Carotid-vertebral artery bypass with saphenous vein graft for symptomatic vertebrobasilar insufficiency.
Duan Hongzhou,Mo Dapeng,Zhang Yang,Zhang Jiayong,Li Liang
OBJECTIVESymptomatic steno-occlusion of the proximal vertebral artery (VA) or subclavian artery (ScA) heralds a poor prognosis and high risk of stroke recurrence despite medical therapy, including antiplatelet or anticoagulant drugs. In some cases, the V2 segment of the cervical VA is patent and perfused via collateral vessels. The authors describe 7 patients who were successfully treated by external carotid artery (ECA)-saphenous vein (SV)-VA bypass.METHODSSeven cases involving symptomatic patients were retrospectively studied: 3 cases of V1 segment occlusion, 2 cases of severe in-stent restenosis in the V1 segment, and 2 cases of occlusion of the proximal ScA. All patients underwent ECA-SV-VA bypass. The ECA was isolated and retracted, and the anterior wall of the transverse foramen was unroofed. The VA was exposed, and then the 2 ends of the SV were anastomosed to the VA and ECA in an end-to-side fashion.RESULTSSurgical procedures were all performed as planned, with no intraoperative complications. There were 2 postoperative complications (severe laryngeal edema in one case and shoulder weakness in another), but both patients recovered fully and measures were taken to minimize laryngeal edema and its effects in subsequent cases. All patients experienced improvement of their symptoms. No new neurological deficits were reported. Postoperative angiography demonstrated that the anastomoses were all patent, and analysis of follow-up data (range of follow-up 12-78 months) revealed no further ischemic events in the vertebrobasilar territory.CONCLUSIONSThe ECA-SV-VA bypass is a useful treatment for patients who suffer medically refractory ischemic events in the vertebrobasilar territory when the proximal part of the VA or ScA is severely stenosed or occluded but the V2 segment of the cervical VA is patent.
Technical options for treatment of in-stent restenosis after carotid artery stenting.
Pourier Vanessa E C,de Borst Gert J
Journal of vascular surgery
OBJECTIVE:This review summarizes the available evidence and analyzes the current trends on treatments for carotid in-stent restenosis (ISR) after carotid artery stenting (CAS). METHODS:An update of a 2010 review of the literature (which included 20 articles) was conducted using PubMed and Embase. All studies published from inception until January 2016 reporting original data on ISR treatments were included. Treatment trends before and after 2005 were compared. RESULTS:We found 22 new articles reporting ISR treatments in 138 patients, of which two (case series) were published before 2005. With the inclusion of the 20 articles of the 2010 report (n = 96 patients), a total of 42 articles were included (23 case reports and 19 case series) reporting 239 interventions for ISR in 234 patients. Of these 42 studies, 14 (including 10 case series) were published before 2005. The interventions were percutaneous transluminal angioplasty (PTA) in 136, repeat CAS in 51, carotid endarterectomy in 39, carotid artery bypass in 10, or brachytherapy in 3. Compared with the articles published before 2005, PTA with regular balloon remains the most practiced treatment (26% before 2005, 40% after 2005). PTA with drug-coated balloons started after 2005. Carotid endarterectomy with stent removal was the second most reported treatment before 2005 but moved to the third place of reported interventions after 2005 owing to an increase in repeat CAS treatment. Of the treated patients, 140 were asymptomatic, 72 were symptomatic, and for 22 the symptomology was unclear. ISR treatment averaged 18 months after CAS, and the follow-up thereafter was 16 months. Treatment for recurrent ISR was performed in 48 of 239 treated arteries, mostly after PTA (n = 35) and repeat CAS (n = 8). CONCLUSIONS:The available evidence for ISR treatment is still limited owing to methodologic heterogeneity; therefore, no recommendation on the optimal intervention can be provided. Although PTA is the common treatment for ISR, recurrent ISR seems to limit the durability, leading to recurrent interventions and cost implications. A uniform definition for ISR is needed with a standardized workup to compare the treatment options based on individual patient data analysis. Drug-eluting techniques are emerging and may become the preferred treatment option, but long-term follow-up is needed to evaluate their efficacy. Further study and understanding of the effect of drug-eluting technologies on the brain and neurologic function is warranted.
Treatment of giant and large fusiform middle cerebral artery aneurysms with excision and interposition radial artery graft in a 4-year-old child: case report.
Mrak Goran,Paladino Josip,Stambolija Vasilije,Nemir Jakob,Sekhar Laligam N
BACKGROUND AND IMPORTANCE:We report an unusual case of complex giant and large fusiform aneurysms not amenable for clipping or coiling in a 4-year-old child managed with aneurysm resection and radial artery interposition graft. CLINICAL PRESENTATION:A 4-year-old child presented with repeated severe headache and vomiting. Computed tomography, magnetic resonance imaging, and magnetic resonance angiography and digital subtraction angiography showed a giant fusiform aneurysm on the right middle cerebral artery (MCA). Because of the complex shape, endovascular treatment or clip reconstruction was not possible, and a bypass procedure was planned. Right frontotemporal craniotomy and orbitotomy was performed. Two aneurysms involving the M1 segment of the MCA were found in line, 1 giant, and the other large in size. The aneurysms were resected and treated with short radial artery interposition graft, which was narrower than the proximal or distal MCA. The child recovered normally, and the bypass was patent after 1 year. CONCLUSION:Large fusiform MCA aneurysms may be difficult to treat, but there are treatment options that include a bypass procedure. Resection and short interposition radial artery graft is an excellent but rare treatment option in a very young child. This was a very successful treatment in this child.
Surgical Management of Complex Middle Cerebral Artery Aneurysms: An Institutional Review.
Bhide Anuj Arun,Yamada Yashuhiro,Kato Yoko,Kawase Tsukasa,Tanaka Riki,Miyatani Kyosuke,Kojima Daijiro,Sayah Ahmed
Asian journal of neurosurgery
Background:Complex middle cerebral artery (MCA) aneurysms are defined as large (≥10 mm) or giant (≥25 mm) aneurysms with M2 branches arising from the aneurysm rather than M1 segments and usually require some form of reconstruction of the bifurcation. Their management is difficult and surgery is preferred over endovascular modalities because of their peculiar angioarchitecture and association with critical branch points or perforators. Objectives:The study was aimed at analyzing surgically managed complex MCA aneurysms and discussing characteristics not favorable for endovascular management, surgical nuances and clipping strategies, patient outcomes, and newer diagnostic modalities which help improve management. Methods:Nine cases of surgically operated complex MCA aneurysms were identified from January 2017 to July 2019. The aneurysm characteristics, surgical nuances, clipping strategies, patient outcomes and points not favoring endovascular management were tabulated and analyzed. Results:The mean maximum aneurysm diameter was 13.4 mm and the mean fundus/neck ratio was 1.6. The average microscope time was 124 min, and the most common method was clip reconstruction. The average number of clips used was 2.7 and the mean follow-up was 13 months. All patients have good postoperative outcome (Modified Rankin Score 0-2). The complete occlusion rate was 88.9% with one intraoperative voluntary residual sac which was coated. Computational fluid dynamic study results done preoperatively correlated with intraoperative findings. Conclusions:MCA aneurysms pose a significant challenge for endovascular treatment because of various factors such as luminal thrombi, complex angio-architecture, precarious branch/perforator locations, broad necks, and fusiform characteristics. Surgical management in experienced hands can tackle all these problems with an armamentarium of clipping techniques and bypass procedures.
The "SHI" Internal Maxillary Bypass for Giant Fusiform Middle Cerebral Artery Bifurcation Aneurysms: 2-Dimensional Operative Video.
Wang Long,Qian Hai,Shi Xiang'en
Although the extracranial-to-intracranial bypass has been widely used for 5 decades, the substantive modification in this technique has rarely presented except for the internal maxillary artery (IMaxA) bypass. Recently, the IMaxA bypass has been redefined as the new "workhorse" for high-flow arterial reconstruction and replaced the cervical artery bypass as the results of sparing second incision, short graft harvesting, and well-matched caliber between donor and recipient. This video demonstrates a 37-year-old female who presented with a 1-month history of severe headache. Her complex middle cerebral artery (MCA) aneurysm was treated by IMaxA bypass with radial artery graft. Preoperative neuroimaging revealed a giant, fusiform, thrombosed aneurysm that extensively involved the sphenoidal (M1) and insular (M2) segments of the MCA. After a multidisciplinary discussion, the reversal high-flow IMaxA bypass was performed, followed by proximal MCA occlusion. We approached the aneurysm using a frontotemporal craniotomy with zygomatic osteotomy to expose the pterygoid segment of IMaxA (IM2), which is defined as the "SHI" IMaxA bypass method. Simultaneously, the radial artery graft was harvested and prepared before being anastomosed in an end-to-end fashion to the IM2 using No. 9-0 polypropylene. The free end of the RAG was then brought to the sylvian fissure and anastomosed to the M2 in an end-to-side manner. The proximal part of M1 after the bypass takeoff was then occluded with a permanent aneurysm clip (Aesculap Instruments Corp., Tuttlingen, Germany). Complete elimination of the aneurysm with a patent graft artery was observed postoperatively, and the patient was discharged with intact neurologic function (modified Rankin Scale score 0).
Rapid Development of an Aneurysm at the Anastomotic Site of a Superficial Temporal Artery to Middle Cerebral Artery Bypass: Case Report and Literature Review.
Potts Matthew B,Horbinski Craig M,Jahromi Babak S
BACKGROUND:Direct extracranial to intracranial (EC-IC) bypass is a valuable treatment option for symptomatic occlusive cerebrovascular disease and complex intracranial aneurysms. Aneurysm formation at or near the anastomotic site is a rarely reported phenomenon, and the pathophysiology and appropriate management of such de novo aneurysms are not clear. CASE DESCRIPTION:Here we present the case of a superficial temporal to middle cerebral artery (STA-MCA) anastomosis that was complicated by aneurysm formation at the anastomotic site. This was treated with microsurgical clipping with preservation of the bypass. Pathologic analysis of the lesion was consistent with a pseudoaneurysm. We provide a literature review of this phenomenon, which is most often associated with low-flow STA-MCA bypasses, including review of the pathologic findings associated with it. CONCLUSION:Pseudoaneurysm formation at the site of an EC-IC bypass is a rare phenomenon that should be recognized and treated to prevent further growth and rupture.
Role of Doppler US in screening for carotid atherosclerotic disease.
Derdeyn C P,Powers W J,Moran C J,Cross D T,Allen B T
PURPOSE:To evaluate Doppler ultrasound (US) as a screening modality before arteriography for extracranial carotid artery disease. MATERIALS AND METHODS:The net benefit in stroke reduction from screening with Doppler US was calculated on the basis of literature estimates of disease prevalence, risk reduction data, and locally validated sensitivities and specificities for detection of carotid artery stenosis and occlusion in 215 patients. RESULTS:Screening a symptomatic population demonstrated a net stroke reduction. Screening asymptomatic populations with a 20% prevalence of > or = 60% stenosis also yielded a net stroke reduction. Screening low-prevalence (5%) asymptomatic populations produced a small benefit, which was lost if arteriographic or surgical complications increased slightly. Arteriographic confirmation of the US diagnosis of occlusion produced a small benefit only in the symptomatic population. CONCLUSION:Screening symptomatic and high-prevalence asymptomatic populations with US reduces stroke. Increased arteriographic or surgical complication rates reduce the benefit of screening in any population.
Surgical management of acute carotid thrombosis after carotid stenting: a report of three cases.
Setacci Carlo,de Donato Gianmarco,Setacci Francesco,Chisci Emiliano,Cappelli Alessandro,Pieraccini Massimo,Castriota Fausto,Cremonesi Alberto
Journal of vascular surgery
We report three cases of symptomatic acute carotid thrombosis occurring after carotid artery stenting (CAS). CASE 1: A patient presented with crescendo transient ischemic attacks on the second day after CAS. Ultrasound images demonstrated incomplete in-stent thrombosis due to plaque protrusion. The urgent surgical procedure consisted of stent removal and carotid thromboendarterectomy. CASE 2: A case of complete thrombosis of a carotid stent occurred 4 days after implantation in a patient with essential thrombocythemia diagnosed by chance. The surgical strategy included stent removal and carotid thromboendarterectomy. CASE 3: Cardiac multiple embolisms in a patient with chronic atrial fibrillation caused concomitant leg ischemia and acute carotid stent occlusion 2 hours after CAS. Cerebral reperfusion was established by embolectomy, without removing the stent. At the same time, the right leg ischemia was resolved by a thromboembolectomy with a Fogarty catheter. These three cases demonstrate that acute thrombosis after carotid stenting can be managed successfully with emergent surgical intervention. Thromboendarterectomy with stent removal or in selected cases, simple thromboembolectomy, can minimize neurologic sequelae in patients suffering from acute post-stenting carotid thrombosis.
The different scenarios of urgent carotid revascularization for crescendo and single transient ischemic attack.
Pini Rodolfo,Faggioli Gianluca,Gargiulo Mauro,Gallitto Enrico,Cacioppa Laura M,Vacirca Andrea,Pisano Emilio,Pilato Alessandro,Stella Andrea
OBJECTIVE:Carotid stenosis with crescendo-transient-ischemic-attack (cTIA) requires a prompt intervention to reduce the stroke risk. Few data are reported in literature about cTIA suggesting a different perioperative risk compared with patients with single TIA (sTIA). This study aimed to compare the outcome of carotid endarterectomy (CEA) in patients with TIA (single/crescendo) and evaluate the outcome risk-factors. METHODS:Data from two tertiary hospitals for vascular treatment were analyzed from 2007 to 2016. All patients with TIA subjected to CEA were considered, comparing the 30-day postoperative stroke and stroke/death in patients with cTIA and sTIA, particularly in the urgent (≤48 h) setting. RESULTS:On a total of 3866 CEA, 888 (23%) were performed in symptomatic patients and 515 for TIA: 365 (71%) patients with sTIA and 150 (29%) with cTIA. When compared with sTIA, cTIA patients were younger and less frequently affected by coronary disease, dyslipidemia, and chronic pulmonary disease; however, contralateral carotid occlusion was more common (20% vs. 10%, P = .004; 56% vs. 46, P = .03; 16% vs. 7%, P = .01; >80 years 26% vs. 16%, P = .01 and 2% vs. 10%, P = .001; respectively). Postoperative stroke and stroke/death were significantly higher in cTIA compared with sTIA (5.3% vs. 1.6%, P = .02 and 6.0% vs. 2.2%, P = .03; respectively). Urgent CEA was performed in 58% ( n: 87) cTIA and in 11% ( n: 56) sTIA( P<.01). The urgent setting did not influence the stroke and stroke/death rate of CEA for sTIA (3.6% vs. 1.3%, P = .21 and 3.6% vs. 1.9%, P = .44, respectively), but was associated with lower rate of events in cTIA (1.1%vs. 11.1%, P = .01 and 2.3% vs. 11.1%, P = .03, respectively). This beneficial effect in patients with cTIA treated within 48-h was confirmed also by multivariate analysis (OR: 0.09, 95% CI: 0.76-0.01, P=.02). CONCLUSIONS:cTIA subjected to CEA have a higher stroke and stroke/death risk compared with patients with sTIA. The urgent setting seems to reduce the stroke/death rate cTIA; for sTIA with a stable neurological condition, the timing of CEA did not influence the outcome.
[Assessing efficacy and risk factors of carotid endarterectomy and carotid stenting in patients with symptomatic stenoses of internal carotid arteries in early postoperative period].
Gavrilenko A V,Ivanov V A,Piven' A V,Kuklin A V,Antonov G I,Bobkov Iu A,Trunin I V,Abugov S A
Angiologiia i sosudistaia khirurgiia = Angiology and vascular surgery
The present work was aimed at comparative assessment of efficacy and risk factors of carotid endarterectomy and carotid stenting in patients suffering from symptomatic stenoses of the internal carotid arteries, with due regard for the degree of the accompanying cardiac pathology, the presence of contralateral occlusion, and severity of chronic cerebrovascular insufficiency. We examined and treated a total of 142 patients diagnosed with stenoses of the internal carotid arteries and symptoms of chronic cerebrovascular insufficiency. In the cohort of those subjected to carotid endarterectomy we performed a total of 76 operations in 73 patients, and in the group of carotid stenting 71 operations of stenting of the internal carotid artery with cerebral protection in 69 patients. Postoperatively we assessed the following parameters: «stroke+lethality», incidence of transitory ischaemiс attacks, incidence rate of cerebrovascular neuropathy, and acute myocardial infarction. In the carotid endarterectomy group, we revealed increased risk for the development of neuropathy of the craniocerebral nerves (OR=0.0564, 95% CI 0.9953, P=0.049). In the group of stenting, we revealed increased risk for the development of transitory ischaemia.
Recurrent stenosis and contralateral occlusion: high-risk situations in carotid endarterectomy?
Domenig Christoph,Hamdan Allen D,Belfield Alana K,Campbell David R,Skillman John J,LoGerfo Frank W,Pomposelli Frank B
Annals of vascular surgery
Carotid angioplasty and stenting (CAS) has been proposed as a treatment option for carotid occlusive disease in high-risk patients including those with recurrent stenosis (RS) and contralateral occlusion (CO). This study reviews the results of carotid endarterectomy (CEA) in patients with RS and CO. We conducted a retrospective review from our vascular registry of 1670 patients who underwent CEAs ( n = 1950) from January 1990 through December 2001. Procedures included RS 86 (4.4%), CO 112 (5.7%), and control 1752 (89.9%). There were 37 strokes in the entire group (1.9%). Among the high-risk group with RS and CO, there were 6 strokes, (RS n = 2, CO n = 4) 3%. There were 31 strokes in the control group 1.8% ( p = NS). Postoperative TIAs were observed more frequently in patients with CO ( n = 2) or RS ( n = 2), 1.8% and 2.3%, respectively ( p < 0.05). Neck hematomas, intracerebral hemorrhages, and myocardial infarctions did not differ between groups. Three deaths occurred within 30 days (0.15%); one was a patient with CO. Renal failure and symptomatic disease were each associated with a higher risk of perioperative stroke; among patients with renal failure there were 6 strokes (4.6%) p < 0.05, in symptomatic patients there were 26 strokes (2.7%) p < 0.05. Multivariate logistic regression analysis confirmed that preoperative renal disease and surgery for symptomatic disease were both significant predictors of perioperative stroke ( p < 0.05; odds ratio 2.177 and 2.943 respectively) while neither RS nor CO was from these results we concluded that the presence of RS and CO do not increase the risk of perioperative stroke in CEA.
Left Vertebral Artery to Common Carotid Artery Transposition in a Patient With Bilateral Vertebral Insufficiency: 3-Dimensional Operative Video.
Gandhi Sirin,Cavallo Claudio,Mascitelli Justin R,Nanaszko Michael J,Zhao Xiaochun,Lawton Michael T
Operative neurosurgery (Hagerstown, Md.)
Extracranial vertebral artery (VA) atherosclerosis is responsible for 14% to 32% of posterior circulation infarctions.1 In the posterior circulation, narrowing of the VA > 30% is significantly associated with strokes. Subclavian artery (SCA) atherosclerosis can produce subclavian steal. Retrograde VA flow around an occluded SCA decreases blood flow to the posterior circulation and causes vertebrobasilar insufficiency (VBI). Flow augmentation to the posterior circulation can be achieved by VA endarterectomy, arterial stenting, VA-common carotid artery (CCA) transposition, or bypass using an interposition graft.2,3 This video illustrates microsurgical revascularization of the proximal VA with VA-CCA transposition. A 58-yr-old man with a prior stroke and chronic right VA occlusion presented with dysarthria and gait instability. Angiographic evaluation confirmed complete midcervical right VA occlusion and left SCA occlusion proximal to VA origin, with subclavian steal. After obtaining patient consent and a failed attempt at endovascular recanalization of the left SCA, a left VA-CCA end-to-side transposition was performed. Neck dissection exposed the left CCA. The thyrocervical trunk served as a landmark to identify the SCA, which was traced proximally to the VA origin. After proximal occlusion, the VA was transected and "fish-mouthed" for end-to-side anastomosis to CCA. An intraluminal, continuous suture technique was used to sew the back walls of this anastomosis. Postoperative computed tomography angiography confirmed bypass patency. Collateral circulation through the thyrocervical and costocervical trunks likely supplied the left arm, and no cerebral, or limb, ischemic symptoms were noted on follow-up. VA-CCA transposition is an uncommon technique for safe and effective revascularization of symptomatic, medically refractory VBI caused by VA occlusion or, as in this case, SCA occlusion with secondary subclavian steal. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.
Carotid angioplasty and stenting in high-risk patients.
Teitelbaum G P,Lefkowitz M A,Giannotta S L
BACKGROUND:To examine our initial experience in carotid stenting (CS) for the prevention of stroke in patients with high-grade carotid stenoses. METHODS:The authors performed 26 CS procedures in 25 carotid vessels in 22 patients over a 15-month period. All carotid stenoses treated, except one, were 70% or greater. Of all CS procedures, 84% were performed for obstructing atherosclerotic plaques. CS was performed in one patient each for carotid dissection and pseudoaneurysms caused by a gunshot wound, post-radiation stenosis, post-carotid endarterectomy (CEA) restenosis, and a flow-obstructing post-CEA intimal flap. Of all patients, 68.2% were symptomatic, with a history of stroke or transient ischemic attacks ipsilateral to the treated carotid artery. In addition, 36.4% of our patients were either hospitalized or required skilled nursing care before CS because of severe neurologic deficits. Using the Sundt CEA-risk classification system, 59.1% of our patients were classified as Grade III and 40.9% were Grade IV pre-CS. All but one patient had either a compelling medical or anatomic reason for endovascular treatment of their carotid disease. We used both Wallstents and Palmaz stents, and all procedures were performed via the transfemoral route. Three procedures were performed in conjunction with detachable platinum coil embolization for multiple carotid pseudoaneurysms, a residual carotid "stump" after previous ICA thrombosis, and an ipsilateral MCA saccular aneurysm. RESULTS:We had a 96.2% procedural technical success rate. There was one death in our series 3 weeks post-CS attributable to myocardial infarction. Despite a high 30-day combined death, stroke, and ipsilateral blindness rate of 27.3% (6/22 patients), only two ipsilateral strokes directly related to CS occurred (7.7% per procedures performed) from which one patient recovered fully within 5 days. The average follow-up post-CS was 5.9 months (range, 3 weeks-15 months). Of successfully treated vessels, 58.3% have undergone 6-month follow-up vascular imaging, which has revealed a 14.3% rate of occlusion or restenosis greater than 50%. At or beyond 1 month post-CS, 19 of 21 surviving patients (90.5%) were ambulatory, fluent of speech, and independent, and none has thus far suffered a delayed stroke or TIA. CONCLUSION:CS seems to be a reasonable alternative to medical management for the treatment of carotid disease in patients deemed to be poor candidates for standard carotid surgery. Longer term follow-up is necessary to assess the durability of carotid revascularization using CS.
[Cerebral bypass surgery].
Imhof H G
Schweizerische Rundschau fur Medizin Praxis = Revue suisse de medecine Praxis
When an obstruction of a cerebral vessel is hemodynamically relevant and insufficiently collateralized--and when the mechanisms of compensation are exhausted--it can lead to ischemia. The second and more common way a vascular obstructive lesion can become symptomatic is the shedding of emboli to the periphery. The extra-/intracranial arterial bypass (EIAB), most often constructed as an anastomosis between the superficial temporal artery (STA) and a cortical branch of the middle cerebral artery (MCA), increases cerebral blood flow when all the mechanisms of compensation are exhausted. When not, it augments the cerebral perfusion reserve. If cerebral ischemia is due to embolism, the therapy of choice is elimination of the embolic source. When using the EIAB in hemodynamically caused ischemia, there are two indications: a therapeutic and a prophylactic one. Differentiation between functional and structural damage of neurons is difficult. Because reversible longlasting functional loss is rare, we reject it as a therapeutic indication. The prophylactic EIAB has to overcome the hemodynamic consequences of an intentional or spontaneous obstruction of extra- or intracranial cerebral vessels. Currently, neither the asymmetry of cerebral perfusion nor a decrease of the the cerebral perfusion reserve are established as risk factors for future ischemic cerebral events. If the MCA is to be occluded, a prophylactic EIAB is indicated: When the intention is to occlude the ICA with its extensive collateral system, the necessity for a bypass has to be evaluated. Most often, spontaneous occlusion of cerebral vessels is of atherosclerotic origin. Because no reliable method exists to differentiate between embolic (arterio-arterial) and hemodynamic ischemia; and since the spontaneous course of atherosclerosis is not predictable, the prophylactic indications for EIAB are unresolved. Nevertheless, many uncontrolled studies have shown a good prophylactic effect after the EIAB. The randomized international EC/IC Bypass Study, which is not accepted without reservation, denies any advantage of the EIAB in treating atherosclerotic vessel lesions when compared to medication with aspirin. Our experience leads us to believe that a prophylactic effect of the EIAB, even with atherosclerotic vessel obstruction, cannot be denied point blank. On the other hand, our experience also confirms that the EIAB should not be the standard treatment for atherosclerotic vessel obstruction. Considering the broad differences in the individual architecture of the cerebral vascular system and its varied amounts of acquired vascular lesions and through the spontaneous development of collaterals, the indications for EIAB, which in some circumstances is very effective, must be assessed for each individual patient.
Atherosclerotic carotid stenoses of apical versus body lesions in high-risk carotid stenting patients.
Park S-T,Kim J K,Yoon K H,Park S-O,Park S W,Kim J S,Kim S J,Suh D C
AJNR. American journal of neuroradiology
BACKGROUND AND PURPOSE:Different lesion locations in the atherosclerotic carotid bulb stenosis have not been clearly defined. We sought to evaluate 2 locations of carotid bulb stenosis in high-risk patients and to determine the relationship of each location to atherosclerotic risk factors and clinical features. MATERIALS AND METHODS:Atherosclerotic carotid plaques of apical versus body lesions, defined according to the area and extent of plaque involvement, were retrospectively analyzed in 200 consecutive high-risk patients who underwent carotid stent placement because of > or =50% symptomatic stenosis. We evaluated interobserver concordance and assessed each type of lesion relative to 13 atherosclerotic risk factors, mode of symptom presentation, infarct pattern, procedure-related factors, and clinical outcomes, by univariate and multivariable logistic regression analysis. RESULTS:Interobserver concordance showed good agreement for differentiating apical and body lesions (kappa = 0.745). Univariate analysis revealed that apical lesions (n = 108, 54%) were associated with pseudo-occlusion (P = .027), older age (P = .073), and alcohol intake (P = .080), whereas body lesions (n = 92, 46%) were associated with hyperlipidemia (P = .001), a wedge-shaped cortical infarct pattern (P = .057), and hyperperfusion syndrome (P = .083). Multivariable logistic regression analysis adjusted by age revealed that hyperlipidemia (P = .002; OR, 3.462; 95% CI, 1.595-7.515) and hyperperfusion (P = .026; OR, 6.727; 95% CI, 1.261-35.894) were independent predictors of body-type lesions. CONCLUSIONS:Atherosclerotic carotid bulb stenosis was found to have 2 distinct locations, body and apical. Hyperlipidemia and cortical wedge-shaped infarcts were more frequently associated with body than with apical stenosis at the time of presentation.
Recurrent Hemispheric Stroke Syndromes in Symptomatic Atherosclerotic Internal Carotid Artery Occlusions: The Carotid Occlusion Surgery Study Randomized Trial.
Nahab Fadi,Liu Michael,Rahman Haseeb A,Rangaraju Srikant,Barrow Daniel,Cawley C Michael,Grubb Robert L,Derdeyn Colin P,Adams Harold P,Videen Tom O,Zimmerman M Bridget,Powers William J
BACKGROUND:There are limited data on outcomes of extracranial-intracranial (EC-IC) bypass in patients with recurrent hemispheric syndromes due to atherosclerotic internal carotid artery occlusion (AICAO). OBJECTIVE:To compare clinical outcomes and efficacy of EC-IC bypass surgery in patients with and without recurrent hemispheric syndromes associated with AICAO in the Carotid Occlusion Surgery Study (COSS). METHODS:In patients enrolled in the COSS trial, we compared baseline characteristics and clinical outcomes for participants with (rHEMI+) and without recurrent hemispheric ischemia (rHEMI-) prior to randomization into surgical vs medical groups. The primary outcome was all stroke and death from randomization through 30 d and ipsilateral ischemic stroke within 2 yr. RESULTS:Of 195 randomized participants, 100 were rHEMI+ (50 in each group). Baseline characteristics between rHEMI+ and rHEMI- participants were similar except rHEMI+ were more likely to have had previous stroke prior to randomization (61% vs 20%, P < .01) and to have TIA as the entry event (59% vs 21%, P < .01). All primary endpoints were ipsilateral ischemic strokes. There were no significant differences in occurrence of the primary endpoint between nonsurgical and surgical participants in rHEMI+ (26.3% vs 22.4%, P = .660) and rHEMI- (18.9% vs 19.5%, P = .943). For nonsurgical participants, there was no significant difference in the primary endpoint for rHEMI+ vs rHEMI- patients (P = .410). CONCLUSION:Patients with recurrent hemispheric stroke syndromes enrolled in the COSS trial did not show benefit from EC-IC bypass compared to medical treatment. Early aggressive risk factor measures should be prioritized to reduce recurrent strokes in these patients.
Patient selection for mechanical thrombectomy.
Nelles M,Greschus S,Möhlenbruch M,Simon B,Wüllner U,Urbach H
PURPOSE:To evaluate the influence of tissue parameters as assessed by multimodal computed tomography and procedural parameters on clinical outcome after mechanical thrombectomy. METHODS:A total of 301 consecutive patients with acute onset ischemic stroke were included in this study. Of these, 65 had thromboembolic occlusions of the carotid T or middle cerebral artery (MCA) and underwent mechanical thrombectomy. Tissue parameters were given by unenhanced CT and perfusion CT (PCT) parameter maps of total hypoperfused tissue, infarct core, and tissue at risk. Procedural parameters comprised time from symptom onset (SO) to PCT, from SO to the first angiographic series, and from SO to vessel recanalization (occlusion time). In a subset of 22 fully recanalized occlusions, infarcted tissue and "tissue at risk" as defined by PCT were coregistered to final infarcts on follow-up imaging. RESULTS:Thrombolysis in cerebral infarction score (TICI) 2b/3 recanalization was achieved in 58/65 patients (89%). Only the infarct core size (p = 0.007) and the ratio of the infarct core relative to the tissue at risk (p = 0.001) yielded significant differences regarding the clinical outcome. Small infarct cores and low ratios of core size relative to the tissue at risk were correlated with a favorable outcome after mechanical thrombectomy. In the PCT coregistration subset, the congruency between predicted infarct cores and final infarcts was 68%, and between tissue at risk and final infarcts 7%, respectively. CONCLUSIONS:The size of the infarct core and the ratio relative to the tissue at risk are more relevant parameters for clinical outcome after mechanical thrombectomy than time related factors.
Comparison of Clinical Characteristics among Subtypes of Visual Symptoms in Patients with Transient Ischemic Attack: Analysis of the PROspective Multicenter registry to Identify Subsequent cardiovascular Events after TIA (PROMISE-TIA) Registry.
Tanaka Koji,Uehara Toshiyuki,Kimura Kazumi,Okada Yasushi,Hasegawa Yasuhiro,Tanahashi Norio,Suzuki Akifumi,Nakagawara Jyoji,Arii Kazumasa,Nagahiro Shinji,Ogasawara Kuniaki,Uchiyama Shinichiro,Matsumoto Masayasu,Iihara Koji,Toyoda Kazunori,Minematsu Kazuo,
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
BACKGROUND:A transient visual symptom (TVS) is a clinical manifestation of transient ischemic attack (TIA). The aim of this study was to investigate differences in clinical characteristics among subtypes of TVS using multicenter TIA registry data. MATERIALS AND METHODS:Patients with TIA visiting within 7 days of onset were prospectively enrolled from 57 hospitals between June 2011 and December 2013. Clinical characteristics were compared between patients with 3 major subtypes of TVS (transient monocular blindness [TMB], homonymous lateral hemianopia [HLH], and diplopia). RESULTS:Of 1365 patients, 106 (7.8%) had TVS, including 40 TMB (38%), 34 HLH (32%), 17 diplopia (16%), and 15 others/unknown (14%). Ninety-one patients with 1 of the 3 major subtypes of TVS were included. Symptoms persisted on arrival in 12 (13%) patients. Isolated TVS was significantly more common in TMB than in HLH and diplopia (88%, 62%, and 0%, respectively; P < .001). Duration of symptoms was shorter in patients with TMB than those with HLH (P = .004). The ABCD score was significantly lower in patients with TMB compared with those with HLH and diplopia (median 2 [interquartile range 2-3] versus 3 [2-4] and 4 [2-5], respectively; P = .005). Symptomatic extracranial internal carotid artery stenosis or occlusion was seen in 14 (16%) patients, and was more frequent in TMB than in HLH and diplopia (28%, 9%, and 0%, respectively; P = .015). CONCLUSIONS:TVS was an uncommon symptom in our TIA multicenter cohort. Some differences in clinical characteristics were found among subtypes of TVS.
Associated Factors and Long-Term Prognosis of 24-Hour Worsening of Arterial Patency After Ischemic Stroke.
Marto João Pedro,Lambrou Dimitris,Eskandari Ashraf,Nannoni Stefania,Strambo Davide,Saliou Guillaume,Maeder Philippe,Sirimarco Gaia,Michel Patrik
Background and Purpose- Early arterial recanalization in acute ischemic stroke is strongly associated with better outcomes. However, early worsening of arterial patency was seldom studied. We investigated potential predictors and long-term prognosis of worsening of arterial patency at 24 hours after stroke onset. Methods- Patients from the Acute Stroke Registry and Analysis of Lausanne registry including admission and 24-hour vascular imaging (computed tomography or magnetic resonance angiography) were included. Worsening of arterial patency was defined as a new occlusion and significant stenosis in any extracranial or intracranial artery, comparing 24 hours with admission imaging. Variables associated with worsening of arterial patency were assessed by stepwise multiple logistic regression. The impact of arterial worsening on 3-month outcome was investigated with an adjusted modified Rankin Scale shift analysis. Results- Among 2152 included patients, 1387 (64.5%) received intravenous thrombolysis and endovascular treatment, and 65 (3.0%) experienced 24-hour worsening of arterial patency. In multivariable analysis, history of hypertension seemed protective (adjusted odds ratio [aOR], 0.45; 95% CI, 0.27-0.75) while higher admission National Institutes of Health Stroke Scale (aOR, 1.06; 95% CI, 1.02-1.10), intracranial (aOR, 4.78; 95% CI, 2.03-11.25) and extracranial stenosis (aOR, 3.67; 95% CI, 1.95-6.93), and good collaterals (aOR, 3.71; 95% CI, 1.54-8.95) were independent predictors of worsening of arterial patency. Its occurrence was associated with a major unfavorable shift in the distribution of the modified Rankin Scale at 3 months (aOR, 5.97; 95% CI, 3.64-9.79). Conclusions- Stroke severity and admission vascular imaging findings may help to identify patients at a higher risk of developing worsening of arterial patency at 24 hours. The impact of worsening of arterial patency on long-term outcome warrants better methods to detect and prevent this early complication.
Predictors of poor outcome despite recanalization: a multiple regression analysis of the NASA registry.
Linfante Italo,Starosciak Amy K,Walker Gail R,Dabus Guilherme,Castonguay Alicia C,Gupta Rishi,Sun Chung-Huan J,Martin Coleman,Holloway William E,Mueller-Kronast Nils,English Joey D,Malisch Tim W,Marden Franklin A,Bozorgchami Hormozd,Xavier Andrew,Rai Ansaar T,Froehler Michael T,Badruddin Aamir,Nguyen Thanh N,Taqi M Asif,Abraham Michael G,Janardhan Vallabh,Shaltoni Hashem,Novakovic Roberta,Yoo Albert J,Abou-Chebl Alex,Chen Peng R,Britz Gavin W,Kaushal Ritesh,Nanda Ashish,Issa Mohammad A,Nogueira Raul G,Zaidat Osama O
Journal of neurointerventional surgery
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.
