Endovascular Treatment in Two Cases of Bilateral Ischemic Stroke

Endovascular Recanalization and Carotid Stenting: The New Approach to Restore Cerebral Perfusion during Aortic Dissection

A type A aortic dissection (TAAD) is a dangerous condition requiring emergency surgery. Due to the similarity of the symptoms of cerebral malperfusion in TAAD and the signs of ischemic stroke, a differential diagnosis of these diseases is not always available. Patients with TAAD after cerebral malperfusion can have a neurological deficit. Thrombolysis is performed in this case. It can worsen the patient's condition and increase the risk of mortality and disability. The aim of the study is to evaluate the new approach to restoring cerebral perfusion during aortic dissection. This approach includes endovascular recanalization and carotid stenting.

METHODS

Two clinical cases of TAAD complicated by cerebral malperfusion are described. The first patient is 73 years old and was admitted as planned to perform transcatheter aortic valve implantation (TAVI) for grade III aortic stenosis. The patient underwent transcatheter aortic valve implantation (TAVI) on the second day after admission. The second patient is 60 years old and was hospitalized by an ambulance with strong hypertension and ischemia. The surgical correction of aortic dissection was postponed until the neurological status assessment in both patients.

RESULTS

The surgery to correct the aorta dissection was deemed inappropriate. The carotid arteries have been reanalyzed, and cerebral perfusion has been restored in a short time in both patients.

CONCLUSION

Acute bilateral internal carotid occlusion is a potentially fatal TAAD outcome. Emergency endovascular recanalization and carotid stenting may be considered one of the few ways to restore cerebral perfusion.

Sequential mechanical thrombectomies in acute bilateral middle cerebral artery strokes: A case report and review of literature

Simultaneous occlusion of both middle cerebral arteries (MCAs) is very rare and usually devastating. Few case reports are available in the literature where bilateral thrombectomy was done simultaneously to remove the clot. High NIH stroke scale with a low level of consciousness can be a clue for the diagnosis. Timely intervention is necessary to decrease morbidity and mortality in these patients. We also reviewed the existing literature where mechanical thrombectomies were done for bilateral MCA stroke in PubMed, Google Scholar, Cochrane, and Embase. Herein, we report a case of 47-year-old female having rheumatic heart disease presented with simultaneous bilateral MCAs occlusion, treated with mechanical thrombectomies successfully.

Technical and clinical outcomes in concurrent multivessel occlusions treated with mechanical thrombectomy: insights from the STAR collaboration

BACKGROUND

Endovascular thrombectomy (EVT) has become the mainstay treatment for large vessel occlusion, with favorable safety and efficacy profile. However, the safety and efficacy of EVT in concurrent multi-territory occlusions (MTVOs) remains unclear.

OBJECTIVE

To investigate the prevalence, clinical and technical outcomes of concurrent EVT for MTVOs.

METHODS

Data were included from the Stroke Thrombectomy and Aneurysm Registry (STAR) with 32 stroke centers for EVT performed to treat bilateral anterior or concurrent anterior and posterior circulation occlusions between 2017 and 2021. Patients with MTVO were identified, and propensity score matching was used to compare this group with patients with occlusion in a single arterial territory.

RESULTS

Of a total of 7723 patients who underwent EVT for acute ischemic stroke, 54 (0.7%) underwent EVT for MTVOs (mean age 69±12.5; female 50%). 28% had bilateral and 72% had anterior and posterior circulations occlusions. The rate of successful recanalization (Thrombolysis in Cerebral Infarction 2b/3), complications, modified Rankin score at 90 days, and mortality was not significantly different between the matched cohorts. Multivariate analysis confirmed that MTVOs were not associated with poor functional outcome, symptomatic intracranial hemorrhage, or longer procedure time.

CONCLUSION

Compared with EVT for single vessel occlusions, EVT in appropriately selected patients with MTVOs has a similar efficacy and safety profile.

Bilateral Middle Cerebral Artery Occlusion: A Successful Case of Bilateral Thrombectomy

Single-vessel occlusions often cause an acute ischemic stroke (AIS) but can rarely be caused by multi-vessel occlusions. Although bilateral AIS is rare, these patients often undergo mechanical thrombectomy as long as they are within the 24-hour window since symptom presentation. We present a case of a female in her 70s who presented to an outside facility with right-sided weakness in her upper and lower extremities, drooping of the right lower face, and aphasia. The patient developed bilateral symptoms on transfer to a tertiary center with neuro-interventional capabilities. Due to concern for a possible bilateral stroke, magnetic resonance imaging was ordered and was remarkable for bilateral middle cerebral artery occlusion. The patient underwent a successful bilateral mechanical thrombectomy within 24 hours of the last known normal. This case demonstrates that mechanical thrombectomy is an excellent treatment option for patients with bilateral occlusions that present within the recommended 24 hours from the last known normal.

