1
|
Lkharrat FZ, Bouchal S, Bennani H, Akammar A, El Bouardi N, Haloua M, Alami B, Boubbou M, Faouzi Belahcen M, Maaroufi M, Alaoui Lamrani MY. Management of a recurrent stroke due to a carotid web. JOURNAL DE MEDECINE VASCULAIRE 2023; 48:136-141. [PMID: 37914458 DOI: 10.1016/j.jdmv.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 08/16/2023] [Indexed: 11/03/2023]
Abstract
Carotid web is a rare intraluminal parietal protrusion in the carotid artery. This vascular anomaly mostly occurs at the bifurcation causing turbulent flow, and is responsible of thrombi formation associated with embolic ischemic events. We report the case of a 35-year-old woman, with no medical history, who presented a recurrent middle cerebral artery (MCA) occlusion within twelve hours caused by a carotid bulb web. Although considered as a rare entity, carotid web is associated with the risk of recurrent strokes in the MCA territory and especially in the absence of the typically recognized risk factors. The key imaging is the CT angiography that shows the web, the cerebral artery occlusion, and the outcome appreciation. Therapeutic strategy associates antithrombotic treatment and operative management with stenting of the carotid web or endarterectomy.
Collapse
Affiliation(s)
- F-Z Lkharrat
- Radiology Department, CHU Hassan II, University Sidi Mohammed Ben Abdellah, Fez, Morocco.
| | - S Bouchal
- Neurology Department, CHU Hassan II, University Sidi Mohammed Ben Abdellah, Fez, Morocco
| | - H Bennani
- Radiology Department, CHU Hassan II, University Sidi Mohammed Ben Abdellah, Fez, Morocco
| | - A Akammar
- Radiology Department, CHU Hassan II, University Sidi Mohammed Ben Abdellah, Fez, Morocco
| | - N El Bouardi
- Radiology Department, CHU Hassan II, University Sidi Mohammed Ben Abdellah, Fez, Morocco
| | - M Haloua
- Radiology Department, CHU Hassan II, University Sidi Mohammed Ben Abdellah, Fez, Morocco
| | - B Alami
- Radiology Department, CHU Hassan II, University Sidi Mohammed Ben Abdellah, Fez, Morocco
| | - M Boubbou
- Radiology Department, CHU Hassan II, University Sidi Mohammed Ben Abdellah, Fez, Morocco
| | - M Faouzi Belahcen
- Neurology Department, CHU Hassan II, University Sidi Mohammed Ben Abdellah, Fez, Morocco
| | - M Maaroufi
- Radiology Department, CHU Hassan II, University Sidi Mohammed Ben Abdellah, Fez, Morocco
| | - M Y Alaoui Lamrani
- Radiology Department, CHU Hassan II, University Sidi Mohammed Ben Abdellah, Fez, Morocco
| |
Collapse
|
2
|
Choi YS, Hwang J, Lee MJ, Lee JH, Youn HJ. Review of North Korean Reports on Cardiovascular Disease Research and Management. Yonsei Med J 2023; 64:309-312. [PMID: 37114633 PMCID: PMC10151233 DOI: 10.3349/ymj.2022.0485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 04/29/2023] Open
Abstract
PURPOSE This study aimed to investigate the quality of medical care in North Korea using data from North Korean medical research. MATERIALS AND METHODS This study included publications containing the keyword "medical" among North Korea's consecutive publications and selected 415 papers related to heart disease, brain disease, and emergency medical care published at The North Korean Data Center of the Ministry of Unification (https://unibook.unikorea.go.kr). Among 40 research articles, we reviewed ten with representative epidemiological data for cardiovascular treatment, and the latest medical materials were selected and analyzed in detail. RESULTS Few studies reported the experience of large-scale medical facilities or verified professional performance. Proof of the efficacy of the latest drugs was rare, although the treatment results of interventional therapy and conventional heart surgery were reported. Efforts to improve emergency medical care and innovation of treatment materials using new technologies were being actively studied. However, careful interpretation is required due to the lack of objectivity in research data and some deviation in the composition of patients included in the data. CONCLUSION Research of cardiovascular disease in North Korea is conducted at a very limited scope, although treatment results appear to be recorded. The management of cardiovascular disease and the establishment of an emergency medical system warrant global attention and cooperation for further improvement.
Collapse
Affiliation(s)
- Yun-Seok Choi
- Research Institute of Healthcare for North Korea, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Junhyeong Hwang
- College of Medicine, Dankook University of Korea, Seoul, Korea
| | - Min-Ji Lee
- Research Institute of Healthcare for North Korea, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung-Hun Lee
- Research Institute of Healthcare for North Korea, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho-Joong Youn
- Research Institute of Healthcare for North Korea, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
3
|
Elwan ME, Mansour OY, Lashin ME, Melake MS. Factors affecting mechanical thrombectomy outcome in acute ischemic stroke patients: an Egyptian sample. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2022. [DOI: 10.1186/s41983-022-00491-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Stroke constitutes a major health problem worldwide, nowadays endovascular treatment is considered to be a standard of care in acute ischemic stroke patients with large vessel occlusion, accurate prediction of outcome of thrombectomy is essential for health care providers, patients and families. We studied different clinical and radiological variables that could predict functional outcome in stroke patients after thrombectomy. Thirty-four consecutive ischemic stroke patients were included, received intravenous tissue plasminogen activator (iv-tpa), then mechanical thrombectomy was done. Patients were clinically assessed at admission with National Institute of Health Stroke Scale (NIHSS) then evaluated by the Alberta Stroke Program early computerized tomography (CT) score (ASPECTS), clot burden scale (CBS) and collateral score (CS) in multiphase computerized tomography angiography (CTA) then good and poor outcomes at 3 months were defined by Modified Rankin Scale (MRS) of 0–2 and 3–6 points, respectively.
Results
Factors associated with good outcome (MRS 0–2) were lower admission NIHSS score (p < 0.037), small infarct core aspects ≥ 6 (p < 0.001), low clot burden (CBS 7–10) (p = 0.046) good collaterals (2–3) (p = 0.038) and absence of post-procedure hemorrhage (p < 0.0005).
Conclusions
Low admission NIHSS score, absence of post-procedure hemorrhage, small infarct core, low clot burden and good collaterals are reliable factors for good clinical outcome.
Collapse
|
4
|
Kwon DH, Jang SH, Park H, Sohn SI, Hong JH. Emergency Cervical Carotid Artery Stenting After Intravenous Thrombolysis in Patients With Hyperacute Ischemic Stroke. J Korean Med Sci 2022; 37:e156. [PMID: 35578588 PMCID: PMC9110268 DOI: 10.3346/jkms.2022.37.e156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/15/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Intravenous recombinant tissue plasminogen activator (IV rtPA) is the mainstay of treatment for acute ischemic stroke to recanalize thrombosed intracranial vessels within 4.5 hours. Emergency carotid artery stenting for the treatment of acute stroke due to steno-occlusion of the proximal internal carotid artery (ICA) can improve symptoms, prevent neurological deterioration, and reduce recurrent stroke risk. The feasibility and safety of the combination therapy of IV rtPA and urgent carotid artery stenting have not been established. METHODS From November 2005 to October 2020, we retrospectively assessed patients who had undergone emergent carotid artery stenting after IV rtPA for hyperacute ischemic stroke due to steno-occlusive proximal ICA lesion. Hemorrhagic transformation, successful recanalization, modified Rankin Scale (mRS) score at 90 days, and stent patency at 3 and 12 months or longer were evaluated. Favorable outcome was defined as a 90-days mRS score of ≤ 2. RESULTS Nineteen patients with hyperacute stroke had undergone emergent carotid artery stenting after IV rtPA therapy. Their median age was 70 (67.5-73.5) years (94.7% men). Among 15 patients with an additional intracranial occlusion after flow restoration in the proximal ICA, a modified TICI grade ≥ 2b was achieved in 11 patients (73.3%). Hemorrhagic transformation occurred in five patients (26.3%); mortality rate was 5.7%. Eleven patients (57.9%) had favorable outcomes at 90 days. Stent patients (94.1%) maintained stent patency for ≥ 12 months. CONCLUSION We showed that emergent carotid artery stenting after IV rtPA therapy for hyperacute stroke caused by atherosclerotic proximal ICA steno-occlusion was feasible and safe.
Collapse
Affiliation(s)
- Doo Hyuk Kwon
- Department of Neurology, Yeungnam University College of Medicine, Daegu, Korea
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Seong Hwa Jang
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea.
| |
Collapse
|
5
|
Mechanical thrombectomy via chronic occluded proximal artery for the endovascular treatment of acute ischemic stroke patients with large vessel occlusion. J Clin Neurosci 2022; 99:130-136. [PMID: 35279585 DOI: 10.1016/j.jocn.2022.01.008] [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: 06/13/2021] [Revised: 12/31/2021] [Accepted: 01/11/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Mechanical thrombectomy (MT) can significantly improve the prognosis of acute ischemic stroke patients with large vessel occlusion. However, for patients with chronic occluded proximal artery, therapeutical strategies are limited because the endovascular route for MT is not readily accessible. METHODS Here, we introduce a safe and effective MT procedure via a chronic occluded proximal artery. We conducted a retrospective study of seven patients with acute ischemic stroke due to large artery occlusion (AIS-LVO) who underwent MT via a chronic occluded proximal artery for endovascular treatment. We analyzed the technical procedure of the MT and the clinical outcomes of these patients. RESULTS The distal thrombus was successfully removed in all patients by opening the occluded proximal artery, thus achieving revascularization with a Thrombolysis in Cerebral Infarction (TICI) of 2b/3. The average time from arterial puncture to reperfusion was 171.14 ± 36.56 min. Three patients had a good modified Rankin scale (mRS) score (0-2) at discharge. Among 4 patients with anterior circulation stroke, 2 recovered completely, 1 had anomic aphasia, and 1 had hemiplegia. Among 3 patients with posterior circulation stroke, 1 recovered completely, 1 had locked-in syndrome, and 1 was comatose. Four patients had good functional prognoses. CONCLUSIONS Mechanical thrombectomy procedure via a chronic occluded proximal artery can be used in patients with well-established collateral compensatory vessels. It is safe and effective in improving the prognosis of patients. It can be used as a remedial treatment strategy for patients with AIS-LVO.
Collapse
|
6
|
Lee CW, Chen KW, Lin YH, Hsu CH, Lu CJ, Tang SC, Chiang PY. Balloon Angioplasty Followed by Aspiration of Large-Vessel Occlusion (BAFALO): An efficient and protective treatment of tandem occlusion. FORMOSAN JOURNAL OF SURGERY 2022. [DOI: 10.4103/fjs.fjs_34_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
7
|
Cirillo L, Romano DG, Vornetti G, Frauenfelder G, Tamburrano C, Taglialatela F, Isceri S, Saponiero R, Napoletano R, Gentile M, Romoli M, Princiotta C, Simonetti L, Zini A. Acute ischemic stroke with cervical internal carotid artery steno-occlusive lesion: multicenter analysis of endovascular approaches. BMC Neurol 2021; 21:362. [PMID: 34535118 PMCID: PMC8447719 DOI: 10.1186/s12883-021-02393-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 09/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Occlusion of the internal carotid artery (ICA), whether isolated or in the setting of a tandem lesion (TL) have a poor response to treatment with intravenous thrombolysis. Previous studies have demonstrated the superiority of mechanical thrombectomy in the treatment of acute ischemic stroke (AIS) following large vessel occlusion, compared to standard intravenous fibrinolysis. The aim of our study was to describe endovascular treatment (EVT) in AIS due to isolated ICA occlusion or TL. METHODS We assessed the association between 90-day outcome and clinical, demographic, imaging, and procedure data in 51 consecutive patients with acute isolated ICA occlusion or TL who underwent EVT. We evaluated baseline NIHSS and mRS, ASPECTS, type of occlusion, stent placement, use of stent retrievers and/or thromboaspiration, duration of the procedure, mTICI, postprocedural therapy and complications. RESULTS A favorable 90-day outcome (mRS 0-2) was achieved in 34 patients (67 %) and was significantly associated with the use of dual antiplatelet therapy after the procedure (p = 0.008), shorter procedure duration (p = 0.031), TICI 2b-3 (p < 0.001) and lack of post-procedural hemorrhagic transformation (p = 0.001). Four patients did not survive, resulting in a mortality rate of 8 %. CONCLUSIONS Our study has shown that EVT in the treatment of AIS due to ICA occlusion is safe, and effective in determining a good functional outcome. ICA stenting led to good angiographic results and therapy with a glycoprotein IIb / IIIa inhibitor immediately after stent release did not result in a greater risk of hemorrhage. The use of post-procedural dual antiplatelet therapy was associated with favorable outcome, without a significant increase in hemorrhagic transformation.
