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Rodrigo-Gisbert M, Hoferica M, García-Tornel A, Requena M, Rubiera M, Lascuevas MDD, Olivé-Gadea M, Diana F, Rizzo F, Muchada M, Carmona T, Rodriguez-Villatoro N, Rodríguez-Luna D, Juega J, Pagola J, Hernández D, Molina CA, Tomasello A, Cognard C, Ribó M. Stent Retriever AssIsted Lysis Technique with Tirofiban: A Potential Bailout Alternative to Angioplasty and Stenting. AJNR Am J Neuroradiol 2024:ajnr.A8374. [PMID: 38849135 DOI: 10.3174/ajnr.a8374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 05/29/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND AND PURPOSE Angioplasty and stent placement have been described as a bailout technique in individuals with failed thrombectomy. We aimed to investigate Stent retriever AssIsted Lysis (SAIL) with tirofiban before angioplasty and stent placement. MATERIALS AND METHODS Patients from 2 comprehensive stroke centers were reviewed (2020-2023). We included patients with failed thrombectomy and/or underlying intracranial stenosis who received SAIL with tirofiban before the intended angioplasty and stent placement. SAIL consisted of deploying a stent retriever through the occluding lesion to create a bypass channel and infuse 10 mL of tirofiban for 10 minutes either intra-arterially or IV. The stent retriever was re-sheathed before retrieval. The primary end points were successful reperfusion (expanded TICI 2b-3) and symptomatic intracerebral hemorrhage. Additional end points included 90-day mRS 0-2 and mortality. RESULTS After a median of 3 (interquartile range, 2-4) passes, 44 patients received the SAIL bridging protocol with tirofiban, and later they were considered potential candidates for angioplasty and stent placement bailout (43.2%, intra-arterial SAIL). Post-SAIL successful reperfusion was obtained in 79.5%. A notable residual stenosis (>50%) after successful SAIL was observed in 45.7%. No significant differences were detected according to post-SAIL: successful reperfusion (intra-arterial SAIL, 80.0% versus IV-SAIL, 78.9%; P = .932), significant stenosis (33.3% versus 55.0%; P = .203), early symptomatic re-occlusion (0% versus 8.0%; P = .207), or symptomatic intracerebral hemorrhage (5.3% versus 8.0%; P = .721). Rescue angioplasty and stent placement were finally performed in 15 (34.1%) patients (intra-arterial SAIL 21.0% versus IV-SAIL 44%; P = .112). At 90 days, mRS 0-2 (intra-arterial SAIL 50.0% versus IV-SAIL 43.5%; P = .086) and mortality (26.3% versus 12.0%; P = .223) were also similar. CONCLUSIONS In patients with stroke in which angioplasty and stent placement are considered, SAIL with tirofiban, either intra-arterial or IV, seems to safely induce sustained recanalization, offering a potential alternative to definitive angioplasty and stent placement.
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Affiliation(s)
- Marc Rodrigo-Gisbert
- From the Stroke Unit, Department of Neurology (M.R.-G., A.G.-T., M. Requena, M. Rubiera, M.O.-G., F.R., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Matúš Hoferica
- Department of Diagnostic Neuroradiology (M.H., C.C.), Hôpital Purpan, Centre Hospitalier Universitaire, Toulouse, France
| | - Alvaro García-Tornel
- From the Stroke Unit, Department of Neurology (M.R.-G., A.G.-T., M. Requena, M. Rubiera, M.O.-G., F.R., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Requena
- From the Stroke Unit, Department of Neurology (M.R.-G., A.G.-T., M. Requena, M. Rubiera, M.O.-G., F.R., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neuroradiology (M. Requena, M.D.D.L., F.D., T.C., D.H., A.T.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marta Rubiera
- From the Stroke Unit, Department of Neurology (M.R.-G., A.G.-T., M. Requena, M. Rubiera, M.O.-G., F.R., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marta De Dios Lascuevas
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neuroradiology (M. Requena, M.D.D.L., F.D., T.C., D.H., A.T.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marta Olivé-Gadea
- From the Stroke Unit, Department of Neurology (M.R.-G., A.G.-T., M. Requena, M. Rubiera, M.O.-G., F.R., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francesco Diana
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neuroradiology (M. Requena, M.D.D.L., F.D., T.C., D.H., A.T.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Federica Rizzo
- From the Stroke Unit, Department of Neurology (M.R.-G., A.G.-T., M. Requena, M. Rubiera, M.O.-G., F.R., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marian Muchada
- From the Stroke Unit, Department of Neurology (M.R.-G., A.G.-T., M. Requena, M. Rubiera, M.O.-G., F.R., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Tomás Carmona
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neuroradiology (M. Requena, M.D.D.L., F.D., T.C., D.H., A.T.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Noelia Rodriguez-Villatoro
- From the Stroke Unit, Department of Neurology (M.R.-G., A.G.-T., M. Requena, M. Rubiera, M.O.-G., F.R., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Rodríguez-Luna
- From the Stroke Unit, Department of Neurology (M.R.-G., A.G.-T., M. Requena, M. Rubiera, M.O.-G., F.R., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jesus Juega
- From the Stroke Unit, Department of Neurology (M.R.-G., A.G.-T., M. Requena, M. Rubiera, M.O.-G., F.R., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jorge Pagola
- From the Stroke Unit, Department of Neurology (M.R.-G., A.G.-T., M. Requena, M. Rubiera, M.O.-G., F.R., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Hernández
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neuroradiology (M. Requena, M.D.D.L., F.D., T.C., D.H., A.T.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos A Molina
- From the Stroke Unit, Department of Neurology (M.R.-G., A.G.-T., M. Requena, M. Rubiera, M.O.-G., F.R., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alejandro Tomasello
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neuroradiology (M. Requena, M.D.D.L., F.D., T.C., D.H., A.T.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Christophe Cognard
- Department of Diagnostic Neuroradiology (M.H., C.C.), Hôpital Purpan, Centre Hospitalier Universitaire, Toulouse, France
| | - Marc Ribó
- From the Stroke Unit, Department of Neurology (M.R.-G., A.G.-T., M. Requena, M. Rubiera, M.O.-G., F.R., M.M., N.R.-V., D.R.-L., J.J., J.P., C.A.M., M.R.), Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Department de Medicina (M.R.-G, A.G.-T., M. Requena, M. Rubiera, M.D.D.L., M.O.-G., F.D., F.R., M.M., T.C., N.R.-V., D.R.-L., J.J., J.P., D.H., C.A.M., A.T., M.R.), Universitat Autònoma de Barcelona, Barcelona, Spain
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Rodriguez-Calienes A, Siddiqui FM, Galecio-Castillo M, Mohammaden MH, Dolia JN, Grossberg JA, Pabaney A, Hassan AE, Tekle WG, Saei H, Miller S, Majidi S, T Fifi J, Valestin G, Siegler JE, Penckofer M, Zhang L, Sheth SA, Salazar-Marioni S, Iyyangar A, Nguyen TN, Abdalkader M, Linfante I, Dabus G, Mehta BP, Sessa J, Jumma MA, Sugg RM, Linares G, Nogueira RG, Liebeskind DS, Haussen DC, Ortega-Gutierrez S. Rescue Therapy for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: A Pooled Analysis of the Society of Vascular and Interventional Neurology Registry. Ann Neurol 2024; 96:343-355. [PMID: 38752428 DOI: 10.1002/ana.26967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE We aimed to evaluate the association between rescue therapy (RT) and functional outcomes compared to medical management (MM) in patients presenting after failed mechanical thrombectomy (MT). METHODS This cross-sectional study utilized prospectively collected and maintained data from the Society of Vascular and Interventional Neurology Registry, spanning from 2011 to 2021. The cohort comprised patients with large vessel occlusions (LVOs) with failed MT. The primary outcome was the shift in the degree of disability, as gauged by the modified Rankin Scale (mRS) at 90 days. Additional outcomes included functional independence (90-day mRS score of 0-2), symptomatic intracranial hemorrhage (sICH), and 90-day mortality. RESULTS Of a total of 7,018 patients, 958 presented failed MT and were included in the analysis. The RT group comprised 407 (42.4%) patients, and the MM group consisted of 551 (57.5%) patients. After adjusting for confounders, the RT group showed a favorable shift in the overall 90-day mRS distribution (adjusted common odds ratio = 1.79, 95% confidence interval [CI] = 1.32-2.45, p < 0.001) and higher rates of functional independence (RT: 28.8% vs MM: 15.7%, adjusted odds ratio [aOR] = 1.93, 95% CI = 1.21-3.07, p = 0.005) compared to the MM group. RT also showed lower rates of sICH (RT: 3.8% vs MM: 9.1%, aOR = 0.52, 95% CI = 0.28-0.97, p = 0.039) and 90-day mortality (RT: 33.4% vs MM: 45.5%, aOR = 0.61, 95% CI = 0.42-0.89, p = 0.009). INTERPRETATION Our findings advocate for the utilization of RT as a potential treatment strategy for cases of LVO resistant to first-line MT techniques. Prospective studies are warranted to validate these observations and optimize the endovascular approach for failed MT patients. ANN NEUROL 2024;96:343-355.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Neuroscience, Clinical Effectiveness, and Public Health Research Group, Universidad Cientifica del Sur, Lima, Peru
| | - Fazeel M Siddiqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Mahmoud H Mohammaden
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jaydevsinh N Dolia
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Aqueel Pabaney
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Wondwossen G Tekle
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Hamzah Saei
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Samantha Miller
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Shahram Majidi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johana T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gabrielle Valestin
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Mary Penckofer
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Linda Zhang
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Sunil A Sheth
- Department of Neurology, Radiology, University of Texas Health McGovern Medical School, Houston, TX, USA
| | - Sergio Salazar-Marioni
- Department of Neurology, Radiology, University of Texas Health McGovern Medical School, Houston, TX, USA
| | - Ananya Iyyangar
- Department of Neurology, Radiology, University of Texas Health McGovern Medical School, Houston, TX, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Mohamad Abdalkader
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Italo Linfante
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, FL, USA
| | - Guilherme Dabus
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, FL, USA
| | | | - Joy Sessa
- Memorial Neuroscience Institute, Pembroke Pines, FL, USA
| | | | - Rebecca M Sugg
- University of South Alabama Medical Center, Mobile, AL, USA
| | | | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Diogo C Haussen
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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Mierzwa AT, Al Kasab S, Nelson A, Gutierrez SO, Vivanco-Suarez J, Farooqui M, Jadhav AP, Desai S, Toth G, Alrohimi A, Nguyen TN, Klein P, Abdalkader M, Salahuddin H, Pandey A, Koduri S, Wilseck Z, Vora N, Aladamat N, Gharaibeh K, Afreen E, Zaidi S, Jumaa M. Thrombectomy Outcomes in Acute Basilar Artery Occlusions Due to Intracranial Atherosclerotic Disease. Neurosurgery 2024:00006123-990000000-01224. [PMID: 38904392 DOI: 10.1227/neu.0000000000003035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/05/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intracranial atherosclerotic disease (ICAD) large vessel occlusion (LVO) is responsible for up to 30% of LVO. In this study, we aimed to determine the likelihood of favorable functional outcomes (modified Rankin Scale 0-3) in acute ICAD-LVO basilar occlusion compared with embolic basilar occlusion. METHODS This is an analysis of the Posterior Circulation Ischemic Stroke Evaluation: Analyzing Radiographic and Intraprocedural Predictors for Mechanical Thrombectomy Registry in which patients with acute basilar artery occlusions from 8 comprehensive stroke centers were included from 2015 to 2021. Patients were dichotomized into with (ICAD-LVO) or without underlying ICAD (embolic). Descriptive statistics for each group and multivariate logistic analysis were performed on the primary outcome. RESULTS Three hundred forty-six patients were included. There were 215 patients with embolic (62%) and 131 patients with ICAD-LVO (38%). Baseline demographics were equivalent between the 2 groups except for sex (male 47% vs 67%; P < .001), history of stroke (12% vs 25%; P = .002), and atrial fibrillation (31% vs 17%; P = .003). At 90 days, patients in the ICAD-LVO cohort were less likely to achieve favorable functional outcomes (odds ratio [OR] 0.41, 95% CI 0.22-0.72; P = .003) after adjusting for potentially confounding factors. In addition, ICAD-LVO strokes were less likely to achieve thrombolysis in cerebral infarction ≥2b (OR 0.29, 95% CI 0.14-0.57; P < .001). ICAD-LVO lesions were more likely to require stent placement (OR 14.94, 95% CI 4.91-45.49; P < .001). Subgroup analysis demonstrated favorable functional outcomes in patients who underwent stenting and angioplasty compared with failed recanalization cohort (OR 4.96, 95% CI 1.68-14.64; P < .004). CONCLUSION Patients with acute basilar ICAD-LVO have higher morbidity and mortality compared with patients with embolic source. Lower rates of successful recanalization in the ICAD-LVO cohort support this finding. Our subgroup analysis demonstrates that stenting should be considered in patients with recanalization failure. Rates of symptomatic intracranial hemorrhage were similar between the ICAD-LVO and embolic cohorts.