Twenty-Four-Hour Reocclusion After Successful Mechanical Thrombectomy: Associated Factors and Long-Term Prognosis.
Marto João Pedro,Strambo Davide,Hajdu Steven D,Eskandari Ashraf,Nannoni Stefania,Sirimarco Gaia,Bartolini Bruno,Puccinelli Francesco,Maeder Philippe,Saliou Guillaume,Michel Patrik
Background and Purpose- Early arterial recanalization is a strong determinant of prognosis in acute ischemic stroke. Nevertheless, reocclusion can occur after initial recanalization. We assessed associated factors and long-term prognosis of reocclusion after successful mechanical thrombectomy (MT). Methods- From the prospectively constructed Acute Stroke Registry and Analysis of Lausanne cohort, we included consecutive patients with anterior and posterior circulation strokes treated by successful MT (modified treatment in cerebral infarction 2b-3) and with 24-hour vascular imaging available. Reocclusion at this time-point was defined as new intracranial occlusion within an arterial segment recanalized at the end of MT. Through multivariate logistic regression, we investigated associated factors and 3-months outcome. In a 4:1 matched-cohort, we also assessed the role of residual thrombus or stenosis on post-recanalization angiographic images as potential predictor of reocclusion. Results- Among 473 patients with successful recanalization, 423 (89%) were included. Of these, 28 (6.6%) had 24-hour reocclusion. Preadmission statin therapy (aOR [adjusted odds ratio], 0.27; 95% CI, 0.08-0.94), intracranial internal carotid artery occlusion (aOR, 3.53; 95% CI, 1.50-8.32), number of passes (aOR, 1.31; 95% CI, 1.06-1.62), transient reocclusion during MT (aOR, 8.55; 95% CI, 2.14-34.09), and atherosclerotic cause (aOR, 3.14; 95% CI, 1.34-7.37) were independently associated with reocclusion. In the matched-cohort analysis, residual thrombus or stenosis was associated with reocclusion (aOR, 15.6; 95% CI, 4.6-52.8). Patients experiencing reocclusion had worse outcome (aOR, 5.0; 95% CI, 1.2-20.0). Conclusions- Reocclusion within 24-hours of successful MT was independently associated with statin pretreatment, occlusion site, more complex procedures, atherosclerotic cause, and residual thrombus or stenosis after recanalization. Reocclusion impact on long-term outcome highlights the need to monitor and prevent this early complication.
Combined local hypothermia and recanalization therapy for acute ischemic stroke: Estimation of brain and systemic temperature using an energetic numerical model.
Lutz Yannick,Loewe Axel,Meckel Stephan,Dössel Olaf,Cattaneo Giorgio
Journal of thermal biology
Local brain hypothermia is an attractive method for providing cerebral neuroprotection for ischemic stroke patients and at the same time reducing systemic side effects of cooling. In acute ischemic stroke patients with large vessel occlusion, combination with endovascular mechanical recanalization treatment could potentially allow for an alleviation of inflammatory and apoptotic pathways in the critical phase of reperfusion. The direct cooling of arterial blood by means of an intra-carotid heat exchange catheter compatible with recanalization systems is a novel promising approach. Focusing on the concept of "cold reperfusion", we developed an energetic model to calculate the rate of temperature decrease during intra-carotid cooling in case of physiological as well as decreased perfusion. Additionally, we discussed and considered the effect and biological significance of temperature decrease on resulting brain perfusion. Our model predicted a 2 °C brain temperature decrease in 8.3, 11.8 and 26.2 min at perfusion rates of 50, 30 and 10ml100g⋅min, respectively. The systemic temperature decrease - caused by the venous blood return to the main circulation - was limited to 0.5 °C in 60 min. Our results underline the potential of catheter-assisted, intracarotid blood cooling to provide a fast and selective brain temperature decrease in the phase of vessel recanalization. This method can potentially allow for a tissue hypothermia during the restoration of the physiological flow and thus a "cold reperfusion" in the setting of mechanical recanalization.
Stenting of Mobile Calcified Emboli After Failed Thrombectomy in Acute Ischemic Stroke: Case Report and Literature Review.
Potts Matthew B,da Matta Lucas,Abdalla Ramez N,Shaibani Ali,Ansari Sameer A,Jahromi Babak S,Hurley Michael C
BACKGROUND:Mobile calcified emboli are a rare cause of large vessel occlusion and acute ischemic stroke and pose unique challenges to standard mechanical thrombectomy techniques. Intracranial stenting has been reported as a rescue maneuver in cases of failed mechanical thrombectomy owing to dissection or calcified atherosclerotic plaques, but its use for calcified emboli is not well described. CASE DESCRIPTION:We present 2 cases of acute ischemic stroke caused by mobile calcified emboli. Standard mechanical thrombectomy techniques using aspiration catheters and stent-retrievers failed to remove these emboli, so intracranial stenting was successfully performed in each case, albeit after overcoming unique challenges associated with the stenting of calcified emboli. We also review the literature on intracranial stenting as a salvage therapy for failed mechanical thrombectomy. CONCLUSIONS:Mobile calcified emboli are rare causes of acute ischemic stroke. Intracranial stenting can be used to successfully treat calcified emboli when mechanical thrombectomy has failed.
Prediction of recanalization in acute stroke patients receiving intravenous and endovascular revascularization therapy.
Zhu Guangming,Michel Patrik,Jovin Tudor,Patrie James T,Xin Wenjun,Eskandari Ashraf,Zhang Weiwei,Wintermark Max
International journal of stroke : official journal of the International Stroke Society
BACKGROUND AND PURPOSE:The study aims to assess the recanalization rate in acute ischemic stroke patients who received no revascularization therapy, intravenous thrombolysis, and endovascular treatment, respectively, and to identify best clinical and imaging predictors of recanalization in each treatment group. METHODS:Clinical and imaging data were collected in 103 patients with acute ischemic stroke caused by anterior circulation arterial occlusion. We recorded demographics and vascular risk factors. We reviewed the noncontrast head computed tomographies to assess for hyperdense middle cerebral artery and its computed tomography density. We reviewed the computed tomography angiograms and the raw images to determine the site and degree of arterial occlusion, collateral score, clot burden score, and the density of the clot. Recanalization status was assessed on recanalization imaging using Thrombolysis in Myocardial Ischemia. Multivariate logistic regressions were utilized to determine the best predictors of outcome in each treatment group. RESULTS:Among the 103 study patients, 43 (42%) received intravenous thrombolysis, 34 (33%) received endovascular thrombolysis, and 26 (25%) did not receive any revascularization therapy. In the patients with intravenous thrombolysis or no revascularization therapy, recanalization of the vessel was more likely with intravenous thrombolysis (P = 0·046) and when M1/A1 was occluded (P = 0·001). In this subgroup of patients, clot burden score, cervical degree of stenosis (North American Symptomatic Carotid Endarterectomy Trial), and hyperlipidemia status added information to the aforementioned likelihood of recanalization at the patient level (P < 0·001). In patients with endovascular thrombolysis, recanalization of the vessel was more likely in the case of a higher computed tomography angiogram clot density (P = 0·012), and in this subgroup of patients gender added information to the likelihood of recanalization at the patient level (P = 0·044). CONCLUSION:The overall likelihood of recanalization was the highest in the endovascular group, and higher for intravenous thrombolysis compared with no revascularization therapy. However, our statistical models of recanalization for each individual patient indicate significant variability between treatment options, suggesting the need to include this prediction in the personalized treatment selection.
Selecting endovascular treatment strategy according to the location of intracranial occlusion in acute stroke.
Pagola Jorge,Rubiera Marta,Flores Alan,Rodríguez-Luna David,Piñeiro Socorro,Muchada Mari A,Quintana Manolo,Alvarez-Sabin Jose,Molina Carlos A,Ribo Marc
Cerebrovascular diseases (Basel, Switzerland)
BACKGROUND:Selection of endovascular approaches for acute stroke patients remains unclear. The efficacy of intra-arterial therapy (IAT) has been demonstrated in the past. However, in the last years, the use of mechanical thrombectomy by retrievers (RET) is increasing at the expense of IAT. We aimed to compare several clinical outcomes between patients treated with IAT or RET. METHODS:In a 6-year period, acute stroke patients (<8 h) with confirmed internal carotid artery (ICA) occlusion or middle cerebral artery (MCA) occlusion undergoing endovascular therapy were prospectively included in our database. Patients who underwent intra-arterial tissue plasminogen activator (tPA) ± microguidewire mechanical clot disruption (IAT group) were compared with those who underwent thrombectomy with the Solitaire® or Trevo® retrievers (RET group). Recanalization (REC) was considered if at the end of the endovascular procedure thrombolysis in cerebral infarction score was 2a-3. Dramatic clinical improvement (DCI) was defined as a decrease of ≥10 NIHSSS points from baseline to discharge or 7 days. RESULTS:One hundred and eighty patients were included, 100 (55.6%) patients in the IAT group and 80 patients (44.4%) in the RET group. There were no differences in baseline characteristics (age, gender, risk factors profile, previous treatment with i.v. tPA, baseline NIHSS, extracranial ICA angioplasty and time to REC). Rates of REC, DCI and symptomatic intracranial hemorrhage were also similar between groups. Among patients with ICA occlusions (41 IAT, 34 RET), REC was significantly higher with RET (83.9 vs. 61%; p = 0.04).There was a trend towards a higher DCI rate in the RET group (32.3%) compared with the IAT group (14.6%; p = 0.06). According to MCA occlusions, there were no major differences in the main outcome variables. The number needed to treat to achieve one additional DCI with RET compared with IAT was 12 for MCA occlusions, and only 5 for ICA occlusions. CONCLUSIONS:Among acute stroke patients undergoing endovascular therapies, the benefits of RET over IAT are greater in ICA occlusions. Retrievers may be considered as the first therapeutic option in these patients.
Restenosis after carotid endarterectomy in a multicenter regional registry.
Goodney Philip P,Nolan Brian W,Eldrup-Jorgensen Jens,Likosky Donald S,Cronenwett Jack L,
Journal of vascular surgery
BACKGROUND:Level I evidence shows conventional carotid endarterectomy (CEA) with patch angioplasty results in lower rates of restenosis. However, whether this information has affected practice patterns and outcomes in real-world vascular surgery settings is unclear. METHODS:Within the Vascular Study Group of New England (VSGNE), we studied 2981 patients undergoing 2981 first-time CEAs between January 1, 2003, and June 31, 2008. Rates of restenosis (defined by duplex ultrasound imaging at the 1-year follow-up) were estimated using life-table analysis. Cox proportional hazards models were used to identify multivariable predictors of postoperative restenosis ≤ 1 year. RESULTS:Across 58 surgeons and 11 hospitals, we studied 2611 conventional CEAs (88% of all CEAs) and 370 eversion CEAs (12% of all CEAs). Median follow-up was 12.8 months (range, 1-35 months). The proportion of conventional CEAs performed with patching increased from 87% to 96% (P < .001) between 2003 and 2008, whereas eversion CEA declined from 18% to 5% (P < .001). Restenosis occurred in 303 patients (10%); by life-table analysis, the restenosis rate at 1 year was 6.2% (95% confidence interval [CI], 4.7%-6.8%). Restenoses were most commonly noncritical: 50%-79% restenosis in 7.9%, 80%-99% restenosis in 1.7%, and occlusion in 0.5%. Univariate analyses showed significant differences in 80% to 100% restenosis by procedure type (2% in conventional CEA, 6% in eversion CEA, P < .002), the year of procedure (3.2% in 2003, 0% in 2008; P < .03), and use of patching in conventional CEA (2.9% no patch, 1% with patch; P < .008). By multivariable analysis, absence of patching (hazard ratio [HR], 3.2; 95% CI, 1.5-7.0), contralateral internal carotid artery stenosis > 80% (HR, 4.1; 95% CI, 1.4-11.5), and dialysis dependence (HR, 3.5; 95% CI, 1.2-9.8) were independently associated with a higher risk of an 80% to 100% restenosis. Of the 51 patients with 80% to 99% restenosis, 14 underwent reintervention ≤ 1 year, comprising 4 reoperations and 10 carotid artery stent procedures. Of the 15 patients with a carotid occlusion ≤ 1 year, transient ischemic attacks occurred in 2 and a disabling stroke in 1. CONCLUSIONS:In our region, restenosis after CEA, especially clinically significant restenosis ≤ 1 year after surgery, decreased slightly over time. This improvement in outcome was associated with several factors, including an increase in patching after conventional CEA, a process of care that was studied and encouraged within our vascular study group. These results highlight the utility of regional quality-improvement efforts in improving outcomes in vascular surgery.
[Tandem occlusions in acute ischemic stroke].
Meyer L,Politi M,Alexandrou M,Papanagiotou P
CLINICAL ISSUE:Acute strokes caused by tandem occlusions include an atherosclerotic or dissective stenosis/occlusion of the extracranial internal carotid artery (eICA) in combination with an intracranial vessel occlusion. STANDARD TREATMENT:Endovascular treatment can be technically challenging but is definitely superior to intravenous thrombolysis alone and achieves good clinical results comparable to those from solitary intracranial occlusions. LATEST STUDY RESULTS:Although there are still no prospectively randomized studies on endovascular treatment for tandem occlusions, currently available data favor acute stenting of the eACI followed by intracranial thrombectomy. PURPOSE OF THE ARTICLE:This review discusses endovascular treatment options for tandem occlusions based on currently available data.
Invasive Fungal Carotiditis: A Rare Manifestation of Cranial Invasive Fungal Disease: Case Series and Systematic Review of the Literature.
Little Jessica S,Cheng Matthew P,Hsu Liangge,Corrales C Eduardo,Marty Francisco M
Open forum infectious diseases
Background:Rhinosinusitis, malignant otitis externa, and skull base osteomyelitis represent a spectrum of cranial invasive fungal disease (IFD). These syndromes have distinct characteristics, yet they may progress to involve similar structures, resulting in inflammation and invasion of the adjacent internal carotid artery (ICA). Invasive fungal carotiditis can have devastating consequences, including cerebral infarction, subarachnoid hemorrhage, and death. Methods:We retrospectively studied all patients diagnosed with cranial IFD and carotid involvement at our institution from 2003 to 2018. We also searched Medline/PubMed for reports of or cranial infections with ICA involvement. All cases with mycologic evidence of cranial IFD and radiographic or pathologic evidence of ICA involvement were included. Results:We identified 78 cases of invasive fungal carotiditis between 1958 and 2018, including 4 cases at our own institution. Forty-one were caused by and 37 by species. Presenting symptoms included vision changes (73%), cranial nerve palsy (69%), and headache (42%). Carotid events included occlusion, aneurysm formation, and vessel rupture. Cerebral infarcts occurred in 50% of cases. Mortality at 6 weeks, 12 weeks, and 2 years was 27%, 41%, and 71% respectively. The median time from symptom onset to death was 150 days for cases due to and 51 days for cases due to species. Conclusions:Invasive fungal carotiditis is a rare but morbid manifestation of cranial IFD. Early suspicion of IFD and administration of antifungal treatment, vascular imaging, and endovascular interventions should be considered to reduce the high mortality of this disease.
The role of argon in stroke.
Li Xiang,Zhang Zhu-Wei,Wang Zhong,Li Jin-Quan,Chen Gang
Medical gas research
Stroke, also known as "cerebrovascular accident", is an acute cerebrovascular disease that is caused by a sudden rupture of blood vessels in the brain or obstruction of the blood supply by blockage of blood vessels, thus including hemorrhagic and ischemic strokes. The incidence of ischemic stroke is higher than that of hemorrhagic stroke, and accounts for 80% of the total number of strokes. However, the mortality rate of hemorrhagic stroke is relatively high. Internal carotid artery and vertebral artery occlusion and stenosis can cause ischemic stroke, and especially males over 40 years of age are at a high risk of morbidity. According to the survey, stroke in urban and rural areas has become the first cause of death in China. It is also the leading cause of disability in Chinese adults. In a word, stroke is characterized by high morbidity, high mortality and high disability rates. Studies have shown that many noble gases have the neuroprotective effects. For example, xenon has been extensively studied in various animal models of neurological injury including stroke, hypoxic-ischemic encephalopathy. Compared to xenon, Argon, as a noble gas, is abundant, cheap and widely applicable, and has been also demonstrated to be neuroprotective in many research studies. In a variety of models, ranging from oxygen-glucose deprivation in cell culture to complex models of mid-cerebral artery occlusion, subarachnoid hemorrhage or retinal ischemia-reperfusion injury in animals. Argon administration after individual injury demonstrated favorable effects, particularly increased cell survival and even improved neuronal function. Therefore the neuroprotective effects of argon may be of possible clinical use for opening a potential therapeutic window in stroke. It is important to illuminate the mechanisms of argon in nerve function and to explore the best use of this gas in stroke treatment.
Ischemic Stroke: What Does the Histological Composition Tell Us About the Origin of the Thrombus?
Sporns Peter B,Hanning Uta,Schwindt Wolfram,Velasco Aglaé,Minnerup Jens,Zoubi Tarek,Heindel Walter,Jeibmann Astrid,Niederstadt Thomas Ulrich
BACKGROUND AND PURPOSE:The introduction of stent retrievers allows for a complete extraction and histological analysis of human thrombi. Ischemic stroke is a major health issue, and differentiation of underlying causes is highly relevant to prevent recurrent stroke. Therefore, histopathologic analysis of the embolic clots after removal may provide valuable information about underlying pathologies. This study analyzes histological clot composition and aims to identify specific patterns that might help to distinguish causes of ischemic stroke. METHODS:Patients with occlusion of the carotid-T or middle cerebral artery who underwent thrombectomy at our university medical center between December 2013 and February 2016 were included. Samples were histologically analyzed (hematoxylin and eosin, Elastica van Gieson, and Prussian blue), additionally immunohistochemistry for CD3, CD20, and CD68/KiM1P was performed. These data, along with additional clinical and interventional parameters, were compared for different stroke subtypes, as defined by the TOAST (Trial of Org 10172 in Acute Stroke Treatment) classification. RESULTS:One hundred eighty-seven patients were included, of these, in 77 patients, cardioembolic; in 46 patients, noncardioembolic; and in 64 patients, cryptogenic pathogenesis was determined. Cardioembolic thrombi had higher proportions of fibrin/platelets (=0.027), less erythrocytes (=0.005), and more leucocytes (=0.026) than noncardioembolic thrombi. We observed a strong overlap of cryptogenic strokes and cardioembolic strokes concerning thrombus histology. The immunohistochemical parameters CD3, CD20, and CD68/KiM1P showed no statistically noticeable differences between stroke subtypes. CONCLUSIONS:Histological thrombus features vary significantly according to the underlying cause and may help to differentiate between cardioembolic and noncardioembolic stroke. In addition, our study supports the hypothesis that most cryptogenic strokes have a cardioembolic cause.
Endovascular therapy of 623 patients with anterior circulation stroke.
Galimanis Aekaterini,Jung Simon,Mono Marie-Luise,Fischer Urs,Findling Oliver,Weck Anja,Meier Niklaus,De Marchis Gian Marco,Brekenfeld Caspar,El-Koussy Marwan,Mattle Heinrich P,Arnold Marcel,Schroth Gerhard,Gralla Jan
BACKGROUND AND PURPOSE:Endovascular therapy of acute ischemic stroke has been shown to be beneficial for selected patients. The purpose of this study is to determine predictors of outcome in a large cohort of patients treated with intra-arterial thrombolysis, mechanical revascularization techniques, or both. METHODS:We prospectively acquired data for 623 patients with acute cerebral infarcts in the carotid artery territory who received endovascular treatment at a single center. Logistic regression analysis was performed to determine predictors of outcome. RESULTS:Median National Institutes of Health Stroke Scale (NIHSS) at admission was 15. Partial or complete recanalization was achieved in 70.3% of patients; it was independently associated with hypercholesterolemia (P=0.02), absence of coronary artery disease (P=0.023), and more proximal occlusion site (P<0.0001). After 3 months, 80.5% of patients had survived, and 48.9% of patients reached favorable outcome (modified Rankin scale score 0-2). Good collaterals (P<0.0001), recanalization (P=0.023), hypercholesterolemia (P=0.03), lower NIHSS at admission (P=0.001), and younger age (P<0.0001) were independent predictors for survival. More peripheral occlusion site (P<0.0001), recanalization (P<0.0001), hypercholesterolemia (P=0.002), good collaterals (P=0.002), lower NIHSS (P<0.0001), younger age (P<0.0001), absence of diabetes (P=0.002), and no previous antithrombotic therapy (P=0.036) predicted favorable outcome. Time to treatment was only a predictor of outcome, when collaterals were excluded from the model. Symptomatic intracerebral hemorrhage occurred in 5.5% and was independently predicted by poor collaterals (P=0.004). CONCLUSIONS:Several independent predictors for outcome and complications were identified. Unlike in intravenous thrombolysis trials, time to treatment was a predictor of outcome only when collaterals were excluded from the model, indicating the important role of collaterals for the time window.
Predictive value of transcranial evoked potentials during mechanical endovascular therapy for acute ischaemic stroke: a feasibility study.
Shiban Ehab,Wunderlich Silke,Kreiser Kornelia,Lehmberg Jens,Hemmer Bernhard,Prothmann Sascha,Zimmer Claus,Meyer Bernhard,Ringel Florian
Journal of neurology, neurosurgery, and psychiatry
BACKGROUND AND PURPOSE:Mechanical endovascular therapy (MET) is a promising adjuvant or stand-alone therapy for acute ischaemic stroke caused by occlusion of a large vessel. Real-time monitoring of recanalisation success with regard to functional outcome is usually not possible because these procedures are mainly performed under general anaesthesia. We present a novel application for evoked potential monitoring for real-time evaluation of reperfusion success with respect to functional outcome during MET for acute ischaemic stroke. METHODS:Prospective observational study from March 2012 to April 2013 of patients presenting with acute ischaemic stroke who were eligible for MET. Transcranial motor evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs) were measured bilaterally during MET throughout the intervention. The electrophysiological data of the contralateral side served as control. Neurological outcome was assessed by the modified Rankin Scale and National Institutes of Health Stroke Scale at 0, 7 and 90 days following intervention. RESULTS:20 patients were examined. MEPs and SSEPs were technically successful in 19 (95%) and 9 (45%) cases, respectively. Successful reperfusion was achieved in 16 cases. Functional recovery was observed in 14 patients. MEPs and SSEPs recovery status was a better predictor of functional recovery than successful reperfusion with a positive predictive value of 92%, 83% and 75% for MEPs, SSEPs and reperfusion, respectively. CONCLUSIONS:MEPs and SSEPs are safe and feasible methods of real-time monitoring of reperfusion success with respect to functional outcome during MET for acute ischaemic stroke.
Cerebral misery perfusion due to carotid occlusive disease.
Maddula Mohana,Sprigg Nikola,Bath Philip M,Munshi Sunil
Stroke and vascular neurology
PURPOSE:Cerebral misery perfusion (CMP) is a condition where cerebral autoregulatory capacity is exhausted, and cerebral blood supply in insufficient to meet metabolic demand. We present an educational review of this important condition, which has a range of clinical manifestations. METHOD:A non-systematic review of published literature was undertaken on CMP and major cerebral artery occlusive disease, using Pubmed and Sciencedirect. FINDINGS:Patients with CMP may present with strokes in watershed territories, collapses and transient ischaemic attacks or episodic movements associated with an orthostatic component. While positron emission tomography is the gold standard investigation for misery perfusion, advanced MRI is being increasingly used as an alternative investigation modality. The presence of CMP increases the risk of strokes. In addition to the devastating effect of stroke, there is accumulating evidence of impaired cognition and quality of life with carotid occlusive disease (COD) and misery perfusion. The evidence for revascularisation in the setting of complete carotid occlusion is weak. Medical management constitutes careful blood pressure management while addressing other vascular risk factors. DISCUSSION:The evidence for the management of patients with COD and CMP is discussed, together with recommendations based on our local experience. In this review, we focus on misery perfusion due to COD. CONCLUSION:Patients with CMP and COD may present with a wide-ranging clinical phenotype and therefore to many specialties. Early identification of patients with misery perfusion may allow appropriate management and focus on strategies to maintain or improve cerebral blood flow, while avoiding potentially harmful treatment.
Floating arterial thrombus related stroke treated by intravenous thrombolysis.
Vanacker P,Cordier M,Janbieh J,Federau C,Michel P
Cerebrovascular diseases (Basel, Switzerland)
BACKGROUND:The effects of intravenous thrombolysis on floating thrombi in cervical and intracranial arteries of acute ischemic stroke patients are unknown. Similarly, the best prevention methods of early recurrences remain controversial. This study aimed to describe the clinical and radiological outcome of thrombolyzed strokes with floating thrombi. METHODS:We retrospectively analyzed all thrombolyzed stroke patients in our institution between 2003 and 2010 with floating thrombi on acute CT-angiography before the intravenous thrombolysis. The floating thrombus was diagnosed if an elongated thrombus of at least 5 mm length, completely surrounded by contrast on supra-aortic neck or intracerebral arteries, was present on CT-angiography. Demographics, vascular risk factors, and comorbidities were recorded and stroke etiology was determined after a standardized workup. Repeat arterial imaging was performed by CTA at 24 h or before if clinical worsening was noted and then by Doppler and MRA during the first week and at four months. RESULTS:Of 409 thrombolyzed stroke patients undergoing acute CT Angiography, seven (1.7%) had a floating thrombus; of these seven, six had it in the anterior circulation. Demographics, risk factors and stroke severity of these patients were comparable to the other thrombolyzed patients. After intravenous thrombolysis, the floating thrombi resolved completely at 24 h in four of the patients, whereas one had an early recurrent stroke and one developed progressive worsening. One patient developed early occlusion of the carotid artery with floating thrombus and subsequently a TIA. The two patients with a stable floating thrombus had no clinical recurrences. In the literature, only one of four reported cases were found to have a thrombolysis-related early recurrence. CONCLUSIONS:Long-term outcome seemed similar in thrombolyzed patients with floating thrombus, despite a possible increase of very early recurrence. It remains to be established whether acute mechanical thrombectomy could be a safer and more effective treatment to prevent early recurrence. However, intravenous thrombolysis should not be withheld in eligible stroke patients.
Prognosis of Acute Intracranial Atherosclerosis-Related Occlusion after Endovascular Treatment.
Lee Jin Soo,Lee Seong-Joon,Yoo Joon Sang,Hong Jeong-Ho,Kim Chang-Hyun,Kim Yong-Won,Kang Dong-Hun,Kim Yong-Sun,Hong Ji Man,Choi Jin Wook,Ovbiagele Bruce,Demchuk Andrew M,Sohn Sung-Il,Hwang Yang-Ha
Journal of stroke
BACKGROUND AND PURPOSE:Little is known about prognosis after endovascular therapy (EVT) for acute large artery occlusion (LAO) caused by underlying intracranial atherosclerotic stenosis (ICAS). Therefore, we investigated the prognosis following EVT according to the underlying etiology of LAO. METHODS:Patients from the Acute Stroke due to Intracranial Atherosclerotic occlusion and Neurointervention-Korean Retrospective (ASIAN KR) registry (n=720) were included if their occlusion was in the intracranial anterior circulation and their onset-to-puncture time was <24 hours. Occlusion was classified according to etiology as follows: no significant stenosis after recanalization (Embolic group), and fixed significant focal stenosis in the occlusion site with flow impairment or re-occlusion observed during EVT (ICAS group). Patients were excluded when significant extracranial carotid lesions existed, and when the intracranial occlusion was intractable to EVT so that the etiology was undetermined. The effect of angiographic etiologic classification on outcomes was evaluated using multivariable analysis that was adjusted for potential confounders. RESULTS:Among eligible patients (n=520), 421 and 99 were classified in the Embolic and ICAS groups, respectively. Patients in the Embolic and ICAS groups had similar successful reperfusion rates with EVT (79.6% vs. 76.8%, P=0.537) and 3-month functional independence (54.5% vs. 45.5%, P=0.104). In multivariable analysis, ICAS-related occlusion (odds ratio, 0.495; 95% confidence interval, 0.269 to 0.913; P=0.024) showed poorer 3-month functional independence compared to embolic occlusion. CONCLUSION:s After EVT, patients with acute ICAS-related occlusion have relatively poor functional outcomes compared to those with embolic occlusion. Novel strategies need to be developed to improve EVT outcomes for ICAS occlusion.
Campbell Bruce C V,De Silva Deidre A,Macleod Malcolm R,Coutts Shelagh B,Schwamm Lee H,Davis Stephen M,Donnan Geoffrey A
Nature reviews. Disease primers
Stroke is the second highest cause of death globally and a leading cause of disability, with an increasing incidence in developing countries. Ischaemic stroke caused by arterial occlusion is responsible for the majority of strokes. Management focuses on rapid reperfusion with intravenous thrombolysis and endovascular thrombectomy, which both reduce disability but are time-critical. Accordingly, improving the system of care to reduce treatment delays is key to maximizing the benefits of reperfusion therapies. Intravenous thrombolysis reduces disability when administered within 4.5 h of the onset of stroke. Thrombolysis also benefits selected patients with evidence from perfusion imaging of salvageable brain tissue for up to 9 h and in patients who awake with stroke symptoms. Endovascular thrombectomy reduces disability in a broad group of patients with large vessel occlusion when performed within 6 h of stroke onset and in patients selected by perfusion imaging up to 24 h following stroke onset. Secondary prevention of ischaemic stroke shares many common elements with cardiovascular risk management in other fields, including blood pressure control, cholesterol management and antithrombotic medications. Other preventative interventions are tailored to the mechanism of stroke, such as anticoagulation for atrial fibrillation and carotid endarterectomy for severe symptomatic carotid artery stenosis.
Factors associated with early recanalization failure following intravenous rt-PA therapy for ischemic stroke.
Koga Masatoshi,Arihiro Shoji,Miyashita Fumio,Yamamoto Haruko,Yamada Naoaki,Nagatsuka Kazuyuki,Minematsu Kazuo,Toyoda Kazunori
Cerebrovascular diseases (Basel, Switzerland)
BACKGROUND:Although intravenous recombinant tissue-type plasminogen activator (rt-PA) therapy can be effective for ischemic stroke, a considerable percentage of patients do not receive any benefit as a result of early recanalization failure. We aimed to investigate the factors associated with early recanalization failure following intravenous rt-PA therapy. METHODS:Patients with acute ischemic stroke and internal carotid artery (ICA) or middle cerebral artery occlusion on initial magnetic resonance angiography (MRA) who received intravenous rt-PA therapy within 3 h of stroke onset and underwent follow-up MRA within 8 h after treatment were enrolled. Baseline characteristics, stroke features, onset to treatment time, initial National Institutes of Health Stroke Scale (NIHSS) score, initial Alberta Stroke Programme Early CT Score on diffusion-weighted imaging-ASPECTS (Alberta Stroke Program Early Computed Tomography Score), the presence of ICA or M1 origin (the residual length <5 mm) (ICA/M1 origin occlusion), initial vital signs, and laboratory findings were recorded. Early recanalization on the follow-up MRA within 8 h was evaluated by modified Mori grade: grade 0, no reperfusion; grade 1, movement of thrombus; grade 2, partial recanalization, and grade 3, complete recanalization. RESULTS:Seventy subjects (35 women, 77 ± 12 years) were enrolled. The median (interquartile range: IQR) NIHSS score was 18 (12.5-24), and the mean onset to treatment time was 141 ± 54 min. ICA was occluded in 29%, M1 origin in 17%, M1 middle in 13%, M1 distal in 26% and M2 in 15%. The median (IQR) pretreatment diffusion weighted imaging-ASPECTS was 8 (6-9), and follow-up time of MRA was 65 min (59-70) after rt-PA therapy. Thirty-two subjects (46%) showed modified Mori grade 0; 10 (14%), grade 1; 9 (13%), grade 2, and 19 (27%), grade 3. Multivariate analyses revealed ICA/M1 origin occlusion (OR 3.71, 95% CI 1.03-14.87, p = 0.044), and C-reactive protein (per 0.1-mg/dl increment, OR 1.19, 95% CI 1.03-1.44, p = 0.013) were independently associated with subjects with no recanalization (grade 0-1), whereas age (per years old, OR 0.93, 95% CI 0.86-0.99, p = 0.014) and high-density lipoprotein cholesterol (per 1-mg/dl increment, OR 0.94, 95% CI 0.89-0.98, p = 0.004) were inversely associated with those. CONCLUSION:ICA/M1 origin occlusion and C-reactive protein were positively and high-density lipoprotein cholesterol was negatively associated with early recanalization failure.
Impact of Periprocedural and Technical Factors and Patient Characteristics on Revascularization and Outcome in the DAWN Trial.
Tekle Wondwossen G,Hassan Ameer E,Jadhav Ashutosh P,Haussen Diogo C,Budzik Ronald F,Bonafe Alain,Bhuva Parita,Yavagal Dileep R,Hanel Ricardo A,Ribo Marc,Cognard Christophe,Sila Cathy A,Smith Wade S,Saver Jeffrey L,Liebeskind David S,Shields Ryan,Nogueira Raul G,Jovin Tudor G,
Background and Purpose- Because of unique attributes of mechanical thrombectomy performed between 6 and 24 hours after symptom onset in acute ischemic stroke patients, it is not known if predictors of angiographic recanalization and favorable outcome in patients treated with thrombectomy in the late (6-24 hour) time window are similar to those treated in the early time window. Methods- We analyzed data from the DAWN trial (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) which enrolled patients with symptom onset 6 to 24hours after last known well and occlusion of the intracranial internal carotid artery or proximal middle cerebral artery with a mismatch between severity of clinical deficit and infarct core volume as identified by computed tomography-perfusion or diffusion magnetic resonance imaging. We evaluated the effect of tandem occlusions, periprocedural heparin use, procedural speed (from puncture to procedure completion), general anesthesia, balloon-guide catheters, thrombectomy device size, and number of passes on substantial reperfusion (modified Thrombolysis in Cerebral Infarction 2b/3) and on likelihood of obtaining a modified Rankin Scale at 3 months indicating functional independence. Results- Of 107 patients who underwent MT in the interventional arm of DAWN, substantial reperfusion and modified Rankin Scale score 0 to 2 at 3 months was seen in 90 (84%) and 52 (49%), respectively. In univariate analysis, general anesthesia (odds ratio [OR] 0.27; =0.042) and ≥3 passes with stent retriever (OR, 0.17; =0.002) were inversely associated with substantial reperfusion. In multivariate analyses, only ≥3 passes were associated with lack of revascularization (OR, 0.17; =0.002). in univariate analysis ≥3 passes (OR, 0.24; =0.003) and baseline National Institutes of Health Stroke Scale score >17 (OR, 0.19; <0.001) were inversely associated with functional independence at 3 months. In multivariate analyses, ≥3 passes (OR, 0.24; =0.003) and National Institutes of Health Stroke Scale score >17 (OR, 0.19; <0.001) remained inversely associated with favorable outcome at 3 months. Conclusions- Patients requiring ≥3 thrombectomy passes had reduced substantial reperfusion and favorable outcome at 3 months in DAWN. Whether or not additional thrombectomy techniques beyond ≥3 thrombectomy passes with the Trevo stent retriever are beneficial for patient outcomes in this patient population remains to be clarified by future studies. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT02142283.
Predictors of neurological deterioration during hospitalization: results from the Chinese Intracranial Atherosclerosis (CICAS) Study.