Collapse
Affiliation(s)
- Luigi Cirillo
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Bologna, Italy. .,UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy.
| | | | - Gianfranco Vornetti
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Bologna, Italy
| | - Giulia Frauenfelder
- UOC Neuroradiologia AOU S. Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Chiara Tamburrano
- Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, Bologna, Italy
| | - Francesco Taglialatela
- UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Salvatore Isceri
- UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Renato Saponiero
- UOC Neuroradiologia AOU S. Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Rosa Napoletano
- UOC Neurologia AOU S. Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Mauro Gentile
- UOC Neurologia e Rete Stroke metropolitana Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Michele Romoli
- UOC Neurologia e Rete Stroke metropolitana Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Ciro Princiotta
- UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Luigi Simonetti
- UOSI Neuroradiologia Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| | - Andrea Zini
- UOC Neurologia e Rete Stroke metropolitana Ospedale Maggiore CA Pizzardi - IRCCS delle scienze Neurologiche di Bologna, Bologna, Italy
| |
Collapse
|
8
|
Azzabi Zouraq S, Bouchal S, Haloua M, Alami B, Boubbou M, Maaroufi M, Alaoui Lamrani MY. Permanent cervical carotid occlusion with coils as an endovascular management of tandem carotid lesions in acute ischemic stroke. JOURNAL DE MÉDECINE VASCULAIRE 2021; 46:93-96. [PMID: 33752852 DOI: 10.1016/j.jdmv.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Affiliation(s)
- S Azzabi Zouraq
- Department of Radiology, CHU de Hassan II, Fès, Morocco; Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco; Neuroscience Laboratory, Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco.
| | - S Bouchal
- Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco; Department of Neurology, CHU de Hassan II de Fès, Fès, Morocco
| | - M Haloua
- Department of Radiology, CHU de Hassan II, Fès, Morocco; Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco; Neuroscience Laboratory, Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco
| | - B Alami
- Department of Radiology, CHU de Hassan II, Fès, Morocco; Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco; Neuroscience Laboratory, Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco
| | - M Boubbou
- Department of Radiology, CHU de Hassan II, Fès, Morocco; Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco; Neuroscience Laboratory, Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco
| | - M Maaroufi
- Department of Radiology, CHU de Hassan II, Fès, Morocco; Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco; Neuroscience Laboratory, Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco
| | - M Y Alaoui Lamrani
- Department of Radiology, CHU de Hassan II, Fès, Morocco; Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco; Neuroscience Laboratory, Faculty of Medicine and Pharmacy of Fez, USMBA, Morocco
| |
Collapse
|
9
|
Hellegering J, Uyttenboogaart M, Bokkers RPH, El Moumni M, Zeebregts CJ, van der Laan MJ. Treatment of the extracranial carotid artery in tandem lesions during endovascular treatment of acute ischemic stroke: a systematic review and meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1278. [PMID: 33178810 PMCID: PMC7607118 DOI: 10.21037/atm-2020-cass-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Endovascular treatment (EVT) is the standard treatment for patients with an acute ischemic stroke due to occlusion of large vessel occlusion (LVO). In 20% of patients, concomitant extracranial internal carotid artery (EICA) lesion is present. These tandem lesions (TL) offer a technical challenge. The treatment strategy for the treatment of the ipsilateral EICA is unclear. The aim of this review is to compare two treatment strategies for TL during EVT: balloon angioplasty (BA) only and immediate carotid artery stenting (iCAS). A systematic review and meta-analysis was performed. Data for each included study was extracted. For comparative studies a meta-analysis was performed. Functional outcome was expressed with the modified Rankin scale and safety endpoints were mortality and symptomatic intracranial hemorrhage (sICH). A total of 72 full text articles evaluating treatment of TL during EVT were screened. Sixteen iCAS and five comparative studies were included for meta-analysis. 53% of patients undergoing iCAS during EVT had good functional outcome in comparison to 45% of patients who underwent only BA. Mortality was comparable at 16% for both groups. The incidences of sICH were 8% and 4% for iCAS and BA respectively. In the meta-analysis, iCAS was associated with good functional outcome, with no significant differences in mortality and sICH with compared to BA. This study shows that treatment with iCAS of a simultaneously ipsilateral EICA lesion during EVT is associated with a favorable functional outcome compared to BA only with no significant difference in mortality or sICH. No conclusion could be drawn about the intracranial or extracranial first approach due to scarce of data. More studies are needed to determine long-term neurological outcomes, the necessity of re-interventions and optimal technical approach (intracranial or extracranial first).
Collapse
Affiliation(s)
- Joyce Hellegering
- Division of Vascular Surgery, Department of Surgery, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mostafa El Moumni
- Division of Vascular Surgery, Department of Surgery, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten J van der Laan
- Division of Vascular Surgery, Department of Surgery, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
10
|
Park JS, Lee JM, Kwak HS, Chung GH. Endovascular treatment of acute carotid atherosclerotic tandem occlusions: Predictors of clinical outcomes as technical aspects and location of tandem occlusions. J Stroke Cerebrovasc Dis 2020; 29:105090. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/30/2020] [Accepted: 06/22/2020] [Indexed: 11/25/2022] Open
|
11
|
Kehara H, Urashita S, Gomibuchi T, Komatsu K, Takahashi K, Tsukioka K, Terasaki T, Kono T, Wada N, Kakizawa Y, Koyama JI, Okada K. Mechanical Thrombectomy for Postoperative Stroke in a Patient with Acute Aortic Dissection Type A. NMC Case Rep J 2020; 7:71-74. [PMID: 32322455 PMCID: PMC7162810 DOI: 10.2176/nmccrj.cr.2019-0134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/18/2019] [Indexed: 11/20/2022] Open
Abstract
Mechanical thrombectomy has been proposed to expand the treatment time window and enhance revascularization. However, it is unclear whether its use can be extended to patients with occlusions in acute aortic dissection, especially the thoracic aorta. A 55-year-old man underwent graft replacement for acute aortic dissection type A. On postoperative day 2, he developed stroke and computed tomography showed occlusion of the right middle cerebral artery. Mechanical thrombectomy was performed by transbrachial approach. Although successful recanalization was achieved, he suffered hemorrhagic stroke. Since there is no other effective treatment and the neurologic outcome with conservative management is poor, we consider mechanical thrombectomy to be a viable therapeutic option for the treatment of postoperative stroke in patients with acute aortic dissection type A. However, further study is warranted regarding the safety of this technique.
Collapse
Affiliation(s)
- Hiromu Kehara
- Department of Cardiovascular Surgery, Suwa Red Cross Hospital, Suwa, Nagano, Japan
| | - Syuichi Urashita
- Department of Cardiovascular Surgery, Kumamoto Red Cross Hospital, Kumamoto, Kumamoto, Japan
| | - Toshihito Gomibuchi
- Department of Cardiovascular Surgery, Suwa Red Cross Hospital, Suwa, Nagano, Japan
| | - Kazunori Komatsu
- Department of Cardiovascular Surgery, Suwa Red Cross Hospital, Suwa, Nagano, Japan
| | - Kouhei Takahashi
- Department of Cardiovascular Surgery, Iida Municipal Hospital, Iida, Nagano, Japan
| | - Katsuaki Tsukioka
- Department of Cardiovascular Surgery, Iida Municipal Hospital, Iida, Nagano, Japan
| | - Takamitsu Terasaki
- Department of Cardiovascular Surgery, Suwa Red Cross Hospital, Suwa, Nagano, Japan
| | - Tetsuya Kono
- Department of Cardiovascular Surgery, Suwa Red Cross Hospital, Suwa, Nagano, Japan
| | - Naomichi Wada
- Department of Neurosurgery, Suwa Red Cross Hospital, Suwa, Nagano, Japan
| | - Yukinari Kakizawa
- Department of Neurosurgery, Suwa Red Cross Hospital, Suwa, Nagano, Japan
| | - Jun-Ichi Koyama
- Neuroendovascular Therapy Center, Shinshu University Hospital, Matsumoto, Nagano, Japan
| | - Kenji Okada
- Department of Cardiovascular Surgery, Kobe University, Kobe, Hyogo, Japan
| |
Collapse
|
12
|
Moon GI, Baek BH, Kim SK, Lee YY, Lee HJ, Yoon W. Predictors of a Favorable Outcome after Emergent Carotid Artery Stenting in Acute Anterior Circulation Stroke Patients. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2020; 81:665-675. [PMID: 36238632 PMCID: PMC9431905 DOI: 10.3348/jksr.2020.81.3.665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/09/2019] [Accepted: 09/14/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Gyeong Il Moon
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea
| | - Byung Hyun Baek
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea
| | - Seul Kee Kim
- Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Yun Young Lee
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea
| | - Hyo-Jae Lee
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea
| | - Woong Yoon
- Department of Radiology, Chonnam National University Medical School, Gwangju, Korea
| |
Collapse
|
13
|
Murias E, Vega P, Lopez-Cancio E, Peña J, Morales E, Benavente L, González M, Larrosa D, Rico M, Riesco N, Cadenas M, Jimenez JM, Chaviano J, Saiz A, Calleja S, Arias F. Dual energy CT in the management of antiplatelet therapy in patients with acute ischemic stroke for carotid obstruction. Interv Neuroradiol 2019; 26:222-230. [PMID: 31684785 DOI: 10.1177/1591019919880425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND PURPOSE Acute tandem occlusions often require carotid stenting. Combination of mechanical and pharmacologic therapies in addition to antiplatelet drugs administered to prevent acute stent thrombosis might increase the risk of intracerebral hemorrhage. We present a protocol of antiplatelet regimen based on early post-procedural dual-energy CT (DE-CT). MATERIAL AND METHODS Fifty consecutive stroke patients with tandem occlusions treated with acute carotid stenting after intracranial thrombectomy and TICI 2b/3 were reviewed. All patients received intravenous lysine acetylsalicylate during the procedure. Dual (aspirin+clopidogrel with or without clopidogrel load, groups A and B, respectively) or mono (aspirin) antiplatelet regimen (group C) was administered 12-24 h later according to brain DE-CT findings. Carotid ultrasonography was performed at 24 h and before discharge. We evaluated the rate of subsequent symptomatic intracranial hemorrhage (SICH) and acute stent thrombosis in each group. RESULTS Between June 2014 and December 2016, 50 patients were included (mean age 66 years, 76% men, baseline NIHSS 16, median time from symptom onset to recanalization 266 min). According to DE-CT, 24 patients were assigned to group A, 19 to group B and 7 to group C (4 of them had SICH at that time). One patient suffered a subsequent SICH (belonging to group B). There was only one stent thrombosis without clinical repercussions in group B. CONCLUSIONS DE-CT may contribute to select antiplatelet regimen after acute carotid stenting in tandem occlusions.
Collapse
Affiliation(s)
- Eduardo Murias
- Department of Radiology-Interventional Neuroradiology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Pedro Vega
- Department of Radiology-Interventional Neuroradiology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Elena Lopez-Cancio
- Department of Neurology - Stroke Unit, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Jorge Peña
- Department of Radiology-Interventional Neuroradiology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Edison Morales
- Department of Radiology-Interventional Neuroradiology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Lorena Benavente
- Department of Neurology - Stroke Unit, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Montserrat González
- Department of Neurology - Stroke Unit, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Davinia Larrosa
- Department of Neurology - Stroke Unit, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Maria Rico
- Department of Neurology - Stroke Unit, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Nuria Riesco
- Department of Neurology - Stroke Unit, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Maria Cadenas
- Department of Radiology-Interventional Neuroradiology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Jose Maria Jimenez
- Department of Radiology-Interventional Neuroradiology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Juan Chaviano
- Department of Radiology-Interventional Neuroradiology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Antonio Saiz
- Department of Radiology-Interventional Neuroradiology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Sergio Calleja
- Department of Neurology - Stroke Unit, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Faustino Arias
- Department of Radiology-Interventional Neuroradiology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| |
Collapse
|
14
|
Beneš V, Bradáč O, Horváth D, Suchomel P, Beneš V. Surgery of acute occlusion of the extracranial internal carotid artery - a meta-analysis. VASA 2019; 49:6-16. [PMID: 31210589 DOI: 10.1024/0301-1526/a000801] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Acute occlusion of the extracranial internal carotid artery (eICA) is associated with poor prognosis. Surgical desobliteration has not received adequate attention in recent years. We therefore conducted a literature review and meta-analysis of surgical studies published after 2000 that treated eICA occlusion surgically in an emergency setting. The search identified 10 relevant articles that included a total of 175 patients. The outcomes analysed included rates of recanalization (93 %), early neurological improvement (66 %), modified Rankin Scale 0-2 (62 %), mortality (5 %), early reocclusion (4 %), in-hospital stroke (4 %) and symptomatic intracerebral haemorrhage (4 %). In conclusion, acute surgical desobliteration of eICA occlusion leads to high rates of recanalization and a majority of patients experience early neurological improvement and achieve favourable outcome. Rates of mortality, early reocclusion, in-hospital stroke and sICH are acceptable in the view of unfavourable natural history.