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Affiliation(s)
- Adam T Mierzwa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
- Department of Neurology, Promedica Stroke Network, Toledo, Ohio, USA
| | - Sami Al Kasab
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ashley Nelson
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Juan Vivanco-Suarez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa City, Iowa, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Shashvat Desai
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anas Alrohimi
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston University Chobanian & Avedisian School of Medicine, Massachusetts, USA
| | - Piers Klein
- Department of Neurology, Radiology, Boston University Chobanian & Avedisian School of Medicine, Massachusetts, USA
| | - Mohamad Abdalkader
- Department of Neurology, Radiology, Boston University Chobanian & Avedisian School of Medicine, Massachusetts, USA
| | - Hisham Salahuddin
- Department of Neurology, Antelope Valley Hospital, Los Angeles, California, USA
| | - Aditya Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Zachary Wilseck
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Nirav Vora
- Department of Neurology, Ohio Health Riverside Methodist Hospital, Columbus, Ohio, USA
| | - Nameer Aladamat
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
| | - Khaled Gharaibeh
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
| | - Ehad Afreen
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
- Department of Neurology, Promedica Stroke Network, Toledo, Ohio, USA
| | - Syed Zaidi
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
- Department of Neurology, Promedica Stroke Network, Toledo, Ohio, USA
| | - Mouhammad Jumaa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
- Department of Neurology, Promedica Stroke Network, Toledo, Ohio, USA
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Zhang L, Xue H, Bu X, Liao J, Tang G, Chen Y, Zhao L, Yang D, Liu L, Liu S. Patchy profile sign in RAPID software: a specific marker for intracranial atherosclerotic stenosis in acute ischemic stroke. Front Neurol 2024; 15:1414959. [PMID: 38872825 PMCID: PMC11169934 DOI: 10.3389/fneur.2024.1414959] [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: 04/09/2024] [Accepted: 05/17/2024] [Indexed: 06/15/2024] Open
Abstract
Purpose Identifying the etiology of acute ischemic stroke (AIS) before endovascular treatment (EVT) is important but challenging. In CT perfusion imaging processed by perfusion software, we observed a phenomenon called patchy profile sign (PPS), that is, the hypoperfusion morphology in RAPID software is a discontinuous sheet pattern. This phenomenon is predominantly observed in patients diagnosed with intracranial atherosclerotic stenosis (ICAS). The study intends to assess whether the PPS can be used to differentiate ICAS from intracranial embolism. Method Patients with AIS due to M1 segment occlusion of the MCA who underwent mechanical thrombectomy were retrospectively enrolled. The receiver operating characteristic (ROC) curve analysis was performed to assess the value of PPS in predicting ICAS. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the PPS for prediction of ICAS were calculated. Results A total of 51 patients were included in the study. The PPS was observed in 10 of 19 (52.6%) patients with ICAS, and in 2 of 32 (6.3%) patients with intracranial embolism (p < 0.001). Interobserver agreement for identifying PPS was excellent (κ = 0.944). The sensitivity, specificity, PPV, NPV, and accuracy of the PPS for predicting ICAS were 52.6, 93.8, 83.3, 76.9, and 78.4%, respectively. Conclusion The PPS on RAPID software is an imaging marker with high specificity for ICAS. Larger sample sizes are imperative to validate the findings.
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Affiliation(s)
- Lingwen Zhang
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Hua Xue
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoqing Bu
- Department of Epidemiology, School of Public Health, Chongqing Medical University, Chongqing, China
| | - Juan Liao
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Ge Tang
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Chen
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Libo Zhao
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Deyu Yang
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Li Liu
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Department of Health Management, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Shudong Liu
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
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5
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Lin H, Shen H, Wang N, Wu T. Monocyte to high-density lipoprotein ratio as an independent predictor of intracranial atherosclerotic stenosis-related emergency large vessel occlusion. Clin Neurol Neurosurg 2024; 239:108228. [PMID: 38460429 DOI: 10.1016/j.clineuro.2024.108228] [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: 09/24/2023] [Revised: 02/19/2024] [Accepted: 03/02/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVE To evaluate the correlation between the monocyte-to-high-density lipoprotein cholesterol ratio (MHR) and intracranial atherosclerotic stenosis-related emergent large vessel occlusion (ICAS-ELVO) in acute ischemic stroke patients with endovascular thrombectomy. METHODS Included in this study were 215 patients who underwent endovascular thrombectomy. They were randomly assigned to training and testing datasets. The patients in training dataset (n=128) were divided into ICAS group (n=65) and embolism group (n=63). MHR was compared between the two groups. According to the cut-off value, patients in testing dataset (n=87) were divided into low-MHR group (n=54) and high-MHR group (n=33). MHR was compared between the two groups. RESULTS In training dataset, the proportion of male patients, diabetic patients and smokers in ICAS group was significantly higher than that in embolism group [(50 (76.9%) vs. 30 (47.6%), P=0.001; 29 (44.6%) vs. 14(22.2%), P=0.007; 37(56.9%) vs. 14 (22.2%), P=0.001; 37 (56.9%) vs. 14 (22.2%), P=0.001], while the mean age and the proportion of patients with coronary heart disease (CHD), stroke and atrial fibrillation were significantly lower [(64.74±9.13 vs. 71.38±13.34, P=0.001; 6 (9.2%) vs. 14 (22.2%), P=0.043; 12 (18.5%) vs. 22 (34.9%), P=0.035; 5 (7.7%)vs. 56 (88.9%), P<0.001)]. The laboratory test results showed that monocyte count was significantly higher and high-density lipoprotein level was significantly lower in ICAS group than those in embolism group (0.61±0.26 vs. 0.45±0.13, P=0.001; 1.17±0.28 vs. 1.37±0.27, P=0.001). MHR in ICAS group was significantly higher than that in embolism group (0.55±0.26 vs. 0.34±0.11, P=0.001). In training set, MHR was found to be an independent predictor for the occurrence of ICAS-ELVO with an adjusted OR of 2.39 (95%CI 1.29-4.48, P=0.006). ROC curve analysis showed that the area under the curve (AUC) of MHR was 0.8 (95% CI, 0.72-0.87, p < 0.001), with a sensitivity of 0.60 and a specificity of 0.873. The optimal cut-off value of the MHR level was 0.46. In testing dataset, the rate of ICAS-ELVO in higher quartile was significantly higher than that in the lower quartile (81.8% vs. 33.3%, P<0.001). Patients with a low MHR had a higher rate of cerebral hemorrhagic than those with a high MHR. CONCLUSION MHR was associated with ICAS-ELVO in acute ischemic stroke patients with endovascular thrombectomy, and the higher level of MHR does benefit to differentiate ICAS from intracranial embolism, suggesting that MHR may prove to be an independent predictor for ICAS-ELVO.
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Affiliation(s)
- Huangbin Lin
- Department of Neurology, The Fourth People's Hospital Affiliated to Tongji University, Shanghai, China.
| | - Hongjian Shen
- Neurovascular Center, Department of Neurology, Changhai Hospital, Naval Medical University, Shanghai, China.
| | - Nuo Wang
- Department of Neurology, Changhai Hospital, Naval Medical University, Shanghai, China.
| | - Tao Wu
- Neurovascular Center, Department of Neurology, Changhai Hospital, Naval Medical University, Shanghai, China.