Ma Yuetao,Liu Liping,Pu Yuehua,Zou Xinying,Pan Yuesong,Soo Yannie,Zhao Xingquan,Wang Yilong,Wong Kasing,Wang Yongjun
OBJECTIVES:Neurological deterioration (ND) after ischaemic stroke has been indicated as an independent risk factor for poor outcome. Previous studies have focussed on ND within the first few days after symptom onset, but many patients are likely to experience deterioration outside of this time frame. We aimed to investigate the predictors of ND during hospitalisation. METHODS:Data were obtained from the Chinese Intracranial Atherosclerosis (CICAS) Study, and patients who were diagnosed with ischaemic stroke and arrived at the hospital within 72 hours after symptom onset were included in the present study. Neurological deterioration was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score of ≥ 2 points at discharge compared with admission. MR angiography (MRA) and duplex colour Doppler ultrasound were used to document the presence of intracranial or extracranial artery stenosis. Intracranial artery stenosis was defined as a reduction in the artery diameter of ≥ 50% on MRA. Multivariate analyses were conducted to determine the potential predictors of ND during hospitalisation. RESULTS:Of the 1996 patients included in this study, 84 (4.21%) developed ND during hospitalisation. Compared with non-ND patients, ND patients showed higher rates of pneumonia (25.0 vs 9.5%, P < 0.001), urinary infection (7.1 vs 1.2%, P < 0.01), stroke recurrence (14.3 vs 1.9%, P < 0.001), watershed infarct (15.5 vs 5.4%, P = 0.002), intracranial internal carotid artery (ICA) stenosis (11.9 vs 6.0%, P = 0.041), middle cerebral artery (MCA) stenosis (39.3 vs 22.0%, P < 0.001) and basilar artery (BA) stenosis (16.7 vs 7.1%, P = 0.011). Multivariate analysis indicated that watershed infarcts (OR, 2.85; 95% CI, 1.04-7.81), MCA (OR, 2.23; 95% CI, 1.17-4.25) and BA (OR, 2.86; 95% CI, 1.19-6.87) stenosis or occlusion were independent risk factors for ND, as was pneumonia (OR, 3.4; 95% CI, 1.46-7.9). DISCUSSION:Patients with watershed infarcts and MCA or BA stenosis or occlusion should be monitored closely, and various therapeutic strategies should be administered simultaneously to prevent pneumonia during hospitalisation.
Prehospital triage of patients with suspected stroke symptoms (PRESTO): protocol of a prospective observational study.
Venema Esmee,Duvekot Martijne H C,Lingsma Hester F,Rozeman Anouk D,Moudrous Walid,Vermeij Frederique H,Biekart Marileen,van der Lugt Aad,Kerkhoff Henk,Dippel Diederik W J,Roozenbeek Bob,
INTRODUCTION:The efficacy of both intravenous treatment (IVT) and endovascular treatment (EVT) for patients with acute ischaemic stroke strongly declines over time. Only a subset of patients with ischaemic stroke caused by an intracranial large vessel occlusion (LVO) in the anterior circulation can benefit from EVT. Several prehospital stroke scales were developed to identify patients that are likely to have an LVO, which could allow for direct transportation of EVT eligible patients to an endovascular-capable centre without delaying IVT for the other patients. We aim to prospectively validate these prehospital stroke scales simultaneously to assess their accuracy in predicting LVO in the prehospital setting. METHODS AND ANALYSIS:Prehospital triage of patients with suspected stroke symptoms (PRESTO) is a prospective multicentre observational cohort study in the southwest of the Netherlands including adult patients with suspected stroke in the ambulance. The paramedic will assess a combination of items from five prehospital stroke scales, without changing the normal workflow. Primary outcome is the clinical diagnosis of an acute ischaemic stroke with an intracranial LVO in the anterior circulation. Additional hospital data concerning the diagnosis and provided treatment will be collected by chart review. Logistic regression analysis will be performed, and performance of the prehospital stroke scales will be expressed as sensitivity, specificity and area under the receiver operator curve. ETHICS AND DISSEMINATION:The Institutional Review Board of the Erasmus MC University Medical Centre has reviewed the study protocol and confirmed that the Dutch Medical Research Involving Human Subjects Act (WMO) is not applicable. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations. The best performing scale, or the simplest scale in case of clinical equipoise, will be integrated in a decision model with other clinical characteristics and real-life driving times to improve prehospital triage of suspected stroke patients. TRIAL REGISTRATION NUMBER:NTR7595.
Novel pathogenic TGFBR1 and SMAD3 variants identified after cerebrovascular events in adult patients with Loeys-dietz syndrome.
Laterza Domenico,Ritelli Marco,Zini Andrea,Colombi Marina,Dell'Acqua Maria Luisa,Vandelli Laura,Bigliardi Guido,Verganti Luca,Vallone Stefano,Vincenzi Chiara,Rosafio Francesca,Ciolli Ludovico,Calabrese Olga,Nichelli Paolo Frigio,Picchetto Livio
European journal of medical genetics
INTRODUCTION:Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder due to heterozygous pathogenic variants in transforming growth factor beta (TGFβ) signaling-related genes. LDS types 1-6 are distinguished depending on the involved gene. LDS is characterized by multiple arterial aneurysms and dissections in addition to variable neurological and systemic manifestations. Patient 1: a 68-year-old man was admitted due to an aphasic transient ischemic attack (TIA). Brain CT-scan and CT angiography revealed a chronic and asymptomatic right vertebral artery dissection. Stroke diagnostic panel was unremarkable. His history showed mild stroke familiarity. At age of 49, he was treated for dissecting-aneurysm of the ascending aorta and started anticoagulation therapy. Seven years later, he underwent surgery for dissecting aneurysm involving aortic arch, descending-thoracic aorta, left subclavian artery, and both iliac arteries. Patient 2: a 47-year-old man presented a left hemiparesis due to right middle cerebral artery (MCA) and anterior cerebral artery (ACA) occlusion caused by right internal carotid artery (ICA) dissection after sport activity. Despite i.v. thrombolysis and mechanical thrombectomy, he developed malignant cerebral infarction and underwent decompressive hemicraniectomy. Digital subtraction angiography showed bilateral carotid and vertebral kinking, aneurysmatic dilatation on both common iliac arteries and proximal ectasia of the descending aorta. His father and his uncle died because of an ischemic stroke and a cerebral aneurysm rupture with a subarachnoid hemorrhage (SAH), respectively. DISCUSSION:in both cases, considering the family history and the multiple dissections and aneurysms, LDS molecular analysis was performed. In patient 1, the novel NM_005902.3 (SMAD3): c.840T > G; p.(Asn280Lys) likely pathogenic variant was identified, thus leading to a diagnosis of LDS type 3. In patient 2, the novel NM_004612.2 (TGFBR1): c.1225T > G; p.(Trp409Gly) likely pathogenic variant was found, allowing for a diagnosis of LDS type 1. CONCLUSION:LDS is characterized by genetic and clinical variability. Our report suggests that this genetically-determined connective tissue disorder is probably underestimated, as it might firstly show up with cerebrovascular events, although mild systemic manifestations. These findings could lead to identify people at risk of severe vascular complications (i.e., through genetic consult on asymptomatic relatives), in order to perform adequate vascular assessments and follow-up to prevent complications such as stroke.
Subacute vessel wall imaging at 7-T MRI in post-thrombectomy stroke patients.
Truong My,Markenroth Bloch Karin,Andersen Mads,Andsberg Gunnar,Töger Johannes,Wassélius Johan
PURPOSE:Reports from 3-T vessel wall MRI imaging have shown contrast enhancement following thrombectomy for acute stroke, suggesting potential intimal damage. Comparisons have shown higher SNR and more lesions detected by vessel wall imaging when using 7 T compared with 3 T. The aim of this study was to investigate the vessel walls after stent retriever thrombectomy using high-resolution vessel wall imaging at 7 T. METHODS:Seven patients with acute stroke caused by occlusion of the distal internal carotid artery (T-occlusion), or proximal medial cerebral artery, and treated by stent retriever thrombectomy with complete recanalization were included and examined by 7-T MRI within 2 days. The MRI protocol included a high-resolution black blood sequence with prospective motion correction (iMOCO), acquired before and after contrast injection. Flow measurements were performed in the treated and untreated M1 segments. RESULTS:All subjects completed the MRI examination. Image quality was independently rated as excellent by two neuroradiologists for all cases, and the level of motion artifacts did not impair diagnostic quality, despite severe motion in some cases. Contrast enhancement correlated with the deployment location of the stent retrievers. Flow data showed complete restoration of flow after treatment. CONCLUSION:Vessel wall imaging with prospective motion correction can be performed in patients following thrombectomy with excellent imaging quality at 7 T. We show that vessel wall contrast enhancement is the normal post-operative state and corresponds to the deployment location of the stent retriever.
CLOTBUST-Hands Free: pilot safety study of a novel operator-independent ultrasound device in patients with acute ischemic stroke.
Barreto Andrew D,Alexandrov Andrei V,Shen Loren,Sisson April,Bursaw Andrew W,Sahota Preeti,Peng Hui,Ardjomand-Hessabi Manouchehr,Pandurengan Renganayaki,Rahbar Mohammad H,Barlinn Kristian,Indupuru Hari,Gonzales Nicole R,Savitz Sean I,Grotta James C
BACKGROUND AND PURPOSE:The Combined Lysis of Thrombus in Brain Ischemia With Transcranial Ultrasound and Systemic T-PA-Hands-Free (CLOTBUST-HF) study is a first-in-human, National Institutes of Health-sponsored, multicenter, open-label, pilot safety trial of tissue-type plasminogen activator (tPA) plus a novel operator-independent ultrasound device in patients with ischemic stroke caused by proximal intracranial occlusion. METHODS:All patients received standard-dose intravenous tPA, and shortly after tPA bolus, the CLOTBUST-HF device delivered 2-hour therapeutic exposure to 2-MHz pulsed-wave ultrasound. Primary outcome was occurrence of symptomatic intracerebral hemorrhage. All patients underwent pretreatment and post-treatment transcranial Doppler ultrasound or CT angiography. National Institutes of Health Stroke Scale scores were collected at 2 hours and modified Rankin scale at 90 days. RESULTS:Summary characteristics of all 20 enrolled patients were 60% men, mean age of 63 (SD=14) years, and median National Institutes of Health Stroke Scale of 15. Sites of pretreatment occlusion were as follows: 14 of 20 (70%) middle cerebral artery, 3 of 20 (15%) terminal internal carotid artery, and 3 of 20 (15%) vertebral artery. The median (interquartile range) time to tPA at the beginning of sonothrombolysis was 22 (13.5-29.0) minutes. All patients tolerated the entire 2 hours of insonation, and none developed symptomatic intracerebral hemorrhage. No serious adverse events were related to the study device. Rates of 2-hour recanalization were as follows: 8 of 20 (40%; 95% confidence interval, 19%-64%) complete and 2 of 20 (10%; 95% confidence interval, 1%-32%) partial. Middle cerebral artery occlusions demonstrated the greatest complete recanalization rate: 8 of 14 (57%; 95% confidence interval, 29%-82%). At 90 days, 5 of 20 (25%, 95% confidence interval, 7%-49) patients had a modified Rankin scale of 0 to 1. CONCLUSIONS:Sonothrombolysis using a novel, operator-independent device, in combination with systemic tPA, seems safe, and recanalization rates warrant evaluation in a phase III efficacy trial. CLINICAL TRIAL REGISTRATION URL:http://www.clinicaltrials.gov. Unique identifier: CLOTBUST-HF NCT01240356.
Prevalence and outcomes of symptomatic intracranial large artery stenoses and occlusions in China: the Chinese Intracranial Atherosclerosis (CICAS) Study.
Wang Yongjun,Zhao Xingquan,Liu Liping,Soo Yannie O Y,Pu Yuehua,Pan Yuesong,Wang Yilong,Zou Xinying,Leung Thomas W H,Cai Yefeng,Bai Qingke,Wu Yiping,Wang Chunxue,Pan Xiaoping,Luo Benyan,Wong Ka Sing Lawrence,
BACKGROUND AND PURPOSE:We aimed to establish the prevalence, characteristics, and outcomes of intracranial atherosclerosis (ICAS) in China by a large, prospective, multicenter study. METHODS:We evaluated 2864 consecutive patients who experienced an acute cerebral ischemia<7 days after symptom onset in 22 Chinese hospitals. All patients underwent magnetic resonance angiography, with measurement of diameter of the main intracranial arteries. ICAS was defined as ≥50% diameter reduction on magnetic resonance angiography. RESULTS:The prevalence of ICAS was 46.6% (1335 patients, including 261 patients with coexisting extracranial carotid stenosis). Patients with ICAS had more severe stroke at admission and stayed longer in hospitals compared with those without intracranial stenosis (median National Institutes of Health Stroke Scale score, 3 versus 5; median length of stay, 14 versus 16 days; both P<0.0001). After 12 months, recurrent stroke occurred in 3.27% of patients with no stenosis, in 3.82% for those with 50% to 69% stenosis, in 5.16% for those with 70% to 99% stenosis, and in 7.27% for those with total occlusion. Cox proportional hazards regression analyses showed that the degree of arterial stenosis, age, family history of stroke, history of cerebral ischemia or heart disease, complete circle of Willis, and National Institutes of Health Stroke Scale score at admission were independent predictors for recurrent stroke at 1 year. The highest rate of recurrence was observed in patients with occlusion with the presence of ≥3 additional risk factors. CONCLUSIONS:ICAS is the most common vascular lesion in patients with cerebrovascular disease in China. Recurrent stroke rate in our study was lower compared with those of previous clinical trials but remains unacceptably high in a subgroup of patients with severe stenosis.
A comparative study of risk factors and the occurrence rate of coronary atherosclerosis in extra- and intracranial atherosclerotic lesions.
Miyawaki Satoru,Maeda Keiichiro
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
BACKGROUND:The risk factors and epidemiology of extracranial and intracranial atherosclerotic lesions may be different. We evaluated the importance of perioperative management of coronary atherosclerotic lesions in carotid endarterectomy (CEA) or carotid artery stenting (CAS) for extracranial cervical carotid artery stenosis and superior temporal artery (STA)-middle cerebral artery (MCA) bypass for intracranial severe MCA stenosis/occlusion. METHODS:The medical records of patients who underwent cerebrovascular surgery at Aizu Chuo Hospital between January 2000 and September 2010 were retrospectively analyzed. Preoperative cardiovascular screening was performed for all patients to prevent perioperative ischemic heart disease-related complications. The number of patients requiring preoperative treatment of the coronary artery was compared. RESULTS:A total of 320 patients underwent surgery for cervical carotid stenosis (IC group; 259 patients with CEA and 61 patients with CAS), and 92 patients underwent STA-MCA bypass for MCA stenosis/occlusion (MC group). Treatment for coronary lesions was required in 35 of 320 patients (10.9%) in the IC group and 14 of 92 patients (15.2%) in the MC group. Surgery was safely performed in both groups without any ischemic heart disease-related complications during the perioperative period. CONCLUSIONS:This study shows the importance of perioperative management of coronary atherosclerotic lesions for STA-MCA bypass, similar to that for CEA/CAS.
Outcome and Treatment Effects in Stroke Associated with Acute Cervical ICA Occlusion.
Gliem Michael,Lee John-Ih,Barckhan Aurica,Turowski Bernd,Hartung Hans-Peter,Jander Sebastian
BACKGROUND:Endovascular therapy (EVT) with stent retrievers in addition to i.v. thrombolysis (IVT) has proven effective in acute stroke patients with middle cerebral artery (MCA, M1 segment) and distal internal carotid artery (ICA) occlusion. Limited data exist concerning acute cervical ICA occlusion, either alone or in combination with intracranial ICA occlusion (tandem occlusion). Therefore we analyzed outcome and treatment effects in stroke associated with cervical ICA occlusion, with specific focus on the impact of intracranial ICA or M1 patency. METHODS:Seventy-eight patients with cervical ICA occlusion from our local stroke unit registry were analyzed retrospectively. Thrombolysis in Cerebral Infarction (TICI) classification, infarct size, modified Rankin scale (mRS), symptomatic intracerebral hemorrhage (ICH), and death were assessed as outcome parameters. RESULTS:Forty-three patients had isolated cervical ICA occlusion whereas 35 patients presented with extra-/intracranial tandem occlusion. Patients underwent IVT alone (n = 23), combined IVT/EVT (n = 28) or no treatment (n = 27). Treated and untreated patients with tandem occlusion had a worse outcome after 90 days compared to isolated cervical occlusion (OR for moderate outcome 0.29, 0.27-0.88, p = 0.01). Additional EVT improved outcome in patients with tandem occlusion (OR for moderate outcome: 15.43, 1.60-148.90, p = 0.008) but not isolated cervical occlusion (OR 1.33, 0.38-11.60, NS). CONCLUSIONS:In contrast to tandem occlusion, stroke outcome in patients with isolated cervical ICA occlusion was generally more benign and not improved by combined IVT/EVT compared to IVT alone. Intracranial vessel patency may be critical for treatment decision in acute cervical ICA occlusion.
Effect of Endovascular Therapy on Subsequent Decompressive Hemicraniectomy in Cardioembolic Ischemic Stroke with Proximal Intracranial Occlusion in the Anterior Circulation: Sub-Analysis of the RESCUE-Japan Registry 2.
Matsukawa Hidetoshi,Kiura Yoshihiro,Sakai Nobuyuki,Yamagami Hiroshi,Uchida Kazutaka,Morimoto Takeshi,Kageyama Hiroto,Yoshimura Shinichi,
Cerebrovascular diseases (Basel, Switzerland)
BACKGROUND:Cardioembolic stroke is associated with a higher rate of functional limitation, which may be related to the larger ischemic lesion size. Endovascular therapy (EVT) for acute stroke caused by large vessel occlusion reduces severe disabilities. OBJECTIVES:We aimed to investigate the relationship between EVT and decompressive hemicraniectomy (DH) in patients with cardioembolic proximal intracranial occlusion in the anterior circulation (CPIOAC) using the data from the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism (RESCUE)-Japan Registry 2. METHODS:Among 2,420 patients in the RESCUE-Japan Registry 2, 555 patients aged 20-80 years with acute cardioembolic occlusion of the internal carotid artery and/or the first segment of the middle cerebral artery were included. The primary outcome was DH. Secondary outcomes were any type of intracranial hemorrhage, symptomatic intracranial hemorrhage indicating neurological worsening of >4 points on the National Institutes of Health Stroke Scale within 72 h after the onset of stroke, and recurrence of stroke or transient ischemic attack (TIA) within 90 days. RESULTS:The median age was 73 years (66-77 years), and 360 patients (65%) were male. DH was performed in 1 of 374 patients in the EVT group and 5 of 181 patients in the no-EVT group (p = 0.032). The incidence of any type of intracranial hemorrhage and symptomatic intracranial hemorrhage within 72 h and recurrence of stroke or TIA within 90 days were similar between both groups. CONCLUSIONS:EVT may reduce DH in patients with CPIOAC without increasing intracranial hemorrhage.
The Use of Tissue Plasminogen Activator in the Treatment of Wallenberg Syndrome Caused by Vertebral Artery Dissection.
Salerno Alexis,Cotter Bradford V,Winters Michael E
The Journal of emergency medicine
BACKGROUND:Acute cerebrovascular accident (CVA) is a devastating cause of patient morbidity and mortality. Up to 10% of acute CVAs in young patients are caused by dissection of the vertebral or carotid artery. Wallenberg syndrome results from a CVA in the vertebral or posterior inferior artery of the cerebellum and manifests as various degrees of cerebellar dysfunction. The administration of a thrombolytic medication has been recommended in the treatment of patients with stroke caused by cervical artery dissection. Surprisingly, there is scant literature on the use of this medication in the treatment of this condition. CASE REPORT:We describe a 42-year-old man with the sudden onset of headache, left-sided neck pain, vomiting, nystagmus, and ataxia 1 h after completing a weightlifting routine. Computed tomography angiography revealed a grade IV left vertebral artery injury with a dissection flap extending distally and resulting in complete occlusion. Subsequent magnetic resonance imaging and angiography demonstrated acute left cerebellar and lateral medullary infarcts, consistent with Wallenberg syndrome. The patient was treated with tissue plasminogen activator, which failed to resolve his symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians frequently manage patients with acute CVAs. For select patients, the administration of tissue plasminogen activator can improve outcomes. However, the risk of major hemorrhage with this medication is significant. Cervical artery dissection is an important cause of acute stroke in young patients and is often missed on initial presentation. It is imperative for the emergency physician to consider acute cervical artery dissection as a cause of stroke and to be knowledgeable regarding the efficacy of thrombolytic medications for this condition.
Intravenous Thrombolysis and Passes of Thrombectomy as Predictors for Endovascular Revascularization in Ischemic Stroke.
Angermaier Anselm,Michel Patrik,Khaw Alexander V,Kirsch Michael,Kessler Christof,Langner Soenke
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
BACKGROUND:Patient selection for endovascular revascularization treatment (ERT) in acute ischemic stroke depends on the expected benefit-risk ratio. As rapid revascularization is a major determinant of good functional outcome, we aimed to identify its predictors after ERT. METHODS:Consecutive stroke patients from a single stroke center with distal internal carotid artery-, proximal middle cerebral artery- or T-occlusions treated with ERT were retrospectively selected. We assessed admission noncontrast computed tomography and computed tomography angiography for thrombus location, thrombus load (clot burden score), and collateral status. Clinical data were extracted from medical charts. Univariate and multivariate regression analyses were performed to identify predictors of revascularization (thrombolysis in cerebral infarction ≥2b) after ERT. RESULTS:A total of 63 patients were identified (median age, 73 years; interquartile range: 62-77; 40 females). Sixteen patients (25.4%) underwent intravenous thrombolysis (ivT) before ERT. Twenty-two patients (34.9%) had additional intra-arterial application of recombinant tissue plasminogen activator. The overall recanalization rate was 66.7%, and 9.5% had symptomatic intracranial bleeding. In-hospital mortality was 15%, and 30% reached good functional outcome at discharge. In the univariate analysis, preceding ivT and the number of passes for thrombectomy (dichotomized ≤2 versus >2) were associated with recanalization. There was a trend for number of thrombectomy passes (as continuous variable) and multimodal ERT. In the multivariate regression analysis, ivT prior to ERT and passes of thrombectomy were identified as independent predictors for recanalization. CONCLUSION:ivT and lower passes of thrombectomy are associated with recanalization after ERT for ischemic stroke with proximal vessel occlusions.
Acute Ischemic Stroke with Vessel Occlusion-Prevalence and Thrombectomy Eligibility at a Comprehensive Stroke Center.
Desai Shashvat M,Starr Matthew,Molyneaux Bradley J,Rocha Marcelo,Jovin Tudor G,Jadhav Ashutosh P
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
INTRODUCTION:Endovascular thrombectomy (ET) for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) can prevent severe disability and mortality. There is currently limited data on the epidemiology of LVO strokes and ET eligibility. We aim to determine the incidence of intracranial vessel occlusion (IVO) strokes eligible for ET per 2018 American Heart Association (AHA) guidelines and characteristics of an AHA ineligible population at a comprehensive stroke center (CSC). METHODS:Retrospective chart review of all consecutive AISs at a CSC between November 2014 and February 2017. Demographic, clinical, and radiographic data were analyzed to determine ET eligibility per AHA guidelines and characteristics of ineligible patients were investigated. RESULTS:Twenty-four percent of AIS harbor an IVO. Thirty percent of IVO strokes and 47% of anterior circulation LVO strokes are thrombectomy eligible per AHA guidelines. Most common reasons for thrombectomy ineligibility among IVO strokes are presence of IVO other than anterior circulation LVO (35%, n = 224), presence of large stroke burden (15%, n = 93), baseline modified Rankin scale greater than or equal to 2 (14%, n = 89), and NIHSS score less than 6 (15%, n = 96). CONCLUSIONS:At a CSC, 1 in 4 AISs harbor an IVO. Seven in 100 acute ischemic strokes, 3 in 10 strokes with vessel occlusion, and 1 in 2 strokes with internal carotid or middle cerebral artery M1 occlusion are thrombectomy eligible per AHA 2018 guidelines. These data highlight that current guidelines render a majority of strokes thrombectomy ineligible and a large window of opportunity exists for clinical investigation.
Remote pre-procedural ischemic stroke as the greatest risk in carotid‑stenting‑associated stroke and death: a single center's experience.
Rašiová Mária,Špak Ľubomír,Farkašová Ľudmila,Pataky Štefan,Koščo Martin,Hudák Marek,Moščovič Matej,Leško Norbert
International angiology : a journal of the International Union of Angiology
BACKGROUND:The goal of carotid artery stenting (CAS) is to decrease the stroke risk in patients with carotid stenosis. This procedure carries an immediate risk of stroke and death and many patients do not benefit from it, especially asymptomatic patients. It is crucial to accurately select the patients who would benefit from carotid procedure, and to rule out those for whom the procedure might be hazardous. Remote ischemic stroke is a known risk factor for stroke recurrence during surgery. The aim of our study was to determine the periprocedural complication risk (within 30 days after CAS) associated with carotid stenting (stroke, death) in patients with and without remote pre-procedural ischemic stroke, to analyze periprocedural risk in other specific patient subgroups treated with CAS, and to determine the impact of observed variables on all-cause mortality during long-term follow-up. METHODS:We conducted a retrospective review of prospectively collected data from all patients treated with protected CAS between June 20, 2008 and December 31, 2015. Patient age, gender, type of carotid stenosis (symptomatic versus asymptomatic), side of stenosis (right or left carotid artery), type of cerebral protection (proximal versus distal), presence of comorbidities (remote ischemic pre-procedural ischemic stroke, coronary artery disease, diabetes mellitus, peripheral artery disease), previous ipsilateral carotid endarterectomy (CEA), contralateral carotid occlusion (CCO) and previous contralateral CAS/CEA were analyzed to identify higher CAS risk and to determine the impact of these variables on all-cause mortality during follow-up. Survival data were obtained from the Health Care Surveillance Authority registry. Mean follow-up was 1054 days (interquartile range 547.3; 1454.8). Remote pre-procedural ischemic stroke was defined as any-territory ischemic stroke >6 months prior to CAS. RESULTS:Primary periprocedural endpoint incidence (stroke/death) in 502 patients was 3.8% (N.=19) of all patients, 5.4% (N.=10) of symptomatic patients and 2.8% (N.=9) of asymptomatic patients. The risk of periprocedural stroke/death was 3.4 times higher in patients with (N.=198) compared to patients without remote ischemic stroke (N.=304) (6.6% versus 2.0% of patients without remote ischemic stroke; P=0.008). Periprocedural stroke/death in symptomatic patients (N.=186) was non-significantly higher in patients with remote ischemic stroke (N.=76) compared with patients without remote ischemic stroke (N.=110) (7.9% versus 3.6%; P=0.206). Asymptomatic patients with remote ischemic stroke (N.=122) had a 5.6-time-higher periprocedural risk of stroke/death compared with asymptomatic patients without remote ischemic stroke (N.=194) (5.7% versus 1.0%; P=0.014). Patients ≥75 years (N.=83) had a 3.0-time-higher periprocedural risk of stroke/death compared with younger patients (N.=419) (8.4% versus 2.9%; P=0.015); a non-significant increase of periprocedural stroke/death was found in both symptomatic (N.=35) and asymptomatic (N.=48) elderly patients (11.4% versus 4.0%, P=0.078; and 6.3% versus 2.4%, P=0.124, respectively). Increased periprocedural risk of stroke/death was not documented in other analyzed patient subgroups. During long-term follow-up, a 1.5-time-higher mortality risk was found in patients with remote ischemic stroke compared with patients without remote ischemic stroke in multivariable analysis; other patient subgroups (except older versus younger patients) did not differ in long-term mortality following carotid stenting. CONCLUSIONS:In our experience, all patients with remote pre-procedural any-territory ischemic stroke belong to risky subgroup for periprocedural stroke death after CAS. All asymptomatic patients with remote ischemic stroke should not be treated with CAS. Remote ischemic stroke increases all-cause mortality in long-term follow-up after carotid stenting. Patients aged ≥75 years also have increased risk of periprocedural stroke and death after CAS. These factors should help us to be more selective when planning carotid procedures.
Opening the window: Ischemic postconditioning reduces the hyperemic response of delayed tissue plasminogen activator and extends its therapeutic time window in an embolic stroke model.
Esmaeeli-Nadimi Ali,Kennedy Derek,Allahtavakoli Mohammad
European journal of pharmacology
It has been reported that ischemic postconditioning (PC) changes the reperfusion pattern in permanent or transient models of stroke and confers neuroprotection. However, the effects of PC and subsequent use of tissue plasminogen activator (tPA) for the treatment of embolic stroke have not yet been investigated. Rats were subjected to stroke by injection of a preformed clot into the middle cerebral artery and randomly assigned to vehicle (saline 0.1 ml/100 g), tPA (3 mg/kg), PC only or PC+tPA (3 mg/kg). tPA was injected at 6 h after embolic stroke and PC was conducted at 6.5 h after ischemia by using five cycles of a 10 s occlusion and 30 s of reopening of the bilateral common carotid arteries. Cerebral blood flow (CBF) was monitored for 60 min from the time of tPA injection. Infarct size, blood brain barrier disruption, edema, neurological deficits, reactive oxygen species and apoptosis were measured 2 days later. PC decreased infarct volume, but PC+tPA was more neuroprotective than PC alone. While tPA alone dramatically increased CBF, conducting PC caused a gradual increase in CBF. A combination of PC+tPA reduced BBB leakage, brain edema, apoptosis and reactive oxygen species levels. Furthermore, a combination of PC+tPA improved neurological functions at 48 h after the induced stroke. In conclusion, PC hampered malignant hyperemia after reperfusion with tPA and extended its therapeutic window up to 6 h. Compared to PC alone, combination of thrombolysis and PC showed a better neuroprotection.
Arterial occlusions increase the risk of in-stent restenosis after vertebral artery ostium stenting.
Li Jingzhi,Hua Yang,Needleman Laurence,Forsberg Flemming,Eisenbray John R,Li Zhaojun,Liu Ran,Tian Xiaojie,Jiao Liqun,Liu Ji-Bin
Journal of neurointerventional surgery
OBJECTIVE:The study was designed to investigate if vascular occlusion in the internal carotid artery (ICA) or the contralateral vertebral artery (VA) contribute to developing in-stent restenosis (ISR) in patients with vertebral artery ostium stenosis (VAOS). METHODS:420 consecutive patients treated with VAOS stents (from a population of 8145 patients with VAOS) from January 2013 to December 2014 were analyzed in this retrospective study; 216 with drug eluted stents and 204 with bare metal stents. Based on pre-stent DSA findings, patients were divided into four groups: both carotid and vertebral arteries patent (PAT), ICA occlusion (ICA-OCC), contralateral VA occlusion (CVA-OCC), and combined occlusions (C-OCC). The incidence of ISR (stenosis >50%) was compared between groups using Cox regression analysis. RESULTS:Of the 420 patients, the mean incidence of ISR was 36.4%, with a median 12 months of follow-up (IQR 3-12). Logistic regression analysis showed that drug eluting stent had less ISR than bare metal stent (OR=0.38, 95% CI 0.19 to 0.75, P=0.01). Cox regression analysis showed that CVA-OCC (HR=1.63, P=0.02) and C-OCC (HR=3.30, P=0.001) were risk factors for ISR but not ICA-OCC (P=0.31). In the CVA-OCC and C-OCC groups, in-stent peak systolic velocity (PSV) ≥140 cm/s, 1 day after successful stenting, was associated with subsequent development of ISR (OR=2.81, 95% CI 1.06 to 7.43, P=0.04). CONCLUSION:Contralateral VA occlusion at the time of stenting increased the risk of ISR, especially if stent PSV on day 1 was >140 cm/s. Bare metal stents had more ISR than drug eluting stents.
Accuracy of CT Angiography for Differentiating Pseudo-Occlusion from True Occlusion or High-Grade Stenosis of the Extracranial ICA in Acute Ischemic Stroke: A Retrospective MR CLEAN Substudy.
Kappelhof M,Marquering H A,Berkhemer O A,Borst J,van der Lugt A,van Zwam W H,Vos J A,Lycklama À Nijeholt G,Majoie C B L M,Emmer B J,
AJNR. American journal of neuroradiology
BACKGROUND AND PURPOSE:The absence of opacification on CTA in the extracranial ICA in acute ischemic stroke may be caused by atherosclerotic occlusion, dissection, or pseudo-occlusion. The latter is explained by sluggish or stagnant flow in a patent artery caused by a distal intracranial occlusion. This study aimed to explore the accuracy of CTA for differentiating pseudo-occlusion from true occlusion of the extracranial ICA. MATERIALS AND METHODS:All patients from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) with an apparent ICA occlusion on CTA and available DSA images were included. Two independent observers classified CTA images as atherosclerotic cause (occlusion/high-grade stenosis), dissection, or suspected pseudo-occlusion. Pseudo-occlusion was suspected if CTA showed a gradual contrast decline located above the level of the carotid bulb, especially in the presence of an occluded intracranial ICA bifurcation (T-occlusion). DSA images, classified into the same 3 categories, were used as the criterion standard. RESULTS:In 108 of 476 patients (23%), CTA showed an apparent extracranial carotid occlusion. DSA was available in 46 of these, showing an atherosclerotic cause in 13 (28%), dissection in 16 (35%), and pseudo-occlusion in 17 (37%). The sensitivity for detecting pseudo-occlusion on CTA was 82% (95% CI, 57-96) for both observers; specificity was 76% (95% CI, 56-90) and 86% (95% CI, 68-96) for observers 1 and 2, respectively. The κ value for interobserver agreement was .77, indicating substantial agreement. T-occlusions were more frequent in pseudo- than true occlusions (82% versus 21%, < .001). CONCLUSIONS:On CTA, extracranial ICA pseudo-occlusions can be differentiated from true carotid occlusions.
Revision Superficial Temporal Artery-Middle Cerebral Artery Bypass Surgery for Recurrent Acute Ischemic Stroke Due to Delayed Occlusion of the Bypass Graft.
Choi Yun-Hee,Park Hyun-Seok,Kang Myong-Jin,Cha Jae-Kwan
Journal of cerebrovascular and endovascular neurosurgery
Intravenous thrombolysis (IVT) and endovascular treatment (EVT) are currently the main treatments for reperfusion in acute ischemic stroke. Although the EVT recanalization rate has increased, unsuccessful recanalization is still observed in 10-30% cases. Superficial temporal artery-middle cerebral artery (STA-MCA) bypass is considered a rescue therapy in such cases, but in most centers it is not usually performed for acute ischemic stroke. Graft occlusion is rare following STA-MCA bypass, but it might lead to recurrent ischemic stroke. We hereby report on a patient with right MCA infarction and in whom EVT failed due to complete proximal internal carotid artery occlusion. He underwent an emergency STA-MCA bypass, resulting in a full recovery of his motor weakness. However, six months later, the patient experienced recurrent acute ischemic stroke due to bypass graft occlusion. His EVT failed again but revision bypass surgery, using STA remnant branch, was successful with full motor weakness recovery. We recommend a revision bypass surgery as a feasible therapeutic option for recurrent cerebral infarction caused by delayed STA graft occlusion.
Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.