Collapse
Affiliation(s)
- Vladimír Beneš
- Department of Neurosurgery, Regional Hospital Liberec, Liberec, Czech Republic
| | - Ondřej Bradáč
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - David Horváth
- Institute of Scientific Information, Charles University, First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Petr Suchomel
- Department of Neurosurgery, Regional Hospital Liberec, Liberec, Czech Republic
| | - Vladimír Beneš
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| |
Collapse
|
15
|
Endovascular Recanalization of Acute Tandem Cervical Carotid and Intracranial Occlusions: Efficacy of Cervical Balloon Angioplasty Alone Then Intracranial Target Recanalization Strategy. World Neurosurg 2019; 126:e1268-e1275. [DOI: 10.1016/j.wneu.2019.02.240] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 11/22/2022]
|
16
|
Pop R, Zinchenko I, Quenardelle V, Mihoc D, Manisor M, Richter JS, Severac F, Simu M, Chibbaro S, Rouyer O, Wolff V, Beaujeux R. Predictors and Clinical Impact of Delayed Stent Thrombosis after Thrombectomy for Acute Stroke with Tandem Lesions. AJNR Am J Neuroradiol 2019; 40:533-539. [PMID: 30765378 DOI: 10.3174/ajnr.a5976] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/23/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There are very few published data on the patency of carotid stents implanted during thrombectomies for tandem lesions in the anterior circulation. We aimed to communicate our experience of stenting in the acute setting with systematic follow-up of stent patency and discuss predictors and clinical repercussions of delayed stent thrombosis. MATERIALS AND METHODS We performed a retrospective study of stroke thrombectomies in a single center between January 2009 and April 2018. Patient files were reviewed to extract patient characteristics, procedural details, imaging studies, and clinical information. Predictors of delayed stent thrombosis and clinical outcome at discharge were analyzed using univariate and multivariate analyses. RESULTS We identified 81 patients treated for tandem lesions: 63 (77.7%) atheromas, 17 (20.9%) dissections, and 1 (1.2%) carotid web. TICI 2b-3 recanalization was achieved in 70 (86.4%) cases. Thirty-five patients (43.2%) were independent (mRS score ≤ 2) at discharge. Among 73 patients with intracranial recanalization and patent stents at the end of the procedure, delayed stent thrombosis was observed in 14 (19.1%). Among 59 patients with patent stents, 44 had further imaging controls (median, 105 days; range, 2-2407 days) and 1 (1.6%) had 50% in-stent stenosis with no retreatment. Stent occlusion rates were 11/39 (28.2%) for periprocedural aspirin treatment versus 3/34 (8.8%) for aspirin and clopidogrel (P = .04). Delayed stent thrombosis was independently associated with higher admission NIHSS scores (OR, 1.1; 95% CI, 1.01-1.28), diabetes (OR, 6.07; 95% CI, 1.2-30.6), and the presence of in-stent thrombus on the final angiographic run (OR, 6.2; 95% CI, 1.4-27.97). Delayed stent thrombosis (OR, 19.78; 95% CI, 2.78-296.83), higher admission NIHSS scores (OR, 1.27, 95% CI, 1.12-1.51), and symptomatic hemorrhagic transformation (OR, 23.65; 95% CI, 1.85-3478.94) were independent predictors of unfavorable clinical outcome at discharge. CONCLUSIONS We observed a non-negligible rate of delayed stent thrombosis with significant negative impact on clinical outcome. Future studies should systematically measure and report stent patency rates.
Collapse
Affiliation(s)
- R Pop
- From the Interventional Neuroradiology Department (R.P., D.M., M.M., J.S.R., R.B.)
- Institut Hopitalo-Universitaire Strasbourg (R.P., R.B.), Strasbourg, France
| | | | | | - D Mihoc
- From the Interventional Neuroradiology Department (R.P., D.M., M.M., J.S.R., R.B.)
| | - M Manisor
- From the Interventional Neuroradiology Department (R.P., D.M., M.M., J.S.R., R.B.)
| | - J S Richter
- From the Interventional Neuroradiology Department (R.P., D.M., M.M., J.S.R., R.B.)
- EA3072, FMTS (J.S.R., O.R., V.W.), University of Strasbourg, Strasbourg, France
| | | | - M Simu
- Neurology Department (M.S.), Victor Babes University of Medicine, Timisoara, Romania
| | - S Chibbaro
- Neurosurgery Department (S.C.), Strasbourg University Hospitals, Strasbourg, France
| | - O Rouyer
- Stroke Unit (I.Z., V.Q., O.R., V.W.)
- EA3072, FMTS (J.S.R., O.R., V.W.), University of Strasbourg, Strasbourg, France
| | - V Wolff
- Stroke Unit (I.Z., V.Q., O.R., V.W.)
- EA3072, FMTS (J.S.R., O.R., V.W.), University of Strasbourg, Strasbourg, France
| | - R Beaujeux
- From the Interventional Neuroradiology Department (R.P., D.M., M.M., J.S.R., R.B.)
- Institut Hopitalo-Universitaire Strasbourg (R.P., R.B.), Strasbourg, France
| |
Collapse
|
17
|
Jadhav AP, Zaidat OO, Liebeskind DS, Yavagal DR, Haussen DC, Hellinger FR, Jahan R, Jumaa MA, Szeder V, Nogueira RG, Jovin TG. Emergent Management of Tandem Lesions in Acute Ischemic Stroke. Stroke 2019; 50:428-433. [DOI: 10.1161/strokeaha.118.021893] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ashutosh P. Jadhav
- From the Department of Neurology, University of Pittsburgh Medical Center, PA (A.P.J., T.G.J.)
| | | | - David S. Liebeskind
- Department of Neurology (D.S.L,)
- University of California Los Angeles (D.S.L., R.J., V.S.)
| | - Dileep R. Yavagal
- Department of Neurological Surgery, University of Miami Miller School of Medicine/Jackson Memorial Hospital, FL (D.R.Y.)
| | - Diogo C. Haussen
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA (D.C.H., R.G.N.)
| | - Frank R. Hellinger
- Department of Radiology, Florida Hospital Neuroscience Institute, Winter Park (F.R.H.)
| | - Reza Jahan
- Department of Radiology, David Geffen School of Medicine (R.J., V.S.)
- University of California Los Angeles (D.S.L., R.J., V.S.)
| | | | - Viktor Szeder
- Department of Radiology, David Geffen School of Medicine (R.J., V.S.)
- University of California Los Angeles (D.S.L., R.J., V.S.)
| | - Raul G. Nogueira
- Department of Neurology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA (D.C.H., R.G.N.)
| | - Tudor G. Jovin
- From the Department of Neurology, University of Pittsburgh Medical Center, PA (A.P.J., T.G.J.)
| |
Collapse
|
18
|
Park SE, Choi DS, Baek HJ, Kim CH, Choi HC, Cho SB, Lee S, Ahn JH. Endovascular therapy of acute ischemic stroke related to tandem occlusion: comparison of occlusion and severe stenosis of the proximal cervical internal carotid artery. Br J Radiol 2018; 92:20180051. [PMID: 30156868 DOI: 10.1259/bjr.20180051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
METHODS We retrospectively reviewed 42 patients with acute ischemic stroke who underwent endovascular treatment for tandem lesions between January 2011 and April 2017. After dividing the patients into two groups according to lesion type of the proximal cervical ICA (complete occlusion and severe stenosis), we analyzed demographic data, angiographic findings and clinical outcomes. A modified Rankin Scale score ≤2 was defined as a favorable clinical outcome. RESULTS Of 42 patients, 27 patients (64.3%) had complete occlusion of the cervical ICA, and the remaining 15 had high-grade stenosis. Successful stenting was performed in all patients with favorable clinical outcomes (27/42, 64.3%). Successful reperfusion score (thrombolysis in cerebral infarction ≥2b) was 78.6%; occlusion group (18/27, 66.7%) vs stenosis group (15/15, 100%) of cases. Mean modified Rankin Scale score at 90 days was 2.36 ± 1.83. The rate of favorable clinical outcome was higher in stenosis group (11/15, 73.3%) than that of occlusion group (16/27, 59.3%) with no statistically significant difference (p = 0.506). CONCLUSION Acute endovascular treatment of carotid artery tandem lesions is a technically feasible and clinically effective intervention regardless of the lesion type in proximal cervical ICA. ADVANCES IN KNOWLEDGE Our study supports the results of previous studies in which endovascular therapy has a favorable clinical outcome in carotid artery tandem occlusion.
Collapse
Affiliation(s)
- Sung Eun Park
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea.,Gyeongsang Institute of Health Science, Gyeongsang National University of Scholl of Medicine, Jinju, Republic of korea
| | - Dae Seob Choi
- Gyeongsang Institute of Health Science, Gyeongsang National University of Scholl of Medicine, Jinju, Republic of korea.,Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Hye Jin Baek
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Chang Hun Kim
- Department of Neurology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of korea
| | - Ho Cheol Choi
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Soo Buem Cho
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Sangmin Lee
- Department of Radiology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Jong-Hwa Ahn
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of korea
| |
Collapse
|
19
|
Wang F, Jiang B, Kanesan L, Zhao Y, Yan B. Higher admission fasting plasma glucose levels are associated with a poorer short-term neurologic outcome in acute ischemic stroke patients with good collateral circulation. Acta Diabetol 2018; 55:703-714. [PMID: 29651557 DOI: 10.1007/s00592-018-1139-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/30/2018] [Indexed: 12/15/2022]
Abstract
AIMS In this retrospective study, we sought to delineate the collateral circulation status of acute ischemic stroke patients by CT perfusion and evaluate 90-day modified Rankin Scale (mRS) scores of patients with good or poor collaterals and its correlation with admission fasting plasma glucose (FPG). METHODS We enrolled acute ischemic stroke patients who presented to our hospital 4.5 h within an onset of the first episode between January 2009 and December 2015. Neurological assessment was performed using the 90-day mRS scores (0-2 for a favorable and 3-6 for an unfavorable neurologic outcome). Relative filling time delay (rFTD) was evaluated by CT perfusion scan. The primary outcomes were 90-day mRS scores stratified by good (rFTD ≤ 4 s) versus poor collateral circulation (rFTD > 4 s). RESULTS Totally 270 patients were included, and 139 (51.5%) patients achieved a favorable neurologic outcome. One hundred eighty-five (68.5%) patients had good collateral circulation. Significantly greater portions of patients with good collateral circulation (60.5%, 112/185) achieved a favorable neurologic outcome compared to those with poor collateral circulation (31.8%, 27/85) (P < 0.05). Patients with good collateral circulation achieving a favorable neurologic outcome had significantly lower baseline FPG (6.6 ± 1.96) than those with good collateral circulation achieving an unfavorable neurologic outcome (8.12 ± 4.02; P = 0.002). Spearman correlation analysis showed that rFTD significantly correlated with 90-day mRS scores (adjusted r = 0.258; P < 0.001) and admission FPG (r = 0.286; P < 0.001). CONCLUSION Higher admission FPG levels are associated with significantly higher rates of unfavorable neurologic outcome of acute ischemic stroke patients with good collateral circulation. FPG and rFTD may serve as useful predictors of short-term patient outcome and could be used for risk stratification in clinical decision making.
Collapse
Affiliation(s)
- Feng Wang
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
- Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, 3050, Australia
| | - Beisi Jiang
- Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, 3050, Australia
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Lasheta Kanesan
- Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, 3050, Australia
| | - Yuwu Zhao
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
| | - Bernard Yan
- Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, 3050, Australia.
| |
Collapse
|
20
|
Endovascular treatment of acute tandem occlusion strokes and stenting first experience. J Clin Neurosci 2018; 47:328-331. [DOI: 10.1016/j.jocn.2017.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 08/17/2017] [Accepted: 09/18/2017] [Indexed: 11/21/2022]
|
21
|
Maus V, Behme D, Borggrefe J, Kabbasch C, Seker F, Hüseyin C, Barnikol UB, Yeo LLL, Brouwer P, Söderman M, Möhlenbruch M, Psychogios MN, Liebig T, Dohmen C, Fink GR, Mpotsaris A. Carotid Artery Stenosis Contralateral to Acute Tandem Occlusion: An Independent Predictor of Poor Clinical Outcome after Mechanical Thrombectomy with Concomitant Carotid Artery Stenting. Cerebrovasc Dis 2017; 45:10-17. [PMID: 29208850 DOI: 10.1159/000484719] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/28/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Cerebral ischemic strokes due to extra-/intracranial tandem occlusions (TO) of the anterior circulation are responsible for causing mechanical thrombectomy (MT). The impact of concomitant contralateral carotid stenosis (CCS) upon outcome remains unclear in this stroke subtype. METHODS Retrospective analysis of prospectively collected data of 4 international stroke centers between 2011 and 2017. One hundred ninety-seven consecutive patients with anterior TO were treated with MT and acute carotid artery stenting (CAS). Clinical (including demographics and National Institutes of Health Stroke Scale [NIHSS]), imaging (including angiographic evaluation of CCS) and procedural data were evaluated. Favorable clinical outcome was defined as modified Rankin Scale (mRS) ≤2 at 90 days. RESULTS In 186 out of 197 TO patients preinterventional CT angiography was available for analysis, thereof 49 patients (26%) presented with CCS. Median admission NIHSS and procedural timings did not differ between groups. Reperfusion was successful in 38 out of 49 patients (78%) vs. 113 out of 148 patients (76%) without CCS. In stark contrast, rate of favorable outcome at 90 days differed significantly between groups (22 vs. 44%; p < 0.05). The presence of CCS in TO was associated with an unfavorable clinical outcome independent of age and NIHSS in multivariate logistic regression (p < 0.05). Final infarct volume was significantly larger in CCS patients (100 ± 127 vs. 63 ± 77 cm3; p < 0.05). Neither all-cause mortality rates (25 vs. 17%) nor frequency of peri-interventional symptomatic intracranial hemorrhage differed between groups (7 vs. 6%). CONCLUSION For patients with anterior TO undergoing MT with concomitant CAS the presence of CCS >50% is an independent predictor of poor clinical outcome. This most likely cause is due to poorer collateral flow to the affected tissue.