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6
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Sakuta K, Yaguchi H, Nakada R, Miyagawa S, Hasegawa I, Okuno K, Teshigawara A, Fuga M, Shimizu K, Iguchi Y. Yield of Whole Body Computed Tomography in Hyper-Acute Stroke Patients With Large Vessel Occlusion. Vasc Endovascular Surg 2024; 58:287-293. [PMID: 37858317 DOI: 10.1177/15385744231209877] [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] [Indexed: 10/21/2023]
Abstract
PURPOSE In the majority of cases, large vessel occlusion (LVO) in ischemic stroke patients has an embolic origin. Systemic embolism can occur simultaneously with brain thrombosis. This retrospective study evaluated the frequency and locations of systemic embolism in LVO stroke patients receiving revascularization therapy. MATERIALS AND METHODS In our facility, we use contrast-enhanced computed tomography (CE-CT) to assess suspected stroke patients and routinely perform CE-CT from the chest to the abdomen after brain CT angiography to rule out contraindications like aortic dissection and trauma for thrombolysis. Systemic embolism is also assessed using these images, while myocardial infarction is evaluated based on electrocardiograms and laboratory findings. Other relevant clinical features of each patient are also analyzed. RESULTS In total, 612 consecutively admitted stroke patients and 32 LVO patients who underwent revascularization therapy were included in the present study. Systemic embolism was identified in four patients (13%). The spleen was the most commonly affected organ, followed by the heart, kidneys, limbs, and lungs. All four patients with systemic embolism exhibited LVO resulting from embolism as the underlying mechanism. CONCLUSION Systemic embolism was observed in 13% of our LVO patients, all of whom had LVO of embolic origin.
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Affiliation(s)
- Kenichi Sakuta
- Department of Neurology, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Hiroshi Yaguchi
- Department of Neurology, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Ryoji Nakada
- Department of Neurology, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Shinji Miyagawa
- Department of Neurology, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Izumu Hasegawa
- Department of Emergency Medicine, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Kenji Okuno
- Department of Emergency Medicine, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Akihiko Teshigawara
- Department of Neurosurgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Michiyasu Fuga
- Department of Neurosurgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Kanichiro Shimizu
- Department of Radiology, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan
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7
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Rodrigo-Gisbert M, García-Tornel A, Requena M, Vielba-Gómez I, Bashir S, Rubiera M, De Dios Lascuevas M, Olivé-Gadea M, Piñana C, Rizzo F, Muchada M, Rodriguez-Villatoro N, Rodríguez-Luna D, Juega J, Pagola J, Hernández D, Molina CA, Terceño M, Tomasello A, Ribo M. Clinico-radiological features of intracranial atherosclerosis-related large vessel occlusion prior to endovascular treatment. Sci Rep 2024; 14:2945. [PMID: 38316891 PMCID: PMC10844212 DOI: 10.1038/s41598-024-53354-z] [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] [Received: 09/15/2023] [Accepted: 01/31/2024] [Indexed: 02/07/2024] Open
Abstract
The identification of large vessel occlusion with underlying intracranial atherosclerotic disease (ICAS-LVO) before endovascular treatment (EVT) continues to be a challenge. We aimed to analyze baseline clinical-radiological features associated with ICAS-LVO that could lead to a prompt identification. We performed a retrospective cross-sectional study of consecutive patients with stroke treated with EVT from January 2020 to April 2022. We included anterior LVO involving intracranial internal carotid artery and middle cerebral artery. We analyzed baseline clinical and radiological variables associated with ICAS-LVO and evaluated the diagnostic value of a multivariate logistic regression model to identify ICAS-LVO before EVT. ICAS-LVO was defined as presence of angiographic residual stenosis or a trend to re-occlusion during EVT procedure. A total of 338 patients were included in the study. Of them, 28 patients (8.3%) presented with ICAS-LVO. After adjusting for confounders, absence of atrial fibrillation (OR 9.33, 95% CI 1.11-78.42; p = 0.040), lower hypoperfusion intensity ratio (HIR [Tmax > 10 s/Tmax > 6 s ratio], (OR 0.69, 95% CI 0.50-0.95; p = 0.025), symptomatic intracranial artery calcification (IAC, OR .15, 95% CI 1.64-26.42, p = 0.006), a more proximal occlusion (ICA, MCA-M1: OR 4.00, 95% CI 1.23-13.03; p = 0.021), and smoking (OR 2.91, 95% CI 1.08-7.90; p = 0.035) were associated with ICAS-LVO. The clinico-radiological model showed an overall well capability to identify ICAS-LVO (AUC = 0.88, 95% CI 0.83-0.94; p < 0.001). In conclusion, a combination of clinical and radiological features available before EVT can help to identify an ICAS-LVO. This approach could be useful to perform a rapid assessment of underlying etiology and suggest specific pathophysiology-based measures. Prospective studies are needed to validate these findings in other populations.
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Affiliation(s)
- Marc Rodrigo-Gisbert
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alvaro García-Tornel
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Isabel Vielba-Gómez
- Stroke Unit, Department of Neurology, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Saima Bashir
- Stroke Unit, Department of Neurology, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Marta Olivé-Gadea
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Piñana
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Federica Rizzo
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marian Muchada
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Noelia Rodriguez-Villatoro
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Rodríguez-Luna
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jesus Juega
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jorge Pagola
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Hernández
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mikel Terceño
- Stroke Unit, Department of Neurology, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Alejandro Tomasello
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Neuroradiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain.
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.
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8
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Al Kasab S, Nguyen TN, Derdeyn CP, Yaghi S, Amin-Hanjani S, Kicielinski K, Zaidat OO, de Havenon A. Emergent Large Vessel Occlusion due to Intracranial Stenosis: Identification, Management, Challenges, and Future Directions. Stroke 2024; 55:355-365. [PMID: 38252763 DOI: 10.1161/strokeaha.123.043635] [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: 08/01/2023] [Accepted: 10/12/2023] [Indexed: 01/24/2024]
Abstract
This comprehensive literature review focuses on acute stroke related to intracranial atherosclerotic stenosis (ICAS), with an emphasis on ICAS-large vessel occlusion. ICAS is the leading cause of stroke globally, with high recurrence risk, especially in Asian, Black, and Hispanic populations. Various risk factors, including hypertension, diabetes, hyperlipidemia, smoking, and advanced age lead to ICAS, which in turn results in stroke through different mechanisms. Recurrent stroke risk in patients with ICAS with hemodynamic failure is particularly high, even with aggressive medical management. Developments in advanced imaging have improved our understanding of ICAS and ability to identify high-risk patients who could benefit from intervention. Herein, we focus on current management strategies for ICAS-large vessel occlusion discussed, including the use of perfusion imaging, endovascular therapy, and stenting. In addition, we focus on strategies that aim at identifying subjects at higher risk for early recurrent risk who could benefit from early endovascular intervention The review underscores the need for further research to optimize ICAS-large vessel occlusion treatment strategies, a traditionally understudied topic.
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Affiliation(s)
- Sami Al Kasab
- Department of Neurology (S.A.K.), Medical University of South Carolina, Charleston
- Department of Neurosurgery (S.A.K., K.K.), Medical University of South Carolina, Charleston
| | | | - Colin P Derdeyn
- Department of Radiology, Carver College of Medicine, Iowa City (C.P.D.)
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (S.Y.)
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, OH (S.A.-H.)
| | - Kimberly Kicielinski
- Department of Neurosurgery (S.A.K., K.K.), Medical University of South Carolina, Charleston
| | - Osama O Zaidat
- Department of Neurology, Mercy Health, Toledo, OH (O.O.Z.)
| | - Adam de Havenon
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, CT (A.d.H.)
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9
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Webb M, Essibayi MA, Al Kasab S, Maier IL, Psychogios MN, Grossberg JA, Alawieh A, Wolfe SQ, Arthur A, Dumont T, Kan P, Kim JT, De Leacy R, Osbun J, Rai A, Jabbour P, Park MS, Crosa R, Levitt MR, Polifka A, Yoshimura S, Matouk C, Williamson RW, Fragata I, Chowdhry SA, Starke RM, Samaniego EA, Cuellar H, Spiotta A, Mascitelli J. Predictors of Angiographic Outcome After Failed Thrombectomy for Large Vessel Occlusion: Insights from the Stroke Thrombectomy and Aneurysm Registry. Neurosurgery 2023; 93:1168-1179. [PMID: 37377425 DOI: 10.1227/neu.0000000000002560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 04/17/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Mechanical thrombectomy failure (MTF) occurs in approximately 15% of cases. OBJECTIVE To investigate factors that predict MTF. METHODS This was a retrospective review of prospectively collected data from the Stroke Thrombectomy and Aneurysm Registry. Patients who underwent mechanical thrombectomy (MT) for large vessel occlusion (LVO) were included. Patients were categorized by mechanical thrombectomy success (MTS) (≥mTICI 2b) or MTF ( RESULTS A total of 6780 patients were included, and 1001 experienced anterior circulation MTF. Patients in the MTF group were older (73 vs 72, P = .044) and had higher poor premorbid modified Rankin Scale (mRS) (10.8% vs 8.4%, P = .017). Onset to puncture time was greater in the MTF group (273 vs 260 min, P = .08). No significant differences were found between the access site, use of balloon guide catheter, frontline technique, or first-pass devices between the MTF and MTS groups. More complications occurred in the MTF group (14% vs 5.8%), including symptomatic intracerebral hemorrhage (9.4% vs 6.1%) and craniectomies (10% vs 2.8%) ( P < .001). On UVA, age, poor pretreatment mRS, increased number of passes, and increased procedure time were associated with MTF. Internal carotid artery, M1, and M2 occlusions had decreased odds of MTF. Poor preprocedure mRS, number of passes, and procedure time remained significant on MVA. A subgroup analysis of posterior circulation LVO revealed that number of passes and total procedure time correlated with increased odds of MTF ( P < .001) while rescue stenting was associated with less odds of MTF (odds ratio 0.20, 95% CI 0.06-0.63). Number of passes remained significant on MVA of posterior circulation occlusion subgroup analysis. CONCLUSION Anterior circulation MTF is associated with more complications and worse outcomes. No differences were found between techniques or devises used for the first pass during MT. Rescue intracranial stenting may decrease the likelihood of MTF for posterior circulation MT.
