrobasilar artery occlusion have underlying ICAS and superimposed in situ thrombosis. These patients have been found to have longer procedure times, lower recanalization rates, higher rates of reocclusion and lower rates of favorable outcomes than patients with embolic occlusion. Here, we discuss the most recent literature regarding the use of glycoprotein IIb/IIIa inhibitors, angioplasty alone, or angioplasty with stenting for rescue therapy in the setting of failed recanalization or instant/imminent reocclusion during thrombectomy. We also present a case of rescue therapy post intravenous tPA and thrombectomy with intra-arterial tirofiban and balloon angioplasty followed by oral dual antiplatelet therapy in a patient with dominant vertebral artery occlusion due to ICAS. Based on the available literature data, we conclude that glycoprotein IIb/IIIa is a reasonably safe and effective rescue therapy for patients who have had a failed thrombectomy or have residual severe intracranial stenosis. Balloon angioplasty and/or stenting may be helpful as a rescue treatment for patients who have had a failed thrombectomy or are at risk of reocclusion. The effectiveness of immediate stenting for residual stenosis after successful thrombectomy is still uncertain. Rescue therapy does not appear to increase the risk of sICH. Randomized controlled trials are warranted to prove the efficacy of rescue therapy.
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Affiliation(s)
- Tigran Khachatryan
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Mohammad Shafie
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Hermelinda Abcede
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Jay Shah
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Masaki Nagamine
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
| | - Justin Granstein
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Ichiro Yuki
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Kiarash Golshani
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Shuichi Suzuki
- Department of Neurological Surgery, University of California, Irvine, Irvine, CA, United States
| | - Wengui Yu
- Department of Neurology, University of California, Irvine, Irvine, CA, United States
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11
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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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12
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Ma A, Detaram HD, Steinfort B, Harrington T, Nguyen TN, Abdalkader M, Siopis G, Bath PM, Dhillon PS, Podlasek A, Qureshi AI, Qiu Z, Krishnan K. Antiplatelet Therapy in Neurointervention. Semin Neurol 2023; 43:466-479. [PMID: 37562452 DOI: 10.1055/s-0043-1771383] [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: 08/12/2023]
Abstract
The aim of this review is to provide an overview of the use of antiplatelet medication in neurointervention, with a focus on the clinical indications for antiplatelet use in both preventing and reducing platelet aggregation. This review will cover current antiplatelet medications, pharmacokinetics, and pharmacodynamics. We will provide an overview of different endovascular devices and discuss the antiplatelet regimes in neurointervention, highlighting gaps in evidence and scope for future studies.Two randomized controlled trials have evaluated antiplatelet use in the setting of acute large vessel occlusion stroke, with neither demonstrating benefit in their overall cohorts. Evidence on antiplatelet medication for both acute and elective stenting for acute stroke and treatment of cerebral aneurysms is currently based on large case series, and practice in neurointervention has increasingly utilized dual antiplatelet regimes with clopidogrel and second-line agents like prasugrel and ticagrelor. Clopidogrel function testing has an increasing role in neurointerventional procedures, particularly for high metal surface area stents such as the braided flow diverter type stents. Intravenous glycoprotein IIB/IIIA inhibitors have been utilized for both acute bridging and rescue therapy.Antiplatelet decision making is complex, and there are few randomized control trials to guide clinical practice. Comparative trials to guide decision making remain important in both the acute and elective settings. Standardised protocols incorporating platelet function testing may play a role in assisting decision making until more robust clinical evidence is available, particularly in the context of acute neurointerventional stenting for stroke and ruptured cerebral aneurysms.
