Intra-arterial thrombolysis in 24 consecutive patients with internal carotid artery T occlusions

Intravenous Thrombolysis before Thrombectomy may Increase the Incidence of Intracranial Hemorrhage inTreating Carotid T Occlusion

BACKGROUND AND PURPOSE

Current evidence does not agree on the merits of direct and bridging thrombectomy. This study aimed to compare the safety and efficacy of direct thrombectomy (DT) and bridging thrombectomy (BT) in treating patients with acute ischaemic stroke due to carotid T occlusion.

METHODS

Patients with stroke due to carotid T occlusion who were treated with DT or BT were retrospectively collected from four advanced stroke centres. Baseline characteristics and clinical outcomes were compared between the groups. Successful recanalization was defined by a modified thrombolysis in cerebral infarction (mTICI) score of 2b or 3. A favourable outcome was defined by a modified Rankin Scale (mRS) score of 0-2 at 90 days after stroke onset. Multivariable analysis was performed to control for potential confounders.

RESULTS

Of the 111 enrolled patients, 57 (51.4%) patients were treated with DT, and 54 (48.6%) were treated with BT. Patients treated with DT had a shorter imaging to puncture (ITP) time (53 min versus 92 min, P<0.001) and symptom onset to puncture (OTP) time (198 min versus 218 min, P=0.045) than patients treated with BT. No significant difference was detected concerning the rate of successful recanalization (80.7% versus 77.8%, P=0.704) or a favourable outcome between patients treated with DT and BT (35.1% versus 33.3%, P=0.846). Patients treated with DT had a lower intracranial haemorrhage (ICH) rate (40.4% versus 59.3%, P=0.046), but the difference was not significant for symptomatic ICH (sICH, 12.3% versus 16.7%, P=0.511) or asymptomatic ICH (aICH, 28.1% versus 42.6%, P=0.109). After adjusting for potential confounding factors, the ratio of favorable prognosis, successful reperfusion, sICH and mortality did not differ between the two groups. However, there was a higher rate of ICH (OR=2.492, 95% CI 1.005 to 6.180, p=0.049) in the BT group as compared with the DT group.

CONCLUSIONS

DT seems equivalent to BT in treating stroke due to carotid T occlusion in favorable outcome, successful recanalization, 90-day morality and sICH. However, BT may increase the incidence of ICH in this specific type stroke.

Combined Surgical and Endovascular Carotid Access for Endovascular Thrombectomy in Acute Ischemic Stroke

OBJECTIVE

Conventional carotid catheterization is impossible in 2%-5% of acute stroke cases. Surgical carotid cutdown may be a necessary bailout strategy to allow for carotid access. We assessed the effectiveness and safety of surgical carotid cutdown for vascular access in interventional acute stroke treatment.

METHODS

We compare imaging and clinical data of 15 consecutive patients, in whom we performed a carotid cutdown for acute stroke treatment with 10 consecutive patients, in whom treatment was discontinued because transfemoral access to the occlusion site was not possible.

RESULTS

Baseline characteristics of both groups were comparable (P ≥ 0.065). Cutdown patients had significantly smaller infarctions (P = 0.031), significantly more often favorable clinical outcome (38% vs. 0% modified Rankin score 0-2, P = 0.046), and a lower mortality (31% vs. 60%, P = 0.222) at 3 months. Other than a small hematoma at the operation site, there were no procedure-related complications.

CONCLUSIONS

Carotid cutdown is an effective bailout strategy for acute stroke patients, in whom conventional catheterization is not possible.

Acute Occlusion of the Distal Internal Carotid Artery : Single Center Experience in 46 Consecutive Cases, review of the literature and proposal of a classification

PURPOSE

The acute distal intracranial occlusion of the internal carotid artery (ICA) is a very complex heterogeneous pathology, characterized by various patterns. Aim of this work is to identify the different types and propose a classification.

METHODS

Among the patients admitted for stroke in the anterior circulation from august 2014 to October 2017, 46 (25%) presented with intracranial distal carotid artery occlusion. The mean age of the patients was 71 (SD 13.7), 65,2% female. The protocol included general and specific neurological examinations, CT, CT-Angiography with multiphase CTA, followed by Angiography. The occlusion was treated by aspiration device alone or associated with stent-retriever. NIHSS at the admission, at discharge and modified ranking Scale (mRS) at four months were examined.

RESULTS

The occlusions presented with various patterns. Depending on its site (located at the distal ICA bifurcation or more proximal at the level of the ophthalmic segment of ICA, with or without extent to ICA bifurcation) taking also into account the various involvement of the cerebral vessels and anatomic variations of Circle of Willis, three groups of occlusion types could be identified (T1, T2 and T3). The collateral circulation, and the possibilities of the endovascular revascularization important for the final outcome, were clearly connected with the type of occlusion. NIHSS at admission was 19.1 (Range from 8 to 30, SD 4.4). Good outcome defined as mRS 0-2 at for months was obtained in 17 patients (37%).

CONCLUSIONS

The proposed classification reproduces more precisely the complexity and heterogeneity of this pathology, being useful in the diagnosis and treatment of these patients.

The Prognostic Value of CT-Angiographic Parameters After Reperfusion Therapy in Acute Ischemic Stroke Patients With Internal Carotid Artery Terminus Occlusion: Leptomeningeal Collateral Status and Clot Burden Score

BACKGROUND

The objective of this study was to investigate the prognostic value of computed tomographic angiography (CTA) based on leptomeningeal collateral (LMC) status and other parameters in acute ischemic stroke (AIS) patients with internal carotid artery (ICA) terminus occlusion treated with endovascular treatment (EVT).

METHODS

All eligible patients from January 2013 to December 2017 undergoing EVT were retrospectively reviewed. The regional leptomeningeal score was used to assess the LMCs on baseline CTA. The collateral status measured by the LMC score (0-20) was trichotomized into 3 groups: good (17-20), intermediate (11-16), and poor (0-10).

RESULTS

Our sample included a total of 119 eligible patients (60 males; mean age, 73 years) with a median baseline National Institute of Health Stroke Scale (NIHSS) score of 14. Patients with a good LMC score had a lower baseline mean NIHSS score, a higher mean Alberta Stroke Program Early CT score, and a higher mean clot burden score (CBS). Baseline NIHSS score <15 (odds ratio [OR] 3.69 95% confidence ratio [CI]: 1.32-10.29, P = .013), CBS ≥ 6 (OR 3.97 95%CI: 1.05-14.99, P = .042), good LMC score (OR 5.14 95%CI: 1.62-16.26, P = .005) and successful recanalization (OR 11.55 95%CI: 2.72-48.99 P = .001) were independent predictors of good clinical outcomes.