Collapse
Affiliation(s)
- Volker Maus
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Jan Borggrefe
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Fatih Seker
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Cicek Hüseyin
- Department of Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Utako Birgit Barnikol
- Clearing Unit Ethics, Medical Faculty of Cologne and Research Unit Ethics, Department of Child and Adolescence Psychiatry, University Hospital of Cologne, Cologne, Germany
| | - Leonard Leong Litt Yeo
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Patrick Brouwer
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Söderman
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Markus Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | | | | | - Christian Dohmen
- Department of Neurology, University Hospital Cologne, Cologne, Germany
| | - Gereon Rudolf Fink
- Department of Neurology, University Hospital Cologne, Cologne, Germany.,Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich, Jülich, Germany
| | | |
Collapse
|
22
|
Eker OF, Panni P, Dargazanli C, Marnat G, Arquizan C, Machi P, Mourand I, Gascou G, Le Bars E, Costalat V, Bonafé A. Anterior Circulation Acute Ischemic Stroke Associated with Atherosclerotic Lesions of the Cervical ICA: A Nosologic Entity Apart. AJNR Am J Neuroradiol 2017; 38:2138-2145. [PMID: 29051203 DOI: 10.3174/ajnr.a5404] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 06/09/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy for patients with acute ischemic stroke with tandem occlusions has been shown to present varying reperfusion successes and clinical outcomes. However, the heterogeneity of tandem occlusion etiology has been strongly neglected in previous studies. We retrospectively investigated patients with acute ischemic stroke atherothrombotic tandem occlusion. MATERIALS AND METHODS All consecutive patients with acute ischemic stroke with atherothrombotic tandem occlusions treated with mechanical thrombectomy in our center between September 2009 and April 2015 were analyzed. They were compared with patients with acute ischemic stroke with dissection-related tandem occlusion and isolated intracranial occlusion treated during the same period. Comparative univariate and multivariate analyses were conducted, including demographic data, safety, and rates of successful recanalization and good clinical outcome. RESULTS Despite comparable baseline severity of neurologic deficits and infarct core extension, patients with atherothrombotic tandem occlusions were older (P < .001), were more frequently smokers (P < .001), and had globally more cardiovascular risk factors (P < .001) than the other 2 groups of patients. The patients with atherothrombotic tandem occlusions had significantly longer procedural times (P < .001), lower recanalization rates (P = .004), and higher global burden of procedural complications (P < .001). In this group, procedural complications (OR = 0.15, P = .02) and the TICI 2b/3 reperfusion scores (OR = 17.76, P = .002) were independently predictive factors of favorable clinical outcome. CONCLUSIONS Our study suggests that atherothrombotic tandem occlusions represent a peculiar and different nosologic entity compared with dissection-related tandem occlusions. This challenging cause of acute ischemic stroke should be differentiated from other etiologies in patient management in future prospective studies.
Collapse
Affiliation(s)
- O F Eker
- From the Service de Neuroradiologie (O.F.E., P.P., C.D., P.M., G.G., E.L.B., V.C., A.B.)
| | - P Panni
- From the Service de Neuroradiologie (O.F.E., P.P., C.D., P.M., G.G., E.L.B., V.C., A.B.).,Department of Neurosurgery and Radiosurgery (P.P.), San Raffaele University Hospital, Milan, Italy
| | - C Dargazanli
- From the Service de Neuroradiologie (O.F.E., P.P., C.D., P.M., G.G., E.L.B., V.C., A.B.)
| | - G Marnat
- Service de Neuroradiologie (G.M., I.M.), Hôpital Pellegrin, CHRU de Bordeaux, Bordeaux, France
| | - C Arquizan
- Service de Neurologie (C.A.), Hôpital Gui de Chauliac, CHRU de Montpellier, Montpellier, France
| | - P Machi
- From the Service de Neuroradiologie (O.F.E., P.P., C.D., P.M., G.G., E.L.B., V.C., A.B.)
| | - I Mourand
- Service de Neuroradiologie (G.M., I.M.), Hôpital Pellegrin, CHRU de Bordeaux, Bordeaux, France
| | - G Gascou
- From the Service de Neuroradiologie (O.F.E., P.P., C.D., P.M., G.G., E.L.B., V.C., A.B.)
| | - E Le Bars
- From the Service de Neuroradiologie (O.F.E., P.P., C.D., P.M., G.G., E.L.B., V.C., A.B.)
| | - V Costalat
- From the Service de Neuroradiologie (O.F.E., P.P., C.D., P.M., G.G., E.L.B., V.C., A.B.)
| | - A Bonafé
- From the Service de Neuroradiologie (O.F.E., P.P., C.D., P.M., G.G., E.L.B., V.C., A.B.)
| |
Collapse
|
23
|
Akpinar CK, Gürkaş E, Aytac E. Carotid angioplasty-assisted mechanical thrombectomy without urgent stenting may be a better option in acute tandem occlusions. Interv Neuroradiol 2017; 23:405-411. [PMID: 28504557 DOI: 10.1177/1591019917701113] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The aim of the study was to assess the efficacy of balloon angioplasty-assisted mechanical thrombectomy without urgent stenting in the carotid artery as another approach for endovascular treatment of tandem occlusions. Methods Fifteen consecutive cases of tandem occlusions treated with the endovascular approach between January 2014 and May 2016 were reviewed. The study cohort included patients with an etiology of large vessel atherosclerosis. Extracranial carotid stenting was performed in another session if post-thrombectomy mRS modified Rankin Score (mRS) was 0-2. Good clinical outcome was determined by follow-up at 7-10, 30 and 90 days according to the mRS. Results Most patients (80%) were male. Eight (53.4%) patients received intravenous thrombolysis before angiography. Proximal revascularization was successful in 100% of cases with balloon angioplasty internal carotid artery (ICA) origin. Successful recanalization (modified thrombolysis in cerebral infarction (mTICI) 2b-3) (mTICI 2 b-3) occurred in 12 cases (80%) and good clinical outcomes were achieved in 10 patients (66.7%). Cervical ICA stent placement was performed in 10 patients with good clinical outcomes. No symptomatic intracranial hemorrhage occurred after delayed ICA stenting Conclusions This is the first reported case series to evaluate this approach for endovascular treatment of tandem occlusions. Carotid angioplasty-assisted mechanical thrombectomy without urgent stenting seems to be a safer approach.
Collapse
Affiliation(s)
- Cetin K Akpinar
- 1 Ankara Numune Training and Research Hospital, Neurology Clinic, Ankara, Turkey
| | - Erdem Gürkaş
- 1 Ankara Numune Training and Research Hospital, Neurology Clinic, Ankara, Turkey
| | - Emrah Aytac
- 2 Fırat University, Medical Faculty, Neurology, Elazig, Turkey
| |
Collapse
|
24
|
Mbabuike N, Gassie K, Brown B, Miller DA, Tawk RG. Revascularization of tandem occlusions in acute ischemic stroke: review of the literature and illustrative case. Neurosurg Focus 2017; 42:E15. [DOI: 10.3171/2017.1.focus16521] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Tandem occlusions continue to represent a major challenge in patients with acute ischemic stroke (AIS). The anterograde approach with proximal to distal revascularization as well as the retrograde approach with distal to proximal revascularization have been reported without clear consensus or standard guidelines.
METHODS
The authors performed a comprehensive search of the PubMed database for studies including patients with carotid occlusions and tandem distal occlusions treated with endovascular therapy. They reviewed the type of approach employed for endovascular intervention and clinical outcomes reported with emphasis on the revascularization technique. They also present an illustrative case of AIS and concurrent proximal cervical carotid occlusion and distal middle cerebral artery occlusion from their own experience in order to outline the management dilemma for similar cases.
RESULTS
A total of 22 studies were identified, with a total of 790 patients with tandem occlusions in AIS. Eleven studies used the anterograde approach, 3 studies used the retrograde approach, 4 studies used both, and in 4 studies the approach was not specified. In the studies that reported Thrombolysis in Cerebral Infarction (TICI) grades, an average of 79% of patients with tandem occlusions were reported to have an outcome of TICI 2b or better. One study found good clinical outcome in 52.5% of the thrombectomy-first group versus 33.3% in the stent-first group, as measured by the modified Rankin Scale (mRS). No study evaluated the difference in time to reperfusion for the anterograde and retrograde approach and its association with clinical outcome. The patient in the illustrative case had AIS and tandem occlusion of the internal carotid and middle cerebral arteries and underwent distal revascularization using a Solitaire stent retrieval device followed by angioplasty and stent treatment of the proximal cervical carotid occlusion. The revascularization was graded as TICI 2b; the postintervention National Institutes of Health Stroke Scale (NIHSS) score was 17, and the discharge NIHSS score was 7. The admitting, postoperative, and 30-day mRS scores were 5, 1, and 1, respectively.
CONCLUSIONS
In stroke patients with tandem occlusions, distal to proximal revascularization represents a reasonable treatment approach and may offer the advantage of decreased time to reperfusion, which is associated with better functional outcome. Further studies are warranted to determine the best techniques in endovascular therapy to use in this subset of patients in order to improve clinical outcome.
Collapse
|
25
|
Al-Mufti F, Amuluru K, Manning NW, Khan I, Peeling L, Gandhi CD, Prestigiacomo CJ, Pushchinska G, Fiorella D, Woo HH. Emergent carotid stenting and intra-arterial abciximab in acute ischemic stroke due to tandem occlusion. Br J Neurosurg 2017; 31:573-579. [PMID: 28298139 DOI: 10.1080/02688697.2017.1297377] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Acute occlusions of the extracranial internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous tissue plasminogen activator (tPA) and present an endovascular challenge. The aim of our study was to retrospectively delineate the feasibility of the combined use of emergent carotid stenting and intra-arterial (IA) Abciximab with intracranial revascularization in the setting of acute ischemic stroke and carotid occlusions at our institution. METHODS Eleven patients with complete cervical carotid occlusion with or without concomitant intracranial ICA and/or MCA occlusion were identified from a single center, retrospective review of patients admitted to the Stroke unit. We evaluated all cases for complications of emergent cervical ICA recanalization employing carotid stenting and IA Abciximab. RESULTS All patients had complete cervical carotid occlusion with (n = 8) or without (n = 3) concomitant intracranial ICA and/or MCA occlusion. Successful emergent cervical ICA recanalization was achieved in all cases. All patients were administered IA Abciximab (dose range 6-17 mg, average 11.4 mg) immediately following the cervical carotid stenting. There was complete recanalization in all patients with no procedural morbidity or mortality. A single case (1/11, 9%) developed asymptomatic hemorrhagic transformation. Upon discharge, 9 patients (9/11, 82%) had a mRS of 0-2 and 2 patients (2/11, 18%) had a mRS of 3. CONCLUSIONS In acute ICA-MCA/distal ICA occlusions, extracranial stenting followed by intracranial IA Abciximab and thrombectomy appears feasible, effective, and safe. Further evaluation of this treatment strategy is warranted.
Collapse
Affiliation(s)
- Fawaz Al-Mufti
- a Department of Neurosurgery , Rutgers University School of Medicine , Newark , NJ , USA
| | - Krishna Amuluru
- a Department of Neurosurgery , Rutgers University School of Medicine , Newark , NJ , USA
| | - Nathan W Manning
- b Department of Neurosurgery , Columbia University Medical Center , New York , NY , USA
| | - Imad Khan
- c Department of Neurology , University of Maryland Medical Center , Baltimore , MD , USA
| | - Lissa Peeling
- d Department of Neurosurgery , University of Saskatchewan , Saskatoon , SK , Canada
| | - Chirag D Gandhi
- a Department of Neurosurgery , Rutgers University School of Medicine , Newark , NJ , USA
| | | | - Galyna Pushchinska
- e Department of Neurosurgery , State University of New York at Stony Brook , Stony Brook , NY , USA
| | - David Fiorella
- e Department of Neurosurgery , State University of New York at Stony Brook , Stony Brook , NY , USA
| | - Henry H Woo
- e Department of Neurosurgery , State University of New York at Stony Brook , Stony Brook , NY , USA
| |
Collapse
|
26
|
Association of Cortical Vein Filling with Clot Location and Clinical Outcomes in Acute Ischaemic Stroke Patients. Sci Rep 2016; 6:38525. [PMID: 27917948 PMCID: PMC5137111 DOI: 10.1038/srep38525] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 11/11/2016] [Indexed: 01/19/2023] Open
Abstract
Delay in cortical vein filling during the late-venous phase (delayed-LCVF) is characterized by opacification of cerebral veins despite contrast clearance from contralateral veins on dynamic computed tomography angiography (dCTA) in acute ischemic stroke (AIS) patients. The aim of the study was to investigate the associations of delayed-LCVF with clot location, reperfusion status at 24 hours, and 90-days functional outcome in AIS patients who received reperfusion therapy. A prospective cohort of AIS patients treated with intravenous thrombolysis was studied. Groupwise comparison, univariate, and multivariate regression analyses were used to study the association of delayed-LCVF with clot location and clinical outcomes. Of 93 patients (mean age = 72 ± 12 years) with hemispheric AIS included in the study, 46 (49%) demonstrated delayed-LCVF. Patients with delayed-LCVF demonstrated a significantly higher proportion of proximal occlusion (72% vs 13%, P =< 0.0001), and poor reperfusion at 24 hours (41% vs 11%, P = 0.001). The proportion of poor functional outcome at 90 days was not significantly different (22/56 (48%) vs 17/61 (36%), P = 0.297). The appearance of delayed-LCVF on baseline dCTA may be a surrogate for large vessel occlusion, and an early marker for poor 24-hour angiographic reperfusion.