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Affiliation(s)
- Alice Ma
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | | | - Brendan Steinfort
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Tim Harrington
- Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Centre, Boston, Massachusetts
| | | | - George Siopis
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Permesh Singh Dhillon
- Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- TIME, Imaging Science and Technology, University of Dundee, Dundee, Scotland, United Kingdom
| | - Anna Podlasek
- Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- TIME, Imaging Science and Technology, University of Dundee, Dundee, Scotland, United Kingdom
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, People's Republic of China
| | - Kailash Krishnan
- Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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13
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Lin MT, Wu HW, Chen HY, Tsai HT, Wu CH. Association of clinical factors to functional outcomes in patients with stroke with large-vessel occlusion after endovascular thrombectomy. J Formos Med Assoc 2023; 122:344-350. [PMID: 36513530 DOI: 10.1016/j.jfma.2022.11.016] [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: 10/17/2022] [Revised: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/PURPOSE Multiple clinical factors have been reported to be associated with functional outcomes in patients with stroke. However, little is known about prognostic predictors of functional independence in patients with stroke undergoing endovascular thrombectomy (EVT). Our study aimed to investigate the correlation between multiple prognostic variables (including EVT and rehabilitation-related parameters) and functional outcomes in patients post-EVT. METHODS This retrospective cohort study recruited patients hospitalized between December 2018 and March 2022. Patients with stroke with large-vessel occlusion who underwent EVT were eligible for inclusion in the study. Prognostic factors, including premorbid characteristics, laboratory data, EVT- and rehabilitation-related parameters, functional activity level, balance ability, swallowing, and sphincter function, were collected. Logistic regression and generalized linear models were used to analyze their correlations with functional outcomes. RESULTS A total of 148 patients were included. In the univariate logistic regression analysis, younger age, premorbid functional independence, higher hemoglobin (Hb) level, lower National Institute of Health Stroke Scale (NIHSS) score, absence of hemorrhagic transformation in 14 days, no nasogastric (NG) tube placement, earlier rehabilitation, frequent daily rehabilitation sessions, more out-of-bed rehabilitation, better ability of sitting up, better initial sitting balance, higher Barthel index (BI), absence of immobility, and neurological complications were associated with favorable outcomes at 3 months. In the stepwise regression model, the predictors of favorable function at 3 months included age, ability to sit up, and frequency of daily rehabilitation sessions; favorable outcomes at 6 months were associated with age, ability to sit up, and swallowing function. CONCLUSION In patients with stroke post-EVT, better functional outcomes were associated with prognostic variables, including younger age, better ability to sit up, normal swallowing function, and frequent daily rehabilitation sessions.
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Affiliation(s)
- Meng-Ting Lin
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Hao-Wei Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Hsing-Yu Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Hsiao-Ting Tsai
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Chueh-Hung Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 100, Taiwan.
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14
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Comparison of Safety and Efficacy after Emergency Stenting in Patients Exhibiting Intracranial Atherosclerotic Stenosis Associated with Large-vessel Occlusion with and without Intravenous Infusion of Tirofiban. Cardiovasc Intervent Radiol 2023; 46:377-384. [PMID: 36797426 PMCID: PMC10014670 DOI: 10.1007/s00270-023-03372-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/23/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE Intracranial rescue stent angioplasty is a bailout strategy for acute stroke patients in cases of unsuccessful endovascular thrombectomy due to underlying atherosclerotic stenosis. However, there is no consensus on a preprocedural and intraprocedural antiplatelet regimen. The aim of this single-centre study was to compare the safety and efficacy of emergency stenting in patients exhibiting intracranial atherosclerotic stenosis-related acute large-vessel occlusion with or without peri-interventional intravenous infusion of tirofiban. MATERIALS AND METHODS We performed a retrospective analysis of 78 patients who were treated with rescuestent angioplasty between 2010 and 2019 due to acute ischaemic stroke. The patients were divided into 2 groups: those who received peri-interventional intravenous tirofiban and those who did not receive tirofiban. We compared clinical safety and functional outcomes in both treatment groups with symptomatic haemorrhage as the primary endpoint. Bivariate and multivariable logistic regression was performed to investigate the association between tirofiban and outcome measures. RESULTS Thirty-seven patients were treated with intravenous tirofiban (47.4%), and 41 patients did not receive intravenous tirofiban (52.6%). Statistical analysis revealed no significant difference between the two groups in the rate of symptomatic haemorrhage (16.2% in the tirofiban group versus 14.6% in the control group, p = 0.847). The 3-month mortality (21.6% in the tirofiban group versus 17.1% in the control group, p = 0.611) and good functional outcomes according to the modified Rankin scale (45.9% versus 34.1%, p = 0.289) were comparable. CONCLUSION The results of our study suggest that the application of tirofiban for rescue stenting after failed mechanical thrombectomy is safe.