CONCLUSIONS

CTA-based LMC status and CBS are powerful predictors of clinical outcomes in patients with an acute ICA terminus occlusion treated with EVT.

Differentiating Carotid Terminus Occlusions into Two Distinct Populations Based on Willisian Collateral Status

Background and Purpose

The outcomes of acute internal carotid artery (ICA) terminus occlusions are poor. We classified ICA terminus occlusions into 2 groups according to the occlusion pattern of the circle of Willis and hypothesized that clinical outcomes would significantly differ between them.

Methods

Consecutive patients with acute ICA terminus occlusions evaluated by baseline computed tomographic angiography were enrolled. We investigated the occlusion patterns in the circle of Willis, retrospectively classified patients into simple ICA terminus occlusion (STO; with good Willisian collaterals from neighboring cerebral circulation) and complex ICA terminus occlusion (CTO; with one or more of A2 anterior cerebral artery, fetal posterior cerebral artery occlusion, or hypoplastic/absent contralateral A1; or with poor collaterals from anterior communicating artery) groups, and compared their baseline characteristics and outcomes.

Results

The STO group (n=58) showed smaller infarct volumes at 72 hours than the CTO group (n=34) (median, 81 mL [interquartile range, 38-192] vs. 414 mL [193-540], P<0.001) and more favorable outcomes (3-month modified Rankin Scale 0-3, 44.8% vs. 8.8%, P<0.001; 3-month mortality, 24.1% vs. 67.6%, P<0.001). In multivariable analyses, STO remained an independent predictor for favorable outcomes (odds ratio 6.1, P=0.010).

Conclusions

Favorable outcomes in STO group suggested that the outcomes of acute ICA terminus occlusions depend on Willisian collateral status. Documenting the subtypes on computed tomographic angiography would help predict patient outcome.

Considerations about Occlusion of the Intracranial Distal Internal Carotid Artery

Occlusion of the intracranial distal internal carotid artery (ICA) is one of the most critical conditions among the cases of acute stroke in the anterior circulation. The introduction of selective endovascular treatment first using thrombolytic agents replaced later by the mechanical thrombectomy using various devices has improved the prognosis in a certain number of these patients. Among the factors influencing the prognosis of these patients, one is the collateral circulation which in these cases is mainly characterized by leptomeningeal anastomoses. The collateral can, however, be impaired, by distal embolization and by anomalies of the Circle of Willis: the aim of this study is to describe these aspects.

Forced arterial suction thrombectomy with the penumbra reperfusion catheter in acute basilar artery occlusion: a retrospective comparison study in 2 Korean university hospitals

BACKGROUND AND PURPOSE

A performance of forced arterial suction thrombectomy was not reported for the treatment of acute basilar artery occlusion. This study compared revascularization performance between intra-arterial fibrinolytic treatment and forced arterial suction thrombectomy with a Penumbra reperfusion catheter in patients with acute basilar artery occlusion.

MATERIALS AND METHODS

Fifty-seven patients with acute basilar artery occlusion were treated with intra-arterial fibrinolysis (n = 25) or forced arterial suction thrombectomy (n = 32). Baseline characteristics, successful revascularization rate, and clinical outcomes were compared between the groups.

RESULTS

Baseline characteristics, the frequency of patients receiving intravenous recombinant tissue plasminogen activator, and mean time interval between symptom onset and femoral puncture did not differ between groups. The forced arterial suction thrombectomy group had a shorter procedure duration (75.5 minutes versus 113.3 minutes, P = .016) and higher successful revascularization rate (88% versus 60%, P = .017) than the fibrinolysis group. Fair outcome, indicated by a modified Rankin Scale 0-3, at 3 months was achieved in 34% of patients undergoing forced arterial suction thrombectomy and 8% of patients undergoing fibrinolysis (P = .019), and the mortality rate was significantly higher in the fibrinolysis group (25% versus 68%, P = .001). Multiple logistic regression analysis identified the forced arterial suction thrombectomy method as an independent predictor of fair outcome with adjustment for age, sex, initial NIHSS score, and the use of intravenous recombinant tissue plasminogen activator (odds ratio, 7.768; 95% CI, 1.246-48.416; P = .028).

CONCLUSIONS

In acute basilar artery occlusion, forced arterial suction thrombectomy demonstrated a higher revascularization rate and improved clinical outcome compared with traditional intra-arterial fibrinolysis. Further clinical trials with the newer Penumbra catheter are warranted.

Assessment of intracranial collaterals on CT angiography in anterior circulation acute ischemic stroke

BACKGROUND AND PURPOSE

Intracranial collaterals influence the prognosis of patients treated with intravenous tissue plasminogen activator in acute anterior circulation ischemic stroke. We compared the methods of scoring collaterals on pre-tPA brain CT angiography for predicting functional outcomes in acute anterior circulation ischemic stroke.

MATERIALS AND METHODS

Two hundred consecutive patients with acute anterior circulation ischemic stroke treated with IV-tPA during 2010-2012 were included. Two independent neuroradiologists evaluated intracranial collaterals by using the Miteff system, Maas system, the modified Tan scale, and the Alberta Stroke Program Early CT Score 20-point methodology. Good and extremely poor outcomes at 3 months were defined by modified Rankin Scale scores of 0-1 and 5-6 points, respectively.

RESULTS

Factors associated with good outcome on univariable analysis were younger age, female sex, hypertension, diabetes mellitus, atrial fibrillation, small infarct core (ASPECTS ≥8), vessel recanalization, lower pre-tPA NIHSS scores, and good collaterals according to Tan methodology, ASPECTS methodology, and Miteff methodology. On multivariable logistic regression, only lower NIHSS scores (OR, 1.186 per point; 95% CI, 1.079-1.302; P = .001), recanalization (OR, 5.599; 95% CI, 1.560-20.010; P = .008), and good collaterals by the Miteff method (OR, 3.341; 95% CI, 1.203-5.099; P = .014) were independent predictors of good outcome. Poor collaterals by the Miteff system (OR, 2.592; 95% CI, 1.113-6.038; P = .027), Maas system (OR, 2.580; 95% CI, 1.075-6.187; P = .034), and ASPECTS method ≤5 points (OR, 2.685; 95% CI, 1.156-6.237; P = .022) were independent predictors of extremely poor outcomes.

