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Negative susceptibility vessel sign might be predictive of complete reperfusion in patients with acute basilar artery occlusion managed with thrombectomy. Eur Radiol 2023; 33:2593-2604. [PMID: 36562785 DOI: 10.1007/s00330-022-09215-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Negative susceptibility vessel sign (SVS) on pre-thrombectomy MRI has been linked to fibrin-rich thrombus and difficult retrieval in anterior ischemic stroke. However, its impact in posterior circulation-large vessel occlusion stroke (PC-LVOS) has not yet been elucidated. We aim to investigate the relationship of SVS parameters with stroke subtypes and their influence on angiographic and functional outcomes. METHODS Prospective thrombectomy registries at two-comprehensive stroke centers were retrospectively reviewed between January 2015 and December 2019 for consecutive MRI-selected patients with PC-LVOS. Two groups were assigned by two independent readers, based on the presence or absence of the SVS (SVS +, SVS -) on MRI-GRE sequence. Multivariate logistic regression analysis was utilized to study primarily the impact of the SVS on the rate of complete recanalization (defined as mTICI 2c/3) at the final series following endovascular thrombectomy (EVT) and whether or not it might influence the efficacy of the frontline EVT strategy. Secondarily, we studied whether the absence of the SVS was predictive of the rate of 90-day functional independence (defined as mRS score < 2). Lastly, both qualitative (SVS +, SVS-) and quantitative (SVS length and diameter) parameters of the SVS were analyzed in association with the puncture to recanalization interval and various stroke etiological subtypes based on TOAST criteria. RESULTS Among 1823 patients, 116 were qualified for final analysis (median age, 68 (59-75) years; male, 65%); SVS was detected in 62.9% (73/116) of cases. SVS length was an independent predictor of procedural duration (p = .01) whilst two-layered SVS was inversely associated with the atherosclerosis etiological subtype (aOR = 0.27, 95% CI 0.08-0.89; p = .03). Successful recanalization was achieved in 82% (60/73) vs. 86% (37/43), p = .80 of patients with SVS (+, -) respectively. Only in SVS (+), stentriever (RR 0.59 (0.4-0.88), p = .009), and contact-aspiration (RR 0.82 (0.7-0.96), p = .01) achieved a lower rate of successful recanalization compared to combined technique. SVS (-) was significantly associated with a higher rate of mTICI 2c/3 (aOR = 4.444; 95% CI 1.466-13.473; p = .008) and showed an indirect effect of 9% towards functional independence mediated by mTICI 2c/3. CONCLUSION SVS parameters in PC-LVOS might predict stroke subtype and indirectly influence the functional outcome by virtue of complete recanalization. KEY POINTS • Negative susceptibility vessel sign (SVS) in patients with basilar occlusion independently predict complete recanalization that indirectly instigated a 3-month favorable outcome following thrombectomy. • The longer the SVS, the higher likelihood of large artery atherosclerosis and the longer the thrombectomy procedure. • Two-layered SVS might be negatively associated with the presence of atherosclerosis, yet already-known limitations of TOAST classification and the absence of pathological analysis should be taken into consideration.
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He G, Deng J, Lu H, Wei L, Zhao Y, Zhu Y, Li Y. Thrombus enhancement sign on CT angiography is associated with the first pass effect of stent retrievers. J Neurointerv Surg 2023; 15:146-152. [PMID: 35110399 DOI: 10.1136/neurintsurg-2021-018447] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/13/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND The thrombus enhancement sign (TES) is thought to be associated with the source of the stroke and thrombus composition. We investigated whether this imaging sign along with other thrombus characteristics could be used to predict the successful first pass effect (FPE) of mechanical thrombectomy. METHODS 246 consecutive patients with acute ischemic stroke in the anterior circulation with large vessel occlusion who underwent thrombectomy with a stent retriever and clot collection were included. Patients were divided into FPE (modified Thrombolysis in Cerebral Infarction (mTICI) grade 2c or 3)/non-FPE (mTICI 0-2b) and modified FPE (mFPE) (mTICI 2b-3)/non-mFPE (mTICI 0-2a) groups based on flow restoration after the first pass. TES presence, thrombus density, thrombus length, clot burden score, and thrombus composition were compared. The association between FPE and imaging biomarkers, along with clinical and interventional parameters, was investigated by univariate and multivariate analysis. RESULTS FPE was achieved in 85 (34.6%) patients. TES presence was significantly lower in the FPE group (64.7% vs 80.7% in the non-FPE group, p=0.008) and mFPE group (69.1% vs 81.0% in the non-mFPE group, p=0.039). Histopathological examination revealed that TES (+) thrombi contained a higher fibrin/platelet proportion (50.9% vs 46.9% in TES (-) thrombi, p=0.029) and fewer erythrocytes (43.3% vs 47.3% in TES (-) thrombi, p=0.030). Thrombus characteristics, namely shorter thrombus length (p=0.032), higher erythrocyte proportions (p=0.026), and less fibrin/platelets (p=0.014), were confirmed in patients with FPE. In multivariable analysis, TES was the only independent predictor of FPE failure (OR 0.51, 95% CI 0.28 to 0.94; p=0.031). CONCLUSIONS TES was independently associated with first pass angiographic failure in patients treated with a stent retriever.