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15
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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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16
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Lehnen NC, Paech D, Zülow S, Bode FJ, Petzold GC, Radbruch A, Dorn F. First Experience with the Nimbus Stentretriever. Clin Neuroradiol 2022; 33:491-497. [DOI: 10.1007/s00062-022-01237-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/31/2022] [Indexed: 12/03/2022]
Abstract
Abstract
Purpose
To share our first experience with the Nimbus stentretriever, a multizone device designed to assist neurointerventionalists in handling fibrin-rich clots in endovascular stroke treatment.
Methods
We retrospectively analyzed the data of patients who were treated with the Nimbus stentretriever at our high-volume stroke center between May 2021 and May 2022. We evaluated the number of passes before Nimbus was used, the number of passes with nimbus, as well as the recanalization success before and after Nimbus according to the modified treatment in cerebral ischemia (mTICI) scale. Also, patient characteristics, procedural times and clinical outcomes were documented.
Results
A total of 21 consecutive patients were included in the study. An mTICI 2b/3 could be achieved in 76.2% and mTICI 2c/3 could be achieved in 57.1%. The mean number of passes was 3.4 before the use of Nimbus, 2.2 with Nimbus, and 5.4 for all passes with and without Nimbus and 4 occlusions (19.0%) were successfully recanalized with direct aspiration after the use of Nimbus. We observed seven subarachnoid hemorrhages (33.3%) and two cases of vasospasm.
Conclusion
In our series, the use of Nimbus resulted in successful recanalization in half of the patients after otherwise unsuccessful thrombectomy maneuvers; therefore, it should be considered as a rescue option if the maneuver with conventional stent retrievers was unsuccessful.
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Machado M, Borges de Almeida G, Sequeira M, Pedro F, Fior A, Carvalho R, Fragata I, Reis J, Nunes AP. Percutaneous transluminal angioplasty and stenting in acute stroke caused by basilar artery steno-occlusive disease: The experience of a single stroke centre. Interv Neuroradiol 2022; 28:547-555. [PMID: 34704502 PMCID: PMC9511620 DOI: 10.1177/15910199211051830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/13/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Percutaneous transluminal angioplasty and stenting in acute stroke due to severe basilar artery stenosis or basilar artery occlusion remain a matter of debate. The higher risk of stroke recurrence in patients with vertebrobasilar stenosis compared to anterior circulation atherosclerotic disease creates high expectations concerning endovascular approaches. This study aims to review our experience with percutaneous transluminal angioplasty and stenting in acute stroke caused by basilar artery steno-occlusive disease. METHODS Our prospective database from June 2014 until December 2020 was screened and patients with acutely symptomatic severe (>80%) basilar artery stenosis or acute basilar artery occlusion who underwent percutaneous transluminal angioplasty and stenting were analysed. RESULTS Twenty-five patients included: 72% men (mean age 68.6 years), all with prior modified Rankin Scale <2. Twelve presented with acute basilar artery occlusion and were submitted to mechanical thrombectomy before percutaneous transluminal angioplasty and stenting, while the remaining had severe basilar artery stenosis. Successful stent placement was achieved in 22 (88%). Procedure-related complications included new small ischemic lesions (16%), basilar artery dissection (8%), vertebral artery dissection (12%) and death (12%). At 3 months post-percutaneous transluminal angioplasty and stenting, 10 out of 23 patients (43.5%) were independent (mRS ≤ 2) and six died. Fourteen patients underwent transcranial Doppler ultrasound 3 months post-percutaneous transluminal angioplasty and stenting: 12 showed residual stenosis, one significant stent restenosis and one presented stent occlusion. CONCLUSIONS Percutaneous transluminal angioplasty and stenting showed to be a technically feasible and reasonably safe procedure in selected patients. However, good clinical outcomes may be difficult to achieve as only 43.5% of the patients remained independent at 3 months. Randomized studies are needed to confirm the efficacy and safety outcomes of percutaneous transluminal angioplasty and stenting in acute stroke caused by basilar artery steno-occlusive disease.