Goyal Mayank,Menon Bijoy K,van Zwam Wim H,Dippel Diederik W J,Mitchell Peter J,Demchuk Andrew M,Dávalos Antoni,Majoie Charles B L M,van der Lugt Aad,de Miquel Maria A,Donnan Geoffrey A,Roos Yvo B W E M,Bonafe Alain,Jahan Reza,Diener Hans-Christoph,van den Berg Lucie A,Levy Elad I,Berkhemer Olvert A,Pereira Vitor M,Rempel Jeremy,Millán Mònica,Davis Stephen M,Roy Daniel,Thornton John,Román Luis San,Ribó Marc,Beumer Debbie,Stouch Bruce,Brown Scott,Campbell Bruce C V,van Oostenbrugge Robert J,Saver Jeffrey L,Hill Michael D,Jovin Tudor G,
Lancet (London, England)
BACKGROUND:In 2015, five randomised trials showed efficacy of endovascular thrombectomy over standard medical care in patients with acute ischaemic stroke caused by occlusion of arteries of the proximal anterior circulation. In this meta-analysis we, the trial investigators, aimed to pool individual patient data from these trials to address remaining questions about whether the therapy is efficacious across the diverse populations included. METHODS:We formed the HERMES collaboration to pool patient-level data from five trials (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND IA) done between December, 2010, and December, 2014. In these trials, patients with acute ischaemic stroke caused by occlusion of the proximal anterior artery circulation were randomly assigned to receive either endovascular thrombectomy within 12 h of symptom onset or standard care (control), with a primary outcome of reduced disability on the modified Rankin Scale (mRS) at 90 days. By direct access to the study databases, we extracted individual patient data that we used to assess the primary outcome of reduced disability on mRS at 90 days in the pooled population and examine heterogeneity of this treatment effect across prespecified subgroups. To account for between-trial variance we used mixed-effects modelling with random effects for parameters of interest. We then used mixed-effects ordinal logistic regression models to calculate common odds ratios (cOR) for the primary outcome in the whole population (shift analysis) and in subgroups after adjustment for age, sex, baseline stroke severity (National Institutes of Health Stroke Scale score), site of occlusion (internal carotid artery vs M1 segment of middle cerebral artery vs M2 segment of middle cerebral artery), intravenous alteplase (yes vs no), baseline Alberta Stroke Program Early CT score, and time from stroke onset to randomisation. FINDINGS:We analysed individual data for 1287 patients (634 assigned to endovascular thrombectomy, 653 assigned to control). Endovascular thrombectomy led to significantly reduced disability at 90 days compared with control (adjusted cOR 2.49, 95% CI 1.76-3.53; p<0.0001). The number needed to treat with endovascular thrombectomy to reduce disability by at least one level on mRS for one patient was 2.6. Subgroup analysis of the primary endpoint showed no heterogeneity of treatment effect across prespecified subgroups for reduced disability (pinteraction=0.43). Effect sizes favouring endovascular thrombectomy over control were present in several strata of special interest, including in patients aged 80 years or older (cOR 3.68, 95% CI 1.95-6.92), those randomised more than 300 min after symptom onset (1.76, 1.05-2.97), and those not eligible for intravenous alteplase (2.43, 1.30-4.55). Mortality at 90 days and risk of parenchymal haematoma and symptomatic intracranial haemorrhage did not differ between populations. INTERPRETATION:Endovascular thrombectomy is of benefit to most patients with acute ischaemic stroke caused by occlusion of the proximal anterior circulation, irrespective of patient characteristics or geographical location. These findings will have global implications on structuring systems of care to provide timely treatment to patients with acute ischaemic stroke due to large vessel occlusion. FUNDING:Medtronic.
Factors associated with recurrent stroke and recanalization in patients presenting with isolated symptomatic carotid occlusion.
Damania D,Kung N T-M,Jain M,Jain A R,Liew J A,Mangla R,Koch G E,Sahin B,Miranpuri A S,Holmquist T M,Replogle R E,Benesch C G,Kelly A G,Jahromi B S
European journal of neurology
BACKGROUND AND PURPOSE:Patients with symptomatic internal carotid artery (ICA) occlusion constitute a small proportion of stroke/transient ischaemic attack patients who are at increased risk of early stroke recurrence and poor outcome. The optimal medical treatment for patients with symptomatic ICA occlusion who are ineligible for thrombolysis or thrombectomy is unknown. METHODS:Consecutive patients presenting at a single center with newly diagnosed symptomatic ICA occlusion (not involving the circle of Willis) were retrospectively reviewed. Those treated with intravenous thrombolysis or intra-arterial thrombolysis/thrombectomy were excluded. Patients were divided into two groups based on whether they experienced recurrent in-hospital stroke. RESULTS:The selected study population (n = 33) represented a small (20.4%) proportion of all newly symptomatic carotid occlusions, who nevertheless had an elevated risk of recurrent stroke during admission (24.2%). Of the variables examined (age, gender, admission National Institutes of Health Stroke Scale score, vascular risk factors, atrial fibrillation, prior stroke/transient ischaemic attack and anticoagulation within 48 h of presentation), only anticoagulation was significantly associated with a lower risk of in-hospital recurrent stroke. Anticoagulated patients showed a decreased incidence of stroke recurrence within the first week (6.7% vs. 38.9%, P = 0.032) and fewer strokes or deaths at 1 month (13.3% vs. 47.1%, P = 0.040). Hemorrhagic transformation was not observed in any patient. On follow-up imaging, ICA recanalization was significantly more frequent in anticoagulated patients (46.2% vs. 9.1%, P = 0.047). CONCLUSION:Patients with newly diagnosed symptomatic ICA occlusion (not involving the circle of Willis) represent a small but high risk subgroup of patients with carotid occlusion. Early anticoagulation was associated with fewer recurrent strokes and increased ICA recanalization. Larger scale prospective studies may be justified.
The impact of Centers for Medicare and Medicaid Services high-risk criteria on outcome after carotid endarterectomy and carotid artery stenting in the SVS Vascular Registry.
Schermerhorn Marc L,Fokkema Margriet,Goodney Philip,Dillavou Ellen D,Jim Jeffrey,Kenwood Christopher T,Siami Flora S,White Rodney A,
Journal of vascular surgery
OBJECTIVE:The Centers for Medicare and Medicaid Services (CMS) require high-risk (HR) criteria for carotid artery stenting (CAS) reimbursement. The impact of these criteria on outcomes after carotid endarterectomy (CEA) and CAS remains uncertain. Additionally, if these HR criteria are associated with more adverse events after CAS, then existing comparative effectiveness analysis of CEA vs CAS may be biased. We sought to elucidate this using data from the SVS Vascular Registry. METHODS:We analyzed 10,107 patients undergoing CEA (6370) and CAS (3737), stratified by CMS HR criteria. The primary endpoint was composite death, stroke, and myocardial infarction (MI) (major adverse cardiovascular event [MACE]) at 30 days. We compared baseline characteristics and outcomes using univariate and multivariable analyses. RESULTS:CAS patients were more likely to have preoperative stroke (26% vs 21%) or transient ischemic attack (23% vs 19%) than CEA. Although age ≥ 80 years was similar, CAS patients were more likely to have all other HR criteria. For CEA, HR patients had higher MACEs than normal risk in both symptomatic (7.3% vs 4.6%; P < .01) and asymptomatic patients (5% vs 2.2%; P < .0001). For CAS, HR status was not associated with a significant increase in MACE for symptomatic (9.1% vs 6.2%; P = .24) or asymptomatic patients (5.4% vs 4.2%; P = .61). All CAS patients had MACE rates similar to HR CEA. After multivariable risk adjustment, CAS had higher rates than CEA for MACE (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.0-1.5), death (OR, 1.5; 95% CI, 1.0-2.2), and stroke (OR, 1.3; 95% CI,1.0-1.7), whereas there was no difference in MI (OR, 0.8; 95% CI, 0.6-1.3). Among CEA patients, age ≥ 80 (OR, 1.4; 95% CI, 1.02-1.8), congestive heart failure (OR, 1.7; 95% CI, 1.03-2.8), EF <30% (OR, 3.5; 95% CI, 1.6-7.7), angina (OR, 3.9; 95% CI, 1.6-9.9), contralateral occlusion (OR, 3.2; 95% CI, 2.1-4.7), and high anatomic lesion (OR, 2.7; 95% CI, 1.33-5.6) predicted MACE. Among CAS patients, recent MI (OR, 3.2; 95% CI, 1.5-7.0) was predictive, and radiation (OR, 0.6; 95% CI, 0.4-0.8) and restenosis (OR, 0.5; 95% CI, 0.3-0.96) were protective for MACE. CONCLUSIONS:Although CMS HR criteria can successfully discriminate a group of patients at HR for adverse events after CEA, certain CMS HR criteria are more important than others. However, CEA appears safer for the majority of patients with carotid disease. Among patients undergoing CAS, non-HR status may be limited to restenosis and radiation.
Contralateral carotid artery occlusion is not a contraindication to carotid endarterectomy even if shunts are not routinely used.
Samson Russell H,Cline Jennifer L,Showalter David P,Lepore Michael R,Nair Deepak G
Journal of vascular surgery
OBJECTIVE:Although controversial, carotid artery stenting (CAS) has been proposed as being safer than carotid endarterectomy (CEA) for patients with a contralateral internal carotid occlusion (CCO). Arguably, with a CCO, CAS should be even safer than CEA if a shunt is not used. Accordingly, we reviewed our experience with 2183 CEAs performed routinely without a shunt to evaluate the risk of CEA performed in a subset of 147 patients with a CCO. METHODS:Between 1988 and 2011, 147 CEAs (111 men [75%], 36 women [25%]) were routinely performed without a shunt despite CCO. Of these patients, 76% were asymptomatic. CEAs were performed by seven surgeons using standard techniques (not eversion), with patients under general anesthesia and blood pressure maintained at >130 mm Hg. All patients received heparin (7500 U), and protamine reversal was routine. Median cross-clamp time was 20 minutes (range, 14-40 minutes). RESULTS:Three neurologic events occurred ≤ 30 days (2.0%). One transient ischemic attack (TIA) occurred immediately, and one occurred on the first postoperative day due to occlusion of the endarterectomy site. One patient sustained an immediate stroke and died of a large computed tomography-documented atheroembolic shower. CONCLUSIONS:Our data demonstrate the safety of CEA in the presence of a CCO, even when performed without a shunt. It is unlikely that the stroke or delayed TIA could be attributed to nonshunting or CCO. Even if so, the stroke and death rates would be lower than those previously reported for patients undergoing CEA in the presence of a CCO. This may be due to short cross-clamp times, careful technique, general anesthesia, and blood pressure support. Given these low adverse event rates, our experience refutes the assumption that patients with a CCO are at such a high risk for CEA that the only alternative is CAS.
Degree of Conjugate Gaze Deviation on CT Predicts Proximal Vessel Occlusion and May Expedite Endovascular Therapy.
Jiang Nan N,Fong Crystal,Sahlas Demetrios J,Monteiro Sandra,Larrazabal Ramiro
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
PURPOSE:Recent trials have demonstrated superior outcomes with combination IV-tPA and endovascular therapy (EVT) within 6 hours of symptom onset in patients with proximal vessel occlusion (ICA, M1, or proximal M1/M2) compared to IV-tPA alone. The current standard of diagnosis for consideration of EVT is CT angiogram (CTA). Unfortunately, not all hospitals are equipped with CTA, and the decision to transfer to tertiary centers is often based on nonenhanced CT. Ipsilateral conjugate gaze deviation (CGD) is associated with worse outcomes and larger infarcts in acute ischemic stroke. We predicted that the more proximal the occlusion, the higher the degree of CGD. MATERIALS AND METHODS:Over a period of 12 months, 182 consecutive patients with acute ischemic stroke treated at our institution were prospectively analyzed. Stroke locations were categorized based on CTA. Average degree of CGD was measured. Patient demographics, ASPECTS, collateral score, National Institutes of Health Stroke Scale, modified Rankin Scale, TICI score, length-of-stay, and mortality were collected. The median follow-up was 30 days. RESULTS:Out of ninety one of 182 patients with (+) CGD, 82 (90%) patients had ICA or middle cerebral artery (MCA) territory infarcts. The median was 25.0° in those with proximal occlusion and 13.7° in those with distal MCA occlusion (P < .001). A higher degree of CGD is positively correlated with proximity of vessel occlusion (correlation coefficient 0.2; P < .05). A cut-off greater than 20.25° (area under the curve = .76) showed a sensitivity of 64.0% and specificity 84.2%. CONCLUSIONS:Measuring degree of CGD may help in early identification of proximal vessel occlusions and expedite transfer for clot retrieval.
Predictors of Symptomatic Intracranial Hemorrhage after Endovascular Therapy in Acute Ischemic Stroke with Large Vessel Occlusion.
Sugiura Yuri,Yamagami Hiroshi,Sakai Nobuyuki,Yoshimura Shinichi,
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
BACKGROUND:The symptomatic intracranial hemorrhage (SICH) is a serious complication of endovascular therapy (EVT) in acute ischemic stroke (AIS) with large vessel occlusion. We aimed to clarify the predictors of SICH after EVT in patients with internal carotid artery (ICA) or proximal M1 segment of middle cerebral artery occlusions. METHODS:Among 1442 AIS patients with large vessel occlusion admitted within 24 hours after onset between July 2010 and June 2011, 226 patients with ICA or proximal M1 occlusions were treated with EVT. SICH was defined as any type of intracranial hemorrhage with a decline in the National Institutes of Health Stroke Scale (NIHSS) score ≥4. RESULTS:Of the 226 patients, 204 with sufficient data were analyzed. SICH was observed in 10 patients (4.9%). Baseline NIHSS score (22 versus 17), serum glucose level (206 mg/dL versus 140 mg/dL), and prior antiplatelet therapy (60.0% versus 21.7%) were significantly higher in patients with SICH than in those without (all P < .01). With receiver operating characteristic analyses, the optimal cutoff values for predicting SICH were NIHSS score ≥19 and serum glucose ≥160 mg/dL. In multivariate analysis, glucose level ≥160 mg/dL (odds ratio: 11.89; 95% confidence interval [CI]: 2.79-65.08), prior antiplatelet therapy (odds ratio: 8.03; 95% CI: 1.83-41.70), and NIHSS score ≥19 (odds ratio: 7.78; 95% CI: 1.63-59.44) were independent predictors of SICH. CONCLUSION:Hyperglycemia, prior antiplatelet therapy, and high baseline NIHSS score were associated with SICH after EVT in AIS patients with ICA or proximal M1 occlusions.
Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation?
Dargazanli Cyril,Consoli Arturo,Gory Benjamin,Blanc Raphaël,Labreuche Julien,Preda Cristian,Bourdain Frédéric,Decroix Jean-Pierre,Redjem Hocine,Ciccio Gabriele,Mazighi Mikael,Smajda Stanislas,Desilles Jean-Philippe,Riva Roberto,Labeyrie Paul-Emile,Coskun Oguzhan,Rodesch Georges,Turjman Francis,Piotin Michel,Lapergue Bertrand,
Cerebrovascular diseases (Basel, Switzerland)
BACKGROUND:In population-based studies, patients presenting with minor or mild stroke symptoms represent about two-thirds of stroke patients, and almost one-third of these patients are unable to ambulate independently at the time of discharge. Although mechanical thrombectomy (MT) has become the standard of care for acute ischaemic stroke with proximal large vessel occlusion (LVO) in the anterior circulation, the management of patients harbouring proximal occlusion and minor-to-mild stroke symptoms has not yet been determined by recent trials. The purpose of this study was to evaluate the impact of reperfusion on clinical outcome in low National Institutes of Health Stroke Scale (NIHSS) patients treated with MT. METHODS:We analysed 138 consecutive patients with acute LVO of the anterior circulation (middle cerebral artery M1 or M2 segment, internal carotid artery or tandem occlusion) with NIHSS <8, having undergone MT in 3 different centres. Reperfusion was graded using the modified thrombolysis in cerebral infarction (TICI) score and 3 grades were defined, ranging from failed or poor reperfusion (TICI 0, 1, 2A) to complete reperfusion (TICI 3). The primary clinical endpoint was an excellent outcome defined as a modified Rankin score (mRs) 0-1 at 3-months. The impact of reperfusion grade was assessed in univariate and multivariate analyses. The secondary endpoints included favourable functional outcome (90-day mRS 0-2), death and safety concerns. RESULTS:Successful reperfusion was achieved in 81.2% of patients (TICI 2B, n = 47; TICI 3, n = 65). Excellent outcome (mRs 0-1) was achieved in 69 patients (65.0%) and favourable outcome (mRs ≤2) in 108 (78.3%). Death occurred in 7 (5.1%). Excellent outcome increased with reperfusion grades, with a rate of 34.6% in patients with failed/poor reperfusion, 61.7% in patients with TICI 2B reperfusion, and 78.5% in patients with TICI 3 reperfusion (p < 0.001). In multivariate analysis adjusted for patient characteristics associated with excellent outcome, the reperfusion grade remained significantly associated with an increase in excellent outcome; the OR (95% CI) was 3.09 (1.06-9.03) for TICI 2B and 6.66 (2.27-19.48) for TICI 3, using the failed/poor reperfusion grade as reference. Similar results were found regarding favourable outcome (90-day mRs 0-2) or overall mRS distribution (shift analysis). CONCLUSION:Successful reperfusion is strongly associated with better functional outcome among patients with proximal LVO in the anterior circulation and minor-to-mild stroke symptoms. Randomized controlled studies are mandatory to assess the benefit of MT compared with optimal medical management in this subset of patients.
Clinical significance of reversal of flow in the vertebral artery identified on cerebrovascular duplex ultrasound.
Policha Aleksandra,Baldwin Melissa,Lee Victoria,Adelman Mark A,Rockman Caron,Berland Todd,Cayne Neal S,Maldonado Thomas S
Journal of vascular surgery
BACKGROUND:Reversal of flow in the vertebral artery (RFVA) is an uncommon finding on cerebrovascular duplex ultrasound examination. The clinical significance of RFVA and the natural history of patients presenting with it are poorly understood. Our objective was to better characterize the symptoms and outcomes of patients presenting with RFVA. METHODS:A retrospective review was performed of all cerebrovascular duplex ultrasound studies performed at our institution between January 2010 and January 2016 (N = 2927 patients). Individuals with RFVA in one or both vertebral arteries were included in the analysis. RESULTS:Seventy-four patients (74/2927 patients [2.5%]) with RFVA were identified. Half of the patients were male. Mean age at the time of the first ultrasound study demonstrating RFVA was 71 years (range, 27-92 years); 78% of patients had hypertension, 28% were diabetic, and 66% were current or former smokers. Indications for the ultrasound examination were as follows: 44% screening/asymptomatic, 7% anterior circulation symptoms, 20% posterior circulation symptoms, 28% follow-up studies after cerebrovascular intervention, and 5% upper extremity symptoms. At the time of the initial ultrasound examination, 21 patients (28%) had evidence of a prior carotid intervention (carotid endarterectomy or carotid stenting), 21 patients had evidence of moderate (50%-79%) carotid artery stenosis (CAS) in at least one carotid artery, and 12 patients (16%) had evidence of severe (>80%) CAS. Of the 15 patients presenting with posterior circulation symptoms, 11 (73%) had evidence of concomitant CAS. In contrast, 22 of the 59 patients (37%) without posterior circulation symptoms had duplex ultrasound findings of CAS (P = .01). The mean duration of follow-up was 28 ± 22 months. Follow-up data were available for 63 patients (85%), including the 15 patients who presented with posterior circulation symptoms. Of these 15 patients, 5 underwent subclavian artery revascularization, including balloon angioplasty and stenting in 4 patients and open/hybrid revascularization in 1 patient. Five individuals were awaiting intervention. Three patients underwent carotid endarterectomy for CAS, with resultant improvement in posterior circulation symptoms. Finally, one patient was deemed too high risk for intervention, and one patient was found to have an alternative cause for symptoms. The remaining 59 patients continued to be asymptomatic during follow-up. One patient progressed to vertebral artery occlusion, and six patients had progression of CAS. CONCLUSIONS:Symptomatic RFVA responds well to intervention, including subclavian artery stenting and carotid intervention in patients with CAS. The majority of patients with this finding are asymptomatic at the time of presentation. Although progression of vertebral artery disease is rare, these patients may benefit from monitoring for progression of CAS with surveillance ultrasound.
Recurrent stroke in symptomatic carotid stenosis awaiting revascularization: A pooled analysis.
Johansson Elias,Cuadrado-Godia Elisa,Hayden Derek,Bjellerup Jakob,Ois Angel,Roquer Jaume,Wester Per,Kelly Peter J
OBJECTIVE:We aimed to quantify the risk and predictors of ipsilateral ischemic stroke in patients with symptomatic carotid stenosis awaiting revascularization (carotid endarterectomy [CEA] or carotid artery stenting) by pooling individual patient data from recent prospective studies with high rates of treatment with modern stroke prevention medications. METHODS:Data were included from 2 prospective hospital-based registries (Umeå, Barcelona) and one prospective population-based study (Dublin). Patients with symptomatic 50%-99% carotid stenosis eligible for carotid revascularization were included and followed for early recurrent ipsilateral stroke or retinal artery occlusion (RAO). RESULTS:Of 607 patients with symptomatic 50%-99% carotid stenosis, 377 met prespecified inclusion criteria. Ipsilateral recurrent ischemic stroke/RAO risk pre-revascularization was 2.7% (1 day), 5.3% (3 days), 11.5% (14 days), and 18.8% (90 days). On bivariate analysis, presentation with a cerebral vs ocular event was associated with higher recurrent stroke risk (log-rank p = 0.04). On multivariable Cox regression, recurrence was associated with older age (adjusted hazard ratio [HR] per 10-year increase 1.5, p = 0.02) with a strong trend for association with cerebral (stroke/TIA) vs ocular symptoms (adjusted HR 2.7, p = 0.06), but not degree of stenosis, smoking, vascular risk factors, or medications. CONCLUSIONS:We found high risk of recurrent ipsilateral ischemic events within the 14-day time period currently recommended for CEA. Randomized trials are needed to determine the benefits and safety of urgent vs subacute carotid revascularization within 14 days after symptom onset.
Selective shunting for carotid endarterectomy in patients with recent stroke.
Hans Sachinder Singh,Catanescu Irina
Journal of vascular surgery
OBJECTIVE:Many surgeons favor routine shunting during carotid endarterectomy (CEA) in patients with recent stroke who otherwise prefer selective shunt placement for other indications of CEA. We analyzed the results of CEA in this group of patients with the strategy of selective shunting. METHODS:A retrospective review was performed of 59 patients (group A) undergoing CEA ≤8 weeks of a stroke (2000-2014) from two midsized teaching hospitals with stroke certification; of these, 38 patients had CEA ≤2 weeks and 21 other had CEA >2 weeks but <8 weeks. All patients sustained a middle cerebral artery stroke with ≥70% ipsilateral internal carotid artery stenosis. Cervical block anesthesia was used in 43 patients and general anesthesia in 16. During the same period, 1036 CEAs were performed for other indications (group B). All patients in group A were evaluated by stroke neurologist with a National Institutes of Health stroke scale score of 1 to 4 in 22 patients (minor stroke) and 5 to 15 in 37 patients (moderate stroke). A shunt was placed if neurologic changes (contralateral motor weakness, aphasia, loss of consciousness) occurred with the carotid cross-clamping or ischemic electroencephalogram changes under general anesthesia were observed. RESULTS:The study population consisted of 59 patients (36 males and 23 females) in group A with mean age of 70.5 ± 10.7 years. Carotid duplex imaging revealed contralateral internal carotid artery stenosis of <50% in 36 patients, 50% to 70% in 13, 71% to 99% in 9, and occlusion in 1. Ten patients (16.9%) required shunt placement, which was similar to the shunt in group B (11.8% for remote stroke, 10.2% for focal transient ischemic attack/monocular blindness, and 10.9% for asymptomatic carotid stenosis). Two patients in group A had perioperative stroke and died (3.4% stroke/mortality). There were no incidences of permanent cranial nerve palsy, myocardial infarction (MI), or hematoma requiring re-exploration in patients undergoing CEA in group A. Postoperative complications in group B included new neurologic deficits (postoperative stroke) in 16 (1.6%), MI in 2 (0.2%), permanent cranial nerve palsy in 3 (0.3%), and re-exploration for neck hematoma in 7 (0.7%). Six patients died after CEA in group B, for a combined stroke/death rate of 2.0%. Seizures after CEA for a recent stroke occurred in three patients (5.1%) in group A and in none in group B (P < .002). Postoperative complications (new neurologic deficits, MI, cranial nerve palsy, and re-exploration for neck hematoma) were similar in both groups (P > .05). CONCLUSIONS:Shunt requirement during CEA for acute stroke is similar to other indications of CEA. Patients undergoing CEA for recent stroke had similar incidence of postoperative new neurologic deficit/mortality, MI, and cranial nerve palsy compared with other indications of CEA but had a higher incidence of perioperative seizures.
Risk Factors for Acute Ischemic Stroke Caused by Anterior Large Vessel Occlusion.
Hendrix Philipp,Sofoluke Nelson,Adams Matthew D,Kunaprayoon Saran,Zand Ramin,Kolinovsky Amy N,Person Thomas N,Gupta Mudit,Goren Oded,Schirmer Clemens M,Rost Natalia S,Faber James E,Griessenauer Christoph J
Background and Purpose- Accurate prediction of acute ischemic stroke (AIS) caused by anterior large vessel occlusion (LVO) that is amendable to mechanical thrombectomy remains a challenge. We developed and validated a prediction model for anterior circulation LVO stroke using past medical history elements present on admission and neurological examination. Methods- We retrospectively reviewed AIS patients admitted between 2009 and 2017 to 3 hospitals within a large healthcare system in the United States. Patients with occlusions of the internal carotid artery or M1 or M2 segments of the middle cerebral artery were randomly split into 2/3 derivation and 1/3 validation cohorts for development of an anterior circulation LVO prediction model and score that was further curtailed for potential use in the prehospital setting. Results- A total of 1654 AIS were reviewed, including 248 (15%) with proximal anterior circulation LVO AIS. In the derivation cohort, National Institutes of Health Stroke Scale score at the time of cerebrovascular imaging, current smoking status, type 2 diabetes mellitus, extracranial carotid, and intracranial atherosclerotic stenosis was significantly associated with anterior circulation LVO stroke. The prehospital score was curtailed to National Institutes of Health Stroke Scale score, current smoking status, and type 2 diabetes mellitus. The areas under the curve for the prediction model, prehospital score, and National Institutes of Health Stroke Scale score alone were 0.796, 0.757, and 0.725 for the derivation cohort and 0.770, 0.689, and 0.665 for the validation cohort, respectively. The Youden index J was 0.46 for a score of >6 with 84.7% sensitivity and 62.0% specificity for the prediction model. Conclusions- Previously reported LVO stroke prediction scores focus solely on elements of the neurological examination. In addition to stroke severity, smoking, diabetes mellitus, extracranial carotid, and intracranial atherosclerotic stenosis were associated with anterior circulation LVO AIS. Although atherosclerotic stenosis may not be known until imaging is obtained, smoking and diabetes mellitus history can be readily obtained in the field and represent important elements of the prehospital score supplementing National Institutes of Health Stroke Scale score.
Literature Review and Case Report of Intravenous Thrombolysis in Acute Cerebral Infarction Attributed to Cervical Arterial Dissection.
Yan Zhihui,Yu Tianxia,Wang Ying,Wang Min,Liang Hui
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
Acute cerebral infarction (ACI) caused by cervical arterial dissection (CAD) is a rare clinical disease. Therapeutic approaches include anticoagulant therapy, antiplatelet aggregation, and thrombolytic therapy. Currently, anticoagulant therapy or antiplatelet aggregation is the primary choice, whereas the thrombolytic therapy is still controversial. In this article, we report a patient with ACI caused by right CAD, which led to a compensatory increase in blood supply to the right middle cerebral artery through the anterior communicating artery. After treatment with intravenous thrombolysis, the clinical symptoms of the patient improved, and the National Institutes of Health Stroke Scale (NIHSS) score declined to 2 points from the initial 14 points. In addition, cranial computed tomography scans showed that there were no signs of intracranial or extracranial hemorrhage, but that the vessel occlusion was still uncured. After 17 days of antiplatelet aggregation treatment, a cranial magnetic resonance angiography scan showed complete recanalization of the right internal carotid artery. Furthermore, the NIHSS score was reduced to 1 point when the patient discharged, and for 3 months of follow-up.
Angiographical Jaggy Sign of Remnant M2 Occlusion during Acute Mechanical Thrombectomy.
Yamaguchi Rei,Aihara Masanori,Shimizu Tatsuya,Sato Koji,Fujimaki Hiroya,Asakura Ken,Tosaka Masahiko,Yoshimoto Yuhei
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
BACKGROUND AND PURPOSE:During mechanical thrombectomy for acute main trunk occlusion, we sometimes encounter difficult situation; 1 M2 branch of the middle cerebral artery is successfully recanalized, while the other remains occluded. In this study, we focused on the angiographical findings of remnant occlusion. METHODS:Among 83 patients who underwent mechanical thrombectomy for the acute internal carotid artery or proximal middle cerebral artery (M1) occlusion, 25 patients (30%) intraoperatively exhibited the remnant M2 occlusion, in spite of the recanalization of the other M2. We classified the angiographical findings of the remnant M2 occlusion and examined the clinical features, prognosis, and complications, in relation to additional thrombectomy. RESULTS:The remnant M2 occlusion was classified into stump type (40%, 10 cases), round deficit type (28%, 7 cases), and jaggy type (32%, 8 cases). Multivariate analysis suggested that noncardioembolic stroke may lead to jaggy type remnant occlusion with marginal significance (P = .051). Additional thrombectomy for the remnant M2 occlusion resulted in failed recanalization in 6% in the nonjaggy (stump or round deficit) type, whereas in 50% in the jaggy type groups (P = .023). Symptomatic intracranial hemorrhage occurred in 6% in the nonjaggy and 38% in the jaggy groups (P = .081), and poor outcome at discharge in 29% and in 50%, respectively. CONCLUSIONS:Angiographical jaggy sign in the remnant M2 occlusion suggests the pre-existing or procedure-related pathology, such as atherosclerosis, vasospasm, or arterial dissection. Additional thrombectomy should be carefully determined, as which might lead to adverse events and poor outcomes.
Cardiac Biomarkers Predict Large Vessel Occlusion in Patients with Ischemic Stroke.
Chang Andrew,Ricci Brittany,Grory Brian Mac,Cutting Shawna,Burton Tina,Dakay Katarina,Jayaraman Mahesh,Merkler Alexander,Reznik Michael,Lerario Michael P,Song Christopher,Kamel Hooman,Elkind Mitchell S V,Furie Karen,Yaghi Shadi
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
BACKGROUND AND PURPOSE:Cardiac biomarkers may help identify stroke mechanisms and may aid in improving stroke prevention strategies. There is limited data on the association between these biomarkers and acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). We hypothesized that cardiac biomarkers (cardiac troponin and left atrial diameter [LAD]) would be associated with the presence of LVO. METHODS:Data were abstracted from a single center prospective AIS database over 18 months and included all patients with AIS with CT angiography of the head and neck. The presence of LVO was defined as proximal LVO of the internal carotid artery terminus, middle cerebral artery (M1 or proximal M2), or basilar artery. Univariate analyses and predefined multivariable models were performed to determine the association between cardiac biomarkers (positive troponin [troponin ≥0.1 ng/mL] and LAD on transthoracic echocardiogram) and LVO adjusting for demographic factors (age and sex), risk factors (hypertension, diabetes, hyperlipidemia, history of stroke, congestive heart failure, coronary heart disease, and smoking), and atrial fibrillation (AF). RESULTS:We identified 1234 patients admitted with AIS; 886 patients (71.8%) had vascular imaging to detect LVO. Of those with imaging available, 374 patients (42.2%) had LVO and 207 patients (23.4%) underwent thrombectomy. There was an association between positive troponin and LVO after adjusting for age, sex and other risk factors (adjusted OR 1.69 [1.08-2.63], P = .022) and this association persisted after including AF in the model (adjusted OR 1.60 [1.02-2.53], P = 0.043). There was an association between LAD and LVO after adjusting for age, sex, and risk factors (adjusted OR per mm 1.03 [1.01-1.05], P = 0.013) but this association was not present when AF was added to the model (adjusted OR 1.01 [0.99-1.04], P = .346). Sensitivity analyses using thrombectomy as an outcome yielded similar findings. CONCLUSIONS:Cardiac biomarkers, particularly serum troponin levels, are associated with acute LVO in patients with ischemic stroke. Prospective studies are ongoing to confirm this association and to test whether anticoagulation reduces the risk of recurrent embolism in this patient population.
Permeability Surface of Deep Middle Cerebral Artery Territory on Computed Tomographic Perfusion Predicts Hemorrhagic Transformation After Stroke.
Li Qiao,Gao Xinyi,Yao Zhenwei,Feng Xiaoyuan,He Huijin,Xue Jing,Gao Peiyi,Yang Lumeng,Cheng Xin,Chen Weijian,Yang Yunjun
BACKGROUND AND PURPOSE:Permeability surface (PS) on computed tomographic perfusion reflects blood-brain barrier permeability and is related to hemorrhagic transformation (HT). HT of deep middle cerebral artery (MCA) territory can occur after recanalization of proximal large-vessel occlusion. We aimed to determine the relationship between HT and PS of deep MCA territory. METHODS:We retrospectively reviewed 70 consecutive acute ischemic stroke patients presenting with occlusion of the distal internal carotid artery or M1 segment of the MCA. All patients underwent computed tomographic perfusion within 6 hours after symptom onset. Computed tomographic perfusion data were postprocessed to generate maps of different perfusion parameters. Risk factors were identified for increased deep MCA territory PS. Receiver operating characteristic curve analysis was performed to calculate the optimal PS threshold to predict HT of deep MCA territory. RESULTS:Increased PS was associated with HT of deep MCA territory. After adjustments for age, sex, onset time to computed tomographic perfusion, and baseline National Institutes of Health Stroke Scale, poor collateral status (odds ratio, 7.8; 95% confidence interval, 1.67-37.14; =0.009) and proximal MCA-M1 occlusion (odds ratio, 4.12; 95% confidence interval, 1.03-16.52; =0.045) were independently associated with increased deep MCA territory PS. Relative PS most accurately predicted HT of deep MCA territory (area under curve, 0.94; optimal threshold, 2.89). CONCLUSIONS:Increased PS can predict HT of deep MCA territory after recanalization therapy for cerebral proximal large-vessel occlusion. Proximal MCA-M1 complete occlusion and distal internal carotid artery occlusion in conjunction with poor collaterals elevate deep MCA territory PS.
Endovascular Treatment of Acute Ischemic Stroke Due to Tandem Occlusions: Large Multicenter Series and Systematic Review.
Grigoryan Mikayel,Haussen Diogo C,Hassan Ameer E,Lima Andrey,Grossberg Jonathan,Rebello Leticia C,Tekle Wondwossen,Frankel Michael,Nogueira Raul G
Cerebrovascular diseases (Basel, Switzerland)
BACKGROUND:Ischemic strokes due to tandem occlusions (TOs) have poor outcomes if they have been treated with only medical interventions. Recent trials demonstrated the effectiveness of endovascular treatment of acute ischemic stroke due to intracranial occlusions; however, most studies excluded patients with TOs. METHODS:Retrospective review of prospectively collected thrombectomy databases from 3 stroke centers between 2011 and 2015. Consecutive patients with tandem extracranial steno-occlusive carotid disease and intracranial occlusions who underwent emergent thrombectomy were selected. Angiographic and clinical outcomes were analyzed; baseline and procedural variables were included in univariate and multivariate analyses to define the independent predictors of good outcomes (90-day modified Rankin Scale ≤2). RESULTS:A total of 100 patients met the study inclusion criteria. The mean age was 64.4 ± 12.5, baseline National Institutes of Health Stroke Scale (NIHSS) 17.6 ± 5.0, time from last known well to puncture 7.3 ± 5.8 h, and Alberta Stroke Program Early CT Score (ASPECTS) 7.5 ± 1.6. Forty percent received intravenous tissue plasminogen activator. Intracranial occlusion sites included: internal carotid artery thrombus, 31%; middle cerebral artery (MCA)-M1, 53%; MCA-M2, 10%; and anterior cerebral artery, 6%. Good outcome was achieved in 42% and successful reperfusion modified thrombolysis in cerebral infarction (mTICI ≥2B) in 88% of the cases, including complete (mTICI 3) reperfusion in 40%. Severe parenchymal hematoma (PH)-2 occurred in 6% of the patients and 90-day mortality was 20%. In the multivariate analysis, younger age (OR 0.93; 95% CI 0.88-0.98; p = 0.004), lower baseline NIHSS (OR 0.84; 95% CI 0.74-0.94; p = 0.003), higher ASPECTS (OR 1.50; 95% CI 1.02-2.19; p = 0.038), and mTICI 3 reperfusion (OR 3.56; 95% CI 1.18-10.76; p = 0.024) were independent predictors of good outcome at 90 days. CONCLUSIONS:Acute endovascular treatment of tandem anterior circulation occlusions yields good outcomes and has similar outcome predictors to isolated intracranial occlusions. Given their comparable clinical behavior, these patients should be included in future trials.
