Cerebral hyperperfusion syndrome after intracranial stenting: Case report and systematic review

Bailout intracranial angioplasty or stenting following thrombectomy for acute large vessel occlusion in China (ANGEL-REBOOT): a multicentre, open-label, blinded-endpoint, randomised controlled trial

BACKGROUND

Unsuccessful recanalisation or reocclusion after thrombectomy is associated with poor outcomes in patients with large vessel occlusion (LVO) acute ischaemic stroke (LVO-AIS). Bailout angioplasty or stenting (BAOS) could represent a promising treatment for these patients. We conducted a randomised controlled trial with the aim to investigate the safety and efficacy of BAOS following thrombectomy in patients with LVO.

METHODS

ANGEL-REBOOT was an investigator-initiated, multicentre, prospective, randomised, controlled, open-label, blinded-endpoint clinical trial conducted at 36 tertiary hospitals in 19 provinces in China. Participants with LVO-AIS 24 h after symptom onset were eligible if they had unsuccessful recanalisation (expanded Thrombolysis In Cerebral Infarction score of 0-2a) or risk of reocclusion (residual stenosis >70%) after thrombectomy. Eligible patients were randomly assigned by the minimisation method in a 1:1 ratio to undergo BAOS as the intervention treatment, or to receive standard therapy (continue or terminate the thrombectomy procedure) as a control group, both open-label. In both treatment groups, tirofiban could be recommended for use during and after the procedure. The primary outcome was the change in modified Rankin Scale score at 90 days, assessed in the intention-to-treat population. Safety outcomes were compared between groups. This trial was completed and registered at ClinicalTrials.gov (NCT05122286).

FINDINGS

From Dec 19, 2021, to March 17, 2023, 706 patients were screened, and 348 were enrolled, with 176 assigned to the intervention group and 172 to the control group. No patients withdrew from the trial or were lost to follow-up for the primary outcome. The median age of patients was 63 years (IQR 55-69), 258 patients (74%) were male, and 90 patients (26%) were female; all participants were Chinese. After random allocation, tirofiban was administered either intra-arterially, intravenously, or both in 334 [96%] of 348 participants. No between-group differences were observed in the primary outcome (common odds ratio 0·86 [95% CI 0·59-1·24], p=0·41). Mortality was similar between the two groups (19 [11%] of 176 vs 17 [10%] of 172), but the intervention group showed a higher risk of symptomatic intracranial haemorrhage (eight [5%] of 175 vs one [1%] of 169), parenchymal haemorrhage type 2 (six [3%] of 175 vs none in the control group), and procedure-related arterial dissection (24 [14%] of 176 vs five [3%] of 172).

INTERPRETATION

Among Chinese patients with unsuccessful recanalisation or who are at risk of reocclusion after thrombectomy, BAOS did not improve clinical outcome at 90 days, and incurred more complications compared with standard therapy. The off-label use of tirofiban might have affected our results and their generalisability, but our findings do not support the addition of BAOS for such patients with LVO-AIS.

FUNDING

Beijing Natural Science Foundation, National Natural Science Foundation of China, National Key R&D Program Beijing Municipal Administration of Hospitals Incubating Program, Shanghai HeartCare Medical Technology, HeMo (China) Bioengineering, Sino Medical Sciences Technology.

Cerebral hyperperfusion syndrome after stenting for revascularization of intracranial internal carotid artery dissection

Cerebral hyperperfusion syndrome (CHS) is one of the complications of cerebral revascularization. The main pathophysiology of CHS was considered to be cerebral autoregulation impairment due to long-standing cerebral hypoperfusion. Herein, we describe the case of a 40-year-old man with symptomatic intracranial arterial dissection (IAD) related to internal carotid artery stenosis. The patient underwent intracranial stenting 11 days after onset due to severe cerebral hypoperfusion presenting with neurological symptoms, and CHS presenting with intracerebral hemorrhage, post-operatively. The present case indicated not only the potential risk of CHS after intracranial stenting in IAD-related stenosis but also that cerebral hypoperfusion-even in a short period-might lead to CHS.

Prediction of cerebral hyperperfusion following carotid endarterectomy using intravoxel incoherent motion magnetic resonance imaging

OBJECTIVES

One of the risk factors for cerebral hyperperfusion following carotid endarterectomy (CEA) is a chronic reduction in cerebral perfusion pressure due to internal carotid artery (ICA) stenosis, which is clinically detected as increased cerebral blood volume (CBV). The perfusion fraction (f) is one of the intra-voxel incoherent motion (IVIM) parameters obtained using magnetic resonance (MR) imaging that theoretically reflects CBV. The present study aimed to determine whether preoperative IVIM-f on MR imaging predicts development of cerebral hyperperfusion following CEA.