Collapse
|
27
|
Lin CM, Chang YJ, Liu CK, Yu CS, Lu HHS. First-ever ischemic stroke in elderly patients: predictors of functional outcome following carotid artery stenting. Clin Interv Aging 2016; 11:985-95. [PMID: 27555753 PMCID: PMC4968667 DOI: 10.2147/cia.s111637] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Age is an important risk factor for stroke, and carotid artery stenosis is the primary cause of first-ever ischemic stroke. Timely intervention with stenting procedures can effectively prevent secondary stroke; however, the impact of stenting on various periprocedural physical functionalities has never been thoroughly investigated. The primary aim of this study was to investigate whether prestenting characteristics were associated with long-term functional outcomes in patients presenting with first-ever ischemic stroke. The secondary aim was to investigate whether patient age was an important factor in outcomes following stenting, measured by the modified Rankin scale (mRS). In total, 144 consecutive patients with first-ever ischemic stroke who underwent carotid artery stenting from January 2010 to November 2014 were included. Clinical data were obtained by review of medical records. The Barthel index (BI) and mRS were used to assess disability before stenting and at 12-month follow-up. In total, 72/144 patients showed improvement (mRS[+]), 71 showed stationary and one showed deterioration in condition (mRS[-]). The prestenting parameters, ratio of cerebral blood volume (1.41 vs 1.2 for mRS[-] vs mRS[+]), BI (75 vs 85), and high-sensitivity C-reactive protein (hsCRP 5.0 vs 3.99), differed significantly between the two outcome groups (P<0.05). The internal carotid artery/common carotid artery ratio (P=0.011), BI (P=0.019), ipsilateral internal carotid artery resistance index (P=0.003), and HbA1c (P=0.039) were all factors significantly associated with patient age group. There was no significant association between age and poststenting outcome measured by mRS with 57% of patients in the ≥75 years age group showing mRS(-) and 43% showing mRS(+) (P=0.371). Our findings indicate that in our elderly patient series, carotid artery stenting may benefit a significant proportion of carotid stenotic patients regardless of age. Ratio of cerebral blood volume, BI, and admission hsCRP could serve as important predictors of mRS improvement and may facilitate differentiation of patients at baseline.
Collapse
Affiliation(s)
- Chih-Ming Lin
- Department of Neurology, Stroke Center, Changhua Christian Hospital, Changhua; Department of Biological Science and Technology, National Chiao Tung University, Hsinchu
| | - Yu-Jun Chang
- Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua
| | - Chi-Kuang Liu
- Department of Medical Imaging, Changhua Christian Hospital, Changhua
| | - Cheng-Sheng Yu
- Institute of Statistics and Big Data Research Center, National Chiao Tung University, Hsinchu, Taiwan
| | - Henry Horng-Shing Lu
- Institute of Statistics and Big Data Research Center, National Chiao Tung University, Hsinchu, Taiwan
| |
Collapse
|
28
|
Sonig A, Levy EI. Neuroendovascular Surgery for Acute Ischemic Stroke: All Patients All the Time. Neurosurgery 2016; 63 Suppl 1:64-72. [PMID: 27399366 DOI: 10.1227/neu.0000000000001281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Ashish Sonig
- Departments of Neurosurgery and.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Elad I Levy
- Departments of Neurosurgery and.,Radiology, Jacobs School of Medicine and Biomedical Sciences, and.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| |
Collapse
|
29
|
Romano DG, Cioni S, Leonini S, Gennari P, Vallone IM, Zandonella A, Puliti A, Tassi R, Casasco A, Martini G, Bracco S. Manual thromboaspiration technique as a first approach for endovascular stroke treatment: A single-center experience. Interv Neuroradiol 2016; 22:529-34. [PMID: 27301390 DOI: 10.1177/1591019916653256] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 05/15/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND For intracranial large vessel occlusion in acute ischemic stroke (AIS), a high degree of revascularization in the minimal amount of time predicts good outcomes. Recently, different studies have shown that the direct aspiration first pass technique (ADAPT technique) for AIS obtains high recanalization rates, fast interventions and low costs when it works as first attempt. This study retrospectively describes revascularization efficacy, duration of procedure, intra and post-procedural complications, early and after 90-days clinical outcome in a group of patients who underwent ADAPT as the primary endovascular approach, eventually followed by stent retriever thrombectomy, for recanalization of large vessels in the anterior circulation. MATERIALS AND METHODS We analyzed clinical and procedural data of patients treated from April 2014 to August 2015. Recanalization was assessed according to the Thrombolysis in Cerebral Infarction score. Clinical outcome was evaluated at discharge and after 3 months (modified Rankin Scale, mRS). RESULTS Overall, 71 patients (mean age of 69.7 years) were treated. Sites of occlusion were anterior circulation (including seven tandem extracranial-intracranial occlusions). In 39 patients i.v. rtPA was attempted. Recanalization of the target vessel was obtained in 87.3% of cases whereas direct aspiration alone was successful in 46/71cases (64.8%) with an average puncture-to-revascularization time of 43.1 minutes. Symptomatic intracranial hemorrhage occurred in 7.8% and embolization to new territories in 5.6%. In total, 38 patients (53.5%) had a good outcome at 90 days follow-up. CONCLUSIONS In our series, the manual thromboaspiration technique has been shown as fast and safe, with good rates of vessel revascularization in 87.3% of patients and neurological outcome <3 mRS in 53.5% of patients.
Collapse
Affiliation(s)
- D G Romano
- Department of Neurological and Sensorineural Sciences, Unit of Neuroimaging and Neurointervention (NINT), Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| | - S Cioni
- Department of Neurological and Sensorineural Sciences, Unit of Neuroimaging and Neurointervention (NINT), Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| | - S Leonini
- Department of Neurological and Sensorineural Sciences, Unit of Neuroimaging and Neurointervention (NINT), Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| | - P Gennari
- Department of Neurological and Sensorineural Sciences, Unit of Neuroimaging and Neurointervention (NINT), Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| | - I M Vallone
- Department of Neurological and Sensorineural Sciences, Unit of Neuroimaging and Neurointervention (NINT), Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| | - A Zandonella
- Department of Neurological and Sensorineural Sciences, Unit of Neuroimaging and Neurointervention (NINT), Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| | - A Puliti
- Department of Human Pathology and Oncology, Section of Radiological Science, University of Siena, Siena, Italy
| | - R Tassi
- Department of Neurological and Sensorineural Sciences, Stroke Unit, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| | - A Casasco
- Unit of Endovascular and Percutaneous Therapy, Clinica Nuestra Senora del Rosario, Madrid, Spain
| | - G Martini
- Department of Neurological and Sensorineural Sciences, Stroke Unit, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| | - S Bracco
- Department of Neurological and Sensorineural Sciences, Unit of Neuroimaging and Neurointervention (NINT), Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| |
Collapse
|
30
|
Romano DG, Cioni S, Vinci SL, Pero G, Comelli C, Comai A, Peschillo S, Mardighian D, Castellan L, Resta F, Piano MG, Comelli S, Barletta L, Puliti A, Leonini S, Bracco S. Thromboaspiration technique as first approach for endovascular treatment of acute ischemic stroke: initial experience at nine Italian stroke centers. J Neurointerv Surg 2016; 9:6-10. [PMID: 26984869 DOI: 10.1136/neurintsurg-2016-012298] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 02/25/2016] [Accepted: 02/26/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Aspiration thrombectomy of large vessel occlusions has made a comeback among recanalization techniques thanks to recent advances in catheter technology resulting in faster recanalization and promising clinical results when used either alone or as an adjunct to stent retriever. This multicenter retrospective study reports angiographic data, complications, and clinical outcome in patients treated with aspiration thrombectomy as the first-line option. MATERIALS AND METHODS We analysed the clinical and procedural data of patients treated from January 2014 to March 2015. Recanalization was assessed according to the Thrombolysis in Cerebral Infarction score. Clinical outcome was evaluated at discharge and after 3 months. RESULTS Overall, 152 patients (mean age 68 years) were treated. Sites of occlusion were 90.8% anterior circulation (including 16.4% tandem extracranial/intracranial occlusions) and 9.2% basilar artery. In 79 patients administration of intravenous tissue plasminogen activator was attempted. Recanalization of the target vessel was obtained in 115/152 cases (75.6%) whereas direct aspiration alone was successful in 83/152 cases (54.6%) with an average puncture to revascularization time of 44.67 min. Symptomatic intracranial hemorrhage occurred in 7.8% and embolization to new territories in 1.9%. 77 patients (50.6%) had a good outcome at 90-day follow-up: 55/96 in the direct aspiration alone group and 22/56 in the aspiration-stent retriever group. CONCLUSIONS Direct aspiration thrombectomy appears a feasible technique with good revascularization results achieved in more than half the patients. In light of the self-reported data, inhomogeneous patient selection, absence of a core imaging laboratory, and a non-standardized approach, the results should be validated in a larger trial.
Collapse
Affiliation(s)
- D G Romano
- Department of Neurological Sciences, Division of Diagnostic and Interventional Neuroradiology, University Hospital of Siena, Italy
| | - S Cioni
- Department of Neurological Sciences, Division of Diagnostic and Interventional Neuroradiology, University Hospital of Siena, Italy
| | - S L Vinci
- Neuroradiology Unit, Department of Radiological Sciences, University of Messina, Messina, Italy
| | - G Pero
- Neuroradiology Department, Niguarda Ca' Granda Hospital, Milan, Italy
| | - C Comelli
- Department of Interventional Radiology and Neuroradiology, S. Giovanni Bosco Emergencies Hospital, Turin, Italy
| | - A Comai
- Department of Radiology, Central Hospital of Bolzano, Italy
| | - S Peschillo
- Department of Neurology and Psychiatry, Endovascular Neurosurgery/Interventional Neuroradiology, "Sapienza" University of Rome, Rome, Italy
| | - D Mardighian
- Department of Neuroradiology, Spedali Civili, University of Brescia, Italy
| | - L Castellan
- Neuroradiology Unit, San Martino Hospital-IST-IRCCS, Genoa, Italy
| | - F Resta
- Department of Cardiology, University of Bari, Bari, Italy
| | - M G Piano
- Neuroradiology Department, Niguarda Ca' Granda Hospital, Milan, Italy
| | - S Comelli
- Department of Interventional Radiology and Neuroradiology, S. Giovanni Bosco Emergencies Hospital, Turin, Italy
| | - L Barletta
- Neuroradiology Unit, San Martino Hospital-IST-IRCCS, Genoa, Italy
| | - A Puliti
- Department of Neurological Sciences, Division of Diagnostic and Interventional Neuroradiology, University Hospital of Siena, Italy
| | - S Leonini
- Department of Neurological Sciences, Division of Diagnostic and Interventional Neuroradiology, University Hospital of Siena, Italy
| | - S Bracco
- Department of Neurological Sciences, Division of Diagnostic and Interventional Neuroradiology, University Hospital of Siena, Italy
| |
Collapse
|
31
|
Marnat G, Mourand I, Eker O, Machi P, Arquizan C, Riquelme C, Ayrignac X, Bonafé A, Costalat V. Endovascular Management of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection Using a Distal to Proximal Approach: Insight from the RECOST Study. AJNR Am J Neuroradiol 2016; 37:1281-8. [PMID: 26965467 DOI: 10.3174/ajnr.a4752] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 01/03/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Internal carotid artery dissection is a common cause of stroke in young adults. It may be responsible for tandem occlusion defined by a cervical steno-occlusive carotid wall hematoma associated with an intracranial large-vessel stroke. Intravenous thrombolysis is associated with a poor clinical outcome in these cases, and endovascular treatment has not been specifically evaluated to date. Our aim was to evaluate endovascular treatment technical and clinical efficiency in this specific occlusion topography, in comparison with treatment of isolated anterior circulation stroke. MATERIALS AND METHODS As part of our ongoing prospective stroke data base started in August 2009 (Prognostic Factors Related to Clinical Outcome Following Thrombectomy in Ischemic Stroke [RECOST] Study), we analyzed all carotid artery dissection tandem occlusion strokes and isolated anterior circulation occlusions. All patients were selected for endovascular treatment according to clinical-radiologic mismatch, NIHSS ≥ 7 and DWI-ASPECTS ≥5, within 6 hours after onset. For carotid artery dissection, the revascularization procedure consisted first of distal recanalization by a stent retriever in the intracranial vessel. Following assessment of the circle of Willis, internal carotid artery stent placement was only performed in case of insufficiency. Carotid artery dissection treatment efficacy, safety, and clinical outcome were compared with the results of the isolated anterior circulation occlusion cohort. RESULTS Two hundred fifty-eight patients with an anterior circulation stroke were analyzed, including 57 with tandem occlusions (22%); among them, 20 were carotid artery dissection-related occlusions (7.6%). The median age of patients with tandem occlusions with internal carotid dissection was 52.45 versus 66.85 years for isolated anterior circulation occlusion (P < .05); the mean initial NIHSS score was 17.53 ± 4.11 versus 17.55 ± 4.8 (P = .983). The median DWI-ASPECTS was 6.05 versus 6.64 (P = .098), and the average time from onset to puncture was 4.38 for tandem occlusions versus 4.53 hours in isolated anterior circulation occlusion (P = .704). Complication rates and symptomatic intracranial hemorrhage were comparable in both groups (5% versus 3%, P = .49). The duration of the procedure was significantly prolonged in case of tandem occlusion (80.69 versus 65.45 minutes, P = .030). Fourteen patients with carotid artery dissection (70%) had a 3-month mRS of ≤ 2, without a significant difference from patients with an isolated anterior circulation occlusion (44%, P = .2). Only 5 carotid artery dissections (25%) necessitated cervical stent placement. No early ipsilateral stroke recurrence was recorded, despite the absence of stent placement in 15 patients (75%) with carotid artery dissection. CONCLUSIONS Mechanical endovascular treatment of carotid artery dissection tandem occlusions is safe and effective compared with isolated anterior circulation occlusion stroke therapy. Hence, a more conservative approach with stent placement only in cases of circle of Willis insufficiency may be a reliable and safe strategy.