CONCLUSIONS

Only the Miteff scoring system for intracranial collaterals is reliable for predicting favorable outcome in thrombolyzed acute anterior circulation ischemic stroke. However, poor outcomes can be predicted by most of the existing methods of scoring intracranial collaterals.

Mechanical Thrombectomy in Acute Occlusion of the Carotid-T: A Retrospective Single Centre Study in 51 Patients

BACKGROUND AND PURPOSE

Acute occlusion of the carotid-T is associated with large ischemic lesions, poor outcome and up to 53 % mortality with conservative therapy. Endovascular mechanical thrombectomy (EMT) is a promising alternative treatment of large vessel occlusion. Here, we examine feasibility, safety and efficiency of EMT in acute ischemic stroke due to carotid-T-occlusion.

METHODS

Single centre, retrospective analysis of 51 consecutive patients with acute occlusion of the carotid-T, treated by EMT within 6 h after symptom onset. Most patients (42/51) were treated with stentretrievers, 33 with stentretrievers only. Recanalization was assessed by the Thrombolysis in Cerebral Infarction (TICI) score. Early and mid-term clinical outcome was evaluated by National Institutes of Health Stroke Scale (NIHSS)- and modified Rankin Scale mRS-scores, respectively.

RESULTS

Successful recanalization (TICI 2b/3) was achieved in 78.4 % (40/51). Good clinical outcome (mRS 0-2) was observed in 24.4 % of patients, and only in patients treated successfully (TICI 2b/3). Stentretrievers yielded higher recanalization rates and better clinical outcomes than non-stentretriever devices. A total of 12 patients died (29.3 %) during the 90-day observation period. Clinically relevant procedure-related complications occurred in two patients, consisting in one vessel perforation with a microwire, and one symptomatic parenchymal haemorrhage after initiation of antiplatelet therapy following the inadvertent detachment of a stentretriever. Another symptomatic haemorrhage, not directly procedure-related, occurred in one additional patient.

CONCLUSION

EMT in acute carotid-T-occlusion is efficient, yielding high recanalization rates, and reasonably safe, with a low rate of clinically relevant complications. Successful recanalization seems to be a prerequisite for good clinical outcome in this severe condition.

Early experience with stent retrievers and comparison with previous-generation mechanical thrombectomy devices for acute ischemic stroke

Object

There is limited information regarding patient outcomes following interventions for stroke during the window for endovascular therapy. Studies have suggested that recently approved stent retrievers are safer and more effective than earlier-generation thrombectomy devices. The authors compared cases in which the Solitaire-FR device was used to those in which a MERCI or Penumbra device was used.

Methods

This study is a single-center retrospective review of 102 consecutive cases of acute stroke in which patients were treated with mechanical thrombectomy devices between 2007 and 2013. Multivariate models, adjusted for confounding factors, were used to investigate functional independence (modified Rankin Scale [mRS] score ≤ 2, and successful reperfusion (thrombolysis in cerebral infarction [TICI] score ≥ 2b).

Results

Thrombectomy device had a significant impact on functional independence (mRS score ≤ 2) at discharge from the hospital (p = 0.040). Solitaire-FR treatment resulted in significantly more patients being discharged as functionally independent in comparison with MERCI treatment (p = 0.016). A multivariate model found the use of Solitaire-FR to improve the odds of good clinical outcome in comparison with prior-generation devices (OR 6.283, 95% CI 1.785–22.119, p = 0.004). Additionally, the use of Solitaire-FR significantly increased the odds of successful reperfusion (OR 3.247, 95% CI 1.160–9.090, p = 0.025).

Conclusions

The stent retriever Solitaire-FR significantly improved the odds of functional independence and successful revascularization of the arterial tree. New interventional technology for stroke continues to mature, but randomized trials are needed to establish the actual benefit to specific patient populations.

Occlusion site does not impact outcome in patients with carotid stroke undergoing endovascular reperfusion

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.

Outcome of mechanical thrombectomy with Solitaire stent as first-line intra-arterial treatment in intracranial internal carotid artery occlusion

INTRODUCTION

Acute stroke from occlusion of the intracranial internal carotid artery (ICA) is associated with a poor clinical outcome despite a thrombolytic treatment. The purpose of this study was to evaluate the outcome of mechanical thrombectomy using the Solitaire stent for the treatment of acute stroke patients with intracranial ICA occlusion.

METHODS

A total of 104 consecutive patients with acute stroke were treated with mechanical thrombectomy using the Solitaire stent as a first-line intra-arterial treatment. We retrospectively reviewed data from 26 of these patients who presented with acute stroke attributable to intracranial ICA occlusion. Rescue treatments in cases of failed Solitaire thrombectomy included intra-arterial urokinase, angioplasty, and forced suction thrombectomy. Successful recanalization was defined as thrombolysis in cerebral ischemia grades 2b to 3. Outcome measure was the modified Rankin Scale (mRS) score of 0-2 at 3 months.

RESULTS

Successful recanalization was achieved in 77% (20/26) of patients. Recanalization was achieved with the Solitaire stent alone in 69% (18/26) of patients. Ten patients (39%) had a good clinical outcome (mRS score of 0-2) at 3 months. There was a good outcome in 50% of patients (10/20) with recanalization and no good outcome in patients (0/6) without recanalization (P = 0.027). None of eight patients who received rescue treatments showed a good outcome. No symptomatic intracerebral hemorrhage occurred. Mortality was 8% (2/26) at 3 months.

CONCLUSION

Mechanical thrombectomy using the Solitaire stent can achieve a high rate of successful recanalization and a very low rate of symptomatic hemorrhage and thus improve a clinical outcome in patients with acute intracranial ICA occlusion.

Endovascular treatment of acute ischemic stroke

Endovascular stroke therapy has revolutionized the management of patients with acute ischemic stroke in the last decade and has facilitated the development of sophisticated stroke imaging techniques and a multitude of thrombectomy devices. This article reviews the scientific basis and current evidence available to support endovascular revascularization and provides brief technical details of the various methods of endovascular thrombectomy with case examples.

The combined use of mechanical thrombectomy devices is feasible for treating acute carotid terminus occlusion

BACKGROUND

Mechanical thrombectomy devices have recently been developed and approved for recanalization of intracranial arterial occlusion. Here, we investigated the feasibility of combined stent-assisted and clot aspiration mechanical thrombectomy for effective recanalization of acute carotid terminus occlusion (CTO).

