Radiologic intervention in the acute stroke patient

Catheter-based neurosalvage for acute embolic complication during carotid intervention

OBJECTIVES

Iatrogenic emboli may be released during carotid intervention, causing permanent neurologic complications and catastrophic outcomes. This article reports the procedural details and clinical results of our series of neurosalvage techniques to manage thromboembolic events during carotid procedures.

METHODS

Between March 2003 and December 2007, 342 patients (283 men, 72.1 +/- 8.9 years old, 121 symptomatic) underwent percutaneous stent deployment in 407 cervical internal carotid arteries in our institution. Visible distal embolization with flow occlusion caused neurologic complications in 10 patients (2.5%), and a structured and stepwise neurosalvage approach was attempted.

RESULTS

Guidewire fragmentation and microcatheter injection of heparin and nitroglycerin were performed in all 10 patients as step 1. Intra-arterial thrombolysis was given in four patients and balloon angioplasty in five, as step 2. Intracranial stenting was done in one patient as the last step. Successful angiographic recanalization (Thrombolysis in Myocardial Infarction [TIMI] grade 2-3) occurred in 9 of 10 (90%). Residual neurologic sequel was observed in five, including three patients with hemorrhage complications (1 received emergent craniotomy). There was no neurologic mortality in this series.

CONCLUSIONS

Acute embolic complication during carotid artery stenting can be managed by catheter-based neurosalvage with effective angiographic recanalization and marginal clinical success.

Physiologic monitoring and anesthesia considerations in acute ischemic stroke

Acute ischemic stroke is considered a neurologic emergency. The perioperative anesthesia management of acute ischemic stroke is challenging owing to the dynamic pathophysiology of the disease itself and the patients' comorbid factors and conditions. Herein, the authors review preoperative assessment, intraoperative and postoperative physiologic monitoring, and anesthesia management, with a focus on the control of the cerebrovascular and cardiovascular circulations. Issues specific to anesthesia monitoring and management in the radiology suite are emphasized.

Management of neurological complications of carotid artery stenting

PURPOSE

To review the neurological complications associated with extracranial carotid artery stenting and to preliminarily assess techniques used to manage these complications.

METHODS

Between April 1994 and August 2000, 450 patients (270 men; mean age 70.2 years, range 27-89) had stents implanted to treat 472 cervical carotid artery stenoses. Over half (257, 57%) of the patients were symptomatic. A variety of stents were implanted percutaneously after predilation of the lesion; a third of the patients received glycoprotein IIb/ IIIa inhibitors intraprocedurally in addition to a standard oral antiplatelet regimen (aspirin and ticlopidine or clopidogrel). Occurrence and management of neurological complications within the 30-day periprocedural period were reviewed.

RESULTS

There were 14 (3.1%) transient ischemic attacks (TIAs), 10 (2.2%) minor strokes, and 3 (0.7%) major strokes. Among 6 (1.3%) procedure-related deaths, 4 had neurological causes. The total stroke and death rate was 4.2% (n = 19). All the TIAs, 4 of which occurred between 1 and 14 days poststenting, were treated medically, as were the minor strokes, 3 of which occurred >24 hours after stenting. Only 2 minor stroke patients had mild residual upper extremity motor deficits. Intra-arterial thrombolytic therapy was administered in 5 cases (2 major strokes survivors and 3 patients who suffered a neurologically-related death); occlusions were identified in the proximal middle cerebral artery (MCA) in 3 and the distal MCA in 2. Angiographic improvement was noted in 4 (80%), but only the 2 (40%) with distal MCA occlusions did well clinically.

CONCLUSIONS

Neurological complications following carotid artery stenting are inevitable. The occurrence of minor strokes >24 hours following stenting may indicate a possible late embolic phenomenon, which warrants investigation. Likewise, the marginal efficacy of intra-arterial thrombolytic therapy demonstrates an inability to lyse embolic plaque and underscores the need for effective distal protection.

Interventional radiology

One of the most interesting things about interventional radiology is how techniques have been borrowed from other areas. The lateral thinking which characterises this new specialty has allowed it to flourish even while it has lost "turf" to other specialties. Inevitably, primary referral to interventional radiologists will happen in the same way as referral to, say, surgeons or cardiologists dose already. Those who administer health funds and medical education will need to adjust to this new situation. This article provides examples of many treatment tasks that the interventional radiologist now tackles.