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Grand T, Dargazanli C, Papagiannaki C, Bruggeman A, Maurer C, Gascou G, Fauche C, Bourcier R, Tessier G, Blanc R, Machaa MB, Marnat G, Barreau X, Ognard J, Gentric JC, Barbier C, Gory B, Rodriguez C, Boulouis G, Eugène F, Thouant P, Ricolfi F, Janot K, Herbreteau D, Eker OF, Cappucci M, Dobrocky T, Möhlenbruch M, Demerath T, Psychogios M, Fischer S, Cianfoni A, Majoie C, Emmer B, Marquering H, Valter R, Lenck S, Premat K, Cortese J, Dormont D, Sourour NA, Shotar E, Samson Y, Clarençon F. Benefit of mechanical thrombectomy in acute ischemic stroke related to calcified cerebral embolus. J Neuroradiol 2022; 49:317-323. [PMID: 35183595 DOI: 10.1016/j.neurad.2022.02.006] [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: 12/22/2021] [Revised: 02/13/2022] [Accepted: 02/13/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Mechanical thrombectomies (MT) in patients with large vessel occlusion (LVO) related to calcified cerebral embolus (CCE) have been reported, through small case series, being associated with low reperfusion rate and worse outcome, compared to regular MT. The purpose of the MASC (Mechanical Thrombectomy in Acute Ischemic Stroke Related to Calcified Cerebral Embolus) study was to evaluate the incidence of CCEs treated by MT and the effectiveness of MT in this indication. METHODS The MASC study is a retrospective multicentric (n = 37) national study gathering the cases of adult patients who underwent MT for acute ischemic stroke with LVO related to a CCE in France from January 2015 to November 2019. Reperfusion rate (mTICI ≥ 2B), complication rate and 90-day mRS were systematically collected. We then conducted a systematic review by searching for articles in PubMed, Cochrane Library, Embase and Google Scholar from January 2015 to March 2020. A meta-analysis was performed to estimate clinical outcome at 90 days, reperfusion rate and complications. RESULTS We gathered data from 35 patients. Reperfusion was obtained in 57% of the cases. Good clinical outcome was observed in 28% of the patients. The meta-analysis retrieved 136 patients. Reperfusion and good clinical outcome were obtained in 50% and 29% of the cases, respectively. CONCLUSION The MASC study found worse angiographic and clinical outcomes compared to regular thrombectomies. Individual patient-based meta-analysis including the MASC findings shows a 50% reperfusion rate and a 29% of good clinical outcome.
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Affiliation(s)
- Téodor Grand
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | | | | | - Agnetha Bruggeman
- Departments of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, NETHERLANDS
| | - Christoph Maurer
- Department of Neuroradiology, Klinikum Augsburg, Augsburg, GERMANY
| | | | - Cédric Fauche
- Department of Neuroradiology, CHU de Poitiers, FRANCE
| | - Romain Bourcier
- Department of Neuroradiology, Hôpital Nord Laennec, Nantes, FRANCE
| | | | - Raphaël Blanc
- Department of Neuroradiology, Fondation Rothschild, Paris, FRANCE
| | - Malek Ben Machaa
- Department of Neuroradiology, Fondation Rothschild, Paris, FRANCE
| | | | | | | | | | | | - Benjamin Gory
- Department of Neuroradiology, Centre Hospitalier Régional et Universitaire, Nancy, FRANCE
| | | | | | | | | | | | - Kevin Janot
- Department of Neuroradiology, CHU de Tours, France
| | | | | | | | - Tomas Dobrocky
- Department of Neuroradiology, Universitätsspital Bern, Bern, SWITZERLAND
| | - Markus Möhlenbruch
- Department of Neurology, University Heidelberg Medical Center, Heidelberg, GERMANY
| | - Theo Demerath
- Department of Neurology, University Freiburg Medical Center, Freiburg, GERMANY
| | - Marios Psychogios
- Department of Neurology, University Basel Medical Center, Basel, SWITZERLAND
| | - Sebastian Fischer
- Department of Neurology, University Bochum Medical Center, Bochum, GERMANY
| | - Alessandro Cianfoni
- Department of Neurology, University Lugano Medical Center, Lugano, SWITZERLAND
| | - Charles Majoie
- Departments of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, NETHERLANDS
| | - Bart Emmer
- Departments of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, NETHERLANDS
| | - Henk Marquering
- Departments of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, NETHERLANDS
| | - Rémi Valter
- Department of Public Health, Hôpital Henri Mondor, Créteil, FRANCE
| | - Stéphanie Lenck
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Kévin Premat
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Jonathan Cortese
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Didier Dormont
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France; Sorbonne University, Paris, FRANCE
| | | | - Eimad Shotar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Yves Samson
- Department of Vascular Neurology, Pitié-Salpêtrière Hospital, Paris, FRANCE
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France; Sorbonne University, Paris, FRANCE; GRC Biofast, Paris, FRANCE.