METHODS

Ten consecutive patients with acute ischemic stroke secondary to CTO who underwent intra-arterial (IA) treatment with both stent retrieval and negative-pressured clot aspiration systems were enrolled. Periprocedural and radiologic findings and clinical outcomes were evaluated.

RESULTS

The median age was 69 years (range, 47-86 years), and the median initial NIHSS score was 17.5 (range, 12-33). Mechanical thrombectomy was performed using a combination of the Solitaire stents and Penumbra system. Thrombolysis in cerebral ischemia [TICI] grade II-III was achieved in eight patients (80.0 %); complete recanalization of the CTO (TICI III) was achieved in three of those patients. Any type of intracranial hemorrhages occurred in four patients (40.0 %), but parenchymal hematoma type 2 was not observed. Four patients died within 3 months (40.0 %).

CONCLUSIONS

Combined mechanical thrombectomy treatment was effective for recanalization of acute CTO. The combination of Solitaire and Penumbra devices can be considered as a treatment option for CTO.

Critical use of balloon angioplasty after recanalization failure with retrievable stent in acute cerebral artery occlusion

OBJECTIVE

Sudden major cerebral artery occlusion often resists recanalization with currently available techniques or can results in massive symptomatic intracranial hemorrhage (sICH) after thrombolytic therapy. The purpose of this study was to examine mechanical recanalization with a retrievable self-expanding stent and balloon in acute intracranial artery occlusions.

METHODS

Twenty-eight consecutive patients with acute intracranial artery occlusions were treated with a Solitaire retrievable stent. Balloon angioplasty was added if successful recanalization was not achieved after stent retrieval. The angiographic outcome was assessed by Thrombolysis in Cerebral Infarction (TICI) and the clinical outcomes were assessed by the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS).

RESULTS

At baseline, mean age was 69.4 years and mean initial NIHSS score was 12.5. A recanalization to TICI 2 or 3 was achieved in 24 patients (85%) after stent retrieval. Successful recanalization was achieved after additional balloon angioplasty in 4 patients. At 90-day follow-up, 24 patients (85%) had a NIHSS improvement of ≥4 and 17 patients (60%) had a good outcome (mRS ≤2). Although there was sICH, there was one death associated with the procedure.

CONCLUSION

Mechanical thromboembolectomy with a retrievable stent followed by additional balloon angioplasty is a safe and effective first-line therapy for acute intracranial artery occlusions especially in case of unsuccessful recanalization after stent thrombectomy.

Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates.

METHODS

Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm.

RESULTS

The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation.

CONCLUSIONS

Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.

Clinical MRI of acute ischemic stroke

The most important service that imaging provides to patients with ischemic stroke is to rapidly identify those patients who are most likely to benefit from immediate treatment. This group includes patients who have severe neurological symptoms due to an occlusion of a major artery, and who are candidates for recanalization using intravenous thrombolysis or intra-arterial intervention to remove the occlusion. Outcomes for these patients are determined by symptom severity, the artery that is occluded, the size of the infarct at the time of presentation, and the effect of treatment. MRI provides key physiological information through MR angiography and diffusion MRI that has been proven to be of high clinical value in identify patients who are in need of immediate treatment. Perfusion MRI provides information about the ischemic penumbra, but its clinical value is unproven. In current clinical practice, the time since stroke onset is dominant over physiologic information provided by MRI in treatment decisions. This will change only when clinical trials prove that stroke physiology as revealed by MRI is superior to time from stroke onset in promoting good clinical outcomes.

The natural history of acute ischemic stroke due to intracranial large-vessel occlusion: what do we know?

Acute ischemic stroke (AIS) is an important public health issue with major impact on not only patients and families but also on the society as well. Among patients who suffer from AIS, those who have the event due to large-vessel occlusion are thought to have the worse outcome. Because most of the effort in endovascular treatment of AIS is aimed toward this type of stroke, it is important to understand its natural history. The goal of this manuscript was to briefly discuss the natural history of AIS due to large-vessel occlusion based on recent literature.

Endovascular treatment of acute ischemic stroke: current indications

Endovascular stroke therapy is an effective means of achieving reperfusion in stroke patients with proximal cerebral artery occlusions. However, current guideline recommendations express uncertainty regarding the clinical efficacy of catheter-based treatments, given the lack of supportive trial data. A critical problem is that it remains unclear which patients will benefit from endovascular therapy. As such, patient selection is likely highly variable in clinical practice. This article will review the existing data to discuss the clinical and imaging factors that are relevant to patient outcomes, and which may be used to guide endovascular treatment decisions. Anterior circulation strokes represent the primary focus of this review.

Cerebralcare Granule® attenuates blood-brain barrier disruption after middle cerebral artery occlusion in rats

Disruption of blood-brain barrier (BBB) and subsequent edema are major contributors to the pathogenesis of ischemic stroke, for which the current clinical therapy remains unsatisfied. Cerebralcare Granule® (CG) is a compound Chinese medicine widely used in China for treatment of cerebrovascular diseases. CG has been demonstrated efficacy in attenuating the cerebral microcirculatory disturbance and hippocampal neuron injury following global cerebral ischemia. However, the effects of CG on BBB disruption following cerebral ischemia have not been investigated. In this study, we examined the therapeutic effect of CG on the BBB disruption in a focal cerebral ischemia/reperfusion (I/R) rat model. Male Sprague-Dawley rats (250 to 300 g) were subjected to 1h middle cerebral artery occlusion (MCAO). CG (0.4 g/kg or 0.8 g/kg) was administrated orally 3h after reperfusion for the first time and then once daily up to 6 days. The results showed that Evans blue extravasation, brain water content, albumin leakage, infarction volume and neurological deficits increased in MCAO model rats, and were attenuated significantly by CG treatment. T2-weighted MRI and electron microscopy further confirmed the brain edema reduction in CG-treated rats. Treatment with CG improved cerebral blood flow (CBF). Western blot analysis and confocal microscopy showed that the tight junction proteins claudin-5, JAM-1, occludin and zonula occluden-1 between endothelial cells were significantly degradated, but the protein expression of caveolin-1, the principal marker of caveolae in endothelial cells, increased after ischemia, all of which were alleviated by CG treatment. In conclusion, the post-treatment with CG significantly reduced BBB permeability and brain edema, which were correlated with preventing the degradation of the tight junction proteins and inhibiting the expression of caveolin-1 in the endothelial cells. These findings provide a novel approach to the treatment of ischemic stroke.