Parent artery occlusion in large, giant, or fusiform aneurysms of the carotid siphon: clinical and imaging results.
Labeyrie M-A,Lenck S,Bresson D,Desilles J-P,Bisdorff A,Saint-Maurice J-P,Houdart E
AJNR. American journal of neuroradiology
BACKGROUND AND PURPOSE:Parent artery occlusion has long been considered the reference treatment for large/giant or fusiform aneurysms of the carotid siphon. However, meager recent data exist on this technique, which tends to be replaced by stent-assisted reconstructive techniques. In our department since 2004, we have assessed the safety, efficacy, and complication risk factors of parent artery occlusion by using coils for trapping these aneurysms. MATERIALS AND METHODS:We determined retrospectively the complication rate, factors associated with the occurrence of an ischemic event, changes in symptoms of mass effect, evolution of the aneurysmal size, and the growth of an additional aneurysm after treatment. RESULTS:Fifty-six consecutive patients were included, with a median age of 54 years (range, 25-85 years; 92% women), 48% with giant aneurysms and 75% with infraclinoid aneurysms. There was a permanent morbidity rate of 5% exclusively due to ischemia, a zero mortality rate, an aneurysmal retraction rate of 91%, and an improvement rate for pain of 98% and for cranial nerve palsy of 72%, with a median follow-up of >3 years. Para-/supraclinoid topography of the aneurysm (P = .043) and the presence of cardiovascular risk factors (P = .024) were associated with an excessive risk of an ischemic event, whereas the presence of a mural thrombus had a protective role (P = .033). CONCLUSIONS:In this study, parent artery occlusion by using coils to treat large/giant or fusiform aneurysms of the carotid siphon was safe and effective, especially for giant infraclinoid aneurysms. According to recent meta-analyses, these results suggest that the validation of stent-assisted reconstructive treatments for these aneurysms requires controlled studies with parent occlusion artery.
Occlusion site does not impact outcome in patients with carotid stroke undergoing endovascular reperfusion.
Leker Ronen R,Eichel Roni,Keigler Galina,Gomori John M,Cohen Jose E
International journal of stroke : official journal of the International Stroke Society
BACKGROUND:It remains unclear whether occlusion site impacts outcome in patients with acute carotid artery occlusions. METHODS:Patients with acute carotid artery occlusion that underwent endovascular reperfusion treatments were prospectively enrolled. Patients with extracranial carotid bifurcation occlusions were compared with those with intracranial carotid-T-occlusions. Collected data included demographics, risk factor profile, and procedure-related variables. Neurological deficits were studied with the National Institutes of Health Stroke Scale and outcome was studied with the modified Rankin Score at day 90 after stroke and dichotomized into favorable (≤2) or unfavorable (>3). Recanalization status was studied with the thrombolysis in cerebral infarction scale. RESULTS:We included 51 patients (33 with extracranial bifurcation occlusion and 18 with intracranial T-occlusion). Patients with T lesions were significantly older (median 74 versus 56 years, P = 0.02), more frequently had atrial fibrillation (61% versus 18%; P = 0.005) and cardioembolism (78% versus 21% P = 0.001), smoked less often (6% versus 42%; P = 0.01), and less often required stent implantation (11% versus 48%; P = 0.015). However, neurological severity, other procedure and peri-procedure-related variables including recanalization rates and percentages of symptomatic hemorrhages did not differ between the groups. Mortality rates (24% versus 23%) and chances for favorable outcomes (33% versus 24%) did not significantly differ. On multivariate logistic regression analysis, occlusion location was not a significant modifier of outcome. CONCLUSIONS:Despite differences in stroke risk factors and treatments used between patients with extracranial bifurcation and intracranial T-occlusions, lesion location in itself does not influence outcome in patients with acute carotid artery occlusion treated with endovascular reperfusion.
A direct aspiration first-pass technique vs stentriever thrombectomy in emergent large vessel intracranial occlusions.
Stapleton Christopher J,Leslie-Mazwi Thabele M,Torok Collin M,Hakimelahi Reza,Hirsch Joshua A,Yoo Albert J,Rabinov James D,Patel Aman B
Journal of neurosurgery
OBJECTIVE Endovascular thrombectomy in patients with acute ischemic stroke caused by occlusion of the proximal anterior circulation arteries is superior to standard medical therapy. Stentriever thrombectomy with or without aspiration assistance was the predominant technique used in the 5 randomized controlled trials that demonstrated the superiority of endovascular thrombectomy. Other studies have highlighted the efficacy of a direct aspiration first-pass technique (ADAPT). METHODS To compare the angiographic and clinical outcomes of ADAPT versus stentriever thrombectomy in patients with emergent large vessel occlusions (ELVO) of the anterior intracranial circulation, the records of 134 patients who were treated between June 2012 and October 2015 were reviewed. RESULTS Within this cohort, 117 patients were eligible for evaluation. ADAPT was used in 47 patients, 20 (42.5%) of whom required rescue stentriever thrombectomy, and primary stentriever thrombectomy was performed in 70 patients. Patients in the ADAPT group were slightly younger than those in the stentriever group (63.5 vs 69.4 years; p = 0.04); however, there were no differences in the other baseline clinical or radiographic factors. Procedural time (54.0 vs 77.1 minutes; p < 0.01) and time to a Thrombolysis in Cerebral Infarction (TICI) scale score of 2b/3 recanalization (294.3 vs 346.7 minutes; p < 0.01) were significantly lower in patients undergoing ADAPT versus stentriever thrombectomy. The rates of TICI 2b/3 recanalization were similar between the ADAPT and stentriever groups (82.9% vs 71.4%; p = 0.19). There were no differences in the rates of symptomatic intracranial hemorrhage or procedural complications. The rates of good functional outcome (modified Rankin Scale Score 0-2) at 90 days were similar between the ADAPT and stentriever groups (48.9% vs 41.4%; p = 0.45), even when accounting for the subset of patients in the ADAPT group who required rescue stentriever thrombectomy. CONCLUSIONS The present study demonstrates that ADAPT and primary stentriever thrombectomy for acute ischemic stroke due to ELVO are equivalent with respect to the rates of TICI 2b/3 recanalization and 90-day mRS scores. Given the reduced procedural time and time to TICI 2b/3 recanalization with similar functional outcomes, an initial attempt at recanalization with ADAPT may be warranted prior to stentriever thrombectomy.
Feasibility of Thrombectomy in Treating Acute Ischemic Stroke Because of Cervical Artery Dissection.
Li Shun,Zi Wenjie,Chen Jingjing,Zhang Shuai,Bai Yongjie,Guo Yongtao,Shang Xianjin,Sun Bo,Liang Meng,Liu Yong,Wan Yue,Wang Mengmeng,Zhao Min,Liu Rui,Zhu Wusheng,Liu Xinfeng,Xu Gelin
Background and Purpose- Acute ischemic stroke caused by cervical artery dissection tend to result in unfavorable outcomes even with appropriate medical treatment. This study evaluated the safety and effectiveness of endovascular thrombectomy in treating acute ischemic stroke associated with cervical artery dissection. Methods- Patients with acute ischemic stroke and with large artery occlusion associated with dissection were selected. Propensity score matching was performed to increase the comparability. Patients with a 90-day modified Rankin Scale score of 0 to 2 were defined as with favorable outcome. Results- Eighty patients with and 80 patients without thrombectomy were enrolled. After propensity score matching, 48 patients with and 48 patients without thrombectomy were matched for further analysis. Proportion of favorable outcome (modified Rankin Scale score of 0-2) was higher in patients with thrombectomy than in those without (66.7% versus 39.6%; P=0.008). There were no significance differences about the incidence of symptomatic intracranial hemorrhage (8.3% versus 4.2%; P=0.677) and the 90-day mortality (10.4% versus 6.3%; P=0.714) between matched patients with and without thrombectomy. Conclusions- Endovascular thrombectomy seems to be an effective treatment in selected patients with acute ischemic stroke associated with cervical artery dissection, but the safety of thrombectomy needs further research.
Carotid artery stenting in acute stroke.
Papanagiotou Panagiotis,Roth Christian,Walter Silke,Behnke Stefanie,Grunwald Iris Q,Viera Julio,Politi Maria,Körner Heiko,Kostopoulos Panagiotis,Haass Anton,Fassbender Klaus,Reith Wolfgang
Journal of the American College of Cardiology
OBJECTIVES:The purpose of this study is to demonstrate the technical success of carotid artery stenting in acute extracranial internal carotid artery (ICA) occlusion as well as the benefit in clinical outcome. BACKGROUND:Stroke caused by acute occlusion of the ICA is associated with a significant level of morbidity and mortality. For this type of lesion, treatment with standard intravenous thrombolysis alone leads to a good clinical outcome in only 17% of the cases, with a death rate as high as 55%. Recanalization of the occluded ICA can lead to an improvement in acute symptoms of stroke, prevent possible deterioration, and reduce long-term stroke risk. At present, there is no consensus treatment for patients with acute ischemic stroke presenting with severe clinical symptoms due to atherosclerotic occlusion of the extracranial ICA. METHODS:Carotid artery stenting was performed in 22 patients with acute atherosclerotic extracranial ICA occlusion within 6 h of stroke symptom onset. In 18 patients, there was an additional intracranial occlusion at the level of the terminal segment of the ICA (n = 4) and at the level of the middle cerebral artery (n = 14). Intracranial occlusions were either treated with the Penumbra system or the Solitaire stent-based recanalization system, or a combination of mechanical recanalization and intra-arterial thrombolysis. Recanalization results were assessed by angiography immediately after the procedure. The neurologic status was evaluated before and after the treatment with a follow-up as long as 90 days using the National Institutes of Health Stroke Scale and the modified Rankin Scale. RESULTS:Successful revascularization of extracranial ICA with acute stent implantation was achieved in 21 patients (95%). There was no acute stent thrombosis. After successful recanalization of the origin of the ICA, the intracranial recanalization with Thrombolysis In Myocardial Infarction flow grade 2/3 was achieved in 11 of the 18 patients (61%). The overall recanalization rate (extracranial and intracranial) was 14 of 22 patients (63%). Nine patients (41%) had a modified Rankin Scale score of ≤2 at 90 days. The mortality rate was 13.6% at 90 days. CONCLUSIONS:Carotid artery stenting in acute atherosclerotic extracranial ICA occlusion with severe stroke symptoms is feasible, safe, and useful within the first 6 h after symptom onset.
Assessment of Single-Barrel Superficial Temporal Artery-Middle Cerebral Artery Bypass in Treatment for Adult Patients with Ischemic-Type Moyamoya Disease.
Tao Xiaoyang,Liu Yin,Chen Jun,Xu Li,Zhou Zhijie,Lei Haiyan,Yin Yiming
Medical science monitor : international medical journal of experimental and clinical research
BACKGROUND Moyamoya disease (MMD) is an idiopathic disease caused by progressive steno-occlusion of the distal internal carotid artery. Ideal surgical treatment for adult patients with ischemic-type MMD has not been achieved. The aim of this study was to evaluate the efficacy of single-barrel superficial temporal artery-middle cerebral artery (STA-MCA) bypass in treatment for adult patients with ischemic-type MMD by analyzing clinical and radiological data retrospectively. MATERIAL AND METHODS The present study included 37 patients with non-hemorrhagic MMD, including 21 women and 16 men (21~55 years old, mean age 38.1 years). The bypass surgery was performed on 56 sides in the 37 patients. The clinical charts, angiographic revascularization, and hemodynamic changes were reviewed at 6-60 months after surgery. RESULTS Among the 37 patients, the clinical symptoms and signs of 32 patients were improved or stabilized. Five patients had complications, including 2 cases of acute cerebral infarction, 1 case of epidural hematoma, and 1 case of transient speech disturbance, and 1 patient died. Follow-up computed tomography perfusion (CTP) revealed that cerebral blood flow (CBF) was markedly improved after surgery (P<0.05). Time to peek (TTP) and mean transit time (MTT) were significantly decreased after surgery (P<0.05). No significant change in cerebral blood volume (CBV) was found after surgery (P>0.05). Postoperative patency was clearly verified in 52 bypasses (92.8%) of 56 bypasses on follow-up DSA imaging. CONCLUSIONS Single-barrel STA-MCA bypass can be considered as an effective surgical treatment, which exhibits satisfactory clinical efficacy in ischemic-type MMD patients.
Endovascular Stroke Treatment of Acute Tandem Occlusion: A Single-Center Experience.
Sallustio Fabrizio,Motta Caterina,Koch Giacomo,Pizzuto Silvia,Campbell Bruce C V,Diomedi Marina,Rizzato Barbara,Davoli Alessandro,Loreni Giorgio,Konda Daniel,Stefanini Matteo,Fabiano Sebastiano,Pampana Enrico,Stanzione Paolo,Gandini Roberto
Journal of vascular and interventional radiology : JVIR
PURPOSE:To evaluate outcomes and prognostic factors in patients with acute ischemic stroke caused by tandem internal carotid artery/middle cerebral artery occlusion undergoing endovascular treatment. MATERIALS AND METHODS:Characteristics of consecutive patients with tandem occlusion (TO) were extracted from a prospective registry. Collateral vessel quality on pretreatment computed tomographic (CT) angiography was evaluated on a 4-point grading scale, and patients were dichotomized as having poor or good collateral flow. Outcome measures included successful reperfusion according to Thrombolysis In Cerebral Infarction score, good outcome at 3 months defined as a modified Rankin scale score ≤ 2, symptomatic intracranial hemorrhage (ICH; sICH), and mortality. RESULTS:A total of 72 patients with TO (mean age, 65.6 y ± 12.8) were treated. Intravenous thrombolysis was performed in 54.1% of patients, and a carotid stent was inserted in 48.6%. Successful reperfusion was achieved in 64% of patients, and a good outcome was achieved in 32%. sICH occurred in 12.5% of patients, and the overall mortality rate was 32%. Univariate analysis demonstrated that good outcome was associated with good collateral flow (P = .0001), successful reperfusion (P = .001), and lower rate of any ICH (P = .02) and sICH (P = .04). On multivariate analysis, good collateral flow (odds ratio [OR], 0.18; 95% confidence interval [CI], 0.04-0.75; P = .01) and age (OR, 1.08; 95% CI, 1.01-1.15; P = .01) were the only predictors of good outcome. The use of more than one device for thrombectomy was the only predictor of sICH (OR, 10.74; 95% CI, 1.37-84.13; P = .02). CONCLUSIONS:Endovascular treatment for TO resulted in good outcomes. Collateral flow and age were independent predictors of good clinical outcomes at 3 months.
Risk Factors of Contralateral Microembolic Infarctions Related to Carotid Artery Stenting.
Ito Hidemichi,Uchida Masashi,Sase Taigen,Kushiro Yuichiro,Wakui Daisuke,Onodera Hidetaka,Takasuna Hiroshi,Morishima Hiroyuki,Oshio Kotaro,Tanaka Yuichiro
This study sought to analyze the incidence of contralateral microembolic infarctions (MIs) on diffusion-weighted imaging (DWI) following protected carotid artery stenting (CAS) and compared the difference of risk factors between ipsilateral and contralateral lesions. From April 2010 to March 2017, 147 CASs in 140 patients were performed. All the patients underwent DWI within 1 week before and 24 hrs after the procedures. CAS was successfully completed in 145 (98.6%) of the 147 procedures. Forty-nine (33.8%) patients with new MIs revealed on postprocedural DWI were enrolled. They were divided into ipsilateral and contralateral groups based on the side of the CAS and MIs. The ipsilateral group indicates patients with MIs exclusively on the side of CAS. The contralateral group includes patients with MIs on the opposite side of the CAS or both sides. Patients with MIs at vertebrobasilar territory were excluded. Patient characteristics, morphology of the carotid artery and aortic arch, and procedural data were retrospectively assessed and compared between the two groups. Twenty-two (15.2%) and 14 (9.7%) patients were assigned to the ipsilateral and contralateral groups, respectively. Advanced age, left-sided stenosis, severe aortic arch calcification (AAC) on chest X-ray and contralateral carotid occlusion significantly increased the occurrence of contralateral MIs. On multivariable logistic regression analysis, severe AAC was statistically more frequent in the contralateral group. In the present study, the incidences of contralateral MIs after CAS is relatively not low. Advanced aortic atherosclerosis is statistically predictive for contralateral MIs. AAC on chest X-ray is a useful finding for estimating aortic atherosclerosis in candidates for CAS.
Riskier-than-expected occlusive treatment of ruptured posterior communicating artery aneurysms: treatment and outcome of 620 consecutive patients.
Huhtakangas Justiina,Lehecka Martin,Lehto Hanna,Rezai Jahromi Behnam,Niemelä Mika,Kivisaari Riku
Journal of neurosurgery
OBJECTIVE:Occlusive treatment of posterior communicating artery (PCoA) aneurysms has been seen as a fairly uncomplicated procedure. The objective here was to determine the radiological and clinical outcome of patients after PCoA aneurysm rupture and treatment and to evaluate the risk factors for impaired outcome.METHODS:In a retrospective clinical follow-up study, data were collected from 620 consecutive patients who had been treated for ruptured PCoA aneurysms at a single center between 1980 and 2014. The follow-up was a minimum of 1 year after treatment or until death.RESULTS:Of the 620 patients, 83% were treated with microsurgical clipping, 8% with endovascular coiling, 2% with the two procedures combined, 1% with indirect surgical methods, and 6% with conservative methods. The most common procedural complications were treatment-related brain infarctions (15%). The occurrence of artery occlusions (10% microsurgical, 8% endovascular) was higher than expected. Most patients made a good recovery at 1 year after aneurysmal subarachnoid hemorrhage (modified Rankin Scale [mRS] score 0-2: 386 patients [62%]). A fairly small proportion of patients were left severely disabled (mRS score 4-5: 27 patients [4%]). Among all patients, 20% died during the 1st year. Independent risk factors for an unfavorable outcome, according to the multivariable analysis, were poor preoperative clinical condition, intracerebral or subdural hematoma due to aneurysm rupture, age over 65 years, artery occlusion on postoperative angiography, occlusive treatment-related ischemia, delayed cerebral vasospasm, and hydrocephalus requiring a shunt.CONCLUSIONS:Even though most patients made a good recovery after PCoA aneurysm rupture and treatment during the 1st year, the occlusive treatment-related complications were higher than expected and caused morbidity even among initially good-grade patients. Occlusive treatment of ruptured PCoA aneurysms seems to be a high-risk procedure, even in a high-volume neurovascular center.
Endovascular thrombectomy and stenting in the management of carotid fibromuscular dysplasia presenting with major ischemic stroke.
Cohen José E,Itshayek Eyal,Keigler Galina,Eichel Roni,Leker Ronen R
Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia
Fibromuscular dysplasia (FMD) affecting the internal carotid artery (ICA) is considered a benign condition; however, retinal and cerebral ischemic events may occur. We present a patient with carotid FMD presenting with a major ischemic stroke due to major embolic occlusion of the ICA in conjunction with a hemodynamic component caused by narrowing and beading of the lumen associated with FMD. The patient was successfully treated with intracranial stent-assisted thrombectomy followed by cervical ICA stenting that aimed to reconstruct and angioplasty the FMD-affected arterial segment. Recently, stent-based thrombectomy has emerged as the most effective endovascular option for the rapid revascularization of major intracranial occlusions; however, to our knowledge, its use in a rare case of FMD-associated major stroke has not yet been reported.
Carotid Artery Stenting With Proximal Embolic Protection via a Transradial or Transbrachial Approach: Pushing the Boundaries of the Technique While Maintaining Safety and Efficacy.
Montorsi Piero,Galli Stefano,Ravagnani Paolo M,Tresoldi Simone,Teruzzi Giovanni,Caputi Luigi,Trabattoni Daniela,Fabbiocchi Franco,Calligaris Giuseppe,Grancini Luca,Lualdi Alessandro,de Martini Stefano,Bartorelli Antonio L
Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists
PURPOSE:To compare the feasibility and safety of proximal cerebral protection to a distal filter during carotid artery stenting (CAS) via a transbrachial (TB) or transradial (TR) approach. METHODS:Among 856 patients who underwent CAS between January 2007 and July 2015, 214 (25%) patients (mean age 72±8 years; 154 men) had the procedure via a TR (n=154) or TB (n=60) approach with either Mo.MA proximal protection (n=61) or distal filter protection (n=153). The Mo.MA group (mean age 73±7 years; 54 men) had significantly more men and more severe stenosis than the filter group (mean age 71±8 years; 100 men). Stent type and CAS technique were left to operator discretion. Heparin and a dedicated closure device or bivalirudin and manual compression were used in TR and TB accesses, respectively. Technical and procedure success, crossover to femoral artery, 30-day major adverse cardiovascular/cerebrovascular events (MACCE; death, all strokes, and myocardial infarction), vascular complications, and radiation exposure were compared between groups. RESULTS:Crossover to a femoral approach was required in 1/61 (1.6%) Mo.MA patient vs 11/153 (7.1%) filter patients mainly due to technical difficulty in engaging the target vessel. Five Mo.MA patients developed acute intolerance to proximal occlusion; 4 were successfully shifted to filter protection. A TR patient was shifted to filter because the Mo.MA system was too short. CAS was technically successful in the remaining 55 (90%) Mo.MA patients and 142 (93%) filter patients. The MACCE rate was 0% in the Mo.MA patients and 2.8% in the filter group (p=0.18). Radiation exposure was similar between groups. Major vascular complications occurred in 1/61 (1.6%) and in 3/153 (1.96%) patients in the Mo.MA and filter groups (p=0.18), respectively, and were confined to the TB approach in the early part of the learning curve. Chronic radial artery occlusion was detected by Doppler ultrasound in 2/30 (6.6%) Mo.MA patients and in 4/124 (3.2%) filter patients by clinical assessment (p=0.25) at 8.1±7.5-month follow-up. CONCLUSION:CAS with proximal protection via a TR or TB approach is a feasible, safe, and effective technique with a low rate of vascular complications.
Risk factor profile and anatomic features of previously asymptomatic patients presenting with carotid-related stroke.
Klarin Derek,Cambria Richard P,Ergul Emel A,Silverman Scott B,Patel Virendra I,LaMuraglia Glenn M,Conrad Mark F,Clouse W Darrin
Journal of vascular surgery
OBJECTIVE:Although carotid atherosclerotic-mediated stroke remains a major cause of morbidity and mortality, some have suggested intervention in carotid stenosis should be limited to symptomatic patients given the advances in medical therapy. The present study was conducted to assess the atherosclerotic risk factor profiles, anatomic features, and clinical outcomes of previously asymptomatic patients admitted with stroke of carotid etiology. METHODS:We reviewed the data from 3382 patients admitted to a tertiary referral center with an ischemic stroke during 2005 to 2015. We focused on patients admitted with a radiographically confirmed infarct ipsilateral to a documented carotid artery stenosis ≥50%, with the admitting neurology team adjudicating the stroke etiology as carotid related. Patients were excluded if they had had a previous transient ischemic attack, previous infarct ipsilateral to any carotid lesion, or previous carotid revascularization, intracranial hemorrhage, or malignancy. Patient demographic data, medical treatments before stroke, stroke admission carotid imaging, and stroke treatments and outcomes were assessed. RESULTS:A total of 219 carotid stroke patients (7% of all strokes) were identified, of whom 61% were white and 66% were men, with a mean age of 68 ± 12 years. Hypertension (79%) and smoking (33% current; 29% former) were predominant risk factors. On admission, 50% were receiving antiplatelet therapy (aspirin, n = 92 [41%]; clopidogrel, n = 9 [4%]; dual therapy, n = 11 [5%]) and 55% were receiving lipid-lowering agents (statin, n = 115 [53%]; other, n = 6 [2%]); 77 patients (35%) were receiving both antiplatelet and lipid-lowering therapy. Of the 219 patients, 156 (71%) presented with a moderate or severe stroke (National Institutes of Health stroke scale ≥5 at admission), 54 (25%) received lytic therapy, 96 (43%) presented with an occluded ipsilateral internal carotid artery, and 117 (53%) ultimately underwent carotid revascularization at a median of 4 days. Individuals receiving both antiplatelet and lipid-lowering therapy were significantly less likely to experience a moderate or severe stroke (44% vs 78%; P = .006). CONCLUSIONS:Internal carotid artery occlusion is the culprit lesion in 43% of carotid-related strokes in those without previous symptoms. Previously asymptomatic patients not receiving combined antiplatelet and lipid-lowering medical therapy presenting with carotid-related stroke are significantly more likely to experience a severe, debilitating stroke. However, those receiving appropriate risk-reduction medical therapy are still at risk of carotid-mediated stroke. These results suggest medical therapy alone is unlikely to be sufficient stroke prevention for patients with significant carotid stenosis.
Endovascular Treatment versus Sonothrombolysis for Acute Ischemic Stroke.
Reinhard Matthias,Taschner Christian A,Hörsch Nicole,Allignol Arthur,Maurer Christoph J,Niesen Wolf-Dirk,Lambeck Johann,Wallesch Claus W,Urbach Horst,Weiller Cornelius,Schuchardt Volker,Griesser-Leute Hans-Jörg
Cerebrovascular diseases (Basel, Switzerland)
BACKGROUND:Currently, there are 2 strategies to increase the effect of systemic thrombolysis with alteplase (rtPA) in acute major stroke: endovascular treatment via stent retrieval and ultrasound enhancement (sonothrombolysis). This study compares these 2 approaches in patients with proximal intracranial occlusion of the anterior circulation. METHODS:Consecutive data on the treatment outcome of acute middle cerebral artery (M1) or carotid T occlusion were collected from 2 stroke centers: one center used rtPA plus endovascular stent retrieval as standard treatment and the other rtPA plus ultrasound (sonothrombolysis). The primary outcome was functional independence (modified Rankin scale (mRS) 0-2) after neurorehabilitation. RESULTS:A total of 132 patients were assessed (n = 73 endovascular, n = 59 sonothrombolysis). The rate of functional independence was higher for endovascular treatment (adjusted OR 3.89 (95% CI 1.36-12.58)). Additionally, ordinal mRS analysis favored the endovascular strategy (adjusted common OR 1.70 (95% CI 0.88-3.31)). Subgroup analysis showed that endovascular treatment was superior for carotid T occlusion (adjusted common OR 5.61 (95% CI 1.60-20.93)), but not for middle cerebral artery occlusion (adjusted common OR 1.07 (95% CI 0.47-2.43)). Symptomatic intracerebral hemorrhage occurred in 3 patients from the endovascular group. CONCLUSIONS:This observational study suggests that endovascular treatment of acute major anterior circulation stroke is superior to sonothrombolysis in terms of functional outcome. This benefit seems to pertain primarily to patients with carotid T occlusion, whereas patients with M1 occlusion seem to profit in a similar way from both methods. ( CLINICAL TRIAL REGISTRATION:URL: http://www.germanctr.de. Unique identifier: DRKS0000x200B;5305.).
Extracranial Carotid Disease and Effect of Intra-arterial Treatment in Patients With Proximal Anterior Circulation Stroke in MR CLEAN.
Berkhemer Olvert A,Borst Jordi,Kappelhof Manon,Yoo Albert J,van den Berg Lucie A,Fransen Puck S S,Beumer Debbie,Schonewille Wouter J,Nederkoorn Paul J,Wermer Marieke J H,Marquering Henk A,Lingsma Hester F,Roos Yvo B W E M,van Oostenbrugge Robert J,Dippel Diederik W J,van Zwam Wim H,Majoie Charles B L M,Emmer Bart J,van der Lugt Aad,
Annals of internal medicine
Background:The presence of extracranial carotid disease (ECD) is associated with less favorable clinical outcomes in patients with acute ischemic stroke caused by intracranial proximal occlusion. Acute intra-arterial treatment (IAT) in the setting of extracranial and intracranial lesions is considered challenging, and whether it yields improved outcomes remains uncertain. Objective:To examine whether the presence of ECD modified the effect of IAT for intracranial proximal anterior circulation occlusion. Design:Prespecified subgroup analysis of a randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands. (Trial registrations: NTR1804 [Netherlands Trial Register] and ISRCTN10888758). Setting:16 hospitals in the Netherlands. Patients:Acute ischemic stroke caused by proximal intracranial arterial occlusion of the anterior circulation. Extracranial carotid disease was defined as cervical internal carotid artery stenosis (>50%) or occlusion. Intervention:IAT treatment versus no IAT. Measurements:The primary outcome was functional outcome, as measured by the modified Rankin Scale at 90 days and reported as adjusted common odds ratio (acOR) for a shift in direction of a better outcome. Multivariable ordinal logistic regression analysis with an interaction term was used to estimate treatment effect modification by ECD. Results:The overall acOR was 1.67 (95% CI, 1.21 to 2.30) in favor of the intervention. The acOR was 3.1 (CI, 1.7 to 5.8) in the prespecified subgroup of patients with ECD versus 1.3 (CI, 0.9 to 1.9) in patients presenting without ECD. Both acORs are in favor of the intervention (P for interaction = 0.07). Limitation:The study was not powered for subgroup analysis. Conclusion:Intra-arterial treatment may be at least as effective in patients with ECD as in those without ECD, and it should not be withheld in these complex patients with acute ischemic stroke. Primary Funding Source:Dutch Heart Foundation, AngioCare BV, Medtronic/Covidien/EV3, MEDAC Gmbh/LAMEPRO, Penumbra, Stryker, and Top Medical/Concentric.
Decreased hyperintense vessels on FLAIR images after endovascular recanalization of symptomatic internal carotid artery occlusion.
Liu Wenhua,Yin Qin,Yao Lingling,Zhu Shuanggen,Xu Gelin,Zhang Renliang,Ke Kaifu,Liu Xinfeng
European journal of radiology
BACKGROUND AND PURPOSE:Hyperintense vessels (HV) on fluid-attenuated inversion recovery (FLAIR) images were assumed to be explained by slow antegrade or retrograde leptomeningeal collateral flow related to extracranial or intracranial artery steno-occlusion. The aim of this study was to investigate the effect of recanalization after endovascular therapy of symptomatic internal carotid artery (ICA) occlusion on the presence of HV. METHODS:Eleven patients with symptomatic ICA occlusion were retrospectively enrolled. Changes in the HV on FLAIR images were examined in affected hemisphere of each patient after successful treatment with endovascular recanalization (angioplasty, n = 3; stent-assisted angioplasty, n = 8). The relationship between postoperative changes in the HV and Thrombolysis In Cerebral Ischemia (TICI) scale (I-III) was assessed. RESULTS:After operation, HV of the 11 affected hemispheres were showed to be decreased (n = 3) or disappeared (n = 8) in treated side. The median interval between pre- and postoperative MRI examinations was 97.0 h (range, from 69. to 48.7h). Of the 8 patients with disappeared HV, 7 achieved high TICI grade flow (III) and 1 had relatively low TICI grade flow (IIc) in treated side. However, all the 3 patients with decreased HV were found to be relatively low TICI grade flow (IIc). CONCLUSION:Our data indicate that endovascular recanalization of ICA occlusion was effective for decreasing HV. Postoperative decrease in HV can be considered as a marker for hemodynamic improvement.
Intravenous tissue plasminogen activator before endovascular treatment increases symptomatic intracranial hemorrhage in patients with occlusion of the middle cerebral artery second division: subanalysis of the RESCUE-Japan Registry.
Takagi Toshinori,Yoshimura Shinichi,Uchida Kazutaka,Enomoto Yukiko,Egashira Yusuke,Yamagami Hiroshi,Sakai Nobuyuki,
INTRODUCTION:No previous study has investigated the relationship between intravenous tissue plasminogen activator (IV t-PA) and intracranial hemorrhage (ICH) according to the location of vessel occlusion. The aim of the present study was to investigate the relationship between preprocedural IV t-PA and endovascular treatment (EVT) and ICH according to the location of occlusion using data from the nationwide prospective registry of acute cerebral large vessel occlusion (LVO), the RESCUE-Japan Registry. METHODS:Among 1442 patients with acute LVO enrolled in the registry, we examined 410 patients who received EVT. Patients were divided into the following four groups according to the location of occlusion: the internal carotid artery (ICA), middle cerebral artery first division (M1), middle cerebral artery second division (M2), and vertebral artery (VA)/basilar artery (BA) groups. RESULTS:A total of 399 patients in whom the occlusion was located in these vessels were finally included. Any ICH (aICH) was identified in 127 (30.9%) patients, and symptomatic ICH (sICH) was identified in 20 (4.9%). Preprocedural IV t-PA did not increase the incidence of aICH in any group and tended to increase the incidence of sICH in only the M2 group. In multivariate analysis of the M2 group, IV t-PA was an independent risk factor for sICH. CONCLUSION:Preprocedural IV t-PA did not increase the incidence of ICH in total, but could increase the incidence of sICH in those with M2 occlusion. IV t-PA before EVT may be an independent risk factor for sICH in patients with M2 occlusion.
Endovascular repair of external carotid artery disease.
Kouvelos George N,Koutsoumpelis Andreas C,Klonaris Chris,Matsagkas Miltiadis I
Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists
PURPOSE:To review the literature on the endovascular management of external carotid artery (ECA) disease. METHODS:A review was conducted of the English-language medical literature from 1985 to 2011 using PubMed, OVID, and EMBASE databases to find all studies involving endovascular management of ECA stenosis. The search identified 21 reports describing endovascular repair of ECA lesions encompassing 56 patients (35 men; mean age 62.6±10.5 years) and 58 arteries. RESULTS:The majority of patients (91.1%) were reported to have ipsilateral ICA occlusion, while 55.6% of patients were symptomatic. In the 56 patients, 33 arteries received stents primarily, while 25 had primary balloon angioplasty; 52 cases involved endovascular repair of ECA stenosis, while 4 patients with a normal ECA had a covered stent deployed to exclude the ICA stump. The technical success rate was 98.3%. During the first 30 days after the procedure, 1 (1.8%) stroke was reported, while 5 (8.9%) transient ischemic attacks were also described. During a follow-up period spanning an average 23.8±18.3 months, none of the patients experienced any clinical cerebrovascular event. Two (3.4%) dilated ECAs developed restenosis, while 1 (1.7%) ECA stent occluded at 6 months. CONCLUSION:Endovascular repair of ECA appears to have low rates of perioperative stroke or death but a high rate of TIAs. The appropriate type of stent and the use of embolic protection need to be established. In the endovascular era, despite the limited data available, this therapeutic approach could be considered a reasonable alternative to conventional open repair, especially in patients with ipsilateral ICA occlusion and concomitant contralateral carotid stenosis or occlusion, an insufficient circle of Willis, and other significant comorbidities.
Cerebral Neuromonitoring during Carotid Endarterectomy and Impact of Contralateral Internal Carotid Occlusion.
Sef Davorin,Skopljanac-Macina Andrija,Milosevic Milan,Skrtic Anita,Vidjak Vinko
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
BACKGROUND:The aim of this study was to identify the reliability of carotid artery stump pressure (SP) in predicting the neurologic changes and correlation with contralateral internal carotid artery (ICA) occlusion in patients undergoing eversion carotid endarterectomy (CEA). The optimal method for monitoring cerebral perfusion during CEA, performed under either local or general anesthesia, is still controversial. METHODS:We prospectively analyzed 118 consecutive patients undergoing eversion CEA under local anesthesia. We had 78 symptomatic (66%) and 40 asymptomatic patients (33.9%). Selective shunting was performed in patients who developed neurologic changes after carotid clamping regardless of SP. Correlation of preoperative symptom status, a degree of stenosis, status of contralateral ICA, arterial blood pressure, SP value, and the intraoperative need for shunting due to neurologic changes was evaluated for both groups: shunted and nonshunted. RESULTS:Selective shunting was performed in 12 patients (10%). There was no significant difference among the groups regarding the demographic characteristics. Mean carotid clamping time was 14.57 minutes. We had no perioperative mortality, stroke, or myocardial infarction. None of the patients required conversion to general anesthesia. We found a mean SP of 31 mm Hg as a reliable threshold for shunting (P < .001; sensitivity 92.3%; specificity 91.3%). Contralateral carotid occlusion was correlated with the significantly lower SP (27 ± 13 mm Hg; P = .001) and the higher need for shunt (50%). CONCLUSIONS:SP measurement is a reliable and simple method for monitoring the collateral cerebral perfusion and can predict the need for shunting during CEA. Patients with the contralateral ICA occlusion showed significantly lower SP, although it did not have impact on the outcome.