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Affiliation(s)
- Matthew Webb
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
| | | | - Sami Al Kasab
- Medical University of South Carolina, Charleston , South Carolina , USA
| | - Ilko L Maier
- University Medical Center Göttingen, Göttingen , Germany
| | | | | | | | | | - Adam Arthur
- University of Tennessee Health Science Center, Memphis , Tennessee , USA
| | - Travis Dumont
- Bannner University of Arizona Medical Center, Tucson , Arizona , USA
| | - Peter Kan
- University of Texas Medical Branch, Galveston , Texas , USA
| | - Joon-Tae Kim
- Chonnam National University Hospital, Gwangju , South Korea
| | | | - Joshua Osbun
- Washington University in St. Louis, St. Louis , Missouri , USA
| | - Ansaar Rai
- Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Pascal Jabbour
- Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Min S Park
- Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Roberto Crosa
- University of Virginia, Charlottesville , Virginia , USA
| | - Michael R Levitt
- Centro Endovascular Neurológico, Médica Uruguaya, Montevideo , Uruguay
| | - Adam Polifka
- University of Washington, Seattle , Washington , USA
| | | | | | | | - Isabel Fragata
- Allegheny General Hospital, Pittsburgh , Pennsylvania , USA
| | | | - Robert M Starke
- NorthShore University Health System, Evanston , Illinois , USA
| | | | | | - Alejandro Spiotta
- Medical University of South Carolina, Charleston , South Carolina , USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
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10
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Mohammaden MH, Haussen DC, Al-Bayati AR, Hassan AE, Tekle W, Fifi JT, Matsoukas S, Kuybu O, Gross BA, Lang M, Narayanan S, Cortez GM, Hanel RA, Aghaebrahim A, Sauvageau E, Farooqui M, Ortega-Gutierrez S, Zevallos CB, Galecio-Castillo M, Sheth SA, Nahhas M, Salazar-Marioni S, Nguyen TN, Abdalkader M, Klein P, Hafeez M, Kan P, Tanweer O, Khaldi A, Li H, Jumaa M, Zaidi SF, Oliver M, Salem MM, Burkhardt JK, Pukenas B, Kumar R, Lai M, Siegler JE, Peng S, Alaraj A, Nogueira RG. General anesthesia vs procedural sedation for failed NeuroThrombectomy undergoing rescue stenting: intention to treat analysis. J Neurointerv Surg 2023; 15:e240-e247. [PMID: 36597943 DOI: 10.1136/jnis-2022-019376] [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: 07/11/2022] [Accepted: 10/16/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is little data available to guide optimal anesthesia management during rescue intracranial angioplasty and stenting (ICAS) for failed mechanical thrombectomy (MT). We sought to compare the procedural safety and functional outcomes of patients undergoing rescue ICAS for failed MT under general anesthesia (GA) vs non-general anesthesia (non-GA). METHODS We searched the data from the Stenting and Angioplasty In Neuro Thrombectomy (SAINT) study. In our review we included patients if they had anterior circulation large vessel occlusion strokes due to intracranial internal carotid artery (ICA) or middle cerebral artery (MCA-M1/M2) segments, failed MT, and underwent rescue ICAS. The cohort was divided into two groups: GA and non-GA. We used propensity score matching to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included functional independence (90-day mRS0-2) and successful reperfusion defined as mTICI2B-3. Safety measures included symptomatic intracranial hemorrhage (sICH) and 90-day mortality. RESULTS Among 253 patients who underwent rescue ICAS, 156 qualified for the matching analysis at a 1:1 ratio. Baseline demographic and clinical characteristics were balanced between both groups. Non-GA patients had comparable outcomes to GA patients both in terms of the overall degree of disability (mRS ordinal shift; adjusted common odds ratio 1.29, 95% CI [0.69 to 2.43], P=0.43) and rates of functional independence (33.3% vs 28.6%, adjusted odds ratio 1.32, 95% CI [0.51 to 3.41], P=0.56) at 90 days. Likewise, there were no significant differences in rates of successful reperfusion, sICH, procedural complications or 90-day mortality among both groups. CONCLUSIONS Non-GA seems to be a safe and effective anesthesia strategy for patients undergoing rescue ICAS after failed MT. Larger prospective studies are warranted for more concrete evidence.
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Affiliation(s)
- Mahmoud H Mohammaden
- Neurology, Emory University, Atlanta, Georgia, USA
- Marcus Stroke and Neuroscience center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Diogo C Haussen
- Neurology, Emory University, Atlanta, Georgia, USA
- Marcus Stroke and Neuroscience center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | | | - Ameer E Hassan
- Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Wondwossen Tekle
- Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stavros Matsoukas
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Okkes Kuybu
- Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
| | | | - Michael Lang
- Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | | | - Gustavo M Cortez
- Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Amin Aghaebrahim
- Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Mudassir Farooqui
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Santiago Ortega-Gutierrez
- Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Cynthia B Zevallos
- Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Sunil A Sheth
- Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Michael Nahhas
- Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | | | - Thanh N Nguyen
- Neurology and Radiology, Boston University School of Medicine, Boston, MA, USA
| | | | - Piers Klein
- Neurology and Radiology, Boston University School of Medicine, Boston, MA, USA
| | - Muhammad Hafeez
- Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | | | - Ahmad Khaldi
- Neurosurgery, WellStar Health System, Marietta, Georgia, USA
| | - Hanzhou Li
- Department of Neurosciences, WellStar Health System, Marietta, Georgia, USA
| | - Mouhammad Jumaa
- Neurology, The University of Toledo Medical Center, Toledo, Ohio, USA
| | - Syed F Zaidi
- Neurology, The University of Toledo Medical Center, Toledo, Ohio, USA
| | - Marion Oliver
- Neurology, The University of Toledo Medical Center, Toledo, Ohio, USA
| | - Mohamed M Salem
- Neurosurgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Neurosurgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Bryan Pukenas
- Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rahul Kumar
- Cooper Hospital University Medical Center, Camden, New Jersey, USA
| | - Michael Lai
- Cooper Hospital University Medical Center, Camden, New Jersey, USA
| | - James E Siegler
- Cooper Hospital University Medical Center, Camden, New Jersey, USA
| | - Sophia Peng
- Neurosurgery, University of Illinois Medical Center at Chicago, Chicago, Illinois, USA
| | - Ali Alaraj
- Neurosurgery, University of Illinois Medical Center at Chicago, Chicago, Illinois, USA
| | - Raul G Nogueira
- Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
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11
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Ahmed R, Maqsood H, Bains RS, Gulraiz A, Kamal M. Intracranial atherosclerotic disease: current management strategies. Ann Med Surg (Lond) 2023; 85:4903-4908. [PMID: 37811034 PMCID: PMC10552953 DOI: 10.1097/ms9.0000000000001145] [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: 06/30/2023] [Accepted: 08/01/2023] [Indexed: 10/10/2023] Open
Abstract
A stroke due to underlying intracranial large artery occlusion, which is atherosclerotic in nature, is known as intracranial atherosclerotic disease (ICAD). It is important to recognize that ischaemic stroke due to ICAD differs from extracranial disease and other stroke aetiologies and requires a nuanced approach. It is a significant cause of stroke worldwide, and severe symptomatic ICAD can present challenges from a therapeutic standpoint, including recurrent ischaemic stroke despite optimal management. Furthermore, exploring the underlying pathophysiological mechanisms responsible for the disease may be necessary while considering treatment options. This narrative review aims to provide an all-encompassing overview of this disease. Epidemiology and clinical pathophysiology will be explored in detail. The findings of large clinical trials will serve as a guide to finding the most optimized management strategies. Another critical question that arises is the treatment of acute ischaemic stroke due to large vessel occlusion with underlying intracranial atherosclerosis, is the treatment and clinical diagnosis the same as for other aetiologies of stroke (i.e. extracranial disease and nonvalvular atrial fibrillation)? Consequently, secondary prevention of patients with ischaemic stroke or transient ischaemic attack will be divided into medical therapy, risk factor control, and endovascular and surgical treatment options.
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Affiliation(s)
| | | | | | | | - Meraj Kamal
- BP Koirala Institute of Health Sciences, Dharan-18, Nepal
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12
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Memon MZ, Ezzeldin M, Biswas A, Ahmad R, Nisar T, Singla A, Muhammad N, Shaltoni H, Kan P, Zaidat OO, Khandelwal P. Novel technique of stent placement via gateway balloon in intracranial atherosclerosis-associated large vessel occlusion. J Neuroimaging 2023; 33:773-780. [PMID: 37391866 DOI: 10.1111/jon.13139] [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: 03/12/2023] [Revised: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND AND PURPOSE Neuroform Atlas stent can be deployed directly via gateway balloon for angioplasty and stent placement without the need for exchange maneuver required for Wingspan stent use. We present our initial experience of this strategy in intracranial atherosclerosis-associated large vessel occlusions. METHODS Patients were identified through mechanical thrombectomy (MT) database from January 2020 to June 2022 at our institutions. Due to reocclusion or impending occlusion, rescue angioplasty with stent placement was performed after initial standard MT. Primary outcomes were good angiographic recanalization with modified thrombolysis in cerebral infarction (mTICI) score of 2b-3, rate of intracranial hemorrhage (ICH), and favorable functional outcome at 3 months, that is, modified Rankin Scale (mRS) score of 0-3. RESULTS We identified 22 patients treated using this technique. Among those, 11 were females with their average age at 66 years (range: 52-85). Initial median National Institute of Health Stroke Scale score was 11 (range: 5-30) and all patients received loading doses of aspirin and P2Y₁₂ inhibitor. After performing submaximal angioplasty and Neuroform Atlas stent deployment through the gateway balloon, we achieved final mTICI of 2b-3 in 20 (90%) patients. One patient had ICH post-op that was asymptomatic. Eight (36%) patients had mRS of 0-3 at 90 days. CONCLUSION Our preliminary experience suggests possible safety and feasibility of deploying Neuroform Atlas stent through a compatible Gateway balloon microcatheter without the need for ICH-associated microcatheter exchange. Further studies with long-term clinical and angiographic follow-up are warranted to corroborate our initial findings.