Intravenous thrombolysis and endovascular therapy for acute ischemic stroke with internal carotid artery occlusion: a systematic review of clinical outcomes

BACKGROUND AND PURPOSE

Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with extremely poor prognosis. The best treatment approach to acute stroke in this setting is unknown. We sought to determine clinical outcomes in patients with acute ischemic stroke attributable to ICA occlusion treated with intravenous (IV) systemic thrombolysis or intra-arterial endovascular therapy.

METHODS

Using the PubMed database, we searched for studies that included patients with acute ischemic stroke attributable to ICA occlusion who received treatment with IV thrombolysis or intra-arterial endovascular interventions. Studies providing data on functional outcomes beyond 30 days and mortality and symptomatic intracerebral hemorrhage (sICH) rates were included in our analysis. We compared the proportions of patients with favorable functional outcomes, sICH, and mortality rates in the 2 treatment groups by calculating χ(2) and confidence intervals for odds ratios.

RESULTS

We identified 28 studies with 385 patients in the IV thrombolysis group and 584 in the endovascular group. Rates of favorable outcomes and sICH were significantly higher in the endovascular group than the IV thrombolysis-only group (33.6% vs 24.9%, P=0.004 and 11.1% vs 4.9%, P=0.001, respectively). No significant difference in mortality rate was found between the groups (27.3% in the IV thrombolysis group vs 32.0% in the endovascular group; P=0.12).

CONCLUSIONS

According to our systematic review, endovascular treatment of acute ICA occlusion results in improved clinical outcomes. A higher rate of sICH after endovascular treatment does not result in increased overall mortality rate.

Outcome of MRI-based intravenous thrombolysis in carotid-T occlusion

Low recanalization rates and poor clinical outcome have been reported after intravenous thrombolysis (IV-tPA) in carotid-T occlusion (CTO). We studied clinical outcome and imaging findings of MRI-based intravenous thrombolysis in CTO. Data of patients with acute ischemic stroke and CTO treated with IV-tPA within 6 h of symptom onset based on MRI criteria were retrospectively analyzed. Vessel occlusion was defined based on MR angiography. Acute diffusion and perfusion lesion volumes and final infarct volumes after 3-7 days were delineated. The National Institutes of Health Stroke Scale (NIHSS) was used to assess the neurological deficit on admission. Recanalization was evaluated after 24 h. Clinical outcome was assessed using the modified Rankin Scale (mRS) after 90 days. Clinical and imaging data were compared to patients with middle cerebral artery main stem occlusion (MCAO). A total of 20 patients with CTO and 51 patients with MCAO were studied. Onset to treatment time, NIHSS on admission, initial diffusion and perfusion lesion volumes, and recanalization rates after 24 h were similar between groups. Final infarct volume was larger for CTO (82 vs. 30 ml, p = 0.006). Although overall outcome was not significantly different between groups (p = 0.251), independent outcome (mRS 0-2) tended to be less frequent in CTO (17 vs. 39 %), while poor outcome (mRS 4-6) appeared more common (72 vs. 43 %). The proportion of patients with good clinical outcome after intravenous thrombolysis in CTO is small. Moreover, final infarct volume is larger and clinical outcome appears to be worse compared to MCAO.

Intra-arterial thrombolysis using double devices: mechanicomechanical or chemicomechanical techniques

Objective

To optimize the recanalization of acute cerebral stroke that were not effectively resolved by conventional intraarterial thrombolysis (IAT), we designed a double device technique to allow for rapid and effective reopening. In this article, we describe the feasibility and efficacy of this technique.

Methods

From January 2008 to September 2009, twenty patients with acute cerebral arterial occlusion (middle cerebral artery : n=12; internal carotid artery terminus : n=5; basilar artery : n=3) were treated by the double device technique. This technique was applied when conventional thrombolytic methods using drug, microwires, microcatheters and balloons did not result in recanalization. In the double device technique, two devices are simultaneously placed at the lesion (for example, one microcatheter and one balloon or two microcatheters). Chemicomechanical or mechanicomechanical thrombolysis was performed simultaneously using various combinations of two devices. Recanalization rates, procedural time, complications, and clinical outcomes were analyzed.

Results

The initial median National Institute of Health Stroke Scale (NIHSS) was 16 (range 5-26). The double device technique was applied after conventional IAT methods failed. Recanalization was achieved in 18 patients (90%). Among them, 55% (11 cases) were complete (thrombolysis in cerebral infarction 2B, 3). The median thrombolytic procedural time including the conventional technique was 135±83.7 minutes (range 75-427). Major symptomatic hemorrhages (neurological deterioration ≥4 points in NIHSS) developed in two patients (10%). Good long term outcomes (modified Rankin Scale ≤2 at 90 days) occurred in 25% (n=5) of the cases. Mortality within 90 days developed in two cases (10%).

Conclusion

The double device technique is a feasible and effective technical option for large vessel occlusion refractory to conventional thrombolysis.

Multimodal reperfusion therapy for large hemispheric infarcts in octogenarians: is good outcome a realistic goal?

BACKGROUND AND PURPOSE

MMRT may be beneficial in a subset of patients with large hemispheric stroke who cannot be treated with systemic thrombolysis. Because most previous studies only included relatively young patients, the outcome of very old patients given MMRT remains unknown.

MATERIALS AND METHODS

Consecutive patients with large hemispheric stroke treated with MMRT and admitted to intensive care were included. We compared neurologic and functional outcomes between patients younger and older than 80 years.

RESULTS

We included 14 patients older than 80 years and compared them with 66 patients who were younger than 80. Cerebrovascular risk factor profile, admission NIHSS scores, stroke etiology and pathogenesis, and procedure-related variables did not differ between the groups except for a higher prevalence of smoking in younger patients. Excellent target vessel recanalization (Thrombolysis in Myocardial Infarction score of 3) and good outcome at 90 days (modified Rankin Score ≤ 2) were more common in younger patients (45% versus 14%, P = .047, and 41% versus 0%, P = .008, respectively). In contrast, mortality rates were higher in octogenarians (43% versus 17%, respectively).

CONCLUSIONS

In this study, very old patients had higher chances of mortality and a very low probability of achieving functional independence even after MMRT. Further prospective studies are needed to examine the futility of MMRT in the very old.