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Affiliation(s)
- Manuel Machado
- Unidade Cerebrovascular, Departamento de Neurociências do, Centro Hospitalar e Universitário de Lisboa Central, Portugal
| | - Gonçalo Borges de Almeida
- Serviço de Neurorradiologia, Departamento de Neurociências do, Centro Hospitalar e Universitário de Lisboa Central, Portugal
| | - Marta Sequeira
- Unidade Cerebrovascular, Departamento de Neurociências do, Centro Hospitalar e Universitário de Lisboa Central, Portugal
| | - Filipa Pedro
- Serviço de Medicina Interna, Hospital Distrital de Santarém, Portugal
| | - Alberto Fior
- Unidade Cerebrovascular, Departamento de Neurociências do, Centro Hospitalar e Universitário de Lisboa Central, Portugal
| | - Rui Carvalho
- Serviço de Neurorradiologia, Departamento de Neurociências do, Centro Hospitalar e Universitário de Lisboa Central, Portugal
| | - Isabel Fragata
- Serviço de Neurorradiologia, Departamento de Neurociências do, Centro Hospitalar e Universitário de Lisboa Central, Portugal
| | - João Reis
- Serviço de Neurorradiologia, Departamento de Neurociências do, Centro Hospitalar e Universitário de Lisboa Central, Portugal
| | - Ana Paiva Nunes
- Unidade Cerebrovascular, Departamento de Neurociências do, Centro Hospitalar e Universitário de Lisboa Central, Portugal
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Wu CH, Chung CP, Chen TY, Yu KW, Lin TM, Tai WA, Luo CB, Chang FC. Influence of angioplasty and stenting on intracranial artery stenosis: preliminary results of high-resolution vessel wall imaging evaluation. Eur Radiol 2022; 32:6788-6799. [DOI: 10.1007/s00330-022-09010-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/13/2022] [Accepted: 06/30/2022] [Indexed: 12/15/2022]
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19
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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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20
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Baek JH, Kim BM, Ihm EH, Kim CH, Kim DJ, Heo JH, Nam HS, Kim YD, Suh S, Kim B, Won Y, Baek BH, Yoon W, Kwon HJ, Chang Y, Jung C, Jeong HW. Clinical outcomes of rescue stenting for failed endovascular thrombectomy: a multicenter prospective registry. J Neurointerv Surg 2022; 14:1166-1172. [PMID: 35022298 DOI: 10.1136/neurintsurg-2021-018308] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/01/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is a primary endovascular modality for acute intracranial large vessel occlusion. However, further treatment, such as rescue stenting, is occasionally necessary for refractory cases. We aimed to investigate the efficacy and safety of rescue stenting in first-line MT failure and to identify the clinical factors affecting its clinical outcome. METHODS A multicenter prospective registry was designed for this study. We enrolled consecutive patients who underwent rescue stenting for first-line MT failure. Endovascular details and outcomes, follow-up patency of the stented artery, and clinical outcomes were summarized and compared between the favorable and unfavorable outcome groups. RESULTS A total of 78 patients were included. Intracranial atherosclerotic stenosis was the most common etiology for rescue stenting (97.4%). Seventy-seven patients (98.7%) were successfully recanalized by rescue stenting. A favorable outcome was observed in 66.7% of patients. Symptomatic intracranial hemorrhage and mortality were observed in 5.1% and 4.0% of patients, respectively. The stented artery was patent in 82.1% of patients on follow-up angiography. In a multivariable analysis, a patent stent on follow-up angiography was an independent factor for a favorable outcome (OR 87.6; 95% CI 4.77 to 1608.9; p=0.003). Postprocedural intravenous maintenance of glycoprotein IIb/IIIa inhibitor was significantly associated with the follow-up patency of the stented artery (OR 5.72; 95% CI 1.45 to 22.6; p=0.013). CONCLUSIONS In this multicenter prospective registry, rescue stenting for first-line MT failure was effective and safe. For a favorable outcome, follow-up patency of the stented artery was important, which was significantly associated with postprocedural maintenance of glycoprotein IIb/IIIa inhibitors.