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Affiliation(s)
- Muhammad Zeeshan Memon
- Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Mohamad Ezzeldin
- Department of Clinical Sciences, College of Medicine, University of Houston, Houston, Texas, USA
| | - Arundhati Biswas
- Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - Rowaid Ahmad
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Taha Nisar
- Department of Neurology, University of South Alabama
| | - Amit Singla
- Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - Nazar Muhammad
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Hashem Shaltoni
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Peter Kan
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Osama O Zaidat
- Departments of Endovascular Neurosurgery and Stroke, St. Vincent Mercy Medical Center, Toledo, Ohio, USA
| | - Priyank Khandelwal
- Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
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13
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Thut MZ, Rhiner N, Thurner P, Madjidyar J, Schubert T, Wegener S, Globas C, Luft AR, Kulcsar Z. Stent reconstruction in intracranial atherosclerotic disease related acute ischemic stroke results in high revascularization rates. J Stroke Cerebrovasc Dis 2023; 32:107232. [PMID: 37453214 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107232] [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: 02/02/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVES Intracranial atherosclerotic disease (ICAD) is a major cause of large vessel occlusion (LVO) in acute ischemic stroke (AIS). Our study aimed to analyze the effect of percutaneous transluminal angioplasty and stenting (PTAS) in patients with ICAD undergoing rescue treatment in terms of functional outcome and mortality rate at 90 days and compare the results to LVO with thromboembolic origins. MATERIALS AND METHODS A retrospective review of a mechanical thrombectomy (MT) single center database from 01/2019 to 09/2021 was carried out using chart review and angiogram analysis. From 469 acute stroke patients, 361 patients were enroled in the study, of whom twenty-four (6.6%) were diagnosed with underlying ICAD and treated with angioplasty and stent reconstruction (PTAS) with a standardized medication protocol. Successful reperfusion, peri-procedural complications, and functional independence at 90 days were collected as outcomes. RESULTS There was no difference in age or admission National Institutes of Health Stroke Scale (NIHSS). Onset to groin puncture (median 460 vs 277 min, P = 0.019) was significantly longer in the ICAD group. The procedure time (median 73 vs 60 min, P = 0.137) did not differ. Successful reperfusion was achieved in 95.8% of ICAD and 91.1% of the remaining patients (P = 0.445). Functional independence (mRS ≤ 2) at 90 days was achieved in 45.8% (11/24) and 42.7% (144/337, (P = 0.767)). The mortality rates (mRS 6) at 90 days were similar (29.2% vs 29.4% (P = 0.983)). CONCLUSION Despite significantly longer treatment delays, the outcome and revascularization rates of ICAD patients were similar to the thromboembolic cohort. Our proposed protocol of PTAS and medication protocol in ICAD was effective with a similar safety profile as MT in general.
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Affiliation(s)
- Mara Z Thut
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Nadine Rhiner
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Patrick Thurner
- Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland
| | - Jawid Madjidyar
- Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland
| | - Tilman Schubert
- Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland
| | - Susanne Wegener
- Department of Neurology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 26, Zurich 8091, Switzerland
| | - Christoph Globas
- Department of Neurology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 26, Zurich 8091, Switzerland
| | - Andreas R Luft
- Department of Neurology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 26, Zurich 8091, Switzerland; Cerneo Center for Neurology and Rehabilitation, Seestrasse 18, Vitznau 6354, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, Clinical Neurocenter, University Hospital Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland.
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14
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Shindo K, Ishikawa K, Nomura R, Morishita M, Oka K, Nakamura H. Mechanical thrombectomy for middle cerebral artery occlusion caused by intracranial internal carotid artery stenosis: A case report. Radiol Case Rep 2023; 18:3054-3059. [PMID: 37434618 PMCID: PMC10331069 DOI: 10.1016/j.radcr.2023.05.070] [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: 02/27/2023] [Revised: 05/18/2023] [Accepted: 05/28/2023] [Indexed: 07/13/2023] Open
Abstract
Tandem internal carotid artery (ICA)/middle cerebral artery (MCA) occlusions are occasionally observed in patients with acute ischemic stroke. Most of them are caused by lesions at the origin of the ICA. In cases of intracranial ICA stenosis, the formation of a large thrombus causing MCA occlusion is extremely rare. Herein We report a case of acute MCA occlusion caused by intracranial ICA stenosis. A 62-year-old female presented with aphasia, right-side weakness, and a National Institute of Health Stroke Scale (NIHSS) score of 5. Magnetic resonance imaging (MRI) showed early ischemic infarction at the precentral gyrus. Left ICA and M1 occlusion were suspected on magnetic resonance angiography. However, the patient had complained of right-side numbness 6 days before the onset. Hence the stroke was assumed to have progressed slowly, and acute occlusion of the left ICA was eliminated as a suspected diagnosis. After admission, the symptoms worsened. MRI showed enlargement of the cerebral infarction. Computed tomography angiography showed complete occlusion of the left M1 and recanalization of the left ICA with severe stenosis of the petrous portion. The etiology of the MCA occlusion was determined to be atherothromboembolism. Percutaneous transluminal angioplasty (PTA) was performed for ICA stenosis, followed by mechanical thrombectomy (MT) for the MCA occlusion. Recanalization of the MCA was achieved. After Seven days, the NIHSS score reduced from a pre-MT assessment of 17-2. PTA followed by MT was safe and effective for treating MCA occlusion caused by intracranial ICA stenosis.
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Affiliation(s)
- Koichiro Shindo
- Department of Neurosurgery, Nakamura Memorial South Hospital, 2-3-1 Kawazoe 2-jo, Minami-ku, Sapporo, Hokkaido 005-8555, Japan
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido Japan
| | - Kohei Ishikawa
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido Japan
| | - Ryota Nomura
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido Japan
| | - Masahiro Morishita
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido Japan
| | - Koji Oka
- Department of Neurosurgery, Nakamura Memorial South Hospital, 2-3-1 Kawazoe 2-jo, Minami-ku, Sapporo, Hokkaido 005-8555, Japan
| | - Hirohiko Nakamura
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido Japan
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15
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Kasab SA, Nelson A, Fargen K, Nguyen T, Derdeyn C, Mokin M, Essibayi MA, Grandhi R, Zaidat OO, DeHavenon A. Management of intracranial arterial stenosis during mechanical thrombectomy: Survey of neuro-interventionalists. Interv Neuroradiol 2023:15910199231196618. [PMID: 37606564 DOI: 10.1177/15910199231196618] [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: 08/23/2023] Open
Abstract
BACKGROUND The optimal management of emergent large vessel occlusion due to underlying intracranial stenosis (intracranial stenosis related large vessel occlusion) remains unknown. The primary aim of this survey analysis was to measure variation in the clinical management of intracranial stenosis related large vessel occlusion during mechanical thrombectomy. METHODS A survey was designed using a web-based survey-building platform and distributed via the Society of NeuroInterventional Surgery (SNIS) and the Society of Vascular and Interventional Neurology (SVIN) websites for a response. Predictors of respondents' level of comfortability stenting were estimated using a binomial logistic regression model. RESULTS We received 105 responses to the survey. Most respondents (54.3%) practiced at an academic Stroke Center. Nearly half of the respondents (49%) had been practicing for 5 or more years independently after fellowship. An average of 54 mechanical thrombectomies were performed by each respondent annually. There was variation in the definition of intracranial stenosis related large vessel occlusion, number of passes performed before pursuing rescue stenting, as well as intra and post-procedural antiplatelet management. Of respondents, 58% felt rescue stenting was very risky, and 55.7% agreed that there was equipoise regarding emergent angioplasty and/or stenting versus medical therapy for intracranial stenosis related large vessel occlusion. Respondents who encountered intracranial stenosis related large vessel occlusion more frequently thought that rescue stenting was less risky. CONCLUSION There is notable variability in the diagnosis and management of intracranial stenosis related large vessel occlusion during mechanical thrombectomy. While most respondents felt rescue stenting was risky, the majority believed the benefit could outweigh the risk. The majority of respondents agreed that equipoise exists regarding the management of intracranial stenosis related large vessel occlusion, highlighting the need for clinical trials in this rare patient population.
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Affiliation(s)
- Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Ashley Nelson
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
| | - Kyle Fargen
- Department of Radiology, Wake Forest University, Winston-Salem, NC, USA
- Department of Neurosurgery, Wake Forest University, Winston-Salem, NC, USA
| | - Thanh Nguyen
- Department of Neurology, Boston Medical Center, Boston, MA, USA
- Department of Radiology, Boston Medical Center, Boston, MA, USA
| | - Colin Derdeyn
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
- Department of Radiology, University of Iowa, Iowa City, IA, USA
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
- Department of Neurology, University of South Florida, Tampa, FL, USA
| | | | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Osama O Zaidat
- Department of Neurology, Mercy Health-St. Vincent Medical Center, Toledo, OH, USA
| | - Adam DeHavenon
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
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16
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Kass-Hout T, Morsi RZ, Thind S, Karrison T, Lee H, Nahab F, Gupta R, Carrión-Penagos J, Awad IA, Coleman E, Brorson JR, McKoy C, Morales J, Mendelson S, Mansour A, Prabhakaran S. Underlying intracranial atherosclerotic disease is associated with worse outcomes in acute large vessel occlusion undergoing endovascular thrombectomy. J Stroke Cerebrovasc Dis 2023; 32:107227. [PMID: 37437522 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107227] [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: 12/24/2022] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Data on large vessel occlusion (LVO) management due to intracranial atherosclerotic disease (ICAD) are scarce. OBJECTIVE To compare clinical outcomes between patients with ICAD and those without ICAD following mechanical thrombectomy (MT). METHODS We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center, and compared in-hospital mortality, 90-day mortality, favorable functional outcome at 90 days, and symptomatic intracranial hemorrhage (ICH) using chi-squared tests and multivariate logistic regression analyses. We defined ICAD as observable plaque at occlusion site post-thrombectomy. RESULTS Among 215 patients (mean age 67.1 ± 16.0 years; 60.5% female; 83.6% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p = 0.027 and 29.0% vs. 14.7%, p = 0.035, respectively). Substantial reperfusion (TICI ≥2b) was achieved less often (84.2% vs. 94.4%, p = 0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p = 0.081). In-hospital and 90-day mortality were more common (36.8% vs. 15.8%, p = 0.003 and 52.6% vs. 26.6%, p = 0.002, respectively) and favorable functional outcome (mRS 0-2) at 90 days was less common (7.9% vs. 33.9%, p = 0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in-hospital mortality (OR=4.1, 95% CI 1.7-9.7), 90-day mortality (OR=3.7, 95% CI 1.6-8.6), and poor functional outcome at 90 days (OR=5.5, 95% CI 1.6-19.4). CONCLUSION Symptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT.