Successful mechanical thrombectomy in acute bilateral M1 middle cerebral artery occlusion: a case report and literature review

BACKGROUND

Acute bilateral occlusion of the middle cerebral artery (MCA) is a very rare condition, and most cases are accompanied by a poor prognosis. However, mechanical thrombectomy (MT) for bilateral MCA is challenging. Here, we report a case of acute unilateral MCA occlusion with sequential acute occlusion of the bilateral MCA during intravenous thrombolysis (IVT). We urgently performed bilateral MT of the MCA and effective recanalization.

CASE PRESENTATION

The patient is a 73-year-old man who complained of a sudden adverse influence on speech and an inability to move his left limb for 2 h. He had a history of paroxysmal atrial fibrillation, but had never used any anticoagulants before. Head and neck computed tomography angiography (CTA) showed embolism in the right M1 MCA. During intravenous alteplase thrombolytic therapy, the patient suddenly became unconscious. Cerebral angiography showed occlusion of the M1 segment of the bilateral MCA in the patients. MT of the bilateral MCA was performed using a combination of a stent retriever and an aspiration catheter with mTici 3 revascularization. On the second day, the patient became conscious, although he had remaining symptoms of speech insufficiency and weakness of the left limb. The mRS score was 2 90 days after the operation.

CONCLUSIONS

Acute bilateral occlusion of the M1 segment of the MCA is extremely rare and is accompanied by high morbidity and high mortality. Intravenous alteplase thrombolysis can increase the risk of atrial thrombus shedding in patients with atrial fibrillation, so patients with acute bilateral MCA occlusion in the M1 segment chose direct MT or bridging therapy, which remains controversial, and the sequence of MT remains to be discussed. Nevertheless, early endovascular treatment can decrease the morbidity and mortality of such patients.

Simultaneous mechanical thrombectomy for bilateral acute internal carotid artery occlusion

Acute bilateral internal carotid occlusion was a very rare disease with a very poor prognosis. Clinical case reports according to the literature showed that mechanical thrombectomy was the most optimal treatment. We reported a clinical case of successful treatment with simultaneous thrombectomy in both occluded carotid arteries. A 62-year-old woman was admitted at our hospital within three hours of stroke onset secondary to an acute simultaneously bilateral carotid artery occlusion. On admission, her NIHSS (National Institutes of Health Stroke Scale) was 32. Non-contrast computed tomography right after that showed hyperacute infarction lesions in both hemispheres with right inferior temporal and insular cortex (Alberta Stroke Program Early CT Score - ASPECTS 8) and left putamen (ASPECTS 9). Her medical history included paroxysmal atrial fibrillation, prior ischemic stroke, pacemaker due to sick sinus syndrome. Her pre-stroke modified Rankin Scale score was 0 that she was fully recovered from previous stroke 4 months ago thanks to successful thrombectomy of the right internal carotid arteries (ICA). This time, the patient underwent again the simultaneous bilateral mechanical thrombectomy of both occluded ICA. The complete recanalization achieved on both sides with recanalization level of TICI-3 (thrombolysis in cerebral infarction) only in 38 mins after the groin puncture. She showed dramatic recovery and was discharged on day 28 with a Rankin Scale score of 2. Mechanical thrombectomy on bilateral ICA performed simultaneously will helps shorten the reperfusion time compared to the alternative one and thus, provides a better prognosis in acute ischemic stroke.

To be, or not to be… Guillain-Barré Syndrome

Guillain-Barré Syndrome (GBS) is currently the most frequent cause of acute flaccid paralysis on a global scale, being an autoimmune disorder wherein demyelination of the peripheral nerves occurs. Its main clinical features are a symmetrical ascending muscle weakness with reduced osteotendinous reflexes and variable sensory involvement. GBS most commonly occurs after an infection, especially viral (including COVID-19), but may also transpire after immunization with certain vaccines or in the development of specific malignancies. Immunoglobulins, plasmapheresis, and glucocorticoids represent the principal treatment modalities, however patients with severe disease progression may require supportive therapy in an intensive care unit. Due to its symptomology, which overlaps with numerous neurological and infectious illnesses, the diagnosis of GBS may often be misattributed to pathologies that are essentially different from this syndrome. Moreover, many of these require specific treatment methods distinct to those recommended for GBS, in lack of which the prognosis of the patient is drastically affected. Such diseases include exposure to toxins either environmental or foodborne, central nervous system infections, metabolic or serum ion alterations, demyelinating pathologies, or even conditions amenable to neurosurgical intervention. This extensive narrative review aims to systematically and comprehensively tackle the most notable and challenging differential diagnoses of GBS, emphasizing on the clinical discrepancies between the diseases, the appropriate paraclinical investigations, and suitable management indications.