Intracranial Hemorrhage, Outcome, and Mortality After Intra-Arterial Therapy for Acute Ischemic Stroke in Patients Under Oral Anticoagulants

Background and Purpose—

Use of intravenous tissue-type plasminogen activator (IV tPA) for acute ischemic stroke is restricted to patients with an international normalized ratio (INR) less than 1.7. However, a recent study showed increased risk of symptomatic intracranial hemorrhage after IV tPA use in patients with oral anticoagulants (OAC) even with an INR less than 1.7. The present study assessed the risk of symptomatic intracranial hemorrhage, clinical outcome, and mortality after intra-arterial therapy (IAT) in patients with and without previous use of OAC.

Methods—

Consecutive patients treated with IAT from December 1992 to October 2010 were included. Clinical outcome and mortality were assessed 90 days after stroke onset. Patients with and without previous use of OAC were compared.

Results—

Overall, 714 patients were treated with IAT. Twenty-eight patients (3.9%) were under OAC at time of symptom onset. Median INR in the OAC group was 1.79 (interquartile range [IQR], 1.41–2.3) and 1.01 (IQR, 1.0–1.09; P <0.0001) in the group without OAC. Patients treated with OAC at admission underwent more often mechanical-only IAT than did patients without OAC (46.4% versus 12.8%; P <0.0001). Comparing patients with and without previous use of OAC, we did not find any statistical difference in the rate of symptomatic intracranial hemorrhage (7.1% versus 6.0%; P =0.80), unfavorable outcome (modified Rankin Scale score, 3–6; 67.9% versus 50.9%; P =0.11), and mortality (17.9% versus 21.6%; P =0.58).

Conclusions—

Previous use of OAC did not significantly increase the risk of symptomatic intracranial hemorrhage after IAT or the risk of unfavorable outcome and mortality 90 days after IAT.

Comparison of the Incidence of parenchymal hematoma and poor outcome in patients with carotid terminus occlusion treated with intra-arterial urokinase alone or with combined IV rtPA and intra-arterial urokinase

BACKGROUND AND PURPOSE

Patients with acute CTO generally have a poor prognosis, despite IV or IA thrombolytic treatment. The goal of this study was to analyze the results of patients with CTO who had IA urokinase treatment with or without initial IV rtPA based on a bridging protocol.

MATERIALS AND METHODS

Sixteen consecutive patients with acute ischemic stroke due to CTO who had combined IV and IA or a single IA thrombolytic treatment were enrolled. The baseline characteristics and prognosis were described. The patients who did and did not develop a PH shortly after treatment were compared.

RESULTS

The mean age was 66.4 years, and the median initial NIHSS score was 17. The median dose of IA urokinase was 320,000 U, and recanalization (TICI grade II-III) was achieved in 12 patients (75%). However, 5 patients died and 10 patients had poor prognosis with mRS 5-6 at discharge. Six patients (37.5%) with a PH had a higher NIHSS score 1 day after treatment (26.7 versus 13.6, P = .002), and they had more frequent mortality (66.7% versus 10.0%, P = .018) and worse prognosis (mRS 5-6; 100% versus 40%, P = .016) at discharge than patients without PH.

CONCLUSIONS

Patients with CTO who received IA urokinase treatment based on a bridging protocol had a poor prognosis. The development of PH might affect this outcome.

Clinical applications of diffusion MR imaging for acute ischemic stroke

Diffusion magnetic resonance imaging is the best imaging tool for detecting acute ischemic brain injury. Studies have shown its high accuracy for delineating irreversible tissue damage within the first few hours after stroke onset; however, the true value of any diagnostic tool is whether it can be used to guide clinical management. This review discusses the role of diffusion imaging in the evaluation of the patient with acute ischemic stroke, and how this role is influenced by other important stroke-related variables, including the level of vessel occlusion and the clinical deficit. The review focuses on decision-making for intravenous and intra-arterial reperfusion therapies.

Current status of endovascular stroke treatment

The management of acute ischemic stroke is rapidly developing.Although acute ischemic stroke is a major cause of adult disability and death, the number of patients requiring emergency endovascular intervention remains unknown, but is a fraction of the overall stroke population. Public health initiatives endeavor to raise public awareness about acute stroke to improve triage for emergency treatment, and the medical community is working to develop stroke services at community and academic medical centers throughout the United States. There is an Accreditation Council for Graduate Medical Education–approved pathway for training in endovascular surgical neuroradiology, the specialty designed to train physicians specifically to treat cerebrovascular diseases. Primary and comprehensive stroke center designations have been defined, yet questions remain about the best delivery model. Telemedicine is available to help community medical centers cope with the complexity of stroke triage and treatment. Should comprehensive care be provided at every community center, or should patients with complex medical needs be triaged to major stroke centers with high-level surgical,intensive care, and endovascular capabilities? Although the answers to these and other questions about stroke care delivery remain unanswered owing to the paucity of empirical data, we are convinced that stroke care regionalization is crucial for delivery of high-quality comprehensive ischemic stroke treatment. A stroke team available 24 hours per day, 7 days per week requires specialty skills in stroke neurology, endovascular surgical neuroradiology, neurosurgery, neurointensive care, anesthesiology, nursing, and technical support for optimal success. Several physician groups with divergent training backgrounds (i.e., interventional neuroradiology, neurosurgery,neurology, peripheral interventional radiology, and cardiology) lay claim to the treatment of stroke patients,particularly the endovascular or interventional methods. Few would challenge neurologists over the responsibility for emergency evaluation and triage of stroke victims for intra intravenous fibrinolysis, even though emergency physicians are most commonly the first to evaluate these patients. There are many unanswered questions about the role of imaging in defining best treatment. Perfusion imaging with CT or MRI appears to have relevance even though its role remains undefined and is the subject of ongoing research. Meanwhile, investigators are exploring new, and perhaps more specific,imaging methods with cerebral metabolic rate of oxygen and cellular acid-base imbalance. There are currently 6 ongoing trials of stroke intervention, many with proprietary technologies and private funding, competing for the same patient population as multicenter trials funded by the NIH. At the same time, much of the interventional stroke treatment currently occurs outside of trials in the community and academic settings without the collection of much-needed data. Market forces will certainly shape future stroke therapy, but it is unclear whether the current combination of private and public funding for these endeavors is the best method of development.

The pattern of leptomeningeal collaterals on CT angiography is a strong predictor of long-term functional outcome in stroke patients with large vessel intracranial occlusion

BACKGROUND AND PURPOSE

The role of noninvasive methods in the evaluation of collateral circulation has yet to be defined. We hypothesized that a favorable pattern of leptomeningeal collaterals, as identified by CT angiography, correlates with improved outcomes.