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Affiliation(s)
- Guangchen He
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiangshan Deng
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Haitao Lu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Liming Wei
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yuwu Zhao
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yuehua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Pilato F, Valente I, Alexandre AM, Calandrelli R, Scarcia L, D’Argento F, Lozupone E, Arena V, Pedicelli A. Correlation between Thrombus Perviousness and Distal Embolization during Mechanical Thrombectomy in Acute Stroke. Diagnostics (Basel) 2023; 13:diagnostics13030431. [PMID: 36766536 PMCID: PMC9914329 DOI: 10.3390/diagnostics13030431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/07/2023] [Accepted: 01/21/2023] [Indexed: 01/27/2023] Open
Abstract
PURPOSE Thrombus permeability has been related to clot composition and treatment outcomes in stroke patients undergoing reperfusion therapies. The aim of this study was to evaluate whether thrombus perviousness, evaluated by multiphase computed tomography angiography (mCTA), is associated with distal embolization risk. METHODS We interrogated our dataset of acute ischemic stroke (AIS) patients involving the M1 segment of the middle cerebral artery (MCA) who had undergone mechanical thrombectomy, and we calculated thrombus average attenuation measurement (dHU) on non-contrast CT (NCCT) and clot perviousness on mCTA. dHU was calculated as the difference between the thrombus HU average value (tHU) and the HU average value on the contralateral side (cHU), while perviousness was calculated as the difference in mean clot density on mCTA and NCCT both in arterial (Perviousness pre-post-1) and delayed (Perviousness pre-post 2) phases. RESULTS A total of 100 patients (53 females (53%), mean age 72.74 [± 2.31]) with M1 occlusion were available for analysis. Perviousness, calculated between baseline and arterial phase of mCTA (Perviousness pre-post1), was lower in patients with distal embolization (p = 0.05), revealing an association between reduced perviousness and distal embolization risk. Logistic regression showed that thrombus perviousness calculated on the arterial phase of mCTA (OR, 0.66; 95% CI, 0.44-0.99] (p = 0.04)) and the contact aspiration technique (OR, 0.39; 95% CI, 0.15-1.02] (p = 0.05)) were protecting factors against distal embolization. CONCLUSION Our study showed an association between reduced perviousness and distal embolization, suggesting that perviousness evaluation may be a useful neuroimaging biomarker in predicting distal embolization risk during mechanical thrombectomy.