F-domain valency determines outcome of signaling through the angiopoietin pathway

Angiopoietins 1 and 2 (Ang1 and Ang2) regulate angiogenesis through their similar F-domains by activating Tie2 receptors on endothelial cells. Despite the similarity in the underlying receptor-binding interaction, the two angiopoietins have opposite effects: Ang1 induces phosphorylation of AKT, strengthens cell-cell junctions, and enhances endothelial cell survival while Ang2 can antagonize these effects, depending on cellular context. To investigate the molecular basis for the opposing effects, we examined the phenotypes of a series of computationally designed protein scaffolds presenting the Ang1 F-domain in a wide range of valencies and geometries. We find two broad phenotypic classes distinguished by the number of presented F-domains: Scaffolds presenting 3 or 4 F-domains have Ang2-like activity, upregulating pFAK and pERK but not pAKT, while scaffolds presenting 6, 8, 12, 30, or 60 F-domains have Ang1-like activity, upregulating pAKT and inducing migration and vascular stability. The scaffolds with 6 or more F-domains display super-agonist activity, producing stronger phenotypes at lower concentrations than Ang1. Tie2 super-agonist nanoparticles reduced blood extravasation and improved blood-brain barrier integrity four days after a controlled cortical impact injury.

Mechanical Thrombectomy for Bihemispheric Infarction Caused by Acute Unilateral Internal Carotid Artery Occlusion in a Patient with Contralateral Chronic Carotid Occlusion: A Case Report

Objective

We report a patient with acute bihemispheric infarction who underwent mechanical thrombectomy.

Case Presentation

A 76-year-old man suddenly developed coma and quadriplegia. Brain MRI and MRA revealed acute bihemispheric infarction due to occlusions of both the internal carotid arteries (ICAs). According to the DSA findings, we considered the left ICA as chronic occlusion and the right as acute. Mechanical thrombectomy for the right ICA occlusion was performed. Total recanalization was achieved using a stent retriever 181 minutes after onset. The left hemisphere was perfused by cross circulation through the anterior communicating artery, but the symptoms did not improve. MRI the day after thrombectomy showed extensive bihemispheric infarction. Recanalization for the bilateral hemispheres was maintained, although the left ICA remained occluded. He died 2 months later due to gastrointestinal bleeding.

Conclusion

Acute bihemispheric infarction due to occlusions of both ICAs is a rare entity. The symptoms are very severe and the therapeutic time window is extremely short because of absent collateral pathways. We should consider pre-existing carotid occlusive disease, determine whether the occlusions are acute or chronic, and perform prompt therapy. Further investigation is warranted to obtain a better outcome.

Simultaneous bilateral mechanical thrombectomy in a patient with COVID-19

Owing to systemic inflammation and widespread vessel endotheliopathy, SARS-CoV-2 has been shown to confer an increased risk of cryptogenic stroke, particularly in patients without any traditional risk factors. In this report, we present a case of a 67-year-old female who presented with acute stroke from bilateral anterior circulation large vessel occlusions, and was incidentally found to be COVID-positive on routine hospital admission screening. The patient had a large area of penumbra bilaterally, and the decision was made to pursue bilateral simultaneous thrombectomy, with two endovascular neurosurgeons working on each side to achieve a faster time to recanalization. Our study highlights the utility and efficacy of simultaneous bilateral thrombectomy, and this treatment paradigm should be considered for use in patients who present with multifocal large vessel occlusions.

Bilateral middle cerebral artery occlusions treated with simultaneous bilateral thrombectomy: an approach to multivessel occlusions

The scarcely described phenomenon of acute ischaemic stroke due to bilateral large vessel occlusions and limited reports of its treatment raises the question about the best method for revascularisation. We present a simultaneous bilateral thrombectomy method on a patient with acute bilateral middle cerebral artery occlusions. This technique resulted in successful vessel recanalisation within 35 min without haemorrhagic complications-deeming the method both safe and effective. Patient outcome was unfavourable, complicated by the patient's history of heart failure and other cardiac-related problems. Patient is residing at a skilled nursing facility with maximal assistance.