Efficacy of endovascular treatment for acute cerebral large-vessel occlusion: analysis of nationwide prospective registry.
Yoshimura Shinichi,Sakai Nobuyuki,Okada Yasushi,Kitagawa Kazuo,Kimura Kazumi,Tanahashi Norio,Hyogo Toshio,Yamagami Hiroshi,Egashira Yusuke,
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
BACKGROUND:The aim of this nationwide, prospective registry of acute cerebral large-vessel occlusion was to assess the efficacy of endovascular treatment (EVT) on outcome in the "real-world" settings. METHODS:Medical information of the patients was anonymized and registered prospectively through a Web site from 84 medical centers in Japan. Reperfusion of the affected arteries was evaluated by the Thrombolysis in Cerebral Infarction grade on cerebral angiography or by the modified Mori grade on magnetic resonance angiography. Clinical outcome was evaluated by modified Rankin Scale (mRS) at 90 days after onset. Symptomatic intracranial hemorrhage and procedure-related complications were also analyzed. RESULTS:Among intravenous tissue plasminogen activator (IV t-PA)-failed patients, no significant difference in favorable outcome was seen with or without EVT overall (41.7% versus 36.8%, P = .55). However, EVT significantly increased favorable outcomes (mRS score 0-2) in patients with internal carotid artery (ICA)/middle cerebral artery M1/basilar artery (BA) occlusion (41.3% versus 20.5%, P = .019). In contrast, among t-PA-ineligible patients, EVT significantly increased favorable outcomes overall (29.1% versus 19.5%; odds ratio, 1.70; P = .007). Furthermore, favorable outcomes were more common in patients with ICA/M1/BA occlusion (29.0% versus 10.3%; odds ratio, 3.56; P < .0001). Multivariate analysis also confirmed the efficacy of IV t-PA, EVT, and their combination for favorable outcome. CONCLUSIONS:EVT significantly improved clinical outcomes in IV t-PA-failed and t-PA-ineligible patients with ICA/M1/BA occlusion. These findings support the introduction of EVT for acute proximal artery occlusion.
Volume of subclinical embolic infarct correlates to long-term cognitive changes after carotid revascularization.
Zhou Wei,Baughman Brittanie D,Soman Salil,Wintermark Max,Lazzeroni Laura C,Hitchner Elizabeth,Bhat Jyoti,Rosen Allyson
Journal of vascular surgery
OBJECTIVE:Carotid intervention is safe and effective in stroke prevention in appropriately selected patients. Despite minimal neurologic complications, procedure-related subclinical microemboli are common and their cognitive effects are largely unknown. In this prospective longitudinal study, we sought to determine long-term cognitive effects of embolic infarcts. METHODS:The study recruited 119 patients including 46% symptomatic patients who underwent carotid revascularization. Neuropsychological testing was administered preoperatively and at 1 month, 6 months, and 12 months postoperatively. Rey Auditory Verbal Learning Test (RAVLT) was the primary cognitive measure with parallel forms to avoid practice effect. All patients also received 3T brain magnetic resonance imaging with a diffusion-weighted imaging (DWI) sequence preoperatively and within 48 hours postoperatively to identify procedure-related new embolic lesions. Each DWI lesion was manually traced and input into a neuroimaging program to define volume. Embolic infarct volumes were correlated with cognitive measures. Regression models were used to identify relationships between infarct volumes and cognitive measures. RESULTS:A total of 587 DWI lesions were identified on 3T magnetic resonance imaging in 81.7% of carotid artery stenting (CAS) and 36.4% of carotid endarterectomy patients with a total volume of 29,327 mm. Among them, 54 DWI lesions were found in carotid endarterectomy patients and 533 in the CAS patients. Four patients had transient postoperative neurologic symptoms and one had a stroke. CAS was an independent predictor of embolic infarction (odds ratio, 6.6 [2.1-20.4]; P < .01) and infarct volume (P = .004). Diabetes and contralateral carotid severe stenosis or occlusion had a trend of positive association with infarct volume, whereas systolic blood pressure ≥140 mm Hg had a negative association (P = .1, .09, and .1, respectively). There was a trend of improved RAVLT scores overall after carotid revascularization. Significantly higher infarct volumes were observed among those with RAVLT decline. Within the CAS cohort, infarct volume was negatively correlated with short- and long-term RAVLT changes (P < .05). CONCLUSIONS:Cognitive assessment of procedure-related subclinical microemboli is challenging. Volumes of embolic infarct correlate with long-term cognitive changes, suggesting that microembolization should be considered a surrogate measure for carotid disease management.
Carotid Artery Stenting Using a Closed-Cell Stent-in-Stent Technique for Unstable Plaque.
Myouchin Kaoru,Takayama Katsutoshi,Wada Takeshi,Miyasaka Toshiteru,Tanaka Toshihiro,Kotsugi Masashi,Kurokawa Shinichiro,Nakagawa Hiroyuki,Kichikawa Kimihiko
Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists
To examine whether carotid artery stenting (CAS) of stenoses with unstable plaque using a closed-cell stent-in-stent technique prevents plaque protrusion. Between December 2014 and August 2018, 35 consecutive patients (mean age 75.8 years; 29 men) with carotid artery stenosis (20 symptomatic) and unstable plaque diagnosed by magnetic resonance imaging were prospectively analyzed. Mean diameter stenosis was 83.5%. All CAS procedures were performed with stent-in-stent placement of Carotid Wallstents using an embolic protection device and conservative postdilation. The technical success rate, incidence of plaque protrusion, ischemic stroke rate within 30 days, and new ipsilateral ischemic lesions on diffusion-weighted imaging (DWI) within 48 hours after CAS were prospectively assessed. Follow-up outcomes included the incidences of ipsilateral stroke and restenosis. The technical success rate was 100%. No plaque protrusion or stroke occurred in any patient. New ischemic lesions were observed on DWI in 10 (29%) patients. During the mean 11.6-month follow-up, no ipsilateral strokes occurred. Two (6%) patients developed asymptomatic restenosis recorded as 53% lumen narrowing and occlusion, respectively. : CAS using a closed-cell stent-in-stent technique for unstable plaque may be useful for preventing plaque protrusion and ischemic complications.
Outcomes and prognostic factors after emergent carotid artery stenting for hyperacute stroke within 6 hours of symptom onset.
Yoon Woong,Kim Byung Moon,Kim Dong Joon,Kim Dong Ik,Kim Seul Kee
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.
Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification and vascular territory of ischemic stroke lesions diagnosed by diffusion-weighted imaging.
Chung Jong-Won,Park Su Hyun,Kim Nayoung,Kim Wook-Joo,Park Jung Hyun,Ko Youngchai,Yang Mi Hwa,Jang Myung Suk,Han Moon-Ku,Jung Cheolkyu,Kim Jae Hyoung,Oh Chang Wan,Bae Hee-Joon
Journal of the American Heart Association
BACKGROUND:The association between the location and the mechanism of a stroke lesion remains unclear. A diffusion-weighted imaging study may help resolve this lack of clarity. METHODS AND RESULTS:We studied a consecutive series of 2702 acute ischemic stroke patients whose stroke lesions were confirmed by diffusion-weighted imaging and who underwent a thorough etiological investigation. The vascular territory in which an ischemic lesion was situated was identified using standard anatomic maps of the dominant arterial territories. Stroke subtype was based on the Trial of ORG 10172 in Acute Stroke Treatment, or TOAST, classification. Large-artery atherosclerosis (37.3%) was the most common stroke subtype, and middle cerebral artery (49.6%) was the most frequently involved territory. Large-artery atherosclerosis was the most common subtype for anterior cerebral, middle cerebral, vertebral, and anterior and posterior inferior cerebellar artery territory infarctions. Small vessel occlusion was the leading subtype in basilar and posterior cerebral artery territories. Cardioembolism was the leading cause in superior cerebellar artery territory. Compared with carotid territory stroke, vertebrobasilar territory stroke was more likely to be caused by small vessel occlusion (21.4% versus 30.1%, P<0.001) and less likely to be caused by cardioembolism (23.2% versus 13.8%, P<0.001). Multiple-vascular-territory infarction was frequently caused by cardioembolism (44.2%) in carotid territory and by large-artery atherosclerosis (52.1%) in vertebrobasilar territory. CONCLUSIONS:Information on vascular territory of a stroke lesion may be helpful in timely investigation and accurate diagnosis of stroke etiology.
Temporary Reversal of Blood Flow During Transcarotid Artery Revascularization Does Not Change Brain Electrical Activity in Lead-In Cases of the ROADSTER 1 Multicenter Trial.
King Alexander H,Motaganahalli Raghu L,Siddiqui Adnan,DeRubertis Brian,Moore Wesley S,DiMuzio Paul,Eccher Matthew A,Kashyap Vikram S
Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists
PURPOSE:To evaluate any intraoperative electroencephalographic (EEG) changes accompanying reversed flow with the ENROUTE Transcarotid Neuroprotection System during transcarotid artery revascularization (TCAR). METHODS:A post hoc analysis was performed of the first 81 consecutive lead-in patients (mean age 72.8±8 years; 61 men) enrolled in the ROADSTER 1 trial at 5 participating institutions. All patients had high-grade carotid artery stenosis [53 (59.3%) left sided; 12 (14.8%) contralateral occlusions] and high-risk criteria for carotid endarterectomy. A third had symptoms of either stroke (13, 16.0%) or transient ischemic attack (14, 17.3%). This subset of early patients underwent EEG monitoring to detect any cerebral changes during reversed flow as an added safety measure mandated by the ROADSTER 1 trial protocol. RESULTS:Mean flow reversal time was 12.9±8.2 minutes. The goal mean arterial pressure during reversed flow was 100 mm Hg, but 7 (8.6%) patients suffered hypotension. One (1.2%) patient had slight EEG changes secondary to blood pressure fluctuation; these resolved with blood pressure elevation. No other EEG changes were noted. One (1.2%) patient had a postoperative stroke and another (1.2%) had postoperative myocardial infarction (MI), leading to 2.5% 30-day stroke/death/MI rate. CONCLUSION:Temporary reversal of blood flow during TCAR is a safe maneuver and does not cause cerebral ischemia in the vast majority of patients, including those with contralateral carotid occlusion. Carotid stenting performed with reversed blood flow mitigates cerebral embolization and periprocedural stroke without concern for brain ischemia.
Risk index for predicting shunt in carotid endarterectomy.
Kretz Benjamin,Abello Nicolas,Bouchot Olivier,Kazandjian Caroline,Beaumont Myriam,Terriat Béatrice,Bernard Alain,Brenot Roger,Steinmetz Eric
Annals of vascular surgery
BACKGROUND:To prevent ischemia during carotid endarterectomy, a routine or selective shunt can be set up in cases of insufficient cerebral perfusion during the carotid clamping. The aim of this study was to analyze predictive factors for shunting under locoregional anesthesia and to validate a risk index to predict shunt. METHODS:Using a prospective database, we studied carotid endarterectomy performed under locoregional anesthesia between January 1, 2003, and December 31, 2010 (n=1,223). A shunt was used because of clinical intolerance of clamping in 88 cases (group S, 7.2%). Clinical, comorbidities, demographics, and duplex scan data were used to compare group S to a control group (group C, n=1,135, 92.8%). A multivariable logistic regression was performed to identify predictors of shunt. Coefficients were assigned to each predictor to propose a predictive score. RESULTS:Patients in group S were significantly older than those in group C (75.6±7.8 years vs. 72.6±9.4 years, P<0.001). Other factors associated with a carotid shunt were female sex (odds ratio [OR]=2.41, 95% confidence interval [CI]: 1.54-3.78, P<0.001), systemic arterial hypertension (OR=2.478, 95% CI: 1.16-4.46, P=0.016), occlusion of the contralateral carotid artery (OR=6.03, 95% CI: 2.91-12.48, P<0.001), and 1 factor against the likelihood of a carotid shunt, a history of contralateral carotid surgery (OR=0.34, 95% CI: 0.12-0.93, P=0.037). The mean flow in the contralateral common carotid artery was 696.5±298.0 mL/sec in group S and 814.7±285.5 mL/sec in group C (P<0.001). Using those 6 items, we propose a prognostic score validated in our series and allowing to divided risk of intolerance of clamping into low-risk (≤6%), intermediate-risk (6.1%-15%), and high-risk (>15%) groups. CONCLUSIONS:We have established the first version of a score that predicts the need for a shunt by studying factors associated with intolerance to clamping. The relevance of this score, validated in our series, must be confirmed and adjusted by studies based on a larger sample size.
Natural history of acute stroke due to occlusion of the middle cerebral artery and intracranial internal carotid artery.
Hernández-Pérez María,Pérez de la Ossa Natalia,Aleu Aitziber,Millán Mònica,Gomis Meritxell,Dorado Laura,López-Cancio Elena,Jovin Tudor,Dávalos Antoni
Journal of neuroimaging : official journal of the American Society of Neuroimaging
BACKGROUND AND PURPOSE:The natural history of acute ischemic stroke (AIS) due to anterior circulation large artery occlusion is not well established. This information is essential for assessment of clinical benefit derived from recanalization therapies. METHODS:Patients with AIS due to anterior circulation large artery occlusion not treated with reperfusion therapies admitted from January 2005 to September 2010 were consecutively selected. Site of occlusion was assessed with transcranial duplex according to Thrombolysis in Brain Infarction (TIBI) grades. Poor outcome was considered as a modified Rankin Scale>2 at 90 days. RESULTS:A total of 120 patients were studied. Site of occlusion was terminal internal carotid artery (TICA) in 13 (10.8%), proximal middle cerebral artery (MCA) in 69 (57.5%), and distal MCA in 38 (31.7%) patients. Overall, 74.2% of patients had poor outcome. There were significant differences in poor outcome between patients with TICA, proximal MCA, and distal MCA occlusion (92%, 87%, 47%, P < .001) and mortality at 90 days (23%, 12%, 3%, P = .001). CONCLUSIONS:Outcome of AIS patients with anterior circulation large artery occlusion not treated with reperfusion therapies is extremely poor in TICA and proximal MCA occlusions with better outcomes noted in distal MCA occlusions. These findings are relevant for estimation of treatment effect of reperfusion therapies according to occlusion location.
Endovascular Treatment in Patients with Persistent Internal Carotid Artery Occlusion after Intravenous Tissue Plasminogen Activator: A Clinical Effectiveness Study.
Hong Jeong-Ho,Sohn Sung-Il,Kang Jihoon,Jang Min Uk,Kim Beom Joon,Han Moon-Ku,Park Tai Hwan,Park Sang-Soon,Lee Kyung Bok,Lee Byung-Chul,Yu Kyung-Ho,Oh Mi Sun,Cha Jae Kwan,Kim Dae Hyun,Lee Jun,Lee Soo Joo,Ko Youngchai,Kim Jae Guk,Park Jong-Moo,Kang Kyusik,Cho Yong-Jin,Hong Keun-Sik,Cho Ki-Hyun,Kim Joon-Tae,Choi Jay Chol,Lee Juneyoung,Lee Ji-Sung,Gorelick Philip B,Bae Hee-Joon
Cerebrovascular diseases (Basel, Switzerland)
BACKGROUND:There has been no large-scale trial comparing endovascular treatment (add-on EVT) after intravenous tissue plasminogen activator (IV tPA) and IV tPA alone in acute ischemic stroke (AIS) caused by internal carotid artery occlusion (ICAO). We aimed at investigating the effectiveness and safety of add-on EVT after IV tPA in AIS patients with ICAO. METHODS:Between March 2010 and March 2013, 3,689 consecutive ischemic stroke patients who were hospitalized within 4.5 h of onset were identified using a prospective stroke registry at 11 centers in Korea. Among them, patients with persistent ICAO after receiving IV tPA and whose 3-month modified Rankin Scale (mRS) was available were finally enrolled. A propensity score analysis with inverse-probability of treatment weighting was used to eliminate baseline imbalances between those receiving add-on EVT and IV tPA alone. RESULTS:Among 264 patients enrolled in this study (mean age 71.4; male 56.4%; median National Institute of Health Stroke Scale score 15), 117 (44.3%) received add-on EVT. The add-on EVT group had a higher frequency of favorable outcome on the mRS ≤2 (35.0 vs. 18.4%; adjusted OR (aOR) 2.79; 95% CI 1.66-4.67) and lower mortality (17.9 vs. 35.4%; aOR 0.24; 95% CI 0.13-0.42) at 3 months, when compared to the IV tPA-alone group. Add-on EVT did not significantly increase the risk of symptomatic hemorrhage (5.1 vs. 4.1%; aOR 1.01; 95% CI 0.37-2.70). The rate of successful recanalization (thrombolysis in cerebral infarction grade ≥2b) in the add-on EVT group was 69.2%. CONCLUSIONS:Compared to an IV tPA alone, add-on EVT can improve clinical outcomes in patients with symptomatic ICAO within 4.5 h of onset without a significant increase of symptomatic hemorrhage.
Risk Factors for Low-Flow Related Ischemic Complications and Neurologic Worsening in Patients with Complex Internal Carotid Artery Aneurysm Treated by Extracranial to Intracranial High-Flow Bypass.
Matsukawa Hidetoshi,Tanikawa Rokuya,Kamiyama Hiroyasu,Tsuboi Toshiyuki,Noda Kosumo,Ota Nakao,Miyata Shiro,Suzuki Go,Takeda Rihee,Tokuda Sadahisa
BACKGROUND:The revascularization technique has remained indispensable for complex aneurysms. However, risk factors for low-flow related ischemic complications (LRICs) and neurologic worsening (NW) have been less well documented. We evaluated the risk factors for LRICs and NW in 67 patients treated with extracranial to intracranial bypass graft using radial artery or saphenous vein graft for complex internal carotid artery (ICA) aneurysm with ICA occlusion. METHODS:Intraoperative middle cerebral artery pressure (MCAP) by backup superficial temporal artery to middle cerebral artery bypass was measured. The MCAP ratio was the ratio of the MCAP after release of the graft bypass to the initial MCAP. LRICs were defined as new neurologic deficits and ipsilateral cerebral blood flow reduction in single-photon emission computed tomography. Early and late NW were defined as an increase in 1 or more modified Rankin Scale at discharge and at the 12-month follow-up examination. RESULTS:During a median follow-up period of 13.3 months, LRICs were observed in 7 patients (10%). The Cox proportional hazards model showed that an MCAP ratio ≤0.80 was significantly related to LRICs. Multivariate logistic regression analysis revealed that perforating artery ischemia was significantly associated with early NW (n = 13, 19%) and late NW (n = 7, 13%). It also showed that LRICs were also significantly related to late NW. CONCLUSIONS:The present study showed that regardless of the graft type, the MCAP ratio was associated with LRICs, which were related to late NW in patients with complex ICA aneurysms treated by extracranial to intracranial high-flow bypass graft.
Perioperative and Follow-up Results of Carotid Artery Stenting and Carotid Endarterectomy in Patients with Carotid Near-Occlusion.
Yan Dong,Tang Xiao,Shi Zhenyu,Wang Lixin,Lin Changpo,Guo Daqiao,Fu Weiguo
Annals of vascular surgery
BACKGROUND:The aim was to compare perioperative and follow-up results of carotid artery stenting (CAS) and carotid endarterectomy (CEA) in patients with carotid near-occlusion (NO). METHODS:A retrospective analysis was conducted from January 2012 to June 2017 on consecutive patients with NO in our center. Perioperative complications, recurrence rate of ischemic stroke, restenosis rate, and mortality in follow-up were compared between the CAS group and CEA group. RESULTS:92 patients (CAS group, 54 and CEA group, 38) were identified. Perioperative (30-day) results were as follows: the rate of new lesions on diffusion-weighted imaging (DWI) was higher in the CAS group (n = 31, 57.4%) than in the CEA group (n = 13, 34.2%) (P = 0.03); no differences were found in ischemic stroke, transient ischemic attack (TIA), cardiac infarction, and death rate between the two groups. Results from follow-up with a mean period of 28.3 (range from 3 to 60) months were as follows: the restenosis rate was lower in the CAS group (n = 1, 1.8%) than the CEA group (n = 4, 10.5%) (P = 0.04); no differences were found in ischemic stroke, TIA, and the death rate between the two groups. Kaplan-Meier survival curves showed that the five-year survival rate was 85.8% of the CAS group and 82.7% of the CEA group (P = 0.61); the five-year rate of freedom from target-lesion restenosis was 93.3% of the CAS group and 80.4% of the CEA group (P = 0.02). CONCLUSIONS:Both CAS and CEA can be used for carotid NO with the same rate of TIA/stroke and long-term survival. The rate of new lesions on DWI after CAS was higher than that in CEA in the perioperative period. CAS had a lower restenosis rate than CEA in follow-up, which might be more beneficial for remodeling of the distal internal carotid artery.
Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): a randomised controlled trial with cost-effectiveness analysis.
Featherstone Roland L,Dobson Joanna,Ederle Jörg,Doig David,Bonati Leo H,Morris Stephen,Patel Nishma V,Brown Martin M
Health technology assessment (Winchester, England)
BACKGROUND:Carotid artery stenting (CAS) is an alternative to carotid endarterectomy (CEA) for the treatment of carotid stenosis, but safety and long-term efficacy were uncertain. OBJECTIVE:To compare the risks, benefits and cost-effectiveness of CAS versus CEA for symptomatic carotid stenosis. DESIGN:International, multicentre, randomised controlled, open, prospective clinical trial. SETTING:Hospitals at 50 centres worldwide. PARTICIPANTS:Patients older than 40 years of age with symptomatic atheromatous carotid artery stenosis. INTERVENTIONS:Patients were randomly allocated stenting or endarterectomy using a computerised service and followed for up to 10 years. MAIN OUTCOME MEASURES:The primary outcome measure was the long-term rate of fatal or disabling stroke, analysed by intention to treat (ITT). Disability was assessed using the modified Rankin Scale (mRS). A cost-utility analysis estimating mean costs and quality-adjusted life-years (QALYs) was calculated over a 5-year time horizon. RESULTS:A total of 1713 patients were randomised but three withdrew consent immediately, leaving 1710 for ITT analysis (853 were assigned to stenting and 857 were assigned to endarterectomy). The incidence of stroke, death or procedural myocardial infarction (MI) within 120 days of treatment was 8.5% in the CAS group versus 5.2% in the CEA group (72 vs. 44 events) [hazard ratio (HR) 1.69, 95% confidence interval (CI) 1.16 to 2.45; p = 0.006]. In the analysis restricted to patients who completed stenting, age independently predicted the risk of stroke, death or MI within 30 days of CAS (relative risk increase 1.17% per 5 years of age, 95% CI 1.01% to 1.37%). Use of an open-cell stent conferred higher risk than a closed-cell stent (relative risk 1.92, 95% CI 1.11 to 3.33), but use of a cerebral protection device did not modify the risk. CAS was associated with a higher risk of stroke in patients with an age-related white-matter changes score of 7 or more (HR 2.98, 95% CI 1.29 to 6.93; p = 0.011). After completion of follow-up with a median of 4.2 years, the number of patients with fatal or disabling stroke in the CAS and CEA groups (52 vs. 49), and the cumulative 5-year risk did not differ significantly (6.4% vs. 6.5%) (HR 1.06, 95% CI 0.72 to 1.57; p = 0.776). Stroke of any severity was more frequent in the CAS group (15.2% vs. 9.4% in the CEA group) (HR 1.712, 95% CI 1.280 to 2.300; p < 0.001). There was no significant difference in long-term rates of severe carotid restenosis or occlusion (10.8% in the CAS group vs. 8.6% in the CEA group) (HR 1.25, 95% CI 0.89 to 1.75; p = 0.20). There was no difference in the distribution of mRS scores at 1-year, 5-year or final follow-up. There were no differences in costs or QALYs between the treatments. LIMITATIONS:Patients and investigators were not blinded to treatment allocation. Interventionists' experience of stenting was less than that of surgeons with endarterectomy. Data on costs of managing strokes were not collected. CONCLUSIONS:The functional outcome after stenting is similar to endarterectomy, but stenting is associated with a small increase in the risk of non-disabling stroke. The choice between stenting and endarterectomy should take into account the procedural risks related to individual patient characteristics. Future studies should include measurement of cognitive function, assessment of carotid plaque morphology and identification of clinical characteristics that determine benefit from revascularisation. TRIAL REGISTRATION:Current Controlled Trials ISRCTN25337470. FUNDING:This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 20. See the NIHR Journal Library website for further project information. Further funding was provided by the Medical Research Council, Stroke Association, Sanofi-Synthélabo and the European Union.
Outcomes of Endovascular Thrombectomy Performed 6-24 h after Acute Stroke from Extracranial Internal Carotid Artery Occlusion.
Okumura Eitaro,Tsurukiri Junya,Ota Takahiro,Jimbo Hiroyuki,Shigeta Keigo,Amano Tatsuo,Ueda Masayuki,Matsumaru Yuji,Shiokawa Yoshiaki,Hirano Teruyuki
Thrombectomy has demonstrated clinical efficacy against acute ischemic stroke caused by intracranial occlusion of the internal carotid artery (ICA), even if performed 6-24 h after onset. This study investigated the outcomes of thrombectomy performed 6-24 h after stroke onset caused by extracranial ICA occlusion. Of 586 stroke patients receiving thrombectomy during the past 3 years and registered in the Tama Registry of Acute Endovascular Thrombectomy database, 24 were identified with ICA occlusion (14 extracranial and 10 intracranial), known to be well 6-24 h before presentation, and with pre-stroke modified Rankin Scale (mRS) score of 0 or 1. Clinical outcomes measured were the rate of functional independence at 90 days according to mRS score of 0-2 and 90 day mortality rate. Of patients with extracranial ICA occlusion, two received additional carotid stenting with thrombectomy. The median interval between the last time the patient was known to be well and hospital arrival was 601 (interquartile range, 476-729 min). Both the rate of functional independence at 90 days and 90 day mortality were comparable between patients with extracranial or intracranial ICA occlusion (36% vs. 40% and 7% vs. 10%, respectively). No symptomatic intracranial hemorrhages occurred within 24 h following treatment of extracranial ICA occlusion. Thrombectomy performed 6-24 h after extracranial ICA results in acceptable functional outcome. Further clinical study is warranted to better define the temporal window of thrombectomy for acceptable functional outcome in patients with extracranial ICA occlusion.
Recanalization therapy for internal carotid artery occlusion presenting as acute ischemic stroke.
Hong Jeong-Ho,Kang Jihoon,Jang Min Uk,Kim Beom Joon,Han Moon-Ku,Park Tai Hwan,Park Sang-Soon,Lee Kyung Bok,Lee Byung-Chul,Yu Kyung-Ho,Oh Mi Sun,Cha Jae Kwan,Kim Dae-Hyun,Lee Jun,Lee Soo Joo,Ko Youngchai,Park Jong-Moo,Kang Kyusik,Cho Yong-Jin,Hong Keun-Sik,Cho Ki-Hyun,Kim Joon-Tae,Lee Juneyoung,Lee Ji Sung,Bae Hee-Joon
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
BACKGROUND:We aimed to describe the current status and clinical outcomes of recanalization therapy for internal carotid artery occlusion (ICAO) presenting as acute ischemic stroke. METHODS:Using a nationwide stroke registry database in Korea, we identified consecutive ischemic stroke patients with ICAO hospitalized within 12 hours of onset between March 2010 and November 2011. RESULTS:ICAO accounted for 10.6% (322 of 3028) of acute ischemic strokes within 12 hours of onset. Among the 322 ICAO patients, 53% underwent recanalization therapy, 41% intravenous thrombolysis (IVT) alone, and 59% endovascular treatment (EVT). Twenty-two percent of those with mild deficits (National Institutes of Health Stroke Scale <4) and 50% of those 80 years of age or more received recanalization therapy. Compared with no treatment, recanalization therapy was not significantly associated with a favorable outcome (3-month modified Rankin scale, 0-2) (adjusted odds ratio [OR], 1.77; 95% confidence interval [CI], .80-3.91; P = .16). However, compared with IVT, EVT significantly improved the odds of favorable outcome (OR, 2.86; 95% CI, 1.19-6.88; P = .02) without significant increase of symptomatic intracranial hemorrhage (OR, 2.18; 95% CI, .42-11.43; P = .36) and 3-month mortality (OR, .53; 95% CI, .23-1.18; P = .12). Successful recanalization rate (Thrombolysis in Cerebral Infarction ≥2a) by EVT was 76%. CONCLUSIONS:In Korea, one tenth of acute ischemic stroke was caused by ICAO, and about 50% were treated by recanalization therapy. EVT was widely used as a recanalization modality (about 60% of cases) despite lack of evidence. However, its effectiveness and safety were acceptable.
Emergent Large Vessel Occlusion Screen Is an Ideal Prehospital Scale to Avoid Missing Endovascular Therapy in Acute Stroke.
Suzuki Kentaro,Nakajima Nobuhito,Kunimoto Kenta,Hatake Seira,Sakamoto Yuki,Hokama Hiroyuki,Nomura Koichi,Hayashi Toshiyuki,Aoki Junya,Suda Satoshi,Nishiyama Yasuhiro,Kimura Kazumi
Background and Purpose- The strong evidence of endovascular therapy in acute ischemic stroke patients with large vessel occlusion (LVO) is revealed. Such patients are required to direct transport to the hospital capable of endovascular therapy. There are several prehospital scales available for paramedics to predict LVO. However, they are time consuming, and several of them include factors caused by other types than LVO. Therefore, we need a fast, simple, and reliable prehospital scale for LVO. Methods- We developed a new prehospital stroke scale, emergent large vessel occlusion (ELVO) screen, for paramedics to predict LVO. The study was prospectively performed by multistroke centers. When paramedics referred to stroke center to accept suspected stroke patients, we obtain the following information over the telephone. ELVO screen was designed focusing on cortical symptoms: 1 observation; presence of eye deviation and 2 questions; paramedics show glasses, what is this? and paramedics show 4 fingers, how many fingers are there? If the presence of eye deviation or ≥1 of the 2 items were incorrect, ELVO screen was identified as positive. We evaluated between results of ELVO screen and presence of LVO on magnetic resonance angiography at hospital arrival. Results- A total of 413 patients (age, 74±13 years; men, 234 [57%]) were enrolled. Diagnosis was ischemic stroke, 271 (66%); brain hemorrhage 73 (18%); subarachnoid hemorrhage, 7 (2%); and not stroke, 62 (15%). One hundred fourteen patients had LVO (internal carotid artery, 33 [29%]; M1, 52 [46%]; M2, 21 [18%]; basilar artery, 5 [4%]; P1, 3 [3%]). Sensitively, specificity, positive predictive value, negative predictive value, and accuracy for ELVO screen to predict LVO were 85%, 72%, 54%, 93% and 76%, respectively. Among 233 patients with negative ELVO screen, only 17 (7%) had LVO, which indicated to be an ideal scale to avoid missing endovascular therapy. Conclusions- The ELVO screen is a simple, fast, and reliable prehospital scale for paramedics to identify stroke patients with LVO for whom endovascular therapy is an effective treatment.
Primary Thrombectomy Versus Combined Mechanical Thrombectomy and Intravenous Thrombolysis in Large Vessel Occlusion Acute Ischemic Stroke.
Guimarães Rocha Mariana,Carvalho Andreia,Rodrigues Marta,Cunha André,Figueiredo Sofia,Martins de Campos António,Gregório Tiago,Paredes Ludovina,Veloso Miguel,Barros Pedro,Castro Sérgio,Ribeiro Manuel,Costa Henrique
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
Mechanical thrombectomy (MT) in combination with intravenous thrombolysis (IVT) is the standard of care for patients with acute ischemic stroke with anterior circulation large vessel occlusion. The particular benefit of IVT in these patients is unknown. We performed a retrospective analysis of patients submitted to MT at our center between January 2015 and June 2017. Functional outcome was prospectively assessed using modified Rankin scale (mRS) at 3 months. A total of 234 patients were enrolled, 152 (65%) in the combined treatment group and 82 (35%) in the direct MT group. Patients receiving combined treatment had a higher frequency of intracranial internal carotid artery occlusion (48 [31.6%] versus 16 [19.5%], P = .048) and significantly less strokes of cardioembolic etiology (72 [47.4%] versus 57 [69.5%], P = .01). Other baseline characteristics did not differ between the 2 groups. Good functional outcome at 3 months (mRS 0-2) was trending toward being higher in patients in the combined treatment group (98 [64.9%] versus 42 [52.5%], P = .066). Rates of symptomatic intracranial hemorrhage (5 [3.3%] versus 4 [4.9%], P = .723) and mortality (15 [9.9%] versus 14 [17.5%], P = .099) did not differ between groups. In multivariate logistic regression analysis, we did not find a statistically significant association between the use of IVT and any of the outcomes studied. Our results suggest that combined treatment carries similar effectiveness and safety than direct MT. Randomized controlled trials regarding this subject are warranted.
The efficacy and safety of endovascular recanalization of occluded large cerebral arteries during the subacute phase of cerebral infarction: a case series report.
Chen Kangning,Hou Xianhua,Zhou Zhenhua,Li Guangjian,Liu Qu,Gui Li,Hu Jun,Shi Shugui
Stroke and vascular neurology
BACKGROUND:Intravenous tissue plasminogen activator with or without mechanical thrombectomy during the acute phase are approved therapies for ischaemic stroke. Due to the short treatment time window (<6 hours) and often treatment failure, these patients would still have an intracranial arterial occlusion (IAO). It is unclear whether these patients can benefit from subsequent interventional recanalizationof their occluded artery in the subacute phase. In this retrospective study, we have examined the efficacy and safety in patients who have received either percutaneous transluminal angioplasty (PTA) or percutaneous transluminal angioplasty and stenting (PTAS) for IAO in the subacute phase of their stroke. METHODS:Patients with subacute symptomatic ischaemic stroke caused by IAO were assessed to identify the responsible artery and low perfusion areas by CT angiography, MR angiography or digital subtraction angiography. In eligible patients, a PTA or PTAS was performed to reopen the occluded artery. Regular antithrombotic therapy, use of statins, control of risk factors and rehabilitation therapy were prescribed after the procedure. All patients had regular follow-up up to 12 months. RESULTS:PTA or PTAS was performed in 16 patients with cerebral infarction caused by IAO in the subacute phase. After the procedure, 12 cases were recanalized, two were partially recanalized and two failed to open. One patient with left C6 segment occlusion of the carotid artery had a central retinal artery embolism after PTAS. The perioperative adverse events were 6.25%. At 3 months, the distribution of modified Rankin scale scores was 0 (seven cases), 1 (three cases), 2 (five cases) and 3 (one case). CONCLUSION:Selective PTA or PTAS could be performed in ischaemic stroke patients with a small infarct size and large area of hypoperfusion from an occluded large cerebral artery after the acute phase. It may improve neurological dysfunction and reduce the incidence of disability.
[Criteria of the efficacy of surgical brain revascularization in patients with chronic cerebral ischemia].
Lukshin V A,Usachev D Yu,Pronin I N,Shmigel'skiy A V,Akhmedov A D,Shevchenko E V
Zhurnal voprosy neirokhirurgii imeni N. N. Burdenko
PURPOSE:The article analyzes results of surgical revascularization in patients with symptoms of chronic cerebral ischemia caused by occlusion of the carotid arteries. MATERIAL AND METHODS:We analyzed 404 surgeries for placement of extra-intracranial microvascular anastomoses (EICMAs) performed in 376 patients between 2000 and 2015. All patients underwent detailed neurological and neuropsychological examinations before surgery and throughout the follow-up period using the neurological deficit scale (NIHSS). Additionally, the medical history data, technical features of surgery, and results of instrumental tests were recorded. For a more detailed study of the cerebral circulation, a SCT perfusion examination was conducted in 58 patients before and after placement of EICMA. RESULTS:All patients were divided into 3 groups, depending on the surgical treatment outcomes: improvement (53%), without significant changes (43%), and worsening of clinical symptoms (4%). A statistical analysis revealed that the efficacy of EICMA surgery ranged from 22 to 79% and was reliably confirmed by hemodynamic and anamnestic factors as well as by technical details of surgery. CONCLUSION:When determining the indications for surgical revascularization in patients with ischemic stroke consequences, the patient's age, occlusion duration, location and size of ischemic lesions should be considered. Also, the choice of the acceptor artery and blood flow through the created anastomosis are of great importance.