METHODS

Data from a prospective cohort study at 2 university-based hospitals where CT angiography was systematically performed in the acute phase of ischemic stroke were analyzed. Patients with complete occlusion of the intracranial internal carotid artery and/or the middle cerebral artery (M1 or M2 segments) were selected. The leptomeningeal collateral pattern was graded as a 3-category ordinal variable (less, equal, or greater than the unaffected contralateral hemisphere). Univariate and multivariate analyses were performed to define the independent predictors of good outcome at 6 months (modified Rankin Scale score ≤2).

RESULTS

One hundred ninety-six patients were selected. The mean age was 69±17 years and the median National Institute of Health Stroke Scale score was 13 (interquartile range, 6 to 17). In the univariate analysis, age, baseline National Institute of Health Stroke Scale score, prestroke modified Rankin Scale score, Alberta Stroke Programme Early CT score, admission blood glucose, history of hypertension, coronary artery disease, congestive heart failure, atrial fibrillation, site of occlusion, and collateral pattern were predictors of outcome. In the multivariate analysis, age (OR, 0.95; 95% CI, 0.93 to 0.98; P=0.001), baseline National Institute of Health Stroke Scale (OR, 0.75; 0.69 to 0.83; P<0.001), prestroke modified Rankin Scale score (OR, 0.41; 0.22 to 0.76; P=0.01), intravenous recombinant tissue plasminogen activator (OR, 4.92; 1.83 to 13.25; P=0.01), diabetes (OR, 0.31; 0.01 to 0.98; P=0.046), and leptomeningeal collaterals (OR, 1.93; 1.06 to 3.34; P=0.03) were identified as independent predictors of good outcome.

CONCLUSIONS

Consistent with angiographic studies, leptomeningeal collaterals on CT angiography are also a reliable marker of good outcome in ischemic stroke.

Intravenous rt-PA versus endovascular therapy for acute ischemic stroke

The influence of baseline stroke severity on outcome makes comparisons between nonrandomized studies of intravenous and intra-arterial (IA) therapy problematic. Using pooled data from the placebo arms of randomized trials in acute ischemic stroke, we derived predictive functions for outcome. We then compared the outcomes from published trials to these functions. Net benefit was calculated by comparison of the individual study with the predicted outcome based on the therapeutic time window. Similar net benefit for IA therapy and intravenous therapy was found at 3 hours and 6 hours; a slight advantage for IA therapy was mitigated by an increase in mortality at 6 hours and by publication bias. No net benefit for IA therapy was shown in the time window greater than 6 hours. Conclusive evidence for the superiority of either therapy awaits prospective randomized trials.

In vitro testing of a new aspiration thrombus device

BACKGROUND

Mechanical thrombectomy can restore blood flow to the brain after acute ischemic stroke, but may be associated with risks, such as breakage of moving parts and clot fragmentation. The aim of this study was to evaluate a new aspiration thrombus device (ATD), the GP ATD, which has no moving parts and extracts clots by suction in a vortex flow pattern.

METHODS

The GP ATD is used to extract porcine blood clots inserted into the middle cerebral artery (MCA) of a model of the circle of Willis, and from porcine aorta.

RESULTS

The GP ATD is navigable around the acute angles of the circle of Willis model and successfully extracts clots that cause complete occlusion of the MCA. There is a strong correlation between the pressure required for clot extraction (mean 31.8, range 30-34 kPa) and its mass (mean 0.08, range 0.03-0.13 g). Complete clot extraction can be demonstrated by computed tomography scanning. Lysis of a 0.15-g thrombus using alteplase at a concentration of 3.4 microg/mL was more effective when delivered and extracted via the GP ATD than via a catheter without the GP ATD or delivered systemically in our circle of Willis model and extracted without suction (clot mass after extraction 0.07, 0.09, and 0.11 g, respectively). Histologic examination does not show evidence of damage of the arterial wall caused by clot extraction at suction pressures of up to 30 kPa via the GP ATD.

CONCLUSION

The GP ATD appears to effectively extract blood clots from models of the MCA without significant clot fragmentation and damage to the arterial wall. Further experiments using arteries in situ are required to confirm these findings.

Decompressive hemicraniectomy improves outcome in patients with failed arterial recanalization after acute carotid artery occlusion

BACKGROUND AND OBJECTIVES

Decompressive hemicraniectomy reduces morbidity and mortality in patients with large hemispheric stroke. However, its role in patients that underwent failed endovascular reperfusion remains unknown.

METHODS

Patients with acute stroke secondary to internal carotid artery occlusion who underwent endovascular multimodal reperfusion therapy were evaluated. Patients with failed revascularization who were referred for decompressive hemicraniectomy were compared with patients with failed reperfusion who did not undergo decompressive hemicraniectomy. Functional outcome was assessed with the modified Rankin Score (mRS) and neurological disability with the NIH Stroke Scale Score (NIHSS) at 90 days from stroke onset.

RESULTS

Six decompressive hemicraniectomy-treated patients were included (four females, mean age: 36.7 years, mean NIHSS: 24.5). None of the decompressive hemicraniectomy-treated patients died compared to six of seven patients with failed multi-modal reperfusion therapy that did not undergo decompressive hemicraniectomy. All decompressive hemicraniectomy-treated patients were discharged to a rehabilitation facility whereas the only surviving non-decompressive hemicraniectomy-treated patient was discharged to a nursing facility. Five of the six decompressive hemicraniectomy-treated (84%) and none of the non-decompressive hemicraniectomy-treated patients had an mRS ≤ 3 at 90 days post-stroke.

DISCUSSION

Decompressive hemicraniectomy can significantly improve functional outcome in patients with large carotid artery strokes that failed to recanalize following multi-modal reperfusion therapy. These results imply that decompressive hemicraniectomy should be planned in patients who undergo multi-modal reperfusion therapy for large carotid artery stroke.

Use of the enterprise™ intracranial stent for revascularization of large vessel occlusions in acute stroke

BACKGROUND AND PURPOSE

Major cerebral thromboembolism often resists recanalization with currently available techniques. The authors present their initial experience with a self-expanding stent for use in intracranial vascular reconstruction, permitting immediate recanalization of acute thromboembolic occlusions of the anterior circulation.