F-domain valency determines outcome of signaling through the angiopoietin pathway

Angiopoietin 1 and 2 (Ang1 and Ang2) modulate angiogenesis and vascular homeostasis through engagement of their very similar F-domain modules with the Tie2 receptor tyrosine kinase on endothelial cells. Despite this similarity in the underlying receptor binding interaction, the two angiopoietins have opposite effects: Ang1 induces phosphorylation of protein kinase B (AKT), strengthens cell-cell junctions and enhances endothelial cell survival while Ang2 antagonizes these effects^1–4. To investigate the molecular basis for the opposing effects, we examined the protein kinase activation and morphological phenotypes produced by a series of computationally designed protein scaffolds presenting the Ang1 F-domain in a wide range of valencies and geometries. We find two broad phenotypic classes distinguished by the number of presented F-domains: scaffolds presenting 4 F-domains have Ang2 like activity, upregulating pFAK and pERK but not pAKT, and failing to induce cell migration and tube formation, while scaffolds presenting 6 or more F-domains have Ang1 like activity, upregulating pAKT and inducing migration and tube formation. The scaffolds with 8 or more F-domains display superagonist activity, producing stronger phenotypes at lower concentrations than Ang1. When examined in vivo, superagonist icosahedral self-assembling nanoparticles caused significant revascularization in hemorrhagic brains after a controlled cortical impact injury.

Primary Multivessel Occlusions Treated With Mechanical Thrombectomy: A Multicenter Analysis and Systemic Literature Review

BACKGROUND AND PURPOSE

Acute ischemic stroke caused by primary multivessel occlusions (pMVO) is a rare but devastating disease. Whether multi-target mechanical thrombectomy for pMVO is beneficial remains unknown.

METHODS

Multicenter retrospective review of patients treated with multi-target mechanical thrombectomy. The following pMVO sites were included: basilar artery, internal carotid artery, and middle cerebral artery (M1 and M2). Baseline characteristics were reported together with interventional technique, technical efficacy, and safety parameters. Clinical outcomes were evaluated applying the National Institutes of Health Stroke Scale and modified Rankin Scale. A systematic literature review was performed to summarize previous reports on pMVO mechanical thrombectomy.

RESULTS

Of 6081 patients screened, 21 patients met the inclusion criteria (0.35% [95% CI, 0.23%-0.53%]). In 70% (14/20) a cardioembolic cause was reported. A successful reperfusion of Thrombolysis in Cerebral Infarction scale score ≥2b was achieved in 95.2% (20/21) for the first and 76.1% (16/21) for the second target vessel. In those who survived the acute hospital stay (n=10/21), median admission National Institutes of Health Stroke Scale improved from 21 (interquartile range, 13-27) to 8 (interquartile range, 2-20) at discharge (P=0.006). Mortality was 60% (12/20) at 90 days and only 20% (4/20) of patients reached modified Rankin Scale score ≤2. Acceptable outcomes were almost exclusively observed in pMVO patients presenting with at least one M2 occlusion.

CONCLUSIONS

Multi-target mechanical thrombectomy for pMVOs is rarely performed; however, the procedure appears to be feasible and safe with high reperfusion rates for both occlusion sites. More than half of all treated patients deceased early and favorable outcomes may only be expected for pMVO patients including at least one M2 occlusion.

Mechanical recanalization for acute bilateral cerebral artery occlusion - literature overview with a case

Background

Acute bilateral internal carotid artery (ICA) and/or middle cerebral artery (MCA) occlusion is extremely rare and associated with poor clinical outcomes. There are only a few reports in the literature about mechanical thrombectomy being performed for acute bilateral occlusions. The treatment strategies and prognoses (clinical outcomes) are therefore unclear.

Methods

A systematic review of the literature was performed through several electronic databases with the following search terms: acute bilateral stroke, mechanical recanalization and thrombectomy.

Results

In the literature, we identified five reports of six patients with bilateral ICA and/or MCA occlusion treated with mechanical recanalization. Additionally, we report our experience with a subsequent contralateral large brain artery occlusion during intravenous thrombolytic therapy, where the outcome after mechanical thrombectomy was not dependent on the time from stroke onset but rather on the capacity of collateral circulation exclusively.

Conclusions

Acute bilateral cerebral (ICA and/or MCA) occlusion leads to sudden severe neurological deficits (comas) with unpredicted prognoses, even when mechanical recanalization is available. As the collateral capacity seems to be more important than the absolute time to flow restoration in determining the outcomes, simultaneous thrombectomy by itself probably does not lead to improved functional outcomes.

Simultaneous Bilateral Carotid Thrombectomies: A Technical Note

BACKGROUND

Although extremely rare, acute bilateral large vessel occlusion (LVO) is a morbid condition that requires prompt intervention.

OBJECTIVE

To report the technique used to achieve recanalization of bilateral internal carotid artery (ICA) terminus occlusions.

METHODS

This is a case of bilateral ICA terminus occlusions managed with simultaneous bilateral thrombectomies with poor collateral circulation.

RESULTS

Recanalization of bilateral ICA with thrombolysis in cerebral infarction (TICI) grade 0 to left TICI 2b flow with distal left A1 occlusion and right TICI 3 flow was achieved in 32 min with the use of simultaneous catheterization and aspiration thrombectomies.

CONCLUSION

The described technique offers an efficient and feasible means to reduce time to recanalization and radiation in cases of bilateral LVO.