Experimental Analysis of Intra-luminal Pressure by Contrast Injection during Mechanical Thrombectomy: Simulation of Rupture Risk of Hidden Cerebral Aneurysm in Tandem Occlusion with Blind Alley

Successful Reperfusion is Associated with Favorable Functional Outcome despite Vessel Perforation during Thrombectomy: A Case Series and Systematic Review

BACKGROUND

Arterial perforation is a potentially serious complication during endovascular thrombectomy.

PURPOSE

Our aim was to describe interventional approaches after arterial perforation during endovascular thrombectomy and to determine whether reperfusion remains associated with favorable outcome despite this complication.

DATA SOURCES

Data from consecutive patients with acute stroke undergoing endovascular thrombectomy were retrospectively collected between 2015 to 2020 from a single-center cohort, and a systematic review was performed using PubMed, EMBASE, and Ovid MEDLINE up to June 2020.

STUDY SELECTION

Articles reporting functional outcome after arterial perforation during endovascular thrombectomy were selected.

DATA ANALYSIS

Functional outcomes of patients achieving successful reperfusion (TICI 2b/3) were compared with outcomes of those with unsuccessful reperfusion in our single-center cohort. We then summarized the literature review to describe interventional approaches and outcomes after arterial perforation during endovascular thrombectomy.

DATA SYNTHESIS

In our single-center cohort, 1419 patients underwent endovascular thrombectomy, among whom 32 (2.3%) had vessel perforation and were included in the analysis. The most common hemostatic strategy was watchful waiting (71% of cases). Patients with successful reperfusion had a higher proportion of favorable 90-day mRS scores (60% versus 12.5%; P = .006) and a lower mortality rate (13.3% versus 56.3%, P = .01) than patients without successful reperfusion. Thirteen articles were included in the systematic review. Successful reperfusion also appeared to be associated with better outcomes.

LIMITATIONS

Given the low number of published reports, we performed only a descriptive analysis.

CONCLUSIONS

Arterial perforation during endovascular thrombectomy is rare but is associated with high mortality rates and poor outcome. However, successful reperfusion remains correlated with favorable outcome in these patients.

Case Report: Trigeminocardiac Reflex in Endovascular Recanalization of Intracranial Internal Carotid Artery Occlusion

Background

The trigeminocardiac reflex (TCR) is a unique brainstem reflex that manifests as sudden negative hemodynamic changes. Although rare, TCR may develop during interventional neuroradiology procedures. Intracranial internal carotid artery occlusion (ICAO) is a cause or risk factor of ischemic stroke. Endovascular recanalization is an effective treatment for intracranial ICAO. The occurrence of TCR during the endovascular treatment of intracranial ICAO has not been reported previously.

Methods

We identified and reviewed four intracranial ICAO cases who suffered a sudden negative hemodynamic change during endovascular therapy at our hospital between March 2019 and December 2020.

Results

There were five sudden heart rate and/or blood pressure drops in the four cases; all occurred just after contrast agents were injected. Some angioarchitectural characteristics were common among the four cases. First, the intracranial internal carotid artery distal to the ophthalmic artery was occluded, leaving the ophthalmic artery as the only outflow tract. Second, there were obstructive factors proximal to the end of the guiding catheter, including a vasospasm or dilated balloon. This type of angioarchitecture with a limited outflow tract creates a “blind alley.” The five negative hemodynamic events all recovered: two spontaneously and three after drug administration. Postoperatively, two of the four patients developed ocular symptoms.

Conclusions

Intracranial ICAOs may produce a distinctive angioarchitecture, such as a blind alley, that predisposes patients to TCR. Surgeons should pay special attention to the possibility of TCR during the endovascular recanalization of intracranial ICAO. Low-pressure contrast injections should be attempted, and anticholinergics should be ready for use.

The Cerebral Arterial Wall in the Development and Growth of Intracranial Aneurysms

A considerable number of people harbor intracranial aneurysms (IA), which is a focal or segmental disease of the arterial wall. The pathophysiologic mechanisms of IAs formation, growth, and rupture are complex. The mechanism also differs with respect to the type of aneurysm. In broad aspects, aneurysms may be considered a disease of the vessel wall. In addition to the classic risk factors and the genetic/environmental conditions, altered structural and pathologic events along with the interaction of the surrounding environment and luminal flow dynamics contribute to the aneurysm’s development and growth. In this review, we have tried to simplify the complex interaction of a multitude of events in relation to vessel wall in the formation and growth of IAs.