PATIENTS AND METHODS

Patients treated with the Cordis Enterprise™ self-expanding intracranial stent system for acute thromboembolic occlusion of the major anterior cerebral arteries were included. Treatment comprised systemic and intraarterial thrombolysis, mechanical thrombectomy, and stent placement. Stent deployment, recanalization rate by means of Thrombolysis In Cerebral Infarction (TICI) scores and the clinical outcome were all assessed.

RESULTS

Six patients presenting with acute carotid T (n = 2) or proximal middle cerebral artery occlusion (n = 4) were treated. The mean National Institutes of Health Stroke Scale (NIHSS) score at presentation was 14; the mean age was 57 years. Successful stent deployment and immediate recanalization were achieved in all six with a TICI score of ≥ 2. Neither distal emboli nor any procedure-related complications were encountered. One patient developed symptomatic intracerebral hemorrhage and two patients needed decompressive craniectomy after treatment. The mean NIHSS score at 10 days was 10, but only one patient showed a complete recovery at 3 months.

CONCLUSION

Intracranial placement of the Enterprise™ self-expanding stent has proven to be feasible and efficient in achieving immediate recanalization of occluded main cerebral arteries. The use of antiplatelet therapy after treatment may, however, increase the risk of reperfusion intracerebral hemorrhage.

Neuroendovascular management of acute ischemic stroke

Endovascular reperfusion therapy is evolving as a promising treatment in the setting of acute ischemic stroke. Careful patient selection and angiographic evaluation of the location and extent of occlusion are necessary for the successful management of stroke patients. Intra-arterial chemical thrombolysis, with such agents as alteplase and urokinase, has shown favorable results in the early management of cerebrovascular ischemia. Mechanical thrombolysis is becoming an adjunctive or alternative treatment therapy via novel clot dissolution and retrieval techniques. Existing and upcoming trials are investigating the safety and efficacy of neuroendovascular therapy while attempting to expand its indications in acute ischemic stroke.

Penumbra system: a novel mechanical thrombectomy device for large-vessel occlusions in acute stroke

BACKGROUND AND PURPOSE

Large IC artery occlusion is often resistant to recanalization. We present our initial experience with the PS.

MATERIALS AND METHODS

Presenting with a severe acute ischemic stroke, the first 27 consecutive patients were considered for thromboaspiration therapy and retrospective data base analysis. All patients received standard thrombectomy treatment as monotherapy or in combination with thrombolysis or IC stent placement. The primary end point was revascularization of the target vessel to grade 2 or 3 on the TICI scale. Secondary end points were improvement of >4 points on the NIHSS score at discharge and favorable outcome, and improvement in overall mortality at 3 months and in sICH- and procedure-related adverse events.

RESULTS

At baseline, the mean age was 66 +/- 14 years and the mean NIHSS score was 14 +/- 7. The anterior circulation was affected in 23 patients, and there were 4 basilar artery occlusions. Intracranial stent placement was performed in 4 patients. A recanalization to TICI 2 or 3 was achieved in 25 patients (93%). None of the patients developed sICH. At hospital discharge, 15 patients (56%) had an NIHSS improvement of >4 and 13 patients (48%) had an mRS score of <2 at 3 months. There was a significant correlation between complete vessel recanalization and favorable outcome. The all-cause mortality at 3 months was 11%.

CONCLUSIONS

The PS showed a high potential for recanalization of acute thromboembolic occlusions of the large cerebral arteries. Complete recanalization was strongly correlated with good clinical outcome.

Multi-Modal Reperfusion Therapy for Patients With Acute Anterior Circulation Stroke in Israel

Background and Purpose— We aimed to delineate prognostic variables in Israeli patients with anterior circulation strokes treated with endovascular multi-modal reperfusion therapy (MMRT).

Methods— Clinical and radiological data from consecutive tpa-ineligible stroke patients with large anterior circulation infarcts involving either the entire internal carotid artery or the proximal middle cerebral artery territory were analyzed. Stroke subtypes were categorized according to TOAST criteria. Neurological deficits were assessed with the NIH stroke scale (NIHSS), and vessel recanalization was determined using the thrombolysis in myocardial infarction (TIMI) scale at the end of MRRT. Good outcome was defined as a modified Rankin score (mRS) ≤2.

Results— Fifty patients were included with a median age of 68. Thirteen patients died and 17 patients achieved an mRS ≤2 at 90 days. Variables associated with survival on multivariate analysis were admission NIHSS <20 (OR 15 95% CI 1 to 230) and postprocedure TIMI score 2 to 3 (OR 35.5 95% CI 2.3 to 603.9). Variables associated with good outcome included admission NIHSS <20 (OR 9.4 95% CI 1.3 to 71.3), day 1 NIHSS <15 (OR 6.4 95% CI 1.1 to 38.4), and postprocedure TIMI 3 (OR 7.4 95% CI 1.1 to 50.3).

Conclusions— MMRT resulted in high survival and good outcome rates in these critically ill patients. Lower baseline impairment and vessel recanalization increase the chances for good outcome. Our results suggest that the benefits of MMRT may merit further study and could be generalized to centers outside the United States and Europe.

MULTIMODAL REPERFUSION THERAPY IN PATIENTS WITH ACUTE BASILAR ARTERY OCCLUSION

OBJECTIVE

Multimodal reperfusion therapy (MMRT) has been advocated for the treatment of acute basilar artery occlusion (ABAO). We aimed to identify prognostic factors in patients with ABAO who underwent MMRT.

METHODS

Clinical and radiological data from consecutive ABAO patients were analyzed. All patients underwent MMRT on an emergency basis. Stroke subtypes were categorized according to TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria. Good outcome was defined as a modified Rankin Scale score of 3 or less and poor outcome as a score of 4 or more at 30 days poststroke.

RESULTS

Twenty-four patients were included (18 men, 6 women) with a mean age of 54.7 years (age range, 26–70 years). Six patients died (25%), and 8 of the surviving 18 patients (44%) achieved a modified Rankin Scale score of 3 or less at 30 days. We could not identify any clinical or radiological variables that were associated with a greater likelihood of good or poor outcome at 30 days other than the presence of good collateral circulation, which was associated with better outcome on univariate analysis.

CONCLUSION

MMRT resulted in high survival and good outcome rates. We could not identify prognostic factors in patients with ABAO treated with MMRT other than the presence of collateral flow. Our results imply that patients should not be excluded from treatment based on clinical or radiological parameters, and that all patients with ABAO should be given the chance to benefit from therapy.