Contralateral occlusion of the internal carotid artery increases the risk of patients undergoing carotid endarterectomy.
Antoniou George A,Kuhan Ganesh,Sfyroeras George S,Georgiadis George S,Antoniou Stavros A,Murray David,Serracino-Inglott Ferdinand
Journal of vascular surgery
BACKGROUND:Controversy exists about whether occlusion of the contralateral internal carotid artery in patients undergoing carotid endarterectomy (CEA) is associated with a worse perioperative prognosis and outcome. METHODS:A systematic review of electronic information sources was undertaken to identify studies comparing perioperative and early outcomes of CEA in patients with occluded and patent contralateral carotid arteries. The methodologic quality of selected studies was independently appraised by two reviewers. Fixed- and random-effects models were applied to synthesize outcome data. RESULTS:Our literature search located 46 articles eligible for inclusion in the review and analysis. The total population comprised 27,265 patients having undergone 28,846 CEAs (occluded contralateral artery group, 3120; patent contralateral artery group, 25,726). Patients with an occluded contralateral carotid artery had increased incidence of stroke (odds ratio [OR], 1.65, 95% confidence interval [CI], 1.30-2.09), transient ischemic attack (OR, 1.57, 95% CI, 1.11-2.21), stroke/transient ischemic attack (OR, 1.52; 95% CI, 1.21-1.90), and death (OR, 1.76; 95% CI, 1.19-2.59) ≤30 days of treatment compared with those with a patent contralateral vessel. No difference in the incidence of myocardial infarction between the two groups was identified (OR, 1.45; 95% CI, 0.73-2.89). CONCLUSIONS:Patients undergoing CEA in the presence of an occluded contralateral carotid artery had increased perioperative and early postoperative risk. Our analysis is limited by heterogeneity in symptom status and practices of intraoperative cerebral protection among the studies. Careful consideration should be given in this subgroup of patients with regard to selection and perioperative and postoperative care to minimize the risk.
Effects of noninvasive facial nerve stimulation in the dog middle cerebral artery occlusion model of ischemic stroke.
Borsody Mark K,Yamada Chisa,Bielawski Dawn,Heaton Tamara,Castro Prado Fernando,Garcia Andrea,Azpiroz Joaquín,Sacristan Emilio
BACKGROUND AND PURPOSE:Facial nerve stimulation has been proposed as a new treatment of ischemic stroke because autonomic components of the nerve dilate cerebral arteries and increase cerebral blood flow when activated. A noninvasive facial nerve stimulator device based on pulsed magnetic stimulation was tested in a dog middle cerebral artery occlusion model. METHODS:We used an ischemic stroke dog model involving injection of autologous blood clot into the internal carotid artery that reliably embolizes to the middle cerebral artery. Thirty minutes after middle cerebral artery occlusion, the geniculate ganglion region of the facial nerve was stimulated for 5 minutes. Brain perfusion was measured using gadolinium-enhanced contrast MRI, and ATP and total phosphate levels were measured using 31P spectroscopy. Separately, a dog model of brain hemorrhage involving puncture of the intracranial internal carotid artery served as an initial examination of facial nerve stimulation safety. RESULTS:Facial nerve stimulation caused a significant improvement in perfusion in the hemisphere affected by ischemic stroke and a reduction in ischemic core volume in comparison to sham stimulation control. The ATP/total phosphate ratio showed a large decrease poststroke in the control group versus a normal level in the stimulation group. The same stimulation administered to dogs with brain hemorrhage did not cause hematoma enlargement. CONCLUSIONS:These results support the development and evaluation of a noninvasive facial nerve stimulator device as a treatment of ischemic stroke.
Vessel Dilation Attenuates Endothelial Dysfunction Following Middle Cerebral Artery Occlusion in Hyperglycemic Rats.
Mu Zhi-Hao,Jiang Zhen,Lin Xiao-Jie,Wang Li-Ping,Xi Yan,Zhang Zhi-Jun,Wang Yong-Ting,Yang Guo-Yuan
CNS neuroscience & therapeutics
OBJECTIVES:Dynamically observe cerebral vascular changes in hyperglycemic rats in vivo and explore the effect of diabetes on endothelial function after ischemic stroke. BACKGROUND:Diabetes affects both large and small vessels in the brain, but the dynamic process and mechanism are unclear. METHODS:We investigated the structural and functional changes of brain vasculature in living hyperglycemic rats and their impact on stroke outcomes via a novel technique: synchrotron radiation angiography. We also examined the effect of prolonged fasudil treatment on arterial reactivity and hemorrhagic transformation. Adult Sprague Dawley rats were treated by streptozotocin to induce type 1 diabetes. These hyperglycemic rats received fasudil pretreatment and then underwent transient middle cerebral artery occlusion. RESULTS:We found that diabetes caused arteries narrowing in the circus Willis as early as 2 weeks after streptozotocin injection (P < 0.05). These vessels were further constricted after middle cerebral artery occlusion. L-NAME could induce regional constrictions and impaired relaxation in hyperglycemic animals. Furthermore, hemorrhagic transformation was also increased in the hyperglycemic rats compared to the control (P < 0.05). In fasudil-treated rats, the internal carotid artery narrowing was ameliorated and L-NAME-induced regional constriction was abolished. Importantly, stroke prognosis was improved in fasudil-treated rats compared to the control (P < 0.05). CONCLUSIONS:Our dynamic angiographic data demonstrated that diabetes could impair the cerebral arterial reactivity. Prolonged fasudil treatment could attenuate arterial dysfunction and improve the prognosis of ischemic stroke by affecting both the large and small vasculature.
Endovascular therapy in 201 patients with acute symptomatic occlusion of the internal carotid artery.
Fischer U,Mono M-L,Schroth G,Jung S,Mordasini P,El-Koussy M,Weck A,Brekenfeld C,Findling O,Galimanis A,Heldner M R,Arnold M,Mattle H P,Gralla J
European journal of neurology
BACKGROUND AND PURPOSE:Endovascular therapy is used increasingly for treatment of acute symptomatic internal carotid artery (ICA) occlusion, although randomized trials are lacking. Predictors of outcome are therefore of special interest. METHODS:From 1992 to 2010 we treated 201 patients with acute ICA occlusion with intra-arterial pharmacological thrombolysis (32), endovascular mechanical therapy (78) or a combination of both (91). All data were assessed prospectively. RESULTS:There were 76/38% patients with tandem occlusions [ICA plus middle (MCA) or anterior cerebral arteries (ACA)], 18/9% without concomitant occlusions of major intracranial arteries (ICA plus branch occlusion) and 107/53% with functional ICA-T occlusions (ICA plus MCA and ACA). Median baseline National Institute of Health Stroke Scale (NIHSS) score was 17. Good recanalization (Thrombolysis in Myocardial Infarction 2-3) was achieved in (157/201) 78% patients and good reperfusion (Thrombolysis in Cerebral Infarction 2-3) in (151/182) 83%. Better recanalization rates were obtained with mechanical approaches, with/without thrombolytics (78/91 = 86% and 64/78 = 82%) compared with pharmacological thrombolysis only (15/32 = 47%; P < 0.001). Twelve patients (6%) suffered symptomatic intracranial haemorrhages. The 3-month outcome was favourable [modified Rankin score (mRS) 0-2] in 54/28% patients and moderate (mRS 0-3) in 90/46%; 60/31% patients died. Only 17/16% patients with functional ICA-T occlusions had favourable outcomes compared with 32/44% with tandem occlusions and 5/31% with ICA plus cerebral branch occlusions (P = 0.001). In multivariate analysis age [odds ratio (OR) = 0.96, 95% confidence interval (CI) = 0.93-0.98], NIHSS on admission (OR = 0.9, 95% CI = 0.83-0.98) and functional ICA-T occlusion (OR = 0.35, 95% CI = 0.16-0.77) were non-modifiable predictors, and vessel recanalization was the only modifiable predictor of outcome (OR = 9.30, 95% CI = 2.03-42.63). CONCLUSIONS:The outcome of acute symptomatic ICA occlusion is poor. However, recanalization is associated with better outcome, and recanalization rates with mechanical techniques were superior to merely pharmacological recanalization attempts.
[Simultaneous reconstruction of the carotid and vertebral arteries using a temporary intraluminal shunt (a clinical case)].
Usachev D Yu,Lukshin V A,Shevchenko E V,Shmigel'skiy A V,Sosnin A D,Akhmedov A D
Zhurnal voprosy neirokhirurgii imeni N. N. Burdenko
The article describes a case of one-stage surgical treatment of a patient with progressive chronic cerebral ischemia caused by combined steno-occlusive lesions of the carotid and vertebral arteries. The disease was complicated by intolerance to temporary occlusion of the carotid artery due to an incomplete circle of Willis. We performed extra-anatomic carotid-vertebral artery bypass with subsequent ipsilateral carotid endarterectomy. A temporary intraluminal shunt was used at the main stage of reconstructive surgery. We use this clinical case to analyze the issues of surgical treatment for combined lesions of the carotid and vertebral arteries and the techniques for prevention of associated ischemic complications.
Medical Therapy for Asymptomatic Patients and Stent Placement for Symptomatic Patients Presenting with Carotid Artery Near-Occlusion with Full Collapse.
Neves Celso Ricardo Bregalda,Casella Ivan Benaduce,da Silva Erasmo Simão,Puech-Leão Pedro
Journal of vascular and interventional radiology : JVIR
PURPOSE:To report long-term results of stent placement and medical therapy for symptomatic and asymptomatic patients, respectively, with carotid artery near-occlusion with full collapse. MATERIALS AND METHODS:Between January 2008 and December 2010, 204 carotid arteries diagnosed by duplex scanning as exhibiting complete occlusion were re-examined with CT angiography; 46 arteries in 46 patients were patent with threadlike lumens and were reclassified as exhibiting near-occlusion with full collapse. Asymptomatic patients (n = 22) received best medical therapy (BMT) alone, and symptomatic patients (n = 24) were referred for carotid artery stent (CAS) placement plus BMT. Patients underwent clinical follow-up for 63.9 months ± 23.6 and duplex surveillance. RESULTS:None of the 22 asymptomatic patients treated with BMT alone experienced neurologic events during the follow-up interval. Four died of unrelated causes, resulting in a cumulative survival rate of 81.8%. Technical failure occurred in 5 of 24 symptomatic patients, but none had perioperative complications related to inability to cross the near-occlusion. Of the 19 patients with procedural success, 1 developed immediate upper limb monoparesis; none had periprocedural myocardial infarction, and none died. At 60-month follow-up, patients who underwent successful CAS placement had neurologic event-free and cumulative survival rates of 89.4% and 89.4%; patients with failed recanalization had neurologic event-free and cumulative survival rates of 0% and 40.0% (P = .01). CONCLUSIONS:Asymptomatic patients with carotid near-occlusion with full collapse experienced good outcomes with BMT alone. Symptomatic patients who underwent CAS placement demonstrated long-term survival and freedom from neurologic event rates comparable to those of asymptomatic patients.
The Carotid and Middle cerebral artery Occlusion Surgery Study (CMOSS): a study protocol for a randomised controlled trial.
Ma Yan,Gu Yuxiang,Tong Xiaoguang,Wang Jiyue,Kuai Dong,Wang Donghai,Ren Jun,Duan Lian,Maimaiti Aili,Cai Yiling,Huang Yujie,Wang Xiaojian,Cao Yi,You Chao,Yu Jiasheng,Jiao Liqun,Ling Feng
BACKGROUND:Patients with symptomatic internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion with haemodynamic insufficiency are at high risk for recurrent stroke when treated medically. METHODS:The Carotid or Middle cerebral artery Occlusion Surgery Study (CMOSS) trial is an ongoing, government-funded, prospective, multicentre, randomised controlled trial. The CMOSS will recruit 330 patients with symptomatic ICA or MCA occlusion (parallel design, 1:1 allocation ratio) and haemodynamic insufficiency. Participants will be allocated to best medical treatment alone or best medicine plus extracranial-intracranial (EC-IC) bypass surgery. The primary outcome events are all strokes or deaths occurring between randomisation and 30 days post operation or post randomisation and ipsilateral ischaemic stroke within 2 years. Recruitment will be finished by December 2016. All the patients will be followed for at least 2 years. The trial is scheduled to complete in 2019. DISCUSSION:The CMOSS will test the hypothesis that EC-IC bypass surgery plus best medical therapy reduces subsequent ipsilateral ischaemic stroke in patients with symptomatic ICA or MCA occlusion and haemodynamic cerebral ischaemia. This manuscript outlines the rationale and the design of the study. CMOSS will allow for more critical reappraisal of the EC-IC bypass for selected patients in China. TRIAL REGISTRATION:NCT01758614 with ClinicalTrials.gov. Registered on 24 December 2012.
Clinical implications of collateral middle cerebral artery flow in acute ischaemic stroke with internal carotid artery occlusion.
Kim J-T,Park M-S,Choi K-H,Nam T-S,Choi S-M,Cho K-H
European journal of neurology
BACKGROUND AND PURPOSE:The presence of collateral middle cerebral artery (MCA) flow via the primary collateral pathway is thought to protect against the progression of cerebral ischaemia. However, there have been few reports on early clinical outcomes according to the presence of collateral MCA flow in acute ischaemic stroke (AIS) with internal carotid artery (ICA) occlusion. Therefore, we sought to investigate the early clinical outcomes and lesion patterns according to the presence of collateral MCA flows in AIS with ICA occlusion. METHODS:This is a retrospective study of patients with AIS with ICA occlusion consecutively admitted to our stroke center between October 2008 and March 2010. Patients were included if they were admitted within 12 h of symptom onset with AIS and symptomatic ICA occlusion. Collateral MCA flow was defined as the presence of MCA signals from proximal M1 to distal MCA branches ipsilateral to the ICA occlusion by magnetic resonance angiography. Early neurological deterioration (END) was defined as a 4-point increase in the National Institutes of Health Stroke Scale (NIHSS) score and persistent neurological deterioration for at least 24 h or newly developed neurological symptoms within 7 days. RESULTS:Sixty-five patients (42 men, 23 women) were finally included. Initial NIHSS scores were significantly lower, and favorable outcomes at 3 months were better in patients with collateral MCA flow than in those without (P < 0.001). Initial lesion patterns were different according to the collateral MCA flow. However, patients with mild AIS might more frequently deteriorate than those with moderate to severe AIS. CONCLUSIONS:In our study, collateral MCA flow reduced initial stroke severity and was associated with favorable outcomes at 3 months but did not seem to protect against END in mild AIS patients with ICA occlusion. Therefore, the results of this study suggest that mild AIS patients with ICA occlusion should be carefully managed because their conditions may deteriorate.
Endovascular stent therapy for extracranial and intracranial carotid artery dissection: single-center experience.
Ohta Hajime,Natarajan Sabareesh K,Hauck Erik F,Khalessi Alexander A,Siddiqui Adnan H,Hopkins L Nelson,Levy Elad I
Journal of neurosurgery
OBJECT:The objective of this study was to evaluate endovascular stent therapy for carotid artery dissections (CADs). METHODS:Retrospective review of data at Millard Fillmore Gates Hospital identified 43 patients with 44 CADs (intracranial and/or extracranial) treated with carotid artery (CA) stent placement between January 2000 and June 2009. RESULTS:Thirty-two CADs were spontaneous and 12 were traumatic; 35 were symptomatic. Lesion locations included the extracranial internal CA (ICA; 24 cases), extracranial ICA with common CA involvement (4 cases), and extracranial ICA-intracranial ICA (16 cases). Carotid artery occlusion was 100% in 15 cases (34.1%), 99% in 6 cases (13.6%), 70%-98% in 13 cases (29.5%), and < 70% in 10 cases (22.7%). Five patients suffered pseudoaneurysms. Stent deployment was successful in 43 (97.7%) of 44 cases. The mean pretreatment score on the National Institutes of Health Stroke Scale was 6.2 ± 6.2. Recanalization (Thrombolysis in Myocardial Infarction Grade 2 or 3) was accomplished for 42 lesions (95.5%). Four patients demonstrated residual parent vessel stenosis (10%-50% in severity). Procedure-related complications occurred in 7 patients and included middle cerebral artery embolism (1 patient), intracranial hemorrhage (2 patients), worsening of dissection (1 patient), stent malpositioning (1 patient), embolic protection filter overload (1 patient), and filter retrieval device fracture (1 patient). Only 2 of these complications caused permanent deficits: the embolism caused a minor but permanent neurological deficit, and 1 intracranial hemorrhage was fatal. At discharge, 36 patients (83.7%) had modified Rankin Scale scores of 0-2 (favorable outcome). During the follow-up interval (mean 19.2 months, range 4-92 months), no patient suffered a new stroke and 1 patient died secondary to preexisting chronic renal failure. In 20 patients with angiographic follow-up, permanent resolution of the dissection was noted in 90.5%; 2 lesions (9.5%) required retreatment. CONCLUSIONS:Endovascular stent-assisted repair of extra- and intracranial CAD was safe and effective in this experience and can be recommended for selected patients. In particular, patients with symptomatic CADs that are not responsive to medical therapy should be considered for interventional treatment.
Carotid Artery Stenosis Contralateral to Acute Tandem Occlusion: An Independent Predictor of Poor Clinical Outcome after Mechanical Thrombectomy with Concomitant Carotid Artery Stenting.
Maus Volker,Behme Daniel,Borggrefe Jan,Kabbasch Christoph,Seker Fatih,Hüseyin Cicek,Barnikol Utako Birgit,Yeo Leonard Leong Litt,Brouwer Patrick,Söderman Michael,Möhlenbruch Markus,Psychogios Marios Nikos,Liebig Thomas,Dohmen Christian,Fink Gereon Rudolf,Mpotsaris Anastasios
Cerebrovascular diseases (Basel, Switzerland)
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.
Robust and enduring atorvastatin-mediated memory recovery following the 4-vessel occlusion/internal carotid artery model of chronic cerebral hypoperfusion in middle-aged rats.
Zaghi Gislene Gonçalves Dias,Godinho Jacqueline,Ferreira Emilene Dias Fiuza,Ribeiro Matheus Henrique Dal Molin,Previdelli Isolde Santos,de Oliveira Rúbia Maria Weffort,Milani Humberto
Progress in neuro-psychopharmacology & biological psychiatry
Chronic cerebral hypoperfusion (CCH) is a common condition associated with the development and/or worsening of age-related dementia.We previously reported persistent memory loss and neurodegeneration after CCH in middle-aged rats. Statin-mediated neuroprotection has been reported after acute cerebral ischemia. Unknown, however, is whether statins can alleviate the outcome of CCH. The present study investigated whether atorvastatin attenuates the cognitive and neurohistological outcome of CCH. Rats (12–15 months old) were trained in a non-food-rewarded radial maze, and then subjected to CCH. Atorvastatin (10 mg/kg, p.o.) was administered for 42 days or 15 days, beginning 5 h after the first occlusion stage. Retrograde memory performance was assessed at 7, 14, 21, 28, and 35 days of CCH, and expressed by “latency,” “number of reference memory errors” and “number of working memory errors.” Neurodegeneration was then examined at the hippocampus and cerebral cortex. Compared to sham, CCH caused profound and persistent memory loss in the vehicle-treated groups, as indicated by increased latency (91.2% to 107.3%) and number of errors (123.5% to 2508.2%), effects from which the animals did not spontaneously recover across time. This CCH-induced retrograde amnesia was completely prevented by atorvastatin (latency: −4.3% to 3.3%; reference/working errors: −2.5% to 45.7%), regardless of the treatment duration. This effect was sustained during the entire behavioral testing period (5 weeks), even after discontinuing treatment. This robust and sustained memory-protective effect of atorvastatin occurred in the absence of neuronal rescue (39.58% to 56.45% cell loss). We suggest that atorvastatin may be promising for the treatment of cognitive sequelae associated with CCH.
Endovascular revascularization for carotid artery occlusion in patients with Takayasu arteritis.
Chen B,Yu H X,Zhang J,Li X X,Wu X G,Yang S J,Qi Y X,Yan C,Wang Z G
European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery
OBJECTIVES:Type I Takayasu arteritis is a progressive inflammatory disease involving the aortic arch and its main branches. If untreated, patients may develop a variety of serious conditions ranging from hemiplegia to death. Whilst there is a relatively strong evidence base for the outcome of surgical techniques, few reports have focused on revascularization using an endovascular technique in patients with Takayasu arteritis. METHODS:From May 2007 to March 2013, 11 consecutive patients with Takayasu arteritis presenting with severe cerebral ischemia symptoms caused by occlusive lesion in carotid artery underwent elective revascularization, 10 on the left carotid artery and 1 on the right. All patients received immunosuppressive treatment pre-and post-operation. Contraindications to open surgery included: ESR >40 mm/h; ipsilateral cerebral infarction of <2 weeks duration and sufficient poor health whereby the patient cannot tolerate general anesthesia. Quality of life was analyzed using the EQ-5D questionnaire before and after surgery. RESULTS:Patients were followed for a mean of 31.6±27.4 months. Seven cases of total occlusion and 2 cases of severe stenosis were recanalized successfully and experienced clinical remission. Recanalization failed in 2 patients, both of whom had occlusion of a long segment of the artery. Initial endovascularization comprised small diameter, low pressure dilatation only to allow time for the reopened arteries to respond. If clinically indicated, repeat angioplasty with a larger diameter balloon was performed 1-3 months later. Major complications occurred in 2 patients. Eight of the recanalized carotid arteries were patent at the end of follow-up and patients had satisfactory quality of life CONCLUSIONS:In patients with Takayasu arteritis, carotid artery recanalization via endovascular surgery combined with immunosuppressive therapy is effective and can be performed safely and repeatedly. The improvement in carotid artery blood flow supplying the central nervous system relieves symptoms of cerebral ischemia and is associated with an improved quality of life.
Initial clinical experience with the micromesh Roadsaver carotid artery stent for the treatment of patients with symptomatic carotid artery disease.
Hopf-Jensen Silke,Marques Leonardo,Preiß Michael,Müller-Hülsbeck Stefan
Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists
PURPOSE:To assess the effectiveness, technical aspects, handling, and safety of the micromesh Roadsaver Carotid Artery Stent in the treatment of atherosclerotic carotid artery stenosis and tandem lesions in ischemic stroke patients. METHODS:Seven patients (5 men; mean age 75±11.4 years, range 53-86) suffering from symptomatic internal carotid artery (ICA) stenosis (mean 76% diameter reduction) were treated with the dual layer closed-cell stent without embolic protection. Postdilation was performed in 6 of 7 patients. Two patients were treated in the context of ischemic stroke and concurrent middle cerebral artery occlusion. Mean National Institutes of Health Stroke Scale score at admission was 12.8±5. RESULTS:All devices were deployed satisfactorily. One wall-adherent thromboembolus in a proximal ICA was covered with the Roadsaver stent in a tandem lesion setting. The modified Rankin Scale (mRS) declined from 3.7±0.7 to 2.4±0.8 in hospital, showing an improvement in clinical symptoms. No complications were detected during or after the procedure. The 30-day mRS was 1.7±1.1. At 6 months, ultrasound examination demonstrated patency of stents and the external carotid arteries. CONCLUSION:The Roadsaver double layer micromesh stent seems to be safe and effective in the treatment of extracranial ICA stenosis and in the context of tandem lesions in ischemic stroke. Further studies with larger populations are warranted.
Acute carotid artery stenting in symptomatic high-grade cervical carotid artery stenosis.
Adachi Kazuhide,Sadato Akiyo,Hayakawa Motoharu,Maeda Shingo,Hirose Yuichi
The safety and efficacy of emergency carotid artery stenting (CAS) for patients with acute ischemic stroke resulting from internal carotid artery stenosis are not established. In this retrospective study, we evaluated outcomes for CAS performed within 2 weeks of acute ischemic stroke for 16 patients treated between December 2009 and February 2014. Cases of internal carotid artery occlusion, internal carotid dissection, or intracranial major arterial trunk occlusion were excluded. Five patients were treated with CAS during the hyperacute phase (within 24 h of stroke onset), three in the advanced phase (within 24 h of stroke-in-evolution after admission), and eight in the acute phase (24 h to 2 weeks after onset). We evaluated modified Rankin scale (mRS) scores 90 days after CAS. For patients treated during the hyperacute phase without intravenous tissue-type plasminogen activator (IV-tPA), two had mRS scores of 2 and one had a score of 3. Two patients treated in the hyperacute phase with IV-tPA had scores of 5: one with symptomatic intracerebral hemorrhage and the other with acute brain swelling. For patients treated in the advanced phase, mRS scores were 1, 3, and 5; the patient with 5 had contralateral cerebral infarction. All patients treated in the acute phase had scores of 2 or lower. Patients treated with IV-tPA in advanced or acute phases had no severe post-CAS complications. CAS was effective and safe for treating ischemic stroke within 2 weeks of onset. However, IV-tPA treatment may be a risk factor for CAS treatment during the hyperacute phase.
Differentiating pseudo-occlusion from true occlusion of proximal internal carotid artery in acute ischemic stroke on CT angiography.
Kim HyeonJu,Kwak Hyo Sung,Chung Gyung Ho,Hwang Seung Bae
Clinical neurology and neurosurgery
OBJECTIVE:A lack of visualization of the proximal internal carotid artery (ICA) on computed tomography angiography (CTA) in acute ischemic stroke may be caused by an atherosclerotic occlusion or a pseudo-occlusion by a massive thrombus in the ICA. Pseudo-occlusion of the proximal ICA is caused by stagnant flow from a distal ICA occlusion. The purpose of this study aimed to use imaging findings of CTA to differentiate pseudo-occlusions from true occlusions of the proximal ICA. PATIENTS AND METHODS:All eligible patients undergoing endovascular treatment after CTA from January 2013 to March 2018 were respectively reviewed. Patients with <2 cm of ICA on CTA images were enrolled in this study. CTA images were classified as having a beak, dome, or flat pattern. RESULTS:Our sample included a total of 66 eligible patients (true occlusion: 31, pseudo-occlusion: 35). The total length of opacification of the proximal ICA in the pseudo-occlusion group was significantly higher compared to that in the true occlusion group (13.9 ± 4.0 vs. 6.1 ± 4.8, p < 0.001). A beak pattern of the proximal ICA on CTA images was significantly higher in the pseudo-occlusion group (82.9% vs. 16.1%, p < 0.001), but a flat pattern was significantly higher in the true occlusion group (58.1% vs. 0%, p < 0.001). Gradual contrast decline of the proximal ICA on CTA images only appeared in the pseudo-occlusion group (51.4%, p < 0.001). CONCLUSIONS:On CTA, imaging patterns of the proximal ICA can be differentiated between true occlusions and pseudo-occlusions.
Usnic acid improves memory impairment after cerebral ischemia/reperfusion injuries by anti-neuroinflammatory, anti-oxidant, and anti-apoptotic properties.
Erfani Sohaila,Valadbeigi Tahereh,Aboutaleb Nahid,Karimi Naser,Moghimi Ali,Khaksari Mehdi
Iranian journal of basic medical sciences
Objectives:Cerebral ischemia/reperfusion causes complex pathological mechanisms that lead to brain tissue damage. Usnic acid is a lichen secondary metabolite that has many different biological properties including anti-inflammatory and anti-oxidant activities. Therefore, the objective of the current study was to investigate the neuroprotective effects of usnic acid on apoptotic cell death, neuroinflammation, anti-oxidant enzyme activities, and oxidative stress levels after transient cerebral ischemia/reperfusion. Materials and Methods:Forty-two male Wistar rats were randomly assigned to three groups (sham, ischemia/reperfusion, and ischemia/reperfusion+usnic acid). Ischemia was induced by 20 min occlusion of common carotid arteries. Injection of usnic acid (25 mg/kg, intraperitoneally) and saline was done at the beginning of reperfusion time. Morris water maze was applied to assess spatial memory. The protein expression amount was measured using immunohistochemical and immunofluorescence staining. Spectrophotometric assay was performed to determine the levels of anti-oxidant enzymes. Results:Usnic acid significantly reduced caspase-3, glial fibrillary acidic protein- positive and ionized calcium-binding adaptor molecule 1-positive cells (0.001) and enhanced spatial memory disorders (0.05) due to brain ischemia. In addition, treatment with usnic acid improves effects in the antioxidant system following cerebral ischemia (0.05). Conclusion:Our findings indicate that usnic acid has neuroprotective properties, which possibly is applicable as a promising candidate for cerebral injuries caused by ischemia.
Emergent intracranial surgical embolectomy in conjunction with carotid endarterectomy for acute internal carotid artery terminus embolic occlusion and tandem occlusion of the cervical carotid artery due to plaque rupture.
Hasegawa Hirotaka,Inoue Tomohiro,Tamura Akira,Saito Isamu
Journal of neurosurgery
Acute internal carotid artery (ICA) terminus occlusion is associated with extremely poor functional outcomes or mortality, especially when it is caused by plaque rupture of the cervical ICA with engrafted thrombus that elongates and extends into the ICA terminus. The goal of this study was to evaluate the efficacy and safety of surgical embolectomy in conjunction with carotid endarterectomy (CEA) for acute ICA terminus occlusion associated with cervical plaque rupture resulting in tandem occlusion. A retrospective review of medical records was performed. Clinical and radiographic characteristics were evaluated, including details of surgical technique, recanalization grade, recanalization time, complications, modified Rankin Scale (mRS) score at 3 months, and National Institutes of Health Stroke Scale (NIHSS) score improvement at 1 month. Three patients (mean age 77.3 years; median presenting NIHSS Score 22, range 19-26) presented with abrupt tandem occlusion of the cervical ICA and ICA terminus and were selected for surgery after confirmation of embolic high-density signal at the ICA terminus on CT and diffusion-weighted imaging (DWI)/magnetic resonance angiography (MRA) mismatch. All patients underwent craniotomy for surgical embolectomy of the ICA terminus embolus followed by cervical exposure, aspiration of long residual proximal embolus ranging from the cervical to cavernous ICA, and removal of ruptured unstable plaque by CEA. Postoperative MRA demonstrated Thrombolysis In Myocardial Infarction (TIMI) 3 recanalization in all patients (100%) without evidence of additional infarction according to DWI. Mean recanalization time from hospital arrival was 234 minutes and from start of surgery, 151 minutes. Serial postoperative CT and MRI studies showed no symptomatic hemorrhage, brain edema, or progression of infarction. The patients' mRS scores at 3 months were 3, 3, and 1. All 3 patients demonstrated marked improvements in NIHSS scores (median 17 points; range 13-23 points) at 1 month. Considering the dismal prognosis associated with ICA terminus occlusion, especially when accompanied by cervical plaque rupture, emergent surgical embolectomy in conjunction with CEA might be an effective and decisive treatment option with a high complete recanalization rate and acceptable safety profile.
Direct Microsurgical Embolectomy for Acute Occlusion of the Internal Carotid Artery and Middle Cerebral Artery.
Hino Akihiko,Oka Hideki,Hashimoto Youichi,Echigo Tadashi,Koseki Hirokazu,Fujii Akihiro,Katsumori Tetsuya,Shiomi Naoto,Nozaki Kazuhiko,Arima Hisatomi,Hashimoto Naoya
BACKGROUND:Surgical embolectomy is the most promising therapy for physically removing emboli from major cerebral arteries. However, it requires an experienced surgical team, time-consuming steps, and is not incorporated into acute stroke therapy. METHODS:We established seamless collaboration between services, refined surgical techniques, and conducted a prospective trial of emergency surgical embolectomy. Surgical indications included the presence of acute hemispheric symptoms, absence of low-density area on computed tomography, evidence of internal carotid artery terminus or proximal middle cerebral artery occlusion, and availability of resources to start surgery within 3 hours of symptom onset. The indications were confirmed by an interdisciplinary team. We assessed revascularization rates, time from admission to surgery and from surgery to recanalization, procedural complications, and clinical outcomes. RESULTS:Between 2005 and 2014, 14 consecutive patients with acute proximal middle cerebral artery or internal carotid artery terminus occlusion underwent emergency surgical embolectomy. All patients showed complete recanalization. Twelve patients survived and 7 had fair functional outcome (Rankin Scale score, ≤3). No significant procedural adverse events occurred. The mean times from admission to start of surgery, from surgery to recanalization, and from onset to recanalization were 14 minutes, 79 minutes, and 223 minutes, respectively. CONCLUSIONS:Our results suggest that microsurgical embolectomy can rapidly, safely, and effectively retrieve clots and deserves reappraisal, although the choice largely depends on local institutional expertise.
Endovascular Treatment of Internal Carotid Artery Dissection Presenting with Acute Ischemic Stroke.
Farouk Mohamed,Sato Kenichi,Matsumoto Yasushi,Tominaga Teiji
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
BACKGROUND:Definitive treatment of carotid dissection-related strokes is currently unproved. The best endovascular technique in this setting remains to be established. OBJECTIVE:To report our experience in endovascular treatment of internal carotid artery dissection presenting with acute strokes. METHODS:Consecutive patients with acute strokes due to internal carotid artery dissection treated with endovascular therapy at our hospital between January 2008 and July 2019 were included. Patients were assigned to endovascular treatment according to clinical-radiologic mismatch, NIHSS greater than or equal to 5, and within 6 hours after symptom onset. The endovascular technique is described. Intracranial recanalization, carotid dilatation, and clinical outcomes were retrospectively analyzed. RESULTS:Seven patients met the inclusion criteria. The mean age was 55 years; 5 patients (71.4%) were male. 71.4% had tandem occlusion strokes, while 28.6% had hemodynamic strokes. The mean onset-to-puncture time was 3.92 hours. Stent-assisted angioplasty for internal carotid artery was done for 85.7% of patients with a mean of 1.6 deployed stents. Dilatation was successful in 83.3% of them. Successful overall recanalization rate was 85.7%. No major complications were encountered. Minor complications occurred in 42.8% of cases. The mean NIHSS score decreased from 13.7 preoperative to 5 after 3 days. Good functional outcome (mRS 0-2) was found in 85.7% of patients at 3 months. No recurrent strokes identified over an average of 40.86 months follow-up. CONCLUSION:Our study provides evidence that endovascular therapy for internal carotid artery dissection-related strokes has high rates of reperfusion and favorable outcomes. Stent-assisted angioplasty of carotid dissection is thought to be safe and effective.
Emergent carotid artery stenting in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion: Comparison of tandem intracranial occlusion and isolated cervical internal carotid artery occlusion.
Park Sung E,Choi Dae S,Baek Hye J,Ryu Kyeong H,Ha Ji Y,Choi Ho C,Lee Sangmin,Won Jungho,Jung Seunguk
Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences
PURPOSE:Acute ischemic strokes caused by steno-occlusive lesion of the cervical internal carotid artery are associated with poor clinical outcome. We evaluated the clinical efficacy of emergent carotid artery stenting for the management of these lesions. We compared the clinical outcomes regarding the intracranial lesion, namely tandem occlusions versus isolated cervical internal carotid artery occlusion. MATERIALS AND METHODS:We retrospectively reviewed patients with acute ischemic stroke who underwent carotid artery stenting for cervical internal carotid artery steno-occlusive lesion between 2011 and 2018. After dividing the patients into two groups according to the presence or absence of intracranial lesions (tandem group and isolated cervical group), we analyzed demographic data, angiographic findings, and clinical outcomes. A modified Rankin Scale score ≤2 was defined as a favorable clinical outcome. RESULTS:Of 75 patients, 46 patients (61.3%) had tandem lesions, and the remaining 29 had only cervical internal carotid artery steno-occlusive lesion. Successful stenting was performed in all patients with favorable clinical outcomes (64.0%). Successful reperfusion score (thrombolysis in cerebral infarction ≥2 b) was 84.0%; tandem group (76.1%) versus isolated cervical group (96.6%) of cases. Mean modified Rankin Scale score at 90-days was 2.09. The rate of favorable clinical outcome showed no statistically significant difference between the two groups ( = 0.454). CONCLUSIONS:Endovascular treatment in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion is a technically feasible and clinically effective intervention regardless of intracranial occlusion. Therefore, we recommend endovascular treatment regardless of the presence of concomitant intracranial artery occlusion for patients with acute ischemic stroke caused by cervical internal carotid artery steno-occlusive lesion.