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Affiliation(s)
- Fabio Pilato
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psichiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
- Operative Research Unit of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 00128 Roma, Italy
- Correspondence:
| | - Iacopo Valente
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma—Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Andrea M. Alexandre
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma—Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Rosalinda Calandrelli
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma—Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Luca Scarcia
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma—Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Francesco D’Argento
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma—Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Emilio Lozupone
- Department of Neuroradiology, Vito Fazzi Hospital, 73100 Lecce, Italy
| | - Vincenzo Arena
- Istituto di Anatomia Patologica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica-Area Anatomia Patologica-Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
| | - Alessandro Pedicelli
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma—Area Diagnostica Per Immagini, 00168 Rome, Italy
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Salahuddin H, Rao RR, Zaidi SF, Prologo-Richardson P, Khalid F, Saju L, Taqi MA, Burgess RR, Jumaa MA. First Pass Effect and Location of Occlusion in Recanalized MCA M1 Occlusions. Front Neurol 2022; 13:884235. [PMID: 35585846 PMCID: PMC9108282 DOI: 10.3389/fneur.2022.884235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/13/2022] [Indexed: 11/24/2022] Open
Abstract
Background The first pass effect has been shown to improve clinical outcomes in patients with middle cerebral artery (MCA) M1 occlusions. Objective To determine the rates of first pass effect in MCA M1 occlusions and determine if proximal or distal location of occlusion modified clinical outcomes. Methods Patients with recanalized MCA M1 occlusions who underwent endovascular thrombectomy (EVT) were reviewed to determine the effect of first pass effect (FPE) and location of occlusion on clinical outcomes. MCA occlusions were classified as proximal if they included the first two thirds of the MCA and involved the lenticulostriate vessels, or distal if they did not. Results We included 261 patients of which 27% achieved FPE. Of the cohort, there were 91 (35%) proximal MCA occlusions and 170 (65%) distal MCA occlusions. Baseline demographics and treatment time metrics were comparable across both groups. There was a trend toward good clinical outcome in patients with or without a FPE (60 vs. 46%; p = 0.06), however a higher rate of excellent clinical outcome was noted in patients with FPE (46 vs. 30%; p = 0.02). When compared by location, patients with distal MCA occlusions had a higher rate of excellent clinical outcome (40 vs. 25%; p = 0.02). Multivariable analysis showed that distal MCA occlusion was the strongest predictor of an excellent clinical outcome and first pass effect. Conclusion Patients with MCA M1 occlusions with FPE have a higher rate of excellent clinical outcomes compared to those who did not. Location of MCA occlusion appears to modify rates of first pass effect and excellent clinical outcomes.
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Affiliation(s)
- Hisham Salahuddin
- Department of Neurology, ProMedica Neurosciences, Toledo, OH, United States
- Department of Neurology, University of Toledo, Toledo, OH, United States
- Department of Neurology, Antelope Valley Hospital, Lancaster, CA, United States
| | - Rahul R. Rao
- Department of Neurology, ProMedica Neurosciences, Toledo, OH, United States
- Department of Neurology, University of Toledo, Toledo, OH, United States
| | - Syed F. Zaidi
- Department of Neurology, ProMedica Neurosciences, Toledo, OH, United States
- Department of Neurology, University of Toledo, Toledo, OH, United States
| | | | - Fatima Khalid
- Department of Neurology, University of Toledo, Toledo, OH, United States
| | - Linda Saju
- Department of Neurology, University of Toledo, Toledo, OH, United States
| | - Muhammad Asif Taqi
- Department of Neurology, Los Robles Hospital, Thousand Oaks, CA, United States
| | - Richard R. Burgess
- Department of Neurology, ProMedica Neurosciences, Toledo, OH, United States
- Department of Neurology, University of Toledo, Toledo, OH, United States
| | - Mouhammad A. Jumaa
- Department of Neurology, ProMedica Neurosciences, Toledo, OH, United States
- Department of Neurology, University of Toledo, Toledo, OH, United States
- *Correspondence: Mouhammad A. Jumaa
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Pilato F, Valente I, Calandrelli R, Alexandre A, Arena V, Dell'Aquila M, Broccolini A, Della Marca G, Morosetti R, Frisullo G, Brunetti V, Distefano M, Pedicelli A, Colosimo C, Di Lazzaro V. Clot evaluation and distal embolization risk during mechanical thrombectomy in anterior circulation stroke. J Neurol Sci 2022; 432:120087. [PMID: 34933250 DOI: 10.1016/j.jns.2021.120087] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/22/2021] [Accepted: 12/07/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Clot features along with patients' clinical features may influence thrombus compactness predisposing at distal embolization during thrombectomy. The aim of this study was to evaluate thrombus features assessed by radiological and histopathological analysis along with patient-related features to predict distal embolization during thrombectomy. METHODS We performed a retrospective analysis of a prospectively maintained dataset of a tertiary stroke center inclusive of all cases of endovascular treatment for acute ischemic stroke involving anterior circulation occlusion. All patients underwent head and neck CT-angiography (CTA) at baseline. Patients were enrolled if thrombus material was suitable for histopathologic analyses. RESULTS A total of 327 patients underwent mechanical thrombectomy between March 2017 and May 2020. Among them, 133 (40.7%) had thrombus material suitable for histopathological analysis but 11 patients were excluded due to posterior circulation occlusion. A total of 122 patients were included in the analysis. A distal embolism was documented in 27 patients (28.4%). Multivariable analysis with distal embolism as dependent variable showed an adjusted OR of 2.64 (95%CI: 0.9-7.73; p-value: 0.08) for anticoagulant therapy, an adjusted OR of 1.38 (95%CI: 1.01-1.91; p-value 0.05) each 5-mm increasing of thrombus length at CTA. No association was found with age, sex, thrombolysis and first thrombectomy technique used. CONCLUSION The combined effect of anticoagulant therapy and thrombus length may have a potentially harmful effect on reperfusion during mechanical recanalization, causing distal embolization and this aspect should be taken into account in patient's risk assessment and when planning treatment strategy.