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Affiliation(s)
- Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (the Republic of).,Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Byung Moon Kim
- Interventional Neuroradiology, Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Eun Hyun Ihm
- Department of Neurosurgery, Andong Hospital, Andong, Korea (the Republic of)
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University Dongsan Medical Center, Daegu, Korea (the Republic of)
| | - Dong Joon Kim
- Interventional Neuroradiology, Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Ji Hoe Heo
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Hyo Suk Nam
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Young Dae Kim
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Sangil Suh
- Department of Radiology, Korea University Guro Hospital, Seoul, Korea (the Republic of)
| | - Byungjun Kim
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea (the Republic of)
| | - Yoodong Won
- Department of Radiology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea (the Republic of)
| | - Byung Hyun Baek
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea (the Republic of)
| | - Woong Yoon
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea (the Republic of)
| | - Hyon-Jo Kwon
- Department of Neurosurgery, Regional Cerebrovascular Center, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea (the Republic of)
| | - Yoonkyung Chang
- Department of Neurology, Ewha Womans University College of Medicine, Mokdong Hospital, Seoul, Korea (the Republic of)
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea (the Republic of)
| | - Hae Woong Jeong
- Diagnostic Radiology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea (the Republic of)
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21
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Huang ZX, Li YK, Li SZ, Huang XJ, Chen Y, Hong QL, Cai QK, Han YF. A Dynamic Nomogram for 3-Month Prognosis for Acute Ischemic Stroke Patients After Endovascular Therapy: A Pooled Analysis in Southern China. Front Aging Neurosci 2021; 13:796434. [PMID: 34966271 PMCID: PMC8710662 DOI: 10.3389/fnagi.2021.796434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Cerebral edema (CDE) is a common complication in patients with acute ischemic stroke (AIS) and can reduce the benefit of endovascular therapy (EVT). To determine whether certain risk factors are associated with a poor prognosis mediated by CDE after EVT. The 759 patients with anterior circulation stroke treated by EVT at three comprehensive stroke centers in China from January 2014 to October 2020 were analyzed. Patients underwent follow-up for 3 months after inclusion. The primary endpoint was a measure of a poor prognosis (modified Rankin Scale score ≥ 3) at 3 months assessed in all patients receiving EVT. Least absolute shrinkage and selection operator and multivariate logistic regression were used to select variables for the prognostic nomogram. Based on these variables, the nomogram was established and validated. In addition, structural equation modeling was used to explore the pathways linking CDE and a poor prognosis. Seven predictors were identified, namely, diabetes, age, baseline Alberta Stroke Program Early CT score, modified Thrombolysis in Cerebral Infarction score, early angiogenic CDE, National Institutes of Health Stroke Scale score, and collateral circulation. The nomogram consisting of these variables showed the best performance, with a large area under the curve in both the internal validation set (0.850; sensitivity, 0.737; specificity, 0.887) and external validation set (0.875; sensitivity, 0.752; specificity, 0.878). In addition, CDE (total path coefficient = 0.24, P < 0.001) served as a significant moderator. A nomogram for predicting a poor prognosis after EVT in AIS patients was established and validated with CDE as a moderator.
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Affiliation(s)
- Zhi-Xin Huang
- Department of Neurology, Guangdong Second Provincial General Hospital, Guangzhou, China.,Department of Neurology, The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.,The School of Medicine, Jinan University, Guangzhou, China
| | - Yong-Kun Li
- Department of Neurology, Fujian Provincial Hospital, Shengli Clinical College of Fujian Medical University, Fuzhou, China.,Department of Neurology, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Shi-Zhan Li
- Department of Neurology, The No. 1 People's Hospital of Yulin, Yulin, China
| | - Xian-Jun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Ying Chen
- Department of Neurology, Xiamen Key Laboratory of Brain Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Quan-Long Hong
- Department of Neurology, The First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, China
| | - Qian-Kun Cai
- Department of Neurology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yun-Fei Han
- Department of Neurology, Medical School of Nanjing University, Jinling Hospital, Nanjing, China
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22