Collapse
Affiliation(s)
- G Marnat
- From the Department of Interventional and Diagnostic Neuroradiology (G.M.), Bordeaux University Hospital, Bordeaux, France
| | - I Mourand
- Departments of Neurology (I.M., C.A., X.A.)
| | - O Eker
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - P Machi
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - C Arquizan
- Departments of Neurology (I.M., C.A., X.A.)
| | - C Riquelme
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - X Ayrignac
- Departments of Neurology (I.M., C.A., X.A.)
| | - A Bonafé
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - V Costalat
- Interventional and Diagnostic Neuroradiology (O.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| |
Collapse
|
32
|
Liu Y, Jia L, Liu B, Meng X, Yang J, Li J, Zhou Y, Jiao L, Hua Y. Evaluation of Endarterectomy Recanalization under Ultrasound Guidance in Symptomatic Patients with Carotid Artery Occlusion. PLoS One 2015; 10:e0144381. [PMID: 26636827 PMCID: PMC4670099 DOI: 10.1371/journal.pone.0144381] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 11/17/2015] [Indexed: 11/18/2022] Open
Abstract
Rigorous screening and good imaging would help perform surgery on carotid artery occlusion CAO safely and effectively. The purpose of this study was to retrospectively evaluate carotid endarterectomy (CEA) recanalization in patients with common carotid artery occlusion (CCAO) or internal carotid artery occlusion (ICAO) with color Doppler flow imaging (CDFI). A total of 59 patients undergoing CEA were enrolled. According to the results of CEA, the patients were divided into successful recanalization (group A) and unsuccessful recanalization (group B) groups. The original diameter, lesion length, proximal-to-distal diameter ratio and echo characteristics of the lesion within the lumen of the carotid artery were recorded before CEA and compared between the two groups. In regards to the achievement of repatency by CEA, the overall success rate was 74.6% (44/59), the success rate in CCAO patients was 75.9% (22/29) and the success rate in ICAO patients was 73.3% (22/30). There was no significant difference in the success rates between the CCAO and ICAO patients (χ2 = 0.050, P = 0.824). The overall rate of stroke and death within 30 postoperative days was 5.1% (3/59). For the CCAO patients, the lesion length in group A was shorter than that in group B (t = 3.221, P = 0.004). For the ICAO patients, the original diameter of the distal ICA was broader (t = 6.254, P = 0.000) and the proximal-to-distal ICA diameter ratio was smaller (t = 8.036, P = 0.000) in group A than in group B. The rate of recanalization for lumens with a homogeneous echo pattern (hypoecho or isoecho) was significantly higher than that for lumens with echo heterogeneity for both the CCAO and ICAO patients (χ2 = 14.477, P = 0.001; χ2 = 10.519, P = 0.003). However, for both the CCAO and ICAO patients, there was no difference in the rate of recanalization between patients with hypoecho and isoecho lesions (χ2 = 0.109, P = 0.742; χ2 = 0.836, P = 0.429). The original diameter, proximal-to-distal ICA diameter ratio, lesion length and echo characteristics may affect the success of CEA recanalization in patients with CCAO and ICAO. CDFI is helpful in screening patients with carotid artery occlusion and may improve the success rate of CEA.
Collapse
Affiliation(s)
- Yumei Liu
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lingyun Jia
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Beibei Liu
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiufeng Meng
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Yang
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jingzhi Li
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yinghua Zhou
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
- * E-mail:
| |
Collapse
|
33
|
Yoon W, Kim BM, Kim DJ, Kim DI, Kim SK. Outcomes and prognostic factors after emergent carotid artery stenting for hyperacute stroke within 6 hours of symptom onset. Neurosurgery 2015; 76:321-9. [PMID: 25599209 DOI: 10.1227/neu.0000000000000610] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The optimal treatment for hyperacute stroke attributable to cervical internal carotid artery (C-ICA) occlusion remains controversial. OBJECTIVE This study sought to evaluate clinical outcomes and prognostic factors after carotid artery stenting (CAS) in patients with hyperacute stroke within 6 hours of onset. METHODS Forty-seven patients with hyperacute stroke attributable to atherosclerotic C-ICA occlusion underwent emergent CAS. Forty-two patients (89.4%) had tandem intracranial artery occlusion (TIO). When patients showed remnant M1 or proximal M2 occlusions after CAS, intracranial recanalization therapy was performed by using pharmacologic thrombolysis and mechanical thrombectomy with a Solitaire stent. Clinical and radiologic data were compared between patients with favorable (modified Rankin scale, 0-2) and unfavorable outcomes. Binary logistic regression analysis was used to find independent prognostic factors. RESULTS Emergent CAS was successful in all but 1 patient. Seven (16.7%) of 42 patients with TIO did not need further treatment, because thrombolysis in cerebral ischemia ≥2b was achieved immediately after CAS. Of the 35 patients who underwent intracranial recanalization therapy for remnant TIO, thrombolysis in cerebral ischemia ≥2b was achieved in 71.4% (25 of 35). Twenty-six patients (55.3%) had favorable outcomes, and mortality was 6.4% at 3 months. Time from symptom onset to carotid recanalization was inversely and independently associated with a favorable outcome for all patients and for those with TIO (P < .05). CONCLUSION In our patient group, emergent CAS for hyperacute stroke caused by atherosclerotic C-ICA occlusion seemed to be effective and safe. Time to carotid recanalization was inversely and independently associated with a favorable outcome.
Collapse
Affiliation(s)
- Woong Yoon
- *Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea; ‡Department of Radiology, Severance Stroke Center, Yonsei University College of Medicine Severance Hospital, Seoul, South Korea
| | | | | | | | | |
Collapse
|
34
|
Steglich-Arnholm H, Krieger DW. Carotid stent-assisted thrombectomy in acute ischemic stroke. Future Cardiol 2015; 11:615-32. [PMID: 26406551 DOI: 10.2217/fca.15.54] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Acute carotid occlusion or near-occlusion with concomitant intracranial embolism cause severe acute ischemic strokes in patients. These concomitant occlusions have suggested poor response to intravenous thrombolysis and complicate endovascular treatment. Nevertheless, endovascular stent-assisted thrombectomy may improve outcome in patients but the treatment is not without concerns. Required antiplatelet therapy to prevent stent thrombosis may increase the rate of intracranial hemorrhage, especially after recent thrombolysis. Furthermore, technical difficulties in access of the intracranial vasculature may cause adverse events, even in the hands of experienced interventionalists. These concerns currently defy the treatment in being recommended for general use and only on a compassionate basis. However, recent patient series have suggested reasonable safety and efficacy for carotid stent-assisted thrombectomy.
Collapse
Affiliation(s)
| | - Derk W Krieger
- Department of Neurology, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark.,Faculty of Health & Medical Science, University of Copenhagen, Blegdamsvej 3B, København N 2200, Denmark
| |
Collapse
|
35
|
Steglich-Arnholm H, Holtmannspötter M, Kondziella D, Wagner A, Stavngaard T, Cronqvist ME, Hansen K, Højgaard J, Taudorf S, Krieger DW. Thrombectomy assisted by carotid stenting in acute ischemic stroke management: benefits and harms. J Neurol 2015; 262:2668-75. [DOI: 10.1007/s00415-015-7895-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 08/28/2015] [Accepted: 08/29/2015] [Indexed: 10/23/2022]
|
36
|
Yang Y, Liang C, Zhang Q, Shen C, Ma S, Mao J, Xu R. Analysis of prognostic factors of endovascular therapy in 59 patients with acute anterior circulation stroke: a retrospective cohort study – observational. Int J Surg 2015; 16:36-41. [PMID: 25743387 DOI: 10.1016/j.ijsu.2015.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 02/02/2015] [Accepted: 02/16/2015] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Endovascular therapy (ET) is increasingly used for stroke patients out of the time window, based on the multimodal treatment (MMT) it can be used alone or in combination. The purpose of this study was to assess the outcome of intra-arterial thrombolysis (IAT) and MMT for acute anterior circulation ischemic stroke (ACIS), and reveal prognostic factors of ET in the authors' stroke center. METHODS A retrospective analysis of the data of 59 patients with ACIS who received ET from 2010 to 2014 in the stroke center was performed. A univariate analysis was conducted to reveal the differences between IAT and MMT, and the distinctions between favorable and unfavorable outcomes, logistic regression analysis was performed to determine the predictors of outcomes. RESULTS Thirty-four patients who accepted MMT had a higher baseline National Institutes of Health Stroke Scale score on admission (18.3 ± 4.2) compared with 25 patients who were treated with IAT (12.6 ± 4.3). The MMT group had a higher patent flow (23/34) (thrombolysis in myocardial infarction grade 2-3) compared with the IAT group (10/25). Moreover, the MMT group had a longer time for emergency department (ED) (5.8 ± 1.4) than the IAT group (5.2 ± 0.8). In multivariate analysis, age, time to ED, and NIHSS score at discharge are predictors for poor outcome, whereas perfect recanalization was associated with favorable outcome. CONCLUSION MMT might be suitable for patients with a severe admission NIHSS and a higher patency rate than IAT. Vessel recanalization was the only predictor for favorable outcome.
Collapse
Affiliation(s)
- Yang Yang
- Department of Neurosurgery, Affiliated Bayi Brain Hospital, General Hospital of Beijing Military Region, Beijing, China
| | - Chunyang Liang
- Department of Neurosurgery, Affiliated Bayi Brain Hospital, General Hospital of Beijing Military Region, Beijing, China.
| | - Qiang Zhang
- Department of Neurosurgery, Affiliated Bayi Brain Hospital, General Hospital of Beijing Military Region, Beijing, China
| | - Chunsen Shen
- Department of Neurosurgery, Affiliated Bayi Brain Hospital, General Hospital of Beijing Military Region, Beijing, China
| | - Shang Ma
- Department of Neurosurgery, Affiliated Bayi Brain Hospital, General Hospital of Beijing Military Region, Beijing, China
| | - Jinlong Mao
- Department of Neurosurgery, Affiliated Bayi Brain Hospital, General Hospital of Beijing Military Region, Beijing, China
| | - Ruxiang Xu
- Department of Neurosurgery, Affiliated Bayi Brain Hospital, General Hospital of Beijing Military Region, Beijing, China
| |
Collapse
|
37
|
Woodward K, Wegryn S, Staruk C, Nyberg EM. The Dotter method revisited: early experience with a novel method of rapid internal carotid artery revascularization in the setting of acute ischemic stroke. J Neurointerv Surg 2015; 8:360-6. [PMID: 25636305 DOI: 10.1136/neurintsurg-2014-011587] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/19/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Tandem occlusive disease in the setting of acute ischemic stroke involving cervical and cerebral arteries has been associated with poor neurological outcome and poses significant challenges to neurointerventionists. Previously described endovascular methods typically involve carotid revascularization with stent placement prior to or following intracranial thrombectomy. Stent-based approaches, however, require the use of antiplatelet therapy which may increase the risk of hemorrhagic transformation. We describe a novel modified Dotter technique which may be used for carotid revascularization in lieu of stenting. This technique can eliminate the need for antiplatelet therapy, reduce procedure times, and possibly reduce hemorrhagic conversion rates. METHODS Seven patients presenting between April 2013 and January 2014 were treated with this technique. All patients had carotid stenosis of 65-100% and tandem middle cerebral artery occlusions. National Institutes of Health (NIH) Stroke Scale scores as well as clinical and procedural times were recorded. Pre- and post-Dotter stenosis was measured using the NASCET criteria. Follow-up imaging and clinical data were reviewed. RESULTS The mean age was 64 years and mean initial NIH Stroke Scale score was 11.7. Mean groin to recanalization time was 26 min. Thrombolysis In Cerebral Infarction grade 2b-3 was achieved in all patients. The mean stenosis was 88% preoperatively and 61% postoperatively. There were no intracranial hemorrhages. The modified Rankin Scale score was 0 in six patients (86%) and 6 in one patient (14%). CONCLUSIONS The Dotter stroke technique is a feasible and safe alternative to carotid stenting in the setting of acute ischemic stroke and may reduce the risk of hemorrhagic conversion. No re-occlusion occurred during follow-up in patients with post-Dotter stenosis ≤65%.