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Affiliation(s)
- Fabio Pilato
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128 Rome, Italy.
| | - Iacopo Valente
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma - Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Rosalinda Calandrelli
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma - Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Andrea Alexandre
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma - Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Vincenzo Arena
- Istituto di Anatomia Patologica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica -Area Anatomia Patologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Marco Dell'Aquila
- Istituto di Anatomia Patologica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica -Area Anatomia Patologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Aldobrando Broccolini
- UOC Neurologia, Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Giacomo Della Marca
- UOC Neurologia, Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Roberta Morosetti
- UOC Neurologia, Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Giovanni Frisullo
- UOC Neurologia, Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Valerio Brunetti
- UOC Neurologia, Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Marisa Distefano
- UOC Neurologia, Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Alessandro Pedicelli
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma - Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Cesare Colosimo
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma - Area Diagnostica Per Immagini, 00168 Rome, Italy; Dipartimento di Diagnostica per Immagini, Università Cattolica del Sacro Cuore, Istituto di Radiologia, 00168 Rome, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128 Rome, Italy
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Liu R, Jin C, Wang L, Yang Y, Fan Y, Wang W. Simulation of stent retriever thrombectomy in acute ischemic stroke by finite element analysis. Comput Methods Biomech Biomed Engin 2021; 25:740-749. [PMID: 34792427 DOI: 10.1080/10255842.2021.1976761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Stent retriever thrombectomy has become an effective method for treating acute ischemic stroke. Successful recanalization cannot be achieved for all patients. The outcome of mechanical thrombectomy may be associated with some mechanical factors, requiring efficient tools that are able to assess the interaction between stent retrievers and clots. In this study, a simulation by finite element analysis was developed to evaluate the outcome of stent retriever thrombectomy for clots of different sizes and frictional properties. The deployment and retrieval of the stent retriever were conducted in a middle cerebral artery model. The recanalization, deformation of the clot and stent retriever and the stress induced in the clot were assessed. The results showed that higher friction could lead to failed recanalization and increased stress in the clot. The simulation method can be used to characterize the mechanical behaviour of stent retrievers and clots, offering a potential tool for the optimization of device design and the selection of surgical strategies.