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Luo G, Gao F, Zhang X, Jia B, Huo X, Liu R, Chi MS, Ma G, Peng G, Zhang J, Qi Z, Guo X, Han B, Tong X, Wang B, Song L, Liu L, He Z, Mo D, Ma N, Sun X, Yang M, Miao Z. Intracranial Stenting as Rescue Therapy After Failure of Mechanical Thrombectomy for Basilar Artery Occlusion: Data From the ANGEL-ACT Registry. Front Neurol 2021; 12:739213. [PMID: 34659098 PMCID: PMC8514631 DOI: 10.3389/fneur.2021.739213] [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: 07/26/2021] [Accepted: 09/03/2021] [Indexed: 11/20/2022] Open
Abstract
Background and Purpose: Studies on rescue therapy for acute posterior circulation stroke due to basilar artery occlusion (BAO) are limited in the modern era of mechanical thrombectomy (MT). The aim of this study was to evaluate the safety and efficacy of rescue stenting (RS) following MT failure in patients with BAO. Methods: Data were collected from the Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke (ANGEL-ACT) prospective registry in China. Patients who underwent MT for BAO with failure of recanalization were enrolled in this study. The patients were divided into the RS and non-RS groups. Clinical and laboratory findings, procedural details, and clinical outcomes were compared between the two groups. Results: Overall, 93 patients with acute BAO were analyzed. The RS group included 81 (87.1%) patients, and the non-RS group included 12 patients. A modified treatment in cerebral infarction (mTICI) score of 2b/3 was achieved in 75 (92.6%) patients in the RS group. Compared with the non-RS group, the RS group had a significantly higher rate of successful recanalization and favorable clinical outcomes (modified Rankin Scale score at 90 days post-procedure, 0–3: 16.7 vs. 51.9%, respectively; P = 0.023) without an increase in the rate of symptomatic intracranial hemorrhage and a significantly lower mortality rate (58.3 vs. 18.5%, respectively; P = 0.006). Furthermore, the use of a glycoprotein IIb/IIIa inhibitor improved the rate of recanalization of the target artery without increasing the rate of symptomatic intracranial hemorrhage. Conclusions: Permanent stenting appears to be a feasible rescue modality when MT fails and might provide functional benefits in patients with acute ischemic stroke due to BAO.
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Affiliation(s)
- Gang Luo
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuelei Zhang
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaochuan Huo
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Raynald Liu
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Man Sum Chi
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Medicine and Geriatrics, Tuen Mun Hospital, Tuen Mun, Hong Kong, SAR China
| | - Gaoting Ma
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Guangge Peng
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jingyu Zhang
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhongqi Qi
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xu Guo
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Neurology, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Bin Han
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Interventional Neurology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Bo Wang
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ligang Song
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lian Liu
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zijun He
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuan Sun
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ming Yang
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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23
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Yeo LLL, Jing M, Bhogal P, Tu T, Gopinathan A, Yang C, Tan BYQ, Arnberg F, Sia CH, Holmin S, Andersson T. Evidence-Based Updates to Thrombectomy: Targets, New Techniques, and Devices. Front Neurol 2021; 12:712527. [PMID: 34566856 PMCID: PMC8459011 DOI: 10.3389/fneur.2021.712527] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/30/2021] [Indexed: 01/23/2023] Open
Abstract
Endovascular thrombectomy (EVT) has been validated in several randomized controlled trials in recent years for its efficacy in the treatment of acute ischemic strokes (AIS) and is now the standard of care according to international guidelines. However, in about 20% of EVT procedures, recanalization is not achieved, and over 50% of patients who undergo EVT still do not have good functional outcome. In this article, we provide an extensive review of the latest evidence and developments in the field of EVT, with particular focus on the factors that improve patient outcomes. These factors include new and adjunctive techniques such as combination of direct aspiration and stent retriever, intra-arterial urokinase or 2b/3a inhibitors, rescue stenting, as well as novel devices including balloon guide catheters and the newer generations of aspiration catheters and stent retrievers. We also examined the latest notion of using first-pass effect (FPE) as the target to achieve during EVT, which has been associated with an improved functional outcome. While the field of EVT has been rapidly evolving, further research is required in specific AIS patient populations such as those with large ischemic core, late presentation beyond 24 h, posterior circulation strokes, and with distal medium vessel occlusion or tandem lesions to better assess its efficacy and safety.