Collapse
Affiliation(s)
| | | | - Carla Staruk
- Fort Sanders Regional Medical Center, Knoxville, Tennessee, USA
| | - Eric M Nyberg
- Department of Radiology, University of Colorado, Aurora, Colorado, USA
| |
Collapse
|
38
|
Linfante I, Starosciak AK, Walker GR, Dabus G, Castonguay AC, Gupta R, Sun CHJ, Martin C, Holloway WE, Mueller-Kronast N, English JD, Malisch TW, Marden FA, Bozorgchami H, Xavier A, Rai AT, Froehler MT, Badruddin A, Nguyen TN, Taqi MA, Abraham MG, Janardhan V, Shaltoni H, Novakovic R, Yoo AJ, Abou-Chebl A, Chen PR, Britz GW, Kaushal R, Nanda A, Issa MA, Nogueira RG, Zaidat OO. Predictors of poor outcome despite recanalization: a multiple regression analysis of the NASA registry. J Neurointerv Surg 2015; 8:224-9. [PMID: 25564538 DOI: 10.1136/neurintsurg-2014-011525] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 12/12/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND Mechanical thrombectomy with stent-retrievers results in higher recanalization rates compared with previous devices. Despite successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) score ≥2b) of 70-83%, good outcomes by 90-day modified Rankin Scale (mRS) score ≤2 are achieved in only 40-55% of patients. We evaluated predictors of poor outcomes (mRS >2) despite successful recanalization (TICI ≥2b) in the North American Solitaire Stent Retriever Acute Stroke (NASA) registry. METHODS Logistic regression was used to evaluate baseline characteristics and recanalization outcomes for association with 90-day mRS score of 0-2 (good outcome) vs 3-6 (poor outcome). Univariate tests were carried out for all factors. A multivariable model was developed based on backwards selection from the factors with at least marginal significance (p≤0.10) on univariate analysis with the retention criterion set at p≤0.05. The model was refit to minimize the number of cases excluded because of missing covariate values; the c-statistic was a measure of predictive power. RESULTS Of 354 patients, 256 (72.3%) were recanalized successfully. Based on 234 recanalized patients evaluated for 90-day mRS score, 116 (49.6%) had poor outcomes. Univariate analysis identified an increased risk of poor outcome for age ≥80 years, occlusion site of internal carotid artery (ICA)/basilar artery, National Institute of Health Stroke Scale (NIHSS) score ≥18, history of diabetes mellitus, TICI 2b, use of rescue therapy, not using a balloon-guided catheter or intravenous tissue plasminogen activator (IV t-PA), and >30 min to recanalization (p≤0.05). In multivariable analysis, age ≥80 years, occlusion site ICA/basilar, initial NIHSS score ≥18, diabetes, absence of IV t-PA, ≥3 passes, and use of rescue therapy were significant independent predictors of poor 90-day outcome in a model with good predictive power (c-index=0.80). CONCLUSIONS Age, occlusion site, high NIHSS, diabetes, no IV t-PA, ≥3 passes, and use of rescue therapy are associated with poor 90-day outcome despite successful recanalization.
Collapse
Affiliation(s)
- Italo Linfante
- Miami Cardiac and Vascular Institute, Baptist Hospital, Miami, Florida, USA Neuroscience Center, Baptist Hospital, Miami, Florida, USA
| | - Amy K Starosciak
- Neuroscience Center, Baptist Hospital, Miami, Florida, USA Center for Research and Grants, Baptist Health South Florida, Coral Gables, Florida, USA
| | - Gail R Walker
- Center for Research and Grants, Baptist Health South Florida, Coral Gables, Florida, USA
| | - Guilherme Dabus
- Miami Cardiac and Vascular Institute, Baptist Hospital, Miami, Florida, USA Neuroscience Center, Baptist Hospital, Miami, Florida, USA
| | | | - Rishi Gupta
- Emory University School of Medicine, Atlanta, Georgia, USA
| | | | | | | | | | - Joey D English
- California Pacific Medical Center, San Francisco, California, USA
| | - Tim W Malisch
- Alexian Brothers Medical Center, Elk Grove Village, Illinois, USA
| | | | | | - Andrew Xavier
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Ansaar T Rai
- West Virginia University Hospital, Morgantown, West Virginia, USA
| | | | | | | | - M Asif Taqi
- St. Luke's Kansas City, Kansas City, Missouri, USA
| | | | | | | | | | - Albert J Yoo
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Peng R Chen
- The University of Texas Medical School at Houston, Houston, Texas, USA
| | - Gavin W Britz
- Methodist Neurological Institute, Houston, Texas, USA
| | | | | | - Mohammad A Issa
- Medical College of Wisconsin/Froedtert Hospital, Milwaukee, Wisconsin, USA
| | | | - Osama O Zaidat
- Medical College of Wisconsin/Froedtert Hospital, Milwaukee, Wisconsin, USA
| |
Collapse
|
39
|
Lescher S, Czeppan K, Porto L, Singer OC, Berkefeld J. Acute Stroke and Obstruction of the Extracranial Carotid Artery Combined with Intracranial Tandem Occlusion: Results of Interventional Revascularization. Cardiovasc Intervent Radiol 2014; 38:304-13. [DOI: 10.1007/s00270-014-1047-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/11/2014] [Indexed: 11/29/2022]
|
40
|
Lockau H, Liebig T, Henning T, Neuschmelting V, Stetefeld H, Kabbasch C, Dorn F. Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results. Neuroradiology 2014; 57:589-98. [PMID: 25404414 DOI: 10.1007/s00234-014-1465-5] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 11/04/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Acute tandem occlusions of the cervical and distal internal carotid artery (ICA) or middle cerebral artery (MCA) are associated with major stroke with intravenous (i.v.) thrombolysis alone in approximately 90 % of patients. The data on endovascular management of tandem occlusions is still limited. The purpose of this study was to review technical aspects and the current state of the literature on acute ICA stenting in combination with stent retriever-based intracranial thrombectomy. METHODS We retrospectively reviewed the data of 37 consecutive patients with tandem occlusions including clinical parameters, angiographic results, procedural aspects, complications, and hemorrhages. RESULTS Median National Institutes of Health Stroke Scale (NIHSS) on admission was 17 (3-30). Intracranial thrombectomy was performed prior to ICA stenting in 25/37 (67.6 %) and after stenting in 12/37 (32.4 %) patients. ICA stenting was successful in all cases, and a thrombolysis in cerebral infarction (TICI) scale 2b/3 result was achieved in 27/37 (73 %) cases. The mean angiography time was significantly shorter in the "thrombectomy first" group (43.1 ± 30.8 vs. 110.8 ± 43.0 min, p < 0.001), and more patients had favorable outcomes after 3 months (13/25 = 52.0 vs. 4/12 = 33.3 %, p = 0.319). In this group, intermediate catheters were used and successfully prevented embolism to unaffected territories in all cases. CONCLUSION Acute stenting of the cervical ICA in combination with intracranial thrombectomy was technically feasible and safe in our series. Thrombectomy prior to proximal stenting was associated with shorter reperfusion times and a tendency towards better clinical outcome leading to a good outcome in about 50 % of the patients. Therefore, we recommend this approach in tandem occlusion requiring stent angioplasty.
Collapse
Affiliation(s)
- H Lockau
- Department of Radiology, University Hospital of Cologne, Kerpenerstr. 62, 50937, Cologne, Germany
| | | | | | | | | | | | | |
Collapse
|
41
|
Duijsens HM, Spaander F, van Dijk LC, Treurniet FE, Keunen RW, Mosch A, Majoie CB, van Overhagen H. Endovascular treatment in patients with acute ischemic stroke and apparent occlusion of the extracranial internal carotid artery on CTA. J Neurointerv Surg 2014; 7:709-14. [DOI: 10.1136/neurintsurg-2014-011297] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 07/25/2014] [Indexed: 11/03/2022]
|
42
|
Two in One: Endovascular Treatment of Acute Tandem Occlusions in the Anterior Circulation. Clin Neuroradiol 2014; 25:397-402. [PMID: 24988990 DOI: 10.1007/s00062-014-0318-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 06/17/2014] [Indexed: 12/24/2022]
Abstract
PURPOSE Acute major stroke with high-grade stenosis or occlusion of the extracranial internal carotid artery (ICA) and additional intracranial large artery occlusion is increasingly treated with a mechanical endovascular approach by extracranial stenting and intracranial thrombectomy due to poor response to systemic thrombolysis with recombinant tissue plasminogen activator (rtPA). This article presents a single centre cohort of this challenging subtype of stroke, describing the technical procedure and analysing the angiographic and clinical outcome. METHODS Clinical and imaging data of all consecutive patients between July 2008 and March 2013 with intracranial artery occlusion in the anterior circulation and additional occlusion or pseudo-occlusion of the cervical ICA were retrospectively analysed with respect to demographical and clinical characteristics. Technical approach, recanalization rate, recanalization time and short-term clinical outcome were determined. RESULTS A total of 43 patients with tandem occlusion in the anterior circulation met the inclusion criteria. Out of these, 32 (74.4%) occlusions and 11 (25.6%) pseudo-occlusions of the extracranial ICA with additional occlusion of the distal segment of the ICA in 7.0% (3/43), the M1-segment of the middle cerebral artery (MCA) in 81.4% (35/43) or the M2-segment of the MCA in 11.6% (5/43) of cases were treated with combined endovascular approach including extracranial stenting with angioplasty and intracranial mechanical thrombectomy. In 76.7% of cases, an angiographic recanalization result of 2b or 3 using the Thrombolysis in Cerebral Infarction (TICI) score was achieved. Mean time from first angiographic series to recanalization was 103 min. A modified Rankin Scale (mRS) score of ≤ 2 was achieved in 32.6% at the time of discharge. CONCLUSION Endovascular therapy of patients with tandem occlusion in the anterior circulation with emergency extracranial stenting and intracranial mechanical thrombectomy appears to be safe and may lead to a satisfactory angiographic result and clinical outcome.
Collapse
|
43
|
Beneš V, Buchvald P, Klimošová S, Eichlová Z, Suchomel P. Acute extracranial occlusion of the internal carotid artery: emergent surgery remains a viable option. Acta Neurochir (Wien) 2014; 156:901-8; discussion 908-9. [PMID: 24584902 DOI: 10.1007/s00701-014-2036-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 02/10/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute symptomatic occlusion of extracranial internal carotid artery (eICA) can lead to a critical and potentially devastating stroke associated with high morbidity and mortality. Optimal treatment remains unclear. We analyzed our institutional experience with emergent surgical recanalization of acutely occluded eICA. METHODS Retrospective analysis of hospital records, surgical reports, imaging studies and outpatient records. Final outcome was assessed according to modified Rankin Scale (mRS). RESULTS Between January 2010 and September 2013, 22 patients underwent emergent surgical recanalization. There were 17 men and five women, mean age 65.4 years (range 37-85). Mean admission National Institute of Health Stroke Scale (NIHSS) was 12 (range 6-21). All patients had evidence of salvageable penumbra on perfusion computed tomography. Tandem intracranial lesion was present in nine patients. Surgical recanalization was successful in 16 patients (72.7 %). Twenty-four hours after surgery, 17 patients (77.2 %) improved by a minimum of 1 point on NIHSS, 14 patients (63.6 %) improved by three and more points; two patients deteriorated by two and five points, the latter treated initially with systemic thrombolysis due to intracranial hemorrhage. No other intracranial hematoma was observed. During 30 days following surgery, two patients died (9 % mortality rate) due to severity of initial stroke. On discharge, four patients were classified as mRS 0, five patients as mRS 1, five patients as mRS 2 and six patients as mRS 4. Favorable recovery (mRS 0-2) was achieved in 14 patients (63.6 %). No change in mRS was observed at three months. CONCLUSIONS Our results suggest that emergent surgical desobliteration of occluded eICA can lead to favorable recovery in a majority of patients. Patient selection based on penumbra imaging is crucial. Given the popularity and simplicity of carotid endarterectomy, the procedure should by no means be abandoned in the treatment of acute eICA occlusion.