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Affiliation(s)
- Ronghui Liu
- Beijing Advanced Innovation Centre for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, China.,Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
| | - Chang Jin
- Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
| | - Lizhen Wang
- Beijing Advanced Innovation Centre for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yisong Yang
- Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
| | - Yubo Fan
- Beijing Advanced Innovation Centre for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Weidong Wang
- Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
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Pilato F, Verdolotti T, Calandrelli R, Valente I, Monelli E, Cottonaro S, Capone F, Motolese F, Iaccarino G, Rossi SS, Colosimo C, Di Lazzaro V. Color-coded multiphase computed tomography angiography may predict outcome in anterior circulation acute ischemic stroke. J Neurol Sci 2021; 430:119989. [PMID: 34547614 DOI: 10.1016/j.jns.2021.119989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/20/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE To evaluate whether arterial and venous color-coded mCTA score may predict clinical outcome in anterior circulation acute ischemic stroke. METHODS Consecutive patients referred to the emergency department with anterior circulation acute ischemic stroke (AIS) were retrospectively reviewed at our center. All patients underwent multimodal brain computed tomography (CT) imaging, including non-contrast CT (NCCT) and multiphase computed tomography angiography (mCTA). Baseline collateral scores of color-coded mCTA, also known as ColorViz, and conventional mCTA were recorded. mCTA was assessed by a 6-point scale whereas color-coded mCTA was assessed by a 3-point scale. In the Color-coded maps, a different color is assigned to intracranial vessels based on the arrival time of the contrast medium and on a per-person adaptive threshold technique. We compared the radiological and clinical features of a group of patients who reached independency (defined as modified Rankin Scale score ≤ 2) with those of patients who did not. A multivariate logistic regression model was then used to assess the potential of color-coded mCTA scores to predict patients' outcome after AIS. RESULTS A total of 86 patients (36 M, 50 F) were enrolled in the study. Multivariate logistic regression showed that score 3 at Color-coded mCTA was a good predictor of favorable outcome (p = 0.003). Moreover, NIHSS at onset (p = 0.004) and discharge (p < 0.001) along with ischemic core area (p = 0.011) were significant predictors of favorable prognosis. CONCLUSION our data confirm that ColorViz is a useful and easily understandable neuroimaging tool that might have a predictive role in assessing the outcome of anterior circulation acute ischemic stroke patients regardless of revascularization therapy.
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Affiliation(s)
- Fabio Pilato
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128 Rome, Italy.
| | - Tommaso Verdolotti
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma-UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Rosalinda Calandrelli
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma-UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Iacopo Valente
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma-UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Edoardo Monelli
- Dipartimento di Diagnostica per Immagini, Università Cattolica del Sacro Cuore, Istituto di Radiologia, 00168 Rome, Italy
| | - Simone Cottonaro
- U.O.C. Diagnostic, Interventional Radiology and Neuroradiology, Garibaldi Hospital, Catania, Italy
| | - Fioravante Capone
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128 Rome, Italy
| | - Francesco Motolese
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128 Rome, Italy
| | - Gianmarco Iaccarino
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128 Rome, Italy
| | - Sergio Soeren Rossi
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128 Rome, Italy
| | - Cesare Colosimo
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma-UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Area Diagnostica Per Immagini, 00168 Rome, Italy; Dipartimento di Diagnostica per Immagini, Università Cattolica del Sacro Cuore, Istituto di Radiologia, 00168 Rome, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128 Rome, Italy
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Belachew NF, Dobrocky T, Meinel TR, Hakim A, Vynckier J, Arnold M, Seiffge DJ, Wiest R, Piechowiak EI, Fischer U, Gralla J, Mordasini P, Kaesmacher J. Risks of Undersizing Stent Retriever Length Relative to Thrombus Length in Patients with Acute Ischemic Stroke. AJNR Am J Neuroradiol 2021; 42:2181-2187. [PMID: 34649917 DOI: 10.3174/ajnr.a7313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/30/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Results regarding the association of thrombus length, stent retriever length, and recanalization success in patients with acute ischemic stroke are inconsistent. We hypothesized that the ratio of thrombus length to stent retriever length may be of particular relevance. MATERIALS AND METHODS Patients with acute ischemic stroke undergoing stent retriever thrombectomy at our institution between January 2010 and December 2018 were reviewed retrospectively. Thrombus length was assessed by measuring the susceptibility vessel sign on SWI using a 1.5T or 3T MR imaging scanner. Multivariable logistic regression models were used to determine the association between thrombus length, stent retriever length, and thrombus length/stent retriever length ratio with first-pass recanalization, overall recanalization, and embolization in new territories. Results are shown as adjusted ORs with 95% CIs. Additional mediation analyses were performed to test for indirect effects on first-pass recanalization and overall recanalization success. RESULTS The main analysis included 418 patients (mean age, 74.9 years). Increasing stent retriever length was associated with first-pass recanalization. Decreasing thrombus length and lower thrombus length/stent retriever length ratios were associated with first-pass recanalization and overall recanalization. Thrombus length and stent retriever length showed no association with first-pass recanalization or overall recanalization once thrombus length/stent retriever length ratio was factored in, while thrombus length/stent retriever length ratio remained a significant factor in both models (adjusted OR, 0.316 [95% CI, 0.112-0.892]; P = .030 and adjusted OR, = 0.366 [95% CI, 0.194-0.689]; P = .002). Mediation analyses showed that decreasing thrombus length and increasing stent retriever length had a significant indirect effect on first-pass recanalization mediated through thrombus length/stent retriever length ratio. The only parameter associated with embolization in new territories was an increasing thrombus length/stent retriever length ratio (adjusted OR, 5.079 [95% CI, 1.332-19.362]; P = .017). CONCLUSIONS Information about thrombus and stent length is more valuable when combined. High thrombus length/stent retriever length ratios, which may raise the risk of unsuccessful recanalization and embolization in new territories, should be avoided by adapting stent retriever selection to thrombus length whenever possible.