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Affiliation(s)
- Tareq Kass-Hout
- Assistant Professor of Neurology and Neurosurgery, Department of Neurology, University of Chicago, 5941 S Maryland Ave., MC 2030, Chicago, IL 60637-1470, United States.
| | - Rami Z Morsi
- Assistant Professor of Neurology and Neurosurgery, Department of Neurology, University of Chicago, 5941 S Maryland Ave., MC 2030, Chicago, IL 60637-1470, United States
| | - Sonam Thind
- Assistant Professor of Neurology and Neurosurgery, Department of Neurology, University of Chicago, 5941 S Maryland Ave., MC 2030, Chicago, IL 60637-1470, United States
| | - Theodore Karrison
- Department of Public Health Sciences, University of Chicago, Chicago, IL, United States
| | - Harrison Lee
- Assistant Professor of Neurology and Neurosurgery, Department of Neurology, University of Chicago, 5941 S Maryland Ave., MC 2030, Chicago, IL 60637-1470, United States
| | - Fadi Nahab
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Rishi Gupta
- Department of Neurosurgery, WellStar Health System, Marietta, GA, United States
| | - Julián Carrión-Penagos
- Assistant Professor of Neurology and Neurosurgery, Department of Neurology, University of Chicago, 5941 S Maryland Ave., MC 2030, Chicago, IL 60637-1470, United States
| | - Issam A Awad
- Neurovascular Surgery Program, Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, IL, United States
| | - Elisheva Coleman
- Assistant Professor of Neurology and Neurosurgery, Department of Neurology, University of Chicago, 5941 S Maryland Ave., MC 2030, Chicago, IL 60637-1470, United States
| | - James R Brorson
- Assistant Professor of Neurology and Neurosurgery, Department of Neurology, University of Chicago, 5941 S Maryland Ave., MC 2030, Chicago, IL 60637-1470, United States
| | - Cedric McKoy
- Assistant Professor of Neurology and Neurosurgery, Department of Neurology, University of Chicago, 5941 S Maryland Ave., MC 2030, Chicago, IL 60637-1470, United States
| | - Jacqueline Morales
- Assistant Professor of Neurology and Neurosurgery, Department of Neurology, University of Chicago, 5941 S Maryland Ave., MC 2030, Chicago, IL 60637-1470, United States
| | - Scott Mendelson
- Assistant Professor of Neurology and Neurosurgery, Department of Neurology, University of Chicago, 5941 S Maryland Ave., MC 2030, Chicago, IL 60637-1470, United States
| | - Ali Mansour
- Assistant Professor of Neurology and Neurosurgery, Department of Neurology, University of Chicago, 5941 S Maryland Ave., MC 2030, Chicago, IL 60637-1470, United States
| | - Shyam Prabhakaran
- Assistant Professor of Neurology and Neurosurgery, Department of Neurology, University of Chicago, 5941 S Maryland Ave., MC 2030, Chicago, IL 60637-1470, United States
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17
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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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18
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de Havenon A, Zaidat OO, Amin-Hanjani S, Nguyen TN, Bangad A, Abassi M, Anadani M, Almallouhi E, Chatterjee R, Mazighi M, Mistry E, Yaghi S, Derdeyn C, Hong KS, Kvernland A, Leslie-Mazwi T, Al Kasab S. Large Vessel Occlusion Stroke due to Intracranial Atherosclerotic Disease: Identification, Medical and Interventional Treatment, and Outcomes. Stroke 2023; 54:1695-1705. [PMID: 36938708 PMCID: PMC10202848 DOI: 10.1161/strokeaha.122.040008] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Large vessel occlusion stroke due to underlying intracranial atherosclerotic disease (ICAD-LVO) is prevalent in 10 to 30% of LVOs depending on patient factors such as vascular risk factors, race and ethnicity, and age. Patients with ICAD-LVO derive similar functional outcome benefit from endovascular thrombectomy as other mechanisms of LVO, but up to half of ICAD-LVO patients reocclude after revascularization. Therefore, early identification and treatment planning for ICAD-LVO are important given the unique considerations before, during, and after endovascular thrombectomy. In this review of ICAD-LVO, we propose a multistep approach to ICAD-LVO identification, pretreatment and endovascular thrombectomy considerations, adjunctive medications, and medical management. There have been no large-scale randomized controlled trials dedicated to studying ICAD-LVO, therefore this review focuses on observational studies.
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Affiliation(s)
| | | | | | | | | | | | | | - Eyad Almallouhi
- Neurology, Medical University of South Carolina, Charleston, SC
| | | | - Mikael Mazighi
- Neurology, Lariboisière hospital-APHP NORD, FHU Neurovasc, Paris Cité University, INSERM 1144, France
| | - Eva Mistry
- Neurology and Rehabilitation Medicine, University of Cincinnati, OH
| | - Shadi Yaghi
- Neurology, Warren Alpert Medical School of Brown University, Providence, RI
| | - Colin Derdeyn
- Neurosurgery, Carver College of Medicine, Iowa City, Iowa
| | - Keun-Sik Hong
- Neurology, Ilsan Paik Hospital, Inje University, Goyang, South Korea
| | | | | | - Sami Al Kasab
- Neurology, Medical University of South Carolina, Charleston, SC
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19
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Sakuta K, Sato T, Nakada R, Kitagawa T, Takatsu H, Fuga M, Miyagawa S, Komatsu T, Sakai K, Mitsumura H, Yaguchi H, Okuno K, Ishibashi T, Murayama Y, Iguchi Y. The REMIT scale: A novel prediction scale for embolism in hyperacute stroke with large vessel occlusion. J Neurol Sci 2023; 449:120666. [PMID: 37148775 DOI: 10.1016/j.jns.2023.120666] [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: 01/17/2023] [Revised: 04/21/2023] [Accepted: 04/27/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND AND PURPOSE Large vessel occlusion (LVO) in hyperacute ischemic stroke occurs mainly by one of two mechanisms, embolism or atherosclerosis. However, the mechanism is difficult to identify prior to treatment. We aimed to investigate the factors associated with embolic LVO in hyperacute ischemic stroke, and to develop a preoperative predictive scale for the event. MATERIALS AND METHODS This retrospective multicenter study was conducted with consecutive ischemic stroke patients with LVO who underwent thrombectomy, thrombolysis, or both. The embolic LVO was defined as an occlusion that underwent recanalization with no residual stenosis. Multivariate logistic regression analysis for embolic LVO was performed to identity the independent risk factors. With this approach, a novel prediction scale (Rating of Embolic Occlusion for Mechanical Thrombectomy [REMIT] scale) was developed. RESULTS A total of 162 patients (104 men; median age 76 years; interquartile range 68-83) were included in this study. Embolic LVO was observed in 121 patients (75%). Multivariate logistic regression analysis showed that embolic LVO was independently associated with high brain natriuretic peptide (BNP), high National Institutes of Health Stroke Scale (NIHSS) on admission, and absence of non-culprit stenosis (NoCS). The REMIT scale comprises high BNP (>100 pg/dL), high NIHSS (>14) and absence of NoCS, with one point for each risk factor. The frequencies of embolic LVO for the REMIT scale scores were as follows: score 0, 25%; score 1, 60%; score 2, 87%; score 3, 97% (C-statistic 0.80, P < 0.001). CONCLUSION The novel REMIT scale has predictive value for embolic LVO.
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Affiliation(s)
- Kenichi Sakuta
- Department of Neurology, The Jikei University Kashiwa Hospital, Chiba, Japan.
| | - Takeo Sato
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryoji Nakada
- Department of Neurology, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Tomomichi Kitagawa
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroki Takatsu
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan
| | - Michiyasu Fuga
- Department of Neurosurgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Shinji Miyagawa
- Department of Neurology, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Teppei Komatsu
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenichiro Sakai
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hidetaka Mitsumura
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroshi Yaguchi
- Department of Neurology, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Kenji Okuno
- Department of Emergency Medicine, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Toshihiro Ishibashi
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan
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20
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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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21
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Ni H, Wang B, Hang Y, Liu S, Jia ZY, Shi HB, Zhao LB. Predictors of Futile Recanalization in Patients with Intracranial Atherosclerosis-Related Stroke Undergoing Endovascular Treatment. World Neurosurg 2023; 171:e752-e759. [PMID: 36584891 DOI: 10.1016/j.wneu.2022.12.101] [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: 08/17/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The predictors of futile recanalization in patients with intracranial atherosclerosis (ICAS)-related stroke are not understood. This study aimed to identify the predictors of futile recanalization after endovascular treatment (EVT) in patients who experience an acute stroke caused by ICAS-related occlusion. METHODS We retrospectively reviewed the data of patients with ICAS-related stroke who underwent EVT from January 2018 to July 2021. Futile recanalization was defined as functional dependence (modified Rankin scale 3-6) despite successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2 b/3). Multivariate logistic regression analysis was used to determine the risk factors associated with futile recanalization. The receiver operating characteristic curve was used to examine the predictive value of the risk prediction model for futile recanalization. RESULTS Of the 87 patients enrolled, futile recanalization was observed in 32 (36.8%). Multivariate logistic analysis showed that older age (OR, 1.05; 95% CI, 1.01-1.10; P = 0.026), a higher National Institutes of Health Stroke Scale (NIHSS) score on admission (OR, 1.25; 95% CI, 1.08-1.45; P = 0.003), and poor collaterals (OR, 5.49; 95% CI, 1.70-17.79; P = 0.004) were independently associated with futile recanalization after EVT in patients with ICAS-related stroke. The receiver operating characteristic curve showed that the model in combination with age, admission NIHSS score, and collateral status could accurately predict futile recanalization in these patients (areas under the curve, 0.85; 95% CI, 0.76-0.92; P < 0.001). CONCLUSIONS Older age, higher NIHSS score on admission, and poor collaterals are predictors of futile recanalization in patients with ICAS-related stroke.
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Affiliation(s)
- Heng Ni
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Bin Wang
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yu Hang
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Sheng Liu
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Zhen-Yu Jia
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lin-Bo Zhao
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China.