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Affiliation(s)
- Leonard L L Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Mingxue Jing
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Pervinder Bhogal
- Department of Neuroradiology, St. Bartholomew's and the Royal London Hospital, London, United Kingdom
| | - Tianming Tu
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Anil Gopinathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Cunli Yang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Benjamin Y Q Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tommy Andersson
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
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24
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Mohammaden MH, Nogueira RG, Tekle W, Ortega-Gutierrez S, Farooqui M, Zevallos CB, Hanel RA, Cortez GM, Aghaebrahim A, Starke RM, Aref H, Elbassiouny A, Gamea A, Alaraj A, Sadeh M, Grigoryan M, Kuybu O, Haussen DC, Sheth SA, Maud A, Cordina SM, Tanweer O, Kan P, Burkhardt JK, Grandhi R, Siddiq F, Hassan AE. Safety and efficacy of balloon-mounted stent in the treatment of symptomatic intracranial atherosclerotic disease: a multicenter experience. J Neurointerv Surg 2021; 14:756-761. [PMID: 34349013 DOI: 10.1136/neurintsurg-2021-017818] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/26/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Randomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications. OBJECTIVE To study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD. METHODS Prospectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up. RESULTS A total of 232 patients were eligible for the analysis (mean age 62.8 years, 34.1% female). The intracranial stenotic lesions were located in the anterior circulation in 135 (58.2%) cases. Recurrent stroke was the qualifying event in 165 (71.1%) while recurrent TIA was identified in 67 (28.9%) cases. The median (IQR) time from the qualifying event to stenting was 5 (2-20.75) days. Strokes were reported in 13 (5.6%) patients within 72 hours of the procedure; 9 (3.9%) ischemic and 4 (1.7%) hemorrhagic, and mortality in 2 (0.9%) cases. Among 189 patients with median follow-up time 6 (3-14.5) months, 12 (6.3%) had TIA and 7 (3.7%) had strokes. Three patients (1.6%) died from causes not related to stroke. CONCLUSION Our study has shown that BMS may be a safe and effective treatment for medically refractory symptomatic ICAD. Additional prospective randomized clinical trials are warranted.
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Affiliation(s)
- Mahmoud H Mohammaden
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA.,Department of Neurology, South Valley University Faculty of Medicine, Qena, Egypt
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Wondwossen Tekle
- Department of Neurology, UTRGV School of Medicine, Harlingen, Texas, USA.,Department of Neurology, Valley Baptist Medical Center, Harlingen, Texas, USA
| | - Santiago Ortega-Gutierrez
- Department of Neuroloy, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Cynthia B Zevallos
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Robert M Starke
- Department of Neurosurgery and Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Hany Aref
- Department of Neurology, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - Ahmed Elbassiouny
- Department of Neurology, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - Ayman Gamea
- Department of Neurology, South Valley University Faculty of Medicine, Qena, Egypt
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Morteza Sadeh
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | | | - Okkes Kuybu
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Sunil A Sheth
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Steve M Cordina
- Department of Neurology, University of South Alabama Health System, Mobile, Alabama, USA
| | - Omar Tanweer
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor Health Care System, Dallas, Texas, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri System, Columbia, Missouri, USA
| | - Ameer E Hassan
- Department of Neurology, UTRGV School of Medicine, Harlingen, Texas, USA .,Department of Neurology, Valley Baptist Medical Center, Harlingen, Texas, USA
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25
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Porto GBF, Sattur MG, Al Kasab S, Spiotta AM. Neuroendovascular Management of Acute Ischemic Basilar Strokes: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E346-E347. [PMID: 34131725 DOI: 10.1093/ons/opab180] [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: 09/25/2020] [Accepted: 04/28/2021] [Indexed: 11/14/2022] Open
Abstract
Basilar artery occlusions (BAOs) are devastating ischemic strokes that account for 1% of all strokes with high morbidity and mortality; however, neuroendovascular techniques such as ADAPT have recently revolutionized the clinical outcomes of these patients.1-3 Common underlying pathology in patients with BAO include intracranial atherosclerotic disease (ICAD) as well as thromboembolic origin.4 Basilar artery ICAD in a setting of acute stroke portends a poor prognosis and post-thrombectomy residual critical flow limiting stenosis treatment options, including balloon angioplasty with or without stent placement.5-7 We present a video illustration of neuroendovascular technique and challenges encountered when managing this pathology. Image at 5:42 reprinted with permission from Alawieh et al, Lessons learned over more than 500 stroke thrombectomies using ADAPT with increasing aspiration catheter size, Neurosurgery, 86(1), 2020, pp. 61-70, with permission from the Congress of Neurological Surgeons.1.