Collapse
Affiliation(s)
- Vladimír Beneš
- Department of Neurosurgery, Regional Hospital Liberec, Husova 10, Liberec, 46001, Czech Republic,
| | | | | | | | | |
Collapse
|
44
|
Son S, Choi DS, Oh MK, Kim SK, Kang H, Park KJ, Choi NC, Kwon OY, Lim BH. Emergency carotid artery stenting in patients with acute ischemic stroke due to occlusion or stenosis of the proximal internal carotid artery: a single-center experience. J Neurointerv Surg 2014; 7:238-44. [PMID: 24634445 DOI: 10.1136/neurintsurg-2014-011141] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The feasibility, safety and effectiveness of emergency carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to proximal internal carotid artery (ICA) stenosis or occlusion are still controversial. In this study we analyzed our experience with eCAS in patients with AIS. METHODS Twenty-two eCAS procedures for proximal ICA stenosis or occlusion were performed in 22 patients at our institution between January 2011 and November 2013. The mean time from stroke symptom onset to presentation was 204 min (range 50-630 min) and the mean initial score on the National Institutes of Health Stroke Scale (NIHSS) was 12.55 (range 5-23). Ten patients had total occlusion of the proximal ICA and the remaining 12 patients had near total occlusion or severe stenosis (mean degree 90.7%, range 80-100%). Eleven patients also had tandem occlusion on the more distal intracranial arteries. RESULTS Successful stent insertion was achieved in all patients and additional thrombectomy using a Solitaire stent or Penumbra aspiration catheter achieved a Thrombolysis In Cerebral Infarction grade of more than 2a in all patients with distal tandem occlusion. Procedure-related complications occurred in one patient (cerebral hyperperfusion syndrome) who recovered successfully. The mean NIHSS score at discharge was 3.55 (range 0-18). The mean modified Rankin Scale score at 3 months was 1 ± 1.67 (range 0-6). CONCLUSIONS eCAS in patients with AIS due to proximal ICA stenosis or occlusion appears to be a technically feasible and effective method for achieving good clinical outcomes.
Collapse
Affiliation(s)
- Seungnam Son
- Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongnam Regional Cardiocerebrovascular Disease Center, Jinju, Korea
| | - Dae Seob Choi
- Gyeongnam Regional Cardiocerebrovascular Disease Center, Jinju, Korea Department of Radiology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Min Kyun Oh
- Gyeongnam Regional Cardiocerebrovascular Disease Center, Jinju, Korea Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea Rehabilitation Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Soo-Kyoung Kim
- Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongnam Regional Cardiocerebrovascular Disease Center, Jinju, Korea
| | - Heeyoung Kang
- Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ki-Jong Park
- Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Nack-Cheon Choi
- Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongnam Regional Cardiocerebrovascular Disease Center, Jinju, Korea Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Oh-Young Kwon
- Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Byeong Hoon Lim
- Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea Gyeongnam Regional Cardiocerebrovascular Disease Center, Jinju, Korea Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea
| |
Collapse
|
45
|
Puri AS, Kühn AL, Kwon HJ, Khan M, Hou SY, Lin E, Chueh J, van der Bom IMJ, Dabus G, Linfante I, Gounis MJ, Wakhloo AK. Endovascular treatment of tandem vascular occlusions in acute ischemic stroke. J Neurointerv Surg 2014; 7:158-63. [PMID: 24578485 DOI: 10.1136/neurintsurg-2013-011010] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE Tandem vascular occlusions are an important cause of acute ischemic stroke (AIS) and present unique treatment challenges. We report our experience of managing a subset of AIS patients with extracranial vascular stenting/angioplasty and intracranial revascularization. METHODS Consecutive patients who presented at three centers with AIS from tandem vascular occlusions confirmed by brain and neck CT imaging were included in the study. We retrospectively analyzed the patient demographics, National Institute of Health Stroke Scale (NIHSS) score and modified Rankin Scale (mRS) score at the time of admission, treatment strategy, angiographic results using the Thrombolysis In Cerebral Infarction (TICI) score, and clinical and imaging follow-up. RESULTS Twenty-eight patients were included. The mean NIHSS score at admission was 18. Extracranial carotid occlusions with a concomitant middle cerebral artery occlusion were seen in 89.3% of patients (n=25) and vertebral artery combined with basilar artery lesions in 10.7% (n=3). An antegrade approach (ie, treatment of the extracranial lesion first) was used in 24 patients (85.7%). Proximal occlusion recanalization was achieved usually with a stent (n=27; 96.4%). Pursuant to intracranial revascularization techniques, ≥ TICI 2A recanalization was seen in 96.4% of patients. An mRS score of ≤ 2 at 90 days was achieved in 56.5% of patients. CONCLUSIONS Our study shows preliminary data from three centers on recanalization of tandem occlusions in patients presenting with AIS. There was a preference to revascularize the proximal occlusion using a stent followed by distal recanalization with mechanical thrombectomy, intra-arterial thrombolysis or a combination of these. This approach has low periprocedural complications and can achieve an excellent angiographic and clinical outcome.
Collapse
Affiliation(s)
- Ajit S Puri
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts, USA
| | - Anna L Kühn
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts, USA
| | - Hyon-Jo Kwon
- Cerebrovascular Center, Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Muhib Khan
- Departments of Neurology, University of Massachusetts, Worcester, Massachusetts, USA
| | - Samuel Y Hou
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts, USA
| | - Eugene Lin
- Baptist Cardiac and Vascular Institute, Baptist Neuroscience Center, Florida International University, Miami, Florida, USA
| | - Juyu Chueh
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts, USA
| | - Imramsjah M J van der Bom
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts, USA
| | - Guilherme Dabus
- Baptist Cardiac and Vascular Institute, Baptist Neuroscience Center, Florida International University, Miami, Florida, USA
| | - Italo Linfante
- Baptist Cardiac and Vascular Institute, Baptist Neuroscience Center, Florida International University, Miami, Florida, USA
| | - Matthew J Gounis
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts, USA
| | - Ajay K Wakhloo
- Division of Neuroimaging and Intervention, Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, Massachusetts, USA
| |
Collapse
|
46
|
Spiotta AM, Lena J, Vargas J, Hawk H, Turner RD, Chaudry MI, Turk AS. Proximal to distal approach in the treatment of tandem occlusions causing an acute stroke. J Neurointerv Surg 2014; 7:164-9. [PMID: 24561885 DOI: 10.1136/neurintsurg-2013-011040] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION A tandem occlusion is a rare presentation of acute stroke that involves an occlusion of the internal carotid artery at the bifurcation with an intracranial middle cerebral artery occlusion. This study describes the experience at our institution in treating tandem occlusions with a proximal to distal approach in the acute stroke setting. METHODS A retrospective review of acute strokes caused by tandem occlusions requiring thrombectomy were performed. RESULTS 16 cases were identified with a mean National Institutes of Health Stroke Scale score at presentation of 13.1 ± 3.9. The proximal occlusion was crossed initially with a microwire in all cases. All carotid occlusions were treated with stenting, and intracranial vessel thrombectomy was performed with a variety of devices. Procedure related complications occurred in two (12.5%) patients. Eight patients (50%) achieved a good outcome (modified Rankin Scale score of 0-2). CONCLUSIONS A tandem occlusion of the carotid artery at the bifurcation with a concomitant intracranial occlusion is a relatively rare and complex presentation of acute stroke. We have found that addressing the proximal lesion first and covering it with a stent prior to performing distal thrombectomy appears to be a safe and effective option in the treatment algorithm.
Collapse
Affiliation(s)
- Alejandro M Spiotta
- Department of Neurosciences, Division of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA Department of Radiology and Radiological Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jonathan Lena
- Department of Neurosciences, Division of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jan Vargas
- Department of Neurosciences, Division of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Harris Hawk
- Department of Radiology and Radiological Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Raymond D Turner
- Department of Neurosciences, Division of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA Department of Radiology and Radiological Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - M Imran Chaudry
- Department of Neurosciences, Division of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA Department of Radiology and Radiological Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aquilla S Turk
- Department of Neurosciences, Division of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA Department of Radiology and Radiological Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
47
|
Kappelhof M, Marquering HA, Berkhemer OA, Majoie CBLM. Intra-arterial treatment of patients with acute ischemic stroke and internal carotid artery occlusion: a literature review. J Neurointerv Surg 2014; 7:8-15. [DOI: 10.1136/neurintsurg-2013-011004] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
48
|
Stampfl S, Ringleb PA, Möhlenbruch M, Hametner C, Herweh C, Pham M, Bösel J, Haehnel S, Bendszus M, Rohde S. Emergency cervical internal carotid artery stenting in combination with intracranial thrombectomy in acute stroke. AJNR Am J Neuroradiol 2013; 35:741-6. [PMID: 24157733 DOI: 10.3174/ajnr.a3763] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE In past years, thrombectomy has become a widely used procedure in interventional neuroradiology for the treatment of acute intracranial occlusions. However, in 10-20% of patients, there are additional occlusions or stenotic lesions of the ipsilateral cervical internal carotid artery. The purpose of this study was to evaluate the feasibility of emergency carotid artery stent placement in combination with intracranial thrombectomy and the clinical outcome of the treated patients. MATERIALS AND METHODS We analyzed clinical and angiographic data of patients who underwent emergency cervical ICA stent placement and intracranial thrombectomy with stent-retriever devices in our institution between November 2009 and July 2012. Recanalization was assessed according to the Thrombolysis in Cerebral-Infarction score. Clinical outcome was evaluated at discharge (NIHSS) and after 3 months (mRS). RESULTS Overall, 24 patients were treated. The mean age was 67.2 years; mean occlusion time, 230.2 minutes. On admission, the median NIHSS score was 18. In all patients, the Thrombolysis in Cerebral Infarction score was zero before the procedure. Stent implantation was feasible in all cases. In 15 patients (62.5%), a Thrombolysis in Cerebral Infarction score ≥ 2b could be achieved. Six patients (25%) improved ≥10 NIHSS points between admission and discharge. After 90 days, the median mRS score was 3.0. Seven patients (29.2%) had a good clinical outcome (mRS 0-2), and 4 patients (16.6%) died, 1 due to fatal intracranial hemorrhage. Overall, symptomatic intracranial hemorrhage occurred in 4 patients (16.6%). CONCLUSIONS Emergency ICA stent implantation was technically feasible in all patients, and the intracranial recanalization Thrombolysis in Cerebral Infarction score of ≥2b was reached in a high number of patients. Clinical outcome and mortality seem to be acceptable for a cohort with severe stroke. However, a high rate of symptomatic intracranial hemorrhage occurred in our study.
Collapse
Affiliation(s)
- S Stampfl
- From the Departments of Neuroradiology (S.S., M.M., C. Herweh, M.P., S.H., M.B., S.R.)
| | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Matsubara N, Miyachi S, Tsukamoto N, Kojima T, Izumi T, Haraguchi K, Asai T, Yamanouchi T, Ota K, Wakabayashi T. Endovascular intervention for acute cervical carotid artery occlusion. Acta Neurochir (Wien) 2013; 155:1115-23. [PMID: 23605254 DOI: 10.1007/s00701-013-1697-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 03/22/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acute cervical carotid artery occlusion presents with a severe neurological deficit and is associated with unfavorable outcomes. In this study, the authors report their experience with patients having had acute ischemic stroke due to cervical carotid occlusion, who underwent endovascular intervention. METHOD Sixteen acute cervical carotid occlusion patients (15 males and 1 female; mean age 67.7 years) were treated by endovascularly between January 2009 and November 2012. Clinical, procedural, and angiographic data were retrospectively evaluated. Successful intracranial recanalization was based on thrombolysis in cerebral infarction score of 2B-3. A favorable outcome was defined as a modified Rankin Scale score of 0-2 at 90 days. FINDINGS The average score of National Institutes of Health Stroke Scale before treatment was 15.9. Ten of 16 patients (63 %) were associated with intracranial tandem occlusion. Ten (63 %) cases were caused by atherosclerotic, 4 (25 %) by atrial fibrillation (AF), and 2 (13 %) by dissection. Thirteen of 16 (81 %) achieved successful cervical recanalization and 7 of 16 (44 %) patients obtained sufficient cervical and intracranial perfusion. As a result, 5 of 16 (31 %) patients demonstrated favorable outcomes. Five of seven patients (71 %) with successful cervical and intracranial recanalization presented favorable outcomes. In contrast, none of the patients without cervical or intracranial recanalization presented favorable outcomes. Three of 6 (50 %) patients initially without intracranial occlusion showed favorable outcomes, but only 2 of 10 (20 %) patients associated with intracranial occlusion had favorable outcomes. On the aspect of etiology, in atherosclerotic cases, 4 of 10 (40 %) showed favorable outcomes. However, all four AF cases deteriorated into poor outcomes. CONCLUSIONS This study demonstrated the feasibility of endovascular intervention for acute cervical carotid artery occlusion. Although treatment for tandem occlusion and AF cases is an issue that should be resolved, intervention must be encouraged. Successful cervical and intracranial revascularization will be essential for favorable outcomes.
Collapse
Affiliation(s)
- Noriaki Matsubara
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|