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22
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Ni H, Hang Y, Wang CD, Liu S, Jia ZY, Shi HB, Zhao LB. Balloon Angioplasty Combined with Tirofiban as a First-Line Rescue Treatment After Failed Mechanical Thrombectomy for Middle Cerebral Artery Occlusion with Underlying Atherosclerosis. World Neurosurg 2022; 166:e306-e312. [PMID: 35809841 DOI: 10.1016/j.wneu.2022.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The standard rescue modality for patients with intracranial atherosclerotic stenosis after failed mechanical thrombectomy (MT) is not well established. We evaluated the safety and efficacy of balloon dilation in combination with tirofiban as the first-line salvage therapy when MT failed in these patients. METHODS We retrospectively analyzed the records of 47 patients admitted between January 2018 and June 2021, with middle cerebral artery atherosclerotic occlusion, who underwent balloon angioplasty in combination with tirofiban as the first-line salvage therapy after the failure of MT. The recanalization outcome, procedure-related complications, symptomatic intracranial hemorrhage, and functional outcome at 90 days were reviewed. RESULTS Recanalization with a modified Thrombolysis in Cerebral Infarction grade of 2b-3 was achieved in 41 (87.2%) of the 47 patients. Acute stents were deployed in another 6 patients who did not achieve successful re-perfusion after balloon angioplasty. Successful recanalization was achieved in 3 of them. One patient (2.1%, 1/47) experienced re-occlusion several days later due to the withdrawal of antiplatelet therapy for parenchymal hematoma. Seven patients (14.9%, 7/47) underwent stent angioplasty in the stable stage (range: 1-2 months) because severe residual stenosis was detected on follow-up imaging. There was only one event of periprocedural complication, namely ectopic migration of emboli. The good functional outcome rate was 55.3% (26/47), without the events of symptomatic intracranial hemorrhage and mortality. CONCLUSIONS Balloon angioplasty in combination with tirofiban is safe and effective for middle cerebral artery atherosclerotic occlusion after the failure of MT.
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Affiliation(s)
- Heng Ni
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yu Hang
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Chen-Dong Wang
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Sheng Liu
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Zhen-Yu Jia
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lin-Bo Zhao
- Department of Interventional Radiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China.
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23
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Imaoka Y, Shindo S, Miura M, Terasaki T, Mukasa A, Todaka T. Hypoperfusion intensity ratio and CBV index as predictive parameters to identify underlying intracranial atherosclerotic stenosis in endovascular thrombectomy. J Neuroradiol 2022; 50:424-430. [DOI: 10.1016/j.neurad.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/17/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
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24
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Psychogios M, Brehm A, López-Cancio E, Marco De Marchis G, Meseguer E, Katsanos AH, Kremer C, Sporns P, Zedde M, Kobayashi A, Caroff J, Bos D, Lémeret S, Lal A, Arenillas JF. European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease. Eur Stroke J 2022; 7:III-IV. [PMID: 36082254 PMCID: PMC9446330 DOI: 10.1177/23969873221099715] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/22/2022] [Indexed: 07/22/2023] Open
Abstract
The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of patients with intracranial atherosclerotic disease (ICAD). The guidelines were prepared following the Standard Operational Procedure of the European Stroke Organisation guidelines and according to GRADE methodology. ICAD represents a major cause of ischemic stroke worldwide, and patients affected by this condition are exposed to a high risk for future strokes and other major cardiovascular events, despite best medical therapy available. We identified 11 relevant clinical problems affecting ICAD patients and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions. The first two questions refer to the asymptomatic stage of the disease, which is being increasingly detected thanks to the routine use of noninvasive vascular imaging. We were not able to provide evidence-based recommendations regarding the optimal detection strategy and management of asymptomatic ICAD, and further research in the field is encouraged as subclinical ICAD may represent a big opportunity to improve primary stroke prevention. The second block of PICOs (3-5) is dedicated to the management of acute large vessel occlusion (LVO) ischemic stroke caused by ICAD, a clinical presentation of this disease that is becoming increasingly relevant and problematic, since it is associated with more refractory endovascular reperfusion procedures. An operational definition of probable ICAD-related LVO is proposed in the guideline. Despite the challenging context, no dedicated randomized clinical trials (RCTs) were identified, and therefore the guideline can only provide with suggestions derived from observational studies and our expert consensus, such as the escalated use of glycoprotein IIb-IIIa inhibitors and angioplasty/stenting in cases of refractory thrombectomies due to underlying ICAD. The last block of PICOs is devoted to the secondary prevention of patients with symptomatic ICAD. Moderate-level evidence was found to recommend against the use of oral anticoagulation as preferred antithrombotic drug, in favor of antiplatelets. Low-level evidence based our recommendation in favor of double antiplatelet as the antithrombotic treatment of choice in symptomatic ICAD patients, which we suggest to maintain during 90 days as per our expert consensus. Endovascular therapy with intracranial angioplasty and or stenting is not recommended as a treatment of first choice in high-grade symptomatic ICAD (moderate-level evidence). Regarding neurosurgical interventions, the available evidence does not support their use as front line therapies in patients with high-grade ICAD. There is not enough evidence as to provide any specific recommendation regarding the use of remote ischemic conditioning in ICAD patients, and further RCTs are needed to shed light on the utility of this promising therapy. Finally, we dedicate the last PICO to the importance of aggressive vascular risk factor management in ICAD, although the evidence derived from RCTs specifically addressing this question is still scarce.
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Affiliation(s)
- Marios Psychogios
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
| | - Alex Brehm
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
| | - Elena López-Cancio
- Department of Neurology, Hospital
Universitario Central de Asturias, Oviedo, Spain
| | - Gian Marco De Marchis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Elena Meseguer
- Department of Neurology and Stroke
Center, Assistance Publique Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster
University and Population Health Research Institute, Hamilton, ON, Canada
| | - Christine Kremer
- Department of Neurology, Skåne
University Hospital, Malmö, Department of Clinical Sciences Lund University, Lund,
Sweden
| | - Peter Sporns
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
- Department of Neuroradiology,
University Clinic Hamburg Eppendorf, Hamburg, Germany
| | - Marialuisa Zedde
- Neurology Unit, Department of
Neuromotor Physiology, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio
Emilia, Italy
- Neurology Unit, Stroke Unit, Azienda
Unità Sanitaria Locale-IRCCS di Reggio Emilia, Italy
| | - Adam Kobayashi
- Department of Pharmacology and
Clinical Pharmacology, Institute of Medical Sciences, Faculty of Medicine –
Collegium Medicum Cardinal Stefan Wyszynski University in Warsaw, Poland
- Department of Neurology and Stroke
Unit, Mazovian Voivodeship Hospital in Siedlce, Poland
| | - Jildaz Caroff
- Department of Interventional
Neuroradiology – NEURI Brain Vascular Center, Bicêtre Hospital, Assistance Publique
Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Daniel Bos
- Department of Radiology and Nuclear
Medicine, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus
MC, Rotterdam, The Netherlands
| | | | - Avtar Lal
- European Stroke Organisation, Basel,
Switzerland
| | - Juan F Arenillas
- Stroke Program, Department of
Neurology, Hospital Clínico Universitario de Valladolid, Spain
- Clinical Neurosciences Research
Group, Department of Medicine, University of Valladolid, Spain
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25
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Mohammaden MH, Haussen DC, Al-Bayati AR, Hassan A, Tekle W, Fifi J, Matsoukas S, Kuybu O, Gross BA, Lang MJ, Narayanan S, Cortez GM, Hanel RA, Aghaebrahim A, Sauvageau E, Farooqui M, Ortega-Gutierrez S, Zevallos C, Galecio-Castillo M, Sheth SA, Nahhas M, Salazar-Marioni S, Nguyen TN, Abdalkader M, Klein P, Hafeez M, Kan P, Tanweer O, Khaldi A, Li H, Jumaa M, Zaidi S, Oliver M, Salem MM, Burkhardt JK, Pukenas BA, Alaraj A, Peng S, Kumar R, Lai M, Siegler J, Nogueira RG. Stenting and Angioplasty in Neurothrombectomy: Matched Analysis of Rescue Intracranial Stenting Versus Failed Thrombectomy. Stroke 2022; 53:2779-2788. [DOI: 10.1161/strokeaha.121.038248] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND:
Successful reperfusion is one of the strongest predictors of functional outcomes after mechanical thrombectomy (MT). Despite continuous advancements in MT technology and techniques, reperfusion failure still occurs in ≈15% to 30% of patients with large vessel occlusion strokes undergoing MT. We aim to evaluate the safety and efficacy of rescue intracranial stenting for large vessel occlusion stroke after failed MT.
METHODS:
The SAINT (Stenting and Angioplasty in Neurothrombectomy) Study is a retrospective analysis of prospectively collected data from 14 comprehensive stroke centers through January 2015 to December 2020. Patients were included if they had anterior circulation large vessel occlusion stroke due to intracranial internal carotid artery and middle cerebral artery-M1/M2 segments and failed MT. The cohort was divided into 2 groups: rescue intracranial stenting and failed recanalization (modified Thrombolysis in Cerebral Ischemia score 0–1). Propensity score matching was used to balance the 2 groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale at 90 days. Secondary outcomes included functional independence (90-day modified Rankin Scale score 0–2). Safety measures included symptomatic intracranial hemorrhage and 90-day mortality.
RESULTS:
A total of 499 patients were included in the analysis. Compared with the failed reperfusion group, rescue intracranial stenting had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 2.31 [95% CI, 1.61–3.32];
P
<0.001), higher rates of functional independence (35.1% versus 7%; adjusted odds ratio [aOR], 6.33 [95% CI, 3.14–12.76];
P
<0.001), and lower mortality (28% versus 46.5%; aOR, 0.55 [95% CI, 0.31–0.96];
P
=0.04) at 90 days. Rates of symptomatic intracerebral hemorrhage were comparable across both groups (7.1% versus 10.2%; aOR, 0.99 [95% CI, 0.42–2.34];
P
=0.98). The matched cohort analysis demonstrated similar results. Specifically, rescue intracranial stenting (n=107) had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 3.74 [95% CI, 2.16–6.57];
P
<0.001), higher rates of functional independence (34.6% versus 6.5%; aOR, 10.91 [95% CI, 4.11–28.92];
P
<0.001), and lower mortality (29.9% versus 43%; aOR, 0.49 [95% CI, 0.25–0.94];
P
=0.03) at 90 days with similar rates of symptomatic intracerebral hemorrhage (7.5% versus 11.2%; aOR, 0.87 [95% CI, 0.31–2.42];
P
=0.79) compared with patients who failed to reperfuse (n=107). There was no heterogeneity of treatment effect across the prespecified subgroups for improvement in functional outcomes.
CONCLUSIONS:
Acute intracranial stenting appears to be a safe and effective rescue strategy in patients with large vessel occlusion stroke who failed MT. Randomized multicenter trials are warranted.