MATERIALS AND METHODS

Sixty-eight patients with unilateral ICA stenosis (≥ 70%) underwent preoperative diffusion-weighted 3-T MR imaging, and IVIM-f maps were generated from these data. Quantitative brain perfusion single-photon emission computed tomography (SPECT) was performed before and immediately after CEA. Regions-of-interest (ROIs) were automatically placed in the bilateral middle cerebral artery territories in all images using a three-dimensional stereotactic ROI template, and affected-to-contralateral ratios in the ROIs were calculated on IVIM-f maps.

RESULTS

Nine patients (13%) exhibited postoperative hyperperfusion (cerebral blood flow increases of ≥ 100% compared with preoperative values in the ROIs on brain perfusion SPECT). Only high IVIM-f ratios were significantly associated with the occurrence of postoperative hyperperfusion (95% confidence interval, 253.8-6774.2; p = 0.0031) on logistic regression analysis. The sensitivity, specificity, and positive and negative predictive values of the IVIM-f ratio to predict the occurrence of postoperative hyperperfusion were 100%, 81%, 45%, and 100%, respectively.

CONCLUSIONS

Preoperative IVIM-f on MR imaging can predict development of cerebral hyperperfusion following CEA.

Application of Balloon AngioplaSty with the dIstal protection of Stent Retriever (BASIS) technique for acute intracranial artery atherosclerosis-related occlusion

Background

Endovascular therapy (EVT) is complex in the context of intracranial atherosclerosis (ICAS)-related large vessel occlusion (LVO) and the re-occlusion rates are high due to residual stenosis, the procedure time is long and the optimal EVT technique is unclear. The Balloon AngioplaSty with the dIstal protection of Stent Retriever (BASIS) technique is a novel thrombectomy technique that allows emergent balloon angioplasty to be performed via the wire of the retrieval stent. Our study presents our initial experience with the BASIS technique in ICAS-related LVO and assesses its feasibility.

Method

In patients with ICAS-related LVO treated with BASIS, clinical and angiographic data were retrospectively analyzed. Angiographic data included first-pass reperfusion (PFR), the rate of residual stenosis, distal emboli, and re-occlusion post-procedure. The Extended Thrombolysis in Cerebral Infarction (eTICI) scale was used to assess reperfusion extent, and an eTICI score ≥2b was defined as successful perfusion. Clinical outcome was evaluated at 3 months (modified Rankin score [mRS]), and an mRS ≤ 2 was defined as a good clinical outcome.

Results

A total of seven patients with ICAS-related LVO were included, and the median age of the patients was 76 years. All patients achieved eTICI 3 reperfusion and FPR. The residual stenosis rate ranged from 5 to 10%. None of the patients had re-occlusion post-procedure. The median puncture-to-reperfusion time was 51 min. None of the patients had a symptomatic cerebral hemorrhage, re-occlusion, distal embolism, and dissection. Good clinical outcomes were observed in four patients (4/7, 57.1%), and 1 patient (1/7, 14.3%) died.

Conclusion

The BASIS technique is feasible and safe for treating acute ICAS-related LVO.

Nontraumatic convexal subarachnoid hemorrhage: A case report

BACKGROUND

Nontraumatic convexal subarachnoid hemorrhage (cSAH) is a rare type of atypical subarachnoid hemorrhage. It mainly presents as a focal and transient neurological deficit with similar manifestations as transient ischemic attack.

CASE SUMMARY

We report a case of a 64-year-old man who visited the hospital with paroxysmal left-sided numbness and weakness is presented in this study. Computed tomography examination indicated a high-density image of the right frontal-parietal sulcus. Digital subtraction angiography showed severe stenosis at the right anterior cerebral artery A2-A3 junction (stenosis rate approximately 70%).

CONCLUSION

The findings of this case indicate that anterior cerebral artery stenosis may lead to the occurrence of cSAH.

Cone-beam CT angiography to assess the microvascular anatomy of intracranial arterial dissections

BACKGROUND

Intracranial artery dissection is a rare and generally under-recognized cause of ischaemic stroke or subarachnoid haemorrhage.

OBJECTIVES

The aim of this study was to analyse the efficacy of cone-beam computed tomography angiography (CBCT-A) to detect arterial ultrastructural alterations in intracranial artery dissection.

METHOD

This is an observational and retrospective case series.

RESULTS

Between January 2018 and November 2020, four patients were admitted with an acute ischaemic stroke due to intracranial dissection studied with CBCT-A. In all cases, the CBCT-A documented vascular ultrastructural alterations related with the intracranial dissection.

CONCLUSIONS

CBCT-A is an intraprocedural diagnostic technique that is useful for the diagnosis of intracranial dissections.