Mechanical thrombectomy with Solitaire stent for acute internal carotid artery occlusion without atherosclerotic stenosis: dissection or cardiogenic thromboembolism.
Ma Y-d,Wang J,Du Z-h,Cao X-y,Zhou D-b,Li B-m
European review for medical and pharmacological sciences
BACKGROUND:In acute ischemic stroke patients, internal carotid artery occlusion with middle cerebral artery (ICA/MCA) occlusion in succession predicts a poor outcome after systemic thrombolysis. It is not known whether this occlusion subtype of the anterior circulation is due to dissections or cardiogenic thromboembolism. We aimed to find useful evidence to judge the condition with accuracy and establish reasonable treatment protocols. PATIENTS AND METHODS:This retrospective study included 7 consecutive patients with acute ICA/MCA occlusion in succession who had undergone mechanical thrombectomy with a Solitaire stent retrieval between January 2012 and June 2013. Then we also reviewed the current literature. RESULTS:The patients had a mean age of 56 years and a mean baseline National Institutes of Health Stroke Scale (NIHSS) score of 20. The procedure resulted in thrombolysis in cerebral ischemia (TICI) scores of 2a or better in all patients, but complete recanalization of the ICA occlusion segment was achieved in only 2 patients. Stenting was not performed in all patients. At 90 days, 1 patient was dead and 4 of the 7 patients had favorable functional outcomes (modified Rankin score (mRS) ≥ 2). We identified 9 studies with 85 patients with nonatherosclerotic acute ICA occlusion who underwent mechanical thrombectomy with Solitaire stent. The mean age was 65 years with a mean baseline National Institute Health Stroke Scale (NIHSS) score of 16 and mean time to treatment of 242 minutes. The mean time of the procedures ranged from 40-160 minutes in 9 studies. Successful recanalization was achieved in 69.4% of the patients and mortality was 16.5%. Favorable outcome (mRS ≤ 2) occurred in 42.4% of patients. Few studies stated whether complete recanalization was achieved in patients with ICA occlusion. CONCLUSIONS:Our results and the literature review suggest that mechanical thrombectomy in acute stroke due to ICA/MCA occlusion is feasible and safe, with high rates of recanalization and favorable functional outcomes. More patients with ICA/MCA occlusion in succession could obtain favorable functional outcomes with accurate judgment of the lesion location and appropriate treatment protocols. However, there is no consensus on how to judge the correct location of the ICA dissected portion and whether stenting is appropriate.
Overview of evidence on emergency carotid stenting in patients with acute ischemic stroke due to tandem occlusions: a systematic review and meta-analysis.
Pires Coelho Andreia,Lobo Miguel,Gouveia Ricardo,Silveira Diogo,Campos Jacinta,Augusto Rita,Coelho Nuno,Canedo Alexandra
The Journal of cardiovascular surgery
INTRODUCTION:Endovascular intracranial thrombectomy (IT) has established itself as the standard of care in treating large-vessel anterior circulation acute ischemic stroke (AIS). However, internal carotid artery (ICA) stenosis/occlusion hampers distal access and controversy about simultaneous emergency ICA stenting ensues. The purpose of this review was to evaluate the safety of emergency ICA stenting in combination with IT for AIS with tandem occlusions. To our knowledge this is the first meta-analysis to evaluate emergency ICA stenting in tandem occlusions, combining results from studies with a control group. EVIDENCE ACQUISITION:A meta-analysis was conducted according to the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. EVIDENCE SYNTHESIS:A total of 649 potentially relevant articles were initially selected. After reviewing at title or abstract level, 87 articles were read in full and 23 were included. These studies recruited 1000 patients, 220 submitted to IT with no emergency ICA stenting and 780 to IT and emergency ICA stenting. Successful revascularization (Thrombolysis in cerebral infarction scale [TICI] ≥2b) was achieved in 48.6-100%. Good outcome (modified Rankin scale [mRS] ≤2) ranged from 18.2-100%. Symptomatic intracranial hemorrhage (sICH) ranged from 0-45.7% (overall N.=168; 17.2%). Mortality at 90 days ranged from 0-45.4% (overall N.=114; 11.7%). Time to recanalization was significantly longer in the stenting group with an overall mean difference of 1.76 (95% CI: 1.59-1.93). CONCLUSIONS:In this meta-analysis time to recanalization was significantly longer in the emergency ICA stenting group. There was no benefit from emergency stenting in parameters such as successful revascularization (TICI≥2b), clinical outcome (mRS≤2) or 90-day mortality. Data on sICH were scarce. Emergency ICA stenting appears to increase time to revascularization and increase the risk of complications with no demonstrated clinical benefit. Furthermore, no prospective, randomized controlled trials demonstrating relative efficacy and safety of concomitant ICA stenting have been published to date. Additional studies must be undertaken to define the role of angioplasty and stenting of the extracranial carotid arteries in the early management of acute stroke in tandem occlusions. Until then, we recommend that ICA stenting concomitant to thrombectomy in acute stroke patients should be avoided.
Risk factors for neurological worsening and symptomatic watershed infarction in internal carotid artery aneurysm treated by extracranial-intracranial bypass using radial artery graft.
Matsukawa Hidetoshi,Tanikawa Rokuya,Kamiyama Hiroyasu,Tsuboi Toshiyuki,Noda Kosumo,Ota Nakao,Miyata Shiro,Oda Jumpei,Takeda Rihee,Tokuda Sadahisa,Kamada Kyousuke
Journal of neurosurgery
OBJECT The revascularization technique, including bypass created using the external carotid artery (ECA), radial artery (RA), and M2 portion of middle cerebral artery (MCA), has remained indispensable for treatment of complex aneurysms. To date, it remains unknown whether diameters of the RA, superficial temporal artery (STA), and C2 portion of the internal carotid artery (ICA) and intraoperative MCA blood pressure have influences on the outcome and the symptomatic watershed infarction (WI). The aim of the present study was to evaluate the factors for the symptomatic WI and neurological worsening in patients treated by ECA-RA-M2 bypass for complex ICA aneurysm with therapeutic ICA occlusion. METHODS The authors measured the sizes of vessels (RA, C2, M2, and STA) and intraoperative MCA blood pressure (initial, after ICA occlusion, and after releasing the RA graft bypass) in 37 patients. Symptomatic WI was defined as presence of the following: postoperative new neurological deficits, WI on postoperative diffusion-weighted imaging, and ipsilateral cerebral blood flow reduction on SPECT. Neurological worsening was defined as the increase in 1 or more modified Rankin Scale scores. First, the authors performed receiver operating characteristic curve analysis for continuous variables and the binary end point of the symptomatic WI. The clinical, radiological, and physiological characteristics of patients with and without the symptomatic WI were compared using the log-rank test. Then, the authors compared the variables between patients with and without neurological worsening at discharge and at the 12-month follow-up examination or last hospital visit. RESULTS Symptomatic WI was observed in 2 (5.4%) patients. The mean MCA pressure after releasing the RA graft (< 55 mm Hg; p = 0.017), mean (MCA pressure after releasing the RA graft)/(initial MCA pressure) (< 0.70 mm Hg; p = 0.032), and mean cross-sectional area ratio ([RA/C2 diameter](2) < 0.40 mm [p < 0.0001] and [STA/C2 diameter](2) < 0.044 mm [p < 0.0001]) were related to the symptomatic WI. All preoperatively independent patients remained independent (modified Rankin Scale score < 3). After adjusting for age and sex, left operative side (p = 0.0090 and 0.038) and perforating artery ischemia (p = 0.0050 and 0.022) were related to neurological worsening at discharge (11 [29%] patients) and at the 12-month follow-up or last hospital visit (8 [22%] patients). CONCLUSIONS Results of the present study showed that the vessel diameter and intraoperative MCA pressure had impacts on the symptomatic WI and that operative side and perforating artery ischemia were related to neurological worsening in patients with complex ICA aneurysms treated by ECA-RA-M2 bypass.
Activation of liver X receptor promotes hippocampal neurogenesis and improves long-term cognitive function recovery in acute cerebral ischemia-reperfusion mice.
Chen Lili,Song Dan,Chen Beibei,Yang Xuemei,Cheng Oumei
Journal of neurochemistry
Cerebral ischemia (CI) leads to cognitive dysfunction due to the loss of hippocampal neurons. Liver X receptors (LXRs), including the LXRα and LXRβ isoforms, are critical for neurogenesis, synaptic plasticity, neurodegeneration, and cholesterol metabolism. However, the potential role of LXRs in the pathogenesis of CI-induced cognitive impairment is unclear. Therefore, we investigated the effects of LXR activation on hippocampal neurogenesis and cognitive function in mice with CI. C57 mice were randomized into four groups that included a sham group and three treatment groups with CI [Vehicle, TO901317 (TO90, an agonist of LXRs) and GSK2033 (an antagonist of LXRs)]. Mice were subjected to bilateral common carotid artery occlusion for 20 min to induce transient CI. The Morris water maze test was executed to detect spatial learning and memory. Proliferation, differentiation, and immature neurons in the subgranular zone (SGZ) were examined using Immunofluorescence. Western blot assay was used to detect the expression of the Wnt/β-catenin signaling pathway-associated protein. TO90 significantly improved spatial learning and memory deficits induced by CI on 28 days. It enhanced the proliferation of neural stem cells, the number of immature neurons and the differentiation from nascent cells to neurons. The expression of the Wnt/β-catenin signaling pathway-associated protein level was totally increased. The forenamed effects of TO90 were decreased in GSK2033 group. Thus, our findings suggest that LXRs activation can improve long-term cognitive dysfunction caused by CI by increasing neurogenesis, and LXRs may serve as a potential therapeutic target for cerebral ischemia. Cover Image for this issue: doi: 10.1111/jnc.14753.
Emergent Carotid Thromboendarterectomy for Acute Symptomatic Occlusion of the Extracranial Internal Carotid Artery.
Gunka Igor,Krajickova Dagmar,Lesko Michal,Jiska Stanislav,Raupach Jan,Lojik Miroslav,Maly Radovan
Vascular and endovascular surgery
BACKGROUND:Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with an extremely poor prognosis. The best treatment approach in this setting is still unknown. The aim of our study was to evaluate the efficacy, safety, and outcomes of emergent surgical revascularization of acute extracranial ICA occlusion in patients with minor to severe ischemic stroke. METHODS:A retrospective analysis was performed using prospectively collected data of consecutive patients who underwent carotid thromboendarterectomy for symptomatic acute ICA occlusion during the period from January 2013 to December 2015. Primary outcomes were disability at 90 days assessed by the modified Rankin Scale (mRS) and neurological deficit at discharge assessed using the National Institute of Health Stroke Scale (NIHSS). Secondary outcomes were the recanalization rate, 30-day overall mortality, and any intracerebral bleeding. RESULTS:During the study period, a total of 6 patients (5 men and 1 woman) with a median age of 64 years (range: 58-84 years) underwent emergent reconstruction for acute symptomatic ICA occlusion within a median of 5.4 hours (range: 2.9-12.0 hours) after symptoms onset. The median presenting NIHSS score was 10.5 points (range: 4-21). Before surgery, 4 patients (66.7%) had been treated by systemic recombinant tissue plasminogen activator lysis. The median time interval between initiation of intravenous thrombolysis and carotid thromboendarterectomy was 117.5 minutes (range: 65-140 minutes). Patency of the ICA was achieved in all patients. On discharge, the median NIHSS score was 2 points (range: 0-11 points). There was no postoperative intracerebral hemorrhage and zero 30-day mortality rate. At 3 months, 5 patients (83.3%) had a good clinical outcome (mRS ≤ 2). CONCLUSION:Patients presenting with minor to severe ischemic stroke syndromes due to isolated extracranial ICA occlusion may benefit from emergent carotid revascularization. Thorough preoperative neuroimaging is essential to aid in selecting eligible candidates for acute surgical intervention.
L. ameliorates brain injury followed by cerebral ischemia-reperfusion in rats by antioxidative and anti-inflammatory mechanisms.
Fu Pin-Kuei,Pan Tai-Long,Yang Chi-Yu,Jeng Kee-Ching,Tang Nou-Ying,Hsieh Ching-Liang
Iranian journal of basic medical sciences
OBJECTIVES: L. (CT) or safflower is widely used in traditional Chinese medicine. This study investigated the effects of CT extract (CTE) on ischemia-reperfusion (I/R) brain injury and elucidated the underlying mechanism. MATERIALS AND METHODS:The I/R model was conducted by occlusion of both common carotid arteries and right middle cerebral artery for 90 min followed by 24 hr reperfusion in Sprague-Dawley rats. CTE (0.2-0.6 g/kg) was administered intraperitoneally before and during ischemia, and during reperfusion period. The cerebral infarction area, neurological deficit scores, free radicals (lucigenin chemiluminescence counts) and pro-inflammatory cytokines expression were measured. RESULTS:Pretreatment and treatment with CTE significantly reduced the cerebral infarction area and neurological deficits. CTE (0.4 g/kg) also reduced blood levels of free radicals and expression of tumor necrosis factor-α and interleukin-1β in the cerebral infarction area. CONCLUSION:The reduction in I/R cerebral infarction caused by CTE is possibly associated with its antioxidation and anti-inflammatory properties.
Selective brain hypothermia-induced neuroprotection against focal cerebral ischemia/reperfusion injury is associated with Fis1 inhibition.
Tang Ya-Nan,Zhang Gao-Feng,Chen Huai-Long,Sun Xiao-Peng,Qin Wei-Wei,Shi Fei,Sun Li-Xin,Xu Xiao-Na,Wang Ming-Shan
Neural regeneration research
Selective brain hypothermia is considered an effective treatment for neuronal injury after stroke, and avoids the complications of general hypothermia. However, the mechanisms by which selective brain hypothermia affects mitochondrial fission remain unknown. In this study, we investigated the effect of selective brain hypothermia on the expression of fission 1 (Fis1) protein, a key factor in the mitochondrial fission system, during focal cerebral ischemia/reperfusion injury. Sprague-Dawley rats were divided into four groups. In the sham group, the carotid arteries were exposed only. In the other three groups, middle cerebral artery occlusion was performed using the intraluminal filament technique. After 2 hours of occlusion, the filament was slowly removed to allow blood reperfusion in the ischemia/reperfusion group. Saline, at 4°C and 37°C, were perfused through the carotid artery in the hypothermia and normothermia groups, respectively, followed by restoration of blood flow. Neurological function was assessed with the Zea Longa 5-point scoring method. Cerebral infarct volume was assessed by 2,3,5-triphenyltetrazolium chloride staining, and apoptosis was assessed by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling staining. Fis1 and cytosolic cytochrome c levels were assessed by western blot assay. Fis1 mRNA expression was assessed by quantitative reverse transcription-polymerase chain reaction. Mitochondrial ultrastructure was evaluated by transmission electron microscopy. Compared with the sham group, apoptosis, Fis1 protein and mRNA expression and cytosolic cytochrome c levels in the cortical ischemic penumbra and cerebral infarct volume were increased after reperfusion in the other three groups. These changes caused by cerebral ischemia/reperfusion were inhibited in the hypothermia group compared with the normothermia group. These findings show that selective brain hypothermia inhibits Fis1 expression and reduces apoptosis, thereby ameliorating focal cerebral ischemia/reperfusion injury in rats. Experiments were authorized by the Ethics Committee of Qingdao Municipal Hospital of China (approval No. 2019008).
Hybrid operation to revascularize long-segment occluded internal carotid artery prevent further ischemic events.
Zhang Kun,Gao Bu-Lang,Zhao Tong-Yuan,Li Tian-Xiao,Xue Jiang-Yu,He Ying-Kun,Cai Dong-Yang,Yang Bo-Wen
PURPOSE:The effects and complications of hybrid procedure (combined carotid endarterectomy and carotid stenting) to revascularize chronic long-segment occlusion of internal carotid artery (ICA) are currently unknown and the purpose of this study. METHODS:Sixty-five patients with long-segment occlusion of ICA were prospectively enrolled and divided into two groups of revascularization with hybrid operation (n = 30) and medication group (n = 35), and clinical and angiographic data were analyzed. RESULTS:The duration from symptom onset to revascularization ranged 17-120 days (mean 40.5 ± 5.0) in the hybrid operation, with a success revascularization rate of 100%. All patients had thrombi extracted with the clot length ranging 5-8 cm (mean 6.3 ± 0.9). The thrombolysis in cerebral infarction grade (TICI) was significantly (P < 0.0001) greater immediately after (median 2,) than before recanalization (0). Periprocedural complications included recurrent laryngeal nerve injury in one patient and intracranial hemorrhage in another (6.7%), but no severe neurological deficits occurred. The symptoms were significantly (P < 0.0001) improved after compared with before operation, with the modified Rankin score of 2.5 ± 0.6 at 3 months postoperation which was significantly (P < 0.0001) improved compared with before revascularization (3.4 ± 0.6). Follow-up angiography revealed patent ICA in all patients with hybrid operation. In the medication alone group, no significant (P > 0.05) improvement was observed with the mRS score of 3.5 ± 0.8 at admission and 3.4 ± 0.7 at 3 months, which was significantly (P < 0.001) greater than in the hybrid operation. CONCLUSION:Hybrid operation may be safe and effective in revascularizing long-segment occlusion of internal carotid artery for prevention of further ischemic events.
Cortical and Internal Watershed Infarcts Might Be Key Signs for Predicting Neurological Deterioration in Patients with Internal Carotid Artery Occlusion with Mild Symptoms.
Amano Yuki,Sano Hiroyasu,Fujimoto Ayataka,Kenmochi Hiroaki,Sato Haruhiko,Akamine Soichi
Cerebrovascular diseases extra
BACKGROUND:Treatment for acute ischemic stroke due to large vessel occlusion (LVO) with mild symptoms is under discussion. Although most patients have good outcomes, some patients deteriorate and have unfavorable results. Imaging findings that predict the prognosis of LVO with mild symptoms are needed to identify patients who require treatment. In this study, we focused on watershed infarctions (WSIs), because this clinical phenomenon quite sensitively reflects changes in cerebral blood flow. The purpose of this study was to assess positive rates of WSI on MRI findings in patients with internal carotid artery (ICA) occlusion, and compare WSI-positive rates between patients divided according to their clinical course. METHODS:We retrospectively collected data of 1,531 patients who presented with acute ischemic stroke between June 2006 and July 2019. Among them, we chose symptomatic ICA occlusion patients with a past history of atrial fibrillation who were treated conservatively. We divided these patients into two groups, those with maintenance or improvement in their NIHSS score after hospitalization, and those whose NIHSS score worsened. We compared WSI-positive rates between these two groups. RESULTS:Thirty-seven of the 1,531 patients were included in this study. Of them, total NIHSS score was maintained or improved in 8 patients (group A), 3 of whom (37.5%) had internal watershed infarctions (IWIs). In group B, consisting of patients whose NIHSS score worsened by >2 at 7 days from symptom onset, 24 (82.8%) had IWIs. Group A thus had statistically lower IWI positivity rates than group B (p = 0.02). Three patients (37.5%) in group A had cortical watershed infarctions (CWIs), while 27 patients in group B (93.1%) had CWIs. Group A thus had a significantly lower CWI positivity rate than group B (p = 0.002). CONCLUSION:In patients with mildly symptomatic ICA occlusion, CWIs and IWIs might be key signs for predicting neurological deterioration after hospitalization.
Predictors of re-canalisation in acute cerebral infarction from occlusion of the terminal internal carotid artery or of the middle cerebral artery mainstem treated with thrombolysis.
Camerlingo Massimo,Tudose Veaceslav,Tognozzi Marcello,Moschini Luca
The International journal of neuroscience
OBJECTIVE:We have evaluated the factors of unsuccessful re-canalisation in a large series of patients with hemispheric cerebral infarction treated with thrombolysis. PATIENTS AND METHODS:All patients aged 18-80 years with an acute hemispheric infarction, admitted within the first few hours of symptoms onset, were immediately submitted to Magnetic Resonance both Imaging (MRI) and Angiography (MRA). MRI and MRA were repeated at 24 h of stroke. Re-canalisation was attributed if grade 2 or 3 of Thrombolysis in Myocardial Infarction (TIMI) criteria for the myocardial infarction. Outcome was rated at three months of stroke. Re-canalisation was matched with ageing and with the common risk factors for stroke. RESULTS:One hundred and twenty-one patients, 70 men and 51 women, with a median age of 67 years, were included. Re-canalisation was seen in 62 patients (51%). Twenty-three patients (19%) died by 90 days of stroke. Re-canalisation was associated to survival (1 death vs. 22, p < 0.0001). Regression analysis retained advanced age (Odds ratio 0.37, 95% Confidence interval 0.13-0.98), baseline National Institute of Health Stroke Scale (NIHSS) (Odds ratio 0.94, 95% Confidence interval 0.89-0.98) and diabetes mellitus (Odds ratio 0.28, 95% Confidence interval 0.09-0.84) as factors contrasting re-canalisation. CONCLUSIONS:Our study indicates that in patients with proven occlusion of the terminal segment of the internal carotid artery and/or of the mainstem of the Middle Cerebral Artery, re-canalisation at 24 h of the acute ischemic stroke is dramatically associated with survival, and halted by advanced age and diabetes mellitus.
Advantages of Staged Angioplasty in a Patient with Internal Carotid Artery Pseudo-Occlusion Besides Prevention of Cerebral Hyperperfusion Syndrome.
Takahashi Satoshi,Akiyama Takenori,Nakahara Jin,Yoshizaki Takahito,Suzuki Norihiro,Yoshida Kazunari
BACKGROUND:Staged angioplasty for carotid artery stenosis has been reported to be effective in preventing postoperative cerebral hyperperfusion syndrome (CHS) in patients with severe carotid stenosis; thus, it is also recommended for patients with internal carotid artery (ICA) pseudo-occlusion, the treatment strategy for which is controversial. CASE DESCRIPTION:This study reports the case of an Asian man in his 50s who had motor aphasia and right-side weakness caused by pseudo-occlusion of the left ICA. After medical treatment, he underwent a staged angioplasty. After the first stage of percutaneous transluminal angioplasty, anterograde blood flow to the left ICA increased but the distal ICA remained partially collapsed. Initially, the second stage of carotid artery stenting (CAS) was planned for 2 weeks after the first stage; however, hemorrhagic infarction was observed the day before the CAS, and it was postponed by 2 weeks, after adjustment of antiplatelet therapy. At the time of the CAS, the diameter of the initially collapsed left distal ICA was remodeled and it was fully dilated; thus, we used a balloon-type embolic protection device and conducted CAS successfully without apparent embolic complications. The postoperative course was uneventful. The patient did not develop CHS. CONCLUSIONS:Besides preventing CHS, staged angioplasty has advantages when used for treating patients with ICA pseudo-occlusions in that the extent of dilation of the distal ICA after percutaneous transluminal angioplasty can be confirmed and the development of a possible hemorrhagic infarction can be assessed before stent placement.
Extracranial posterior communicating artery bypass for revascularization of patients with common carotid artery occlusion.
Schneider Ulf Christoph,von Weitzel-Mudersbach Paul,Hoffmann Karl-Titus,Vajkoczy Peter
BACKGROUND:Extracranial-intracranial bypass surgery provides blood flow augmentation in patients suffering from intracranial or long-distance conductance artery stenosis or occlusion that otherwise cannot be treated. The standard procedure for these cases is an anastomosis between the superficial temporal and middle cerebral arteries. However, in patients presenting with common carotid artery occlusion, the superficial temporal artery is no longer sufficiently perfused. For these patients, alternative revascularization strategies have to be applied. OBJECTIVE:To describe a novel strategy for revascularization of patients with common carotid artery occlusion, ie, the extracranial posterior communicating artery bypass. METHODS:Two patients with chronic cerebrovascular compromise resulting in transitory ischemic attacks and/or border-zone infarctions caused by common carotid artery occlusion were referred to our institution. A radial artery bypass was established between the third segment of the vertebral artery and an M3 branch of the middle cerebral artery. The vertebral artery was exposed between the vertebral lamina of C1 and occipital bone via a paramedian incision. The bypass was tunneled subcutaneously, conducted intracranially via a tailored extended burr-hole craniotomy, and anastomosed to a recipient M3 vessel. RESULTS:The postoperative course of both patients was uneventful in terms of cerebral ischemia or bleeding complications. In both patients, postoperative angiographic controls revealed an excellent bypass function with markedly improved hemispheric filling of multiple middle cerebral artery branches. The patients were discharged without new neurological symptoms. CONCLUSION:Our extracranial posterior communicating artery bypass using a radial artery transplant from the vertebral artery to the middle cerebral artery is a useful tool to treat patients suffering from hemodynamic cerebrovascular compromise caused by common carotid artery occlusion.
Ring-Stripping Retrograde Endarterectomy for Treatment of Common Carotid Artery Occlusion: A Minimally Invasive, Effective Procedure.
Wang Xiaomin,Liu Yandong,Bai Jun,Zhi Kangkang,Qu Lefeng
Annals of vascular surgery
BACKGROUND:To evaluate the efficacy and safety of in situ ring-stripping retrograde carotid endarterectomy (IS-RRCEA) in long-segment, symptomatic, chronic common carotid artery occlusion (CCAO). METHODS:Thirty-nine patients (24 men; 15 women) with symptomatic chronic CCAO who underwent IS-RRCEA in our center were included retrospectively. The mean age of the men was significantly less than that of the women (59.6 ± 5.8 vs. 67.8 ± 6.3 years; P < 0.001). Risk factors, clinical characteristics, and CCAO classification of patients and effectiveness and safety of IS-RRCEA were analyzed. RESULTS:Patients presented with the following symptoms: dizziness (6; 15.4%), transient ischemic attack (TIA; 33; 84.6%), and decreased vision (15; 38.5%). IS-RRCEA was performed on the left side in 25 (64.1%) cases and on the right side in 14 (35.9%) cases. The technical success rate of the procedure was 100%. Cerebral perfusion on the ipsilateral site improved in all patients. In the postoperative period, stroke and myocardial infarction occurred in one patient, and recurrent laryngeal nerve damage occurred in another; these patients' symptoms mostly resolved except for residual paresis in the stroke patient. Thirty-eight patients (97.4%) were followed for a mean of 29 ± 13.3 months after the IS-RRCEA; in 1-year follow-up, 31 patients (31/33; 93.9%) with preoperative TIA have had no TIAs; 2 patients (2/33; 6.1%) have fewer TIAs. Two patients (2/6; 33.3%) with preoperative dizziness have had no dizziness, and 4 (4/6; 66.7%) have had fewer episode of dizziness, no recurrent stenosis (>50%), or recognized occlusion. CONCLUSIONS:Our single-center experience indicates that IS-RRCEA is an effective treatment for selected types of CCAO. Studies of the operation in larger populations with longer term follow-up should be conducted.
Three-Year Clinical Results of Carotid Artery Stenting in Treating Patients with Contralateral Carotid Artery Occlusion.
Guo Jianming,Guo Lianrui,Tong Zhu,Wang Zhonggao,Dardik Alan,Gu Yongquan
Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association
BACKGROUND:Patients presenting a carotid stenosis and contralateral carotid occlusion (CCO) have been historically considered at high risk of carotid surgical treatment, and there are few data regarding short-term recovery after stenting therapy in patients with CCO. The aim of this study is to evaluate the short-term recovery and safety of stenting for patients with CCO and different subgroup population. METHODS:We retrospectively reviewed the records of consecutive patients with CCO who were treated with stenting endovascular methods between 2008 and 2014. The postoperative outcomes were analyzed according to age, ischemic symptom, cerebral infarction history, and collateral situation subgroups, respectively. RESULTS:Fifty-eight consecutive patients with CCO were treated and 49 (84.5%) completed a 3-year follow-up. There were significant higher stroke, myocardial infarction, or death events in the aged (≥75 years old) group and poor collateral group (P = .007 and .0024, respectively). There was no difference in the 3-year primary endpoint incidence between the cerebral ischemia symptom subgroups and cerebral infarction history subgroups. Event-free survival, aged group, and poor collateral group were lower (P = .007 and P = .0024, respectively). CONCLUSIONS:Carotid artery stenting (CAS) for patients with common carotid artery is a safe and effective therapy. Factors such as age 75 years or older and poor collateral are associated with a higher 3-year rate of postprocedural stroke, myocardial infarction and death, and lower event-free survival in patients with CCO treated by CAS. Meanwhile, our data do not show a significant impact of cerebral ischemic symptom and cerebral infarction history on clinical outcome of patients with CCO undergoing CAS.
Pseudo-Occlusion of the Internal Carotid Artery in Acute Ischemic Stroke: Clinical Outcome after Mechanical Thrombectomy.
Jung Woo Sang,Lee Jin Soo,Solander Sten,Choi Jin Wook
Pseudo-occlusion (PO) of the cervical internal carotid artery (cICA) can be caused by distal ICA occlusion. We explored the clinical impact of PO after mechanical thrombectomy (MT). Patients who underwent MT to treat distal ICA occlusions between July 2012 and March 2018 were reviewed. A cICA-PO was defined as when single phase computed tomography angiography (CTA) revealed a gradual decline in contrast above the level of the carotid bulb. We investigated the relationship between a cICA-PO and outcome; we also explored the association between successful recanalization and outcome. Among 71 patients, 40 (56.3%) exhibited cICA-PO and more likely to experience poor outcomes (80.0% vs. 25.8%, P < 0.001), hemorrhagic transformation (32.5% vs. 9.6%, P = 0.01), and a lower rate of successful recanalization (65.0% vs. 90.3%, P = 0.014) than the non-PO group. In binary logistic regression, a cICA-PO was independently associated with a poor outcome (odds ratio, 4.278; 95% CI, 1.080-33.006; P = 0.045). In the cICA-PO group, all patients who failed recanalization (n = 15) experienced poor outcomes, as did 69.2% of patients in whom recanalization was successful (P = 0.018). cICA-POs are common and have worse outcomes than non-PO patients. Patients with cICA-POs are more likely to exhibit poor outcomes after MT, particularly when recanalization fails.
Human CCR5high effector memory cells perform CNS parenchymal immune surveillance via GZMK-mediated transendothelial diapedesis.
Herich Sebastian,Schneider-Hohendorf Tilman,Rohlmann Astrid,Khaleghi Ghadiri Maryam,Schulte-Mecklenbeck Andreas,Zondler Lisa,Janoschka Claudia,Ostkamp Patrick,Richter Jannis,Breuer Johanna,Dimitrov Stoyan,Rammensee Hans-Georg,Grauer Oliver M,Klotz Luisa,Gross Catharina C,Stummer Walter,Missler Markus,Zarbock Alexander,Vestweber Dietmar,Wiendl Heinz,Schwab Nicholas
Brain : a journal of neurology
Although the CNS is immune privileged, continuous search for pathogens and tumours by immune cells within the CNS is indispensable. Thus, distinct immune-cell populations also cross the blood-brain barrier independently of inflammation/under homeostatic conditions. It was previously shown that effector memory T cells populate healthy CNS parenchyma in humans and, independently, that CCR5-expressing lymphocytes as well as CCR5 ligands are enriched in the CNS of patients with multiple sclerosis. Apart from the recently described CD8+ CNS tissue-resident memory T cells, we identified a population of CD4+CCR5high effector memory cells as brain parenchyma-surveilling cells. These cells used their high levels of VLA-4 to arrest on scattered VCAM1, their open-conformation LFA-1 to crawl preferentially against the flow in search for sites permissive for extravasation, and their stored granzyme K (GZMK) to induce local ICAM1 aggregation and perform trans-, rather than paracellular diapedesis through unstimulated primary brain microvascular endothelial cells. This study included peripheral blood mononuclear cell samples from 175 healthy donors, 29 patients infected with HIV, with neurological symptoms in terms of cognitive impairment, 73 patients with relapsing-remitting multiple sclerosis in remission, either 1-4 weeks before (n = 29), or 18-60 months after the initiation of natalizumab therapy (n = 44), as well as white matter brain tissue of three patients suffering from epilepsy. We here provide ex vivo evidence that CCR5highGZMK+CD4+ effector memory T cells are involved in CNS immune surveillance during homeostasis, but could also play a role in CNS pathology. Among CD4+ T cells, this subset was found to dominate the CNS of patients without neurological inflammation ex vivo. The reduction in peripheral blood of HIV-positive patients with neurological symptoms correlated to their CD4 count as a measure of disease progression. Their peripheral enrichment in multiple sclerosis patients and specific peripheral entrapment through the CNS infiltration inhibiting drug natalizumab additionally suggests a contribution to CNS autoimmune pathology. Our transcriptome analysis revealed a migratory phenotype sharing many features with tissue-resident memory and Th17.1 cells, most notably the transcription factor eomesodermin. Knowledge on this cell subset should enable future studies to find ways to strengthen the host defence against CNS-resident pathogens and brain tumours or to prevent CNS autoimmunity.
Tissue-resident lymphocytes: from adaptive to innate immunity.
Sun Haoyu,Sun Cheng,Xiao Weihua,Sun Rui
Cellular & molecular immunology
Efficient immune responses against invading pathogens often involve coordination between cells from both the innate and adaptive immune systems. For multiple decades, it has been believed that CD8 memory T cells and natural killer (NK) cells constantly and uniformly recirculate. Only recently was the existence of noncirculating memory T and NK cells that remain resident in the peripheral tissues, termed tissue-resident memory T (T) cells and tissue-resident NK (trNK) cells, observed in various organs owing to improved techniques. T cells populate a wide range of peripheral organs, including the skin, sensory ganglia, gut, lungs, brain, salivary glands, female reproductive tract, and others. Recent findings have demonstrated the existence of T in the secondary lymphoid organs (SLOs) as well, leading to revision of the classic theory that they exist only in peripheral organs. trNK cells have been identified in the uterus, skin, kidney, adipose tissue, and salivary glands. These tissue-resident lymphocytes do not recirculate in the blood or lymphatic system and often adopt a unique phenotype that is distinct from those of circulating immune cells. In this review, we will discuss the recent findings on the tissue residency of both innate and adaptive lymphocytes, with a particular focus on CD8 memory T cells, and describe some advances regarding unconventional T cells (invariant NKT cells, mucosal-associated invariant T cells (MAIT), and γδ T cells) and the emerging family of trNK cells. Specifically, we will focus on the phenotypes and functions of these subsets and discuss their implications in anti-viral and anti-tumor immunity.
Tissue-resident memory T cells populate the human brain.
Smolders Joost,Heutinck Kirstin M,Fransen Nina L,Remmerswaal Ester B M,Hombrink Pleun,Ten Berge Ineke J M,van Lier René A W,Huitinga Inge,Hamann Jörg
Most tissues are populated by tissue-resident memory T cells (T cells), which are adapted to their niche and appear to be indispensable for local protection against pathogens. Here we show that human white matter-derived brain CD8 T cells can be subsetted into CD103CD69 and CD103CD69 T cells both with a phenotypic and transcription factor profile consistent with T cells. Specifically, CD103 expression in brain CD8 T cells correlates with reduced expression of differentiation markers, increased expression of tissue-homing chemokine receptors, intermediate and low expression of the transcription factors T-bet and eomes, increased expression of PD-1 and CTLA-4, and low expression of cytolytic enzymes with preserved polyfunctionality upon activation. Brain CD4 T cells also display T cell-associated markers but have low CD103 expression. We conclude that the human brain is surveilled by T cells, providing protection against neurotropic virus reactivation, whilst being under tight control of key immune checkpoint molecules.