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Affiliation(s)
- N F Belachew
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.)
| | - T Dobrocky
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.)
| | - T R Meinel
- Department of Neurology (T.R.M., J.V., M.A., D.J.S., U.F.)
| | - A Hakim
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.)
| | - J Vynckier
- Department of Neurology (T.R.M., J.V., M.A., D.J.S., U.F.)
| | - M Arnold
- Department of Neurology (T.R.M., J.V., M.A., D.J.S., U.F.)
| | - D J Seiffge
- Department of Neurology (T.R.M., J.V., M.A., D.J.S., U.F.)
| | - R Wiest
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.)
| | - E I Piechowiak
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.)
| | - U Fischer
- Department of Neurology (T.R.M., J.V., M.A., D.J.S., U.F.)
| | - J Gralla
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.)
| | - P Mordasini
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.)
| | - J Kaesmacher
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.).,Diagnostic, Interventional and Pediatric Radiology (J.K.), Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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9
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Ospel JM, van der Lugt A, Gounis M, Goyal M, Majoie CBLM. A clinical perspective on endovascular stroke treatment biomechanics. J Biomech 2021; 127:110694. [PMID: 34419825 DOI: 10.1016/j.jbiomech.2021.110694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/27/2021] [Accepted: 08/09/2021] [Indexed: 12/27/2022]
Abstract
Acute ischemic stroke (AIS) is caused by blockage of an arterial blood vessel in the brain by a thrombus, which interrupts oxygen supply to the brain parenchyma. The goal of endovascular stroke treatment (mechanical thrombectomy) is to restore blood flow as quickly and completely as possible. There are numerous factors that influence endovascular treatment success. They can be broadly grouped into a) factors related to blood vessels, b) factors related to the thrombus, c) factors related to endovascular treatment technique and tools and d) operator-related factors. While blood vessel and tgthro thrombus-related factors are mostly non-modifiable in the acute setting, operator and technique-related factors can be modified, and extensive research is currently being done to investigate the complex interplay of all these variables, and to optimize the modifiable factors to the maximum possible extent. In this review, we will describe these factors and how they interact with each other in detail, and outline some of their practical implications. We will conclude with a short summary and outlook on future directions for optimizing endovascular treatment success.
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Affiliation(s)
- Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada; Department of Neuroradiology, University Hospital Basel, Basel, Switzerland; Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada.
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
| | - Matthew Gounis
- Department of Radiology, University of Massachusetts Medical School, Worcester, United States
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada; Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Charles B L M Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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10
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Grosse GM, Werlein C, Blume N, Abu-Fares O, Götz F, Gabriel MM, Ernst J, Leotescu A, Worthmann H, Kühnel MP, Jonigk DD, Falk CS, Weissenborn K, Schuppner R. Circulating Cytokines and Growth Factors in Acute Cerebral Large Vessel Occlusion-Association with Success of Endovascular Treatment. Thromb Haemost 2021; 122:623-632. [PMID: 34225367 PMCID: PMC9142215 DOI: 10.1055/a-1544-5431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Mechanical thrombectomy (MT) is a highly efficient treatment in patients with acute ischemic stroke due to large vessel occlusion (LVO). However, in a relevant proportion of LVO, no sufficient recanalization can be achieved. The composition of cerebral thrombi is highly heterogeneous and may constitute a relevant factor for insufficient reperfusion. We hypothesized that circulating cytokines and growth factors involved in thromboinflammation and platelet activation may be associated with reperfusion status and thrombus composition in patients undergoing MT. An according biomarker panel was measured in plasma specimens taken prior to MT and at a 7-day follow-up. The reperfusion status was categorized into sufficient or insufficient. The composition of retrieved thrombi was histologically analyzed. Differences of baseline biomarker concentrations between insufficient and sufficient reperfusions were highest for interferon (IFN)-γ, epidermal growth factor, platelet-derived growth factor (PDGF)-AB/BB, and IFN-γ-induced protein 10 (IP-10/CXCL10). After applying correction for multiple comparisons and logistic regression analysis adjusting for stroke etiology, intravenous thrombolysis, and vascular risk factors, PDGF-AB/BB was identified as an independent predictor of reperfusion status (odds ratio: 0.403; 95% confidence interval: 0.199-0.819). Histological analysis revealed that the majority of thrombi had a mixed composition. In conclusion, this study provides the first evidence that cytokines and growth factors are potential effectors in patients undergoing MT for the treatment of acute ischemic stroke.