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Affiliation(s)
- Guilherme B F Porto
- Division of Neuroendovascular Surgery, Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mithun G Sattur
- Division of Neuroendovascular Surgery, Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sami Al Kasab
- Division of Neuroendovascular Surgery, Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro M Spiotta
- Division of Neuroendovascular Surgery, Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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26
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Stracke CP, Fiehler J, Meyer L, Thomalla G, Krause LU, Lowens S, Rothaupt J, Kim BM, Heo JH, Yeo LLL, Andersson T, Kabbasch C, Dorn F, Chapot R, Hanning U. Emergency Intracranial Stenting in Acute Stroke: Predictors for Poor Outcome and for Complications. J Am Heart Assoc 2020; 9:e012795. [PMID: 32122218 PMCID: PMC7335566 DOI: 10.1161/jaha.119.012795] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Stent‐retriever thrombectomy is the first‐line therapy in acute stroke with intracranial large vessel occlusion. In case of failure of stent‐retriever thrombectomy, rescue stent angioplasty might be the only treatment option to achieve permanent recanalization. This study aims at identifying predictors for poor outcome and complications in a large, multicenter cohort receiving rescue stent angioplasty. Methods and Results We performed a retrospective analysis of patients with large vessel occlusion who were treated with rescue stent angioplasty after stent‐retriever thrombectomy between 2012 and 2018 in 7 neurovascular centers. We defined 2 binary outcomes: (1) functional clinical outcome (good modified Rankin Scale, 0–2; and poor modified Rankin Scale, 4–6) and (2) early symptomatic intracerebral hemorrhage. Impacts of clinical, radiological, and interventional parameters on outcomewere assessed in uni‐ and multivariable logistic regression models. Two hundred ten patients were included with target vessels located within the anterior circulation (136 of 210; 64.8%) and posterior circulation (74 of 210; 35.2%). Symptomatic intracerebral hemorrhage occured in 22 patients, 86.4% (19 of 22) after anterior and 13.6% (3 of 22) after posterior circulation large vessel occlusion. Good functional outcome was observed in 44.8% (73 of 163). A higher National Institutes of Health Stroke Scale on admission (adjusted odds ratio, 1.10; P=0.002), a higher premorbid modified Rankin Scale (adjusted odds ratio, 2.02; P=0.049), and a modified Thrombolysis in Cerebral Infarction score of 0 to 2a after stenting (adjusted odds ratio, 23.24; P<0.001) were independent predictors of poor functional outcome. Conclusions Use of rescue stent angioplasty can be considered for acute intracranial large vessel occlusion in cases after unsuccessful stent‐retriever thrombectomy. Likelihood of symptomatic intracerebral hemorrhage is higher in anterior circulation stroke.
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Affiliation(s)
- Christian Paul Stracke
- Department of Intracranial Endovascular Therapy Alfried-Krupp Krankenhaus Hospital Essen Germany.,Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Götz Thomalla
- Department of Neurology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Lars Udo Krause
- Department of Neurology Klinikum Osnabruck Osnabruck Germany
| | - Stephan Lowens
- Department of Radiology Klinikum Osnabruck Osnabruck Germany
| | - Jan Rothaupt
- Department of Radiology Klinikum Osnabruck Osnabruck Germany
| | - Byung Moon Kim
- Department of Radiology Interventional Neuroradiology Severance Stroke Center Severance Hospital Yonsei University College of Medicine Seoul South Korea
| | - Ji Hoe Heo
- Department of Neurology Severance Stroke Center Severance Hospital Yonsei University College of Medicine Seoul South Korea
| | - Leonard L L Yeo
- Department of Neuroradiology Karolinska University Hospital Stockholm Sweden.,Department of Clinical Neuroscience Karolinska Institutet Stockholm Sweden.,Division of Neurology Department of Medicine National University Health System Singapore
| | - Tommy Andersson
- Department of Neuroradiology Karolinska University Hospital Stockholm Sweden.,Department of Clinical Neuroscience Karolinska Institutet Stockholm Sweden.,Department Medical Imaging AZ Groeninge Kortrijk Belgium
| | | | - Franziska Dorn
- Department of Neuroradiology University Hospital of Munich Germany
| | - Rene Chapot
- Department of Intracranial Endovascular Therapy Alfried-Krupp Krankenhaus Hospital Essen Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
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