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Bruggeman AAE, Kappelhof M, Arrarte Terreros N, Tolhuisen ML, Konduri PR, Boodt N, van Beusekom HMM, Hund HM, Taha A, van der Lugt A, Roos YBWEM, van Es ACGM, van Zwam WH, Postma AA, Dippel DWJ, Lingsma HF, Marquering HA, Emmer BJ, Majoie CBLM. Endovascular treatment for calcified cerebral emboli in patients with acute ischemic stroke. J Neurosurg 2021; 135:1402-1412. [PMID: 33799302 DOI: 10.3171/2020.9.jns201798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Calcified cerebral emboli (CCE) are a rare cause of acute ischemic stroke. The authors aimed to assess the association of CCE with functional outcome, successful reperfusion, and mortality. Furthermore, they aimed to assess the effectiveness of intravenous alteplase treatment and endovascular treatment (EVT), as well as the best first-line EVT approach in patients with CCE. METHODS The Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry is a prospective, observational multicenter registry of patients treated with EVT for acute ischemic stroke in 16 intervention hospitals in the Netherlands. The association of CCE with functional outcome, reperfusion, and mortality was evaluated using logistic regression models. Univariable comparisons were made to determine the effectiveness of intravenous alteplase treatment and the best first-line EVT approach in CCE patients. RESULTS The study included 3077 patients from the MR CLEAN Registry. Fifty-five patients (1.8%) had CCE. CCE were not significantly associated with worse functional outcome (adjusted common OR 0.71, 95% CI 0.44-1.15), and 29% of CCE patients achieved functional independence. An extended Thrombolysis in Cerebral Infarction score ≥ 2B was significantly less often achieved in CCE patients compared to non-CCE patients (adjusted OR [aOR] 0.52, 95% CI 0.28-0.97). Symptomatic intracranial hemorrhage occurred in 8 CCE patients (15%) vs 171 of 3022 non-CCE patients (6%; p = 0.01). The median improvement on the National Institutes of Health Stroke Scale (NIHSS) was 2 in CCE patients versus 4 in non-CCE patients (p = 0.008). CCE were not significantly associated with mortality (aOR 1.16, 95% CI 0.64-2.12). Intravenous alteplase use in CCE patients was not associated with functional outcome or reperfusion. In CCE patients with successful reperfusion, stent retrievers were more often used as the primary treatment device (p = 0.04). CONCLUSIONS While patients with CCE had significantly lower reperfusion rates and less improvement on the NIHSS after EVT, CCE were not significantly associated with worse functional outcome or higher mortality rates. Therefore, EVT should still be considered in this specific group of patients.