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Affiliation(s)
- Gerrit M. Grosse
- Department of Neurology, Hannover Medical School, Hannover, Germany,Address for correspondence Gerrit M. Grosse, MD Department of Neurology, Hannover Medical SchoolCarl-Neuberg-Str. 1, 30625 HannoverGermany
| | | | - Nicole Blume
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Omar Abu-Fares
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Friedrich Götz
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Maria M. Gabriel
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Johanna Ernst
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Andrei Leotescu
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Hans Worthmann
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Mark P. Kühnel
- Institute of Pathology, Hannover Medical School, Hannover, Germany,Member of the German Center for Lung Research (DZL), Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Danny D. Jonigk
- Institute of Pathology, Hannover Medical School, Hannover, Germany,Member of the German Center for Lung Research (DZL), Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Christine S. Falk
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | | | - Ramona Schuppner
- Department of Neurology, Hannover Medical School, Hannover, Germany
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11
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Tolhuisen ML, Kappelhof M, Dutra BG, Jansen IGH, Guglielmi V, Dippel DWJ, van Zwam WH, van Oostenbrugge RJ, van der Lugt A, Roos YBWEM, Majoie CBLM, Caan MWA, Marquering HA. Influence of Onset to Imaging Time on Radiological Thrombus Characteristics in Acute Ischemic Stroke. Front Neurol 2021; 12:693427. [PMID: 34220695 PMCID: PMC8253046 DOI: 10.3389/fneur.2021.693427] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 05/14/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: Radiological thrombus characteristics are associated with patient outcomes and treatment success after acute ischemic stroke. These characteristics could be expected to undergo time-dependent changes due to factors influencing thrombus architecture like blood stasis, clot contraction, and natural thrombolysis. We investigated whether stroke onset-to-imaging time was associated with thrombus length, perviousness, and density in the MR CLEAN Registry population. Methods: We included 245 patients with M1-segment occlusions and thin-slice baseline CT imaging from the MR CLEAN Registry, a nation-wide multicenter registry of patients who underwent endovascular treatment for acute ischemic stroke within 6.5 h of onset in the Netherlands. We used multivariable linear regression to investigate the effect of stroke onset-to-imaging time (per 5 min) on thrombus length (in mm), perviousness and density (both in Hounsfield Units). In the first model, we adjusted for age, sex, intravenous thrombolysis, antiplatelet use, and history of atrial fibrillation. In a second model, we additionally adjusted for observed vs. non-observed stroke onset, CT-angiography collateral score, direct presentation at a thrombectomy-capable center vs. transfer, and stroke etiology. We performed exploratory subgroup analyses for intravenous thrombolysis administration, observed vs. non-observed stroke onset, direct presentation vs. transfer, and stroke etiology. Results: Median stroke onset-to-imaging time was 83 (interquartile range 53–141) min. Onset to imaging time was not associated with thrombus length nor perviousness (β 0.002; 95% CI −0.004 to 0.007 and β −0.002; 95% CI −0.015 to 0.011 per 5 min, respectively) and was weakly associated with thrombus density in the fully adjusted model (adjusted β 0.100; 95% CI 0.005–0.196 HU per 5 min). The subgroup analyses showed no heterogeneity of these findings in any of the subgroups, except for a significantly positive relation between onset-to-imaging time and thrombus