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Affiliation(s)
- Mahmoud H. Mohammaden
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine-Atlanta, GA (M.H.M., D.C.H.)
| | - Diogo C. Haussen
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine-Atlanta, GA (M.H.M., D.C.H.)
| | - Alhamza R. Al-Bayati
- UPMC Stroke Institute, Departments of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, PA (A.R.A.-B., O.K., B.A.G., M.J.L., S.N., R.G.N.)
| | - Ameer Hassan
- Department of Neurology, Valley Baptist Medical Center, Harlingen, TX (A.H., W.T.)
| | - Wondwossen Tekle
- Department of Neurology, Valley Baptist Medical Center, Harlingen, TX (A.H., W.T.)
| | - Johanna Fifi
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York (J.F., S.M.)
| | - Stavros Matsoukas
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York (J.F., S.M.)
| | - Okkes Kuybu
- UPMC Stroke Institute, Departments of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, PA (A.R.A.-B., O.K., B.A.G., M.J.L., S.N., R.G.N.)
| | - Bradley A. Gross
- UPMC Stroke Institute, Departments of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, PA (A.R.A.-B., O.K., B.A.G., M.J.L., S.N., R.G.N.)
| | - Michael J. Lang
- UPMC Stroke Institute, Departments of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, PA (A.R.A.-B., O.K., B.A.G., M.J.L., S.N., R.G.N.)
| | - Sandra Narayanan
- UPMC Stroke Institute, Departments of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, PA (A.R.A.-B., O.K., B.A.G., M.J.L., S.N., R.G.N.)
| | - Gustavo M. Cortez
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, FL (G.M.C., R.A.H., A.A., E.S.)
| | - Ricardo A. Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, FL (G.M.C., R.A.H., A.A., E.S.)
| | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, FL (G.M.C., R.A.H., A.A., E.S.)
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, FL (G.M.C., R.A.H., A.A., E.S.)
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.F., S.O.-G., C.Z., M.G.-C.)
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.F., S.O.-G., C.Z., M.G.-C.)
| | - Cynthia Zevallos
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.F., S.O.-G., C.Z., M.G.-C.)
| | - Milagros Galecio-Castillo
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.F., S.O.-G., C.Z., M.G.-C.)
| | - Sunil A. Sheth
- Department of Neurology, University of Texas, Houston (S.A.S., M.N., S.S.-M.)
| | - Michael Nahhas
- Department of Neurology, University of Texas, Houston (S.A.S., M.N., S.S.-M.)
| | | | - Thanh N. Nguyen
- Department of Neurology, Radiology, Boston University School of Medicine, MA (T.N.N., M.A., P.K.)
| | - Mohamad Abdalkader
- Department of Neurology, Radiology, Boston University School of Medicine, MA (T.N.N., M.A., P.K.)
| | - Piers Klein
- Department of Neurology, Radiology, Boston University School of Medicine, MA (T.N.N., M.A., P.K.)
| | - Muhammad Hafeez
- Department of Neurosurgery, Baylor School of Medicine, Houston, TX (M.H., P.K., O.T.)
| | - Peter Kan
- Department of Neurosurgery, Baylor School of Medicine, Houston, TX (M.H., P.K., O.T.)
| | - Omar Tanweer
- Department of Neurosurgery, Baylor School of Medicine, Houston, TX (M.H., P.K., O.T.)
| | - Ahmad Khaldi
- Department of Neurosciences, WellStar Health System, Atlanta, GA (A.K., H.L.)
| | - Hanzhou Li
- Department of Neurosciences, WellStar Health System, Atlanta, GA (A.K., H.L.)
| | - Mouhammad Jumaa
- Department of Neurology, University of Toledo, OH (M.J., S.Z., M.O.)
| | - Syed Zaidi
- Department of Neurology, University of Toledo, OH (M.J., S.Z., M.O.)
| | - Marion Oliver
- Department of Neurology, University of Toledo, OH (M.J., S.Z., M.O.)
| | - Mohamed M. Salem
- Department of Neurosurgery, University of Pennsylvania, Philadelphia (M.M.S., J.-K.B., B.A.P.)
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania, Philadelphia (M.M.S., J.-K.B., B.A.P.)
| | - Bryan A. Pukenas
- Department of Neurosurgery, University of Pennsylvania, Philadelphia (M.M.S., J.-K.B., B.A.P.)
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago (A.A., S.P.)
| | - Sophia Peng
- Department of Neurosurgery, University of Illinois at Chicago (A.A., S.P.)
| | - Rahul Kumar
- Department of Neurology, Cooper University Medical Center, Camden, NJ (R.K., M.L., J.S.)
| | - Michael Lai
- Department of Neurology, Cooper University Medical Center, Camden, NJ (R.K., M.L., J.S.)
| | - James Siegler
- Department of Neurology, Cooper University Medical Center, Camden, NJ (R.K., M.L., J.S.)
| | - Raul G. Nogueira
- UPMC Stroke Institute, Departments of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, PA (A.R.A.-B., O.K., B.A.G., M.J.L., S.N., R.G.N.)
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Sakuta K, Yaguchi H, Kida H, Sato T, Miyagawa S, Mitsumura H, Fuga M, Ishibashi T, Okuno K, Murayama Y, Iguchi Y. The meaning of non-culprit stenosis in hyperacute stroke with large vessel occlusion. J Neurol Sci 2022; 436:120247. [DOI: 10.1016/j.jns.2022.120247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/13/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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Zhang J, Jia B, Pan Y, Yu Z, Deng Y, Mo D, Ma N, Gao F, Miao Z. A comparison between different endovascular treatment strategies for acute large vessel occlusion due to intracranial artery atherosclerosis: data from ANGEL-ACT Registry. Neuroradiology 2022; 64:1627-1638. [PMID: 35348815 DOI: 10.1007/s00234-022-02933-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of our study is to compare the characteristics and clinical outcomes among the different endovascular treatment (EVT) strategies for large vessel occlusion underlying intracranial atherosclerosis (ICAS-LVO) in a recent nationwide registry. METHODS Patients with isolated ICAS-LVO were enrolled in our analysis and were categorized into three groups: first-line mechanical thrombectomy (MT) with rescue angioplasty and/or stenting (MT + RS), direct angioplasty and/or stenting without thrombectomy (DA), and MT alone. Baseline and periprocedural characteristics, successful recanalization, and 90-day functional outcomes were compared. RESULTS Of 396 patients with isolated ICAS-LVO in our study, successful recanalization was achieved in 94.5%, 100%, and 90.9% of patients in the MT + RS, DA, and MT groups, respectively. The 90-day functional independence in the three groups was 50.8%, 59.0%, and 45.1%. The main efficacy and safety outcomes showed no significant differences among the groups. First-pass recanalization (FPR) was more observed in the MT group (43.4%), the recanalization rate per attempt in the MT group gradually decreased until the fourth attempt, and further maneuvers showed recanalization rates of ≈0% per attempt. MT + RS (adjusted odds ratio [aOR] 0.10, p < 0.0001) and DA (aOR 0.18, p = 0.0013) were associated with lower FPR rate than MT alone in the multivariable logistic regression. CONCLUSIONS The technical feasibility and favorable outcomes of several EVT strategies for ICAS-LVO were established in our study. First-line MT with a bailout angioplasty is a reasonable option for ICAS-LVO, and DA is an effective option for the cases when ICAS-LVO is strongly suspected before EVT procedure.
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Affiliation(s)
- Jingyu Zhang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zequan Yu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Yiming Deng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, China.
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Al Kasab S, Almallouhi E, Spiotta AM. Rescue Endovascular Treatment for Emergent Large Vessel Occlusion With Underlying Intracranial Atherosclerosis: Current State and Future Directions. Front Neurol 2021; 12:734971. [PMID: 34759882 PMCID: PMC8573125 DOI: 10.3389/fneur.2021.734971] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/22/2021] [Indexed: 11/23/2022] Open
Abstract
Intracranial atherosclerosis (ICAS) is one of the most common causes of stroke worldwide and is associated with high risk of stroke recurrence. While the most common clinical presentation is acute–subacute transient ischemic attack or ischemic stroke, occasionally, patients with underlying ICAS present with acute occlusion of the affected vessel. Diagnosis and endovascular management of ICAS-related emergent large vessel occlusion (ELVO) can be challenging. Herein, we review the current evidence supporting endovascular management of ICAS-related ELVO and discuss future directions.
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Affiliation(s)
- Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, Charleston, SC, United States.,Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - Eyad Almallouhi
- Department of Neurology, Medical University of South Carolina, Charleston, SC, United States.,Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - Alejandro M Spiotta
- Department of Neurology, Medical University of South Carolina, Charleston, SC, United States
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Shin I, Kim BM, Kim DJ. Stent Opening Visualization During Mechanical Thrombectomy; Relationship with the Retrieved Clot and Procedural Success. J Stroke Cerebrovasc Dis 2021; 31:106168. [PMID: 34688210 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/28/2021] [Accepted: 10/06/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE The angiographic visualization of the stent during mechanical thrombectomy (MT) may provide information regarding the characteristics of the underlying occluding clot, device-clot interaction, and recanalization. The purpose of this study was to evaluate the open stent sign in relation to the retrieved clot and recanalization. METHODOLOGY 78 patients treated with the stent retriever for acute stroke were retrospectively reviewed. The open stent sign was defined as full opening (>80% of normal vessel diameter) of the stent on DSA after deployment across the occlusion. The retrieved clot was visually classified as red or non-red clots. The relationship between the open stent sign and the patient characteristics, recanalization, retrieved clot, and clinical outcome were analyzed. RESULTS Overall successful recanalization and good outcome was achieved in 68 (87.2%) and 35 (44.9%) patients, respectively. Open stent sign was seen in 52 patients (66.7%). Occlusions showing positive open stent sign was associated with significantly higher first pass effect (44.2% vs 19.2%, p=0.044) and successful recanalization rate (94.2% vs 73.1%, p=0.013) compared to negative open stent sign. The open stent sign was associated with higher incidence of red clot (75.0% vs 38.9%, p=0.008). On multivariate analysis, the open stent sign (OR 22.721, 95% CI 1.953-264.372, p=0.013) was a predictor of successful recanalization. CONCLUSIONS The visualization of the open stent during MT of acute ischemic stroke may provide added information in terms of clot characteristics and procedural success. The open stent sign is associated with red clots, higher first pass effect and successful recanalization.
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Affiliation(s)
- Ilah Shin
- Department of Radiology, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Republic of Korea.
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