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Affiliation(s)
| | - Manon Kappelhof
- Departments of1Radiology and Nuclear Medicine
- 2Biomedical Engineering and Physics, and
| | | | - Manon L Tolhuisen
- Departments of1Radiology and Nuclear Medicine
- 2Biomedical Engineering and Physics, and
| | - Praneeta R Konduri
- Departments of1Radiology and Nuclear Medicine
- 2Biomedical Engineering and Physics, and
| | - Nikki Boodt
- Departments of3Radiology and Nuclear Medicine
- Departments of3Radiology and Nuclear Medicine
- 5Public Health
| | | | - Hajo M Hund
- 6Histology and MS Imaging Lab at Experimental Cardiology, and
- 6Histology and MS Imaging Lab at Experimental Cardiology, and
- 8Department of Radiology, Haaglanden MC, Den Haag
| | - Aladdin Taha
- 4Neurology, and
- 6Histology and MS Imaging Lab at Experimental Cardiology, and
| | | | - Yvo B W E M Roos
- 9Neurology, Amsterdam University Medical Centers, AMC, Amsterdam
| | - Adriaan C G M van Es
- 10Department of Radiology and Nuclear Medicine, Leiden University Medical Center, Leiden; and
| | - Wim H van Zwam
- 11Department of Radiology and Nuclear Medicine, School for Mental Health and Sciences, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Alida A Postma
- 11Department of Radiology and Nuclear Medicine, School for Mental Health and Sciences, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | | - Henk A Marquering
- Departments of1Radiology and Nuclear Medicine
- 2Biomedical Engineering and Physics, and
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Fasen BACM, Heijboer RJJ, Hulsmans FJH, Kwee RM. CT Angiography in Evaluating Large-Vessel Occlusion in Acute Anterior Circulation Ischemic Stroke: Factors Associated with Diagnostic Error in Clinical Practice. AJNR Am J Neuroradiol 2020; 41:607-611. [PMID: 32165362 DOI: 10.3174/ajnr.a6469] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE It is currently not completely clear how well radiologists perform in evaluating large-vessel occlusion on CTA in acute ischemic stroke. The purpose of this study was to investigate potential factors associated with diagnostic error. MATERIALS AND METHODS Five hundred twenty consecutive patients with a clinical diagnosis of acute ischemic stroke (49.4% men; mean age, 72 years) who underwent CTA to evaluate large-vessel occlusion of the proximal anterior circulation were included. CTA scans were retrospectively reviewed by a consensus panel of 2 neuroradiologists. Logistic regression analysis was performed to investigate the association between several variables and missed large-vessel occlusion at the initial CTA interpretation. RESULTS The prevalence of large-vessel occlusion was 16% (84/520 patients); 20% (17/84) of large-vessel occlusions were missed at the initial CTA evaluation. In multivariate analysis, non-neuroradiologists were more likely to miss large-vessel occlusion compared with neuroradiologists (OR = 5.62; 95% CI, 1.06-29.85; P = .04), and occlusions of the M2 segment were more likely to be missed compared with occlusions of the distal internal carotid artery and/or M1 segment (OR = 5.69; 95% CI, 1.44-22.57; P = .01). There were no calcified emboli in initially correctly identified large-vessel occlusions. However, calcified emboli were present in 4 of 17 (24%) initially missed or misinterpreted large-vessel occlusions. CONCLUSIONS Several factors may have an association with missing a large-vessel occlusion on CTA, including the CTA interpreter (non-neuroradiologists versus neuroradiologists), large-vessel occlusion location (M2 segment versus the distal internal carotid artery and/or M1 segment), and large-vessel occlusion caused by calcified emboli. Awareness of these factors may improve the accuracy in interpreting CTA and eventually improve stroke outcome.
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Affiliation(s)
- B A C M Fasen
- From the Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands
| | - R J J Heijboer
- From the Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands
| | - F-J H Hulsmans
- From the Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands
| | - R M Kwee
- From the Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands.
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Maurer CJ, Dobrocky T, Joachimski F, Neuberger U, Demerath T, Brehm A, Cianfoni A, Gory B, Berlis A, Gralla J, Möhlenbruch MA, Blackham KA, Psychogios MN, Zickler P, Fischer S. Endovascular Thrombectomy of Calcified Emboli in Acute Ischemic Stroke: A Multicenter Study. AJNR Am J Neuroradiol 2020; 41:464-468. [PMID: 32029470 DOI: 10.3174/ajnr.a6412] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 12/23/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Large intracranial vessel occlusion due to calcified emboli is a rare cause of major stroke. We assessed the prevalence, imaging appearance, the effectiveness of mechanical thrombectomy, and clinical outcome of patients with large-vessel occlusion due to calcified emboli. MATERIALS AND METHODS We performed a retrospective analysis of clinical and procedural data of consecutive patients who underwent mechanical thrombectomy due to calcified emboli in 7 European stroke centers. RESULTS We screened 2969 patients, and 40 patients matched the inclusion criteria, accounting for a prevalence of 1.3%. The mean maximal density of the thrombus was 327 HU (range, 150-1200 HU), and the mean thrombus length was 9.2 mm (range, 4-20 mm). Four patients had multiple calcified emboli, and 2 patients had an embolic event during an endovascular intervention. A modified TICI score of ≥2b was achieved in 57.5% (23/40), with minimal-to-no reperfusion (modified TICI 0-1) in 32.5% (13/40) and incomplete reperfusion (modified TICI 2a) in 10% (4/40). Excellent outcome (mRS 0-1) was achieved in only 20.6%, functional independence (mRS 0-2) in 26.5% and 90-day mortality was 55.9%. CONCLUSIONS Acute ischemic stroke with large-vessel occlusion due to calcified emboli is a rare entity in patients undergoing thrombectomy, with considerably worse angiographic outcome and a higher mortality compared with patients with noncalcified thrombi. Good functional recovery at 3 months can still be achieved in about a quarter of patients.
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Affiliation(s)
- C J Maurer
- From the Departments of Diagnostic and Interventional Radiology and Neuroradiology (C.J.M., F.J., A.Berlis)
| | - T Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology (T.Dobrocky, J.G.), University of Bern, Inselspital, Bern, Switzerland
| | - F Joachimski
- From the Departments of Diagnostic and Interventional Radiology and Neuroradiology (C.J.M., F.J., A.Berlis)
| | - U Neuberger
- Department of Neuroradiology (U.N., M.A.M.), University of Heidelberg, Heidelberg, Germany
| | - T Demerath
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - A Brehm
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Neuroradiology (A.Brehm, M.N.P.), University Medical Center Göttingen, Göttingen, Germany
| | - A Cianfoni
- Department of Neuroradiology (A.C.), Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - B Gory
- Department of Diagnostic and Therapeutic Neuroradiology (B.G.), University Hospital of Nancy, Institut National de la Santé et de la Recherche Médicale U1254, Nancy, France
| | - A Berlis
- From the Departments of Diagnostic and Interventional Radiology and Neuroradiology (C.J.M., F.J., A.Berlis)
| | - J Gralla
- University Institute of Diagnostic and Interventional Neuroradiology (T.Dobrocky, J.G.), University of Bern, Inselspital, Bern, Switzerland
| | - M A Möhlenbruch
- Department of Neuroradiology (U.N., M.A.M.), University of Heidelberg, Heidelberg, Germany
| | - K A Blackham
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - M N Psychogios
- Department of Neuroradiology (T.Demerath, A.Brehm, K.A.B., M.N.P.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Neuroradiology (A.Brehm, M.N.P.), University Medical Center Göttingen, Göttingen, Germany
| | - P Zickler
- Neurology and Neurophysiology (P.Z.), Universitätsklinikum Augsburg, Augsburg, Germany
| | - S Fischer
- Institut für Diagnostische und Interventionelle Radiologie, Neuroradiologie (S.F.), Nuklearmedizin, Knappschaftskrankenhaus Bochum-Langendreer, Universitätsklinik, Bochum, Germany
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5
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Imaging Clot Characteristics in Stroke and its Possible Implication on Treatment. Clin Neuroradiol 2019; 30:27-35. [DOI: 10.1007/s00062-019-00841-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/17/2019] [Indexed: 12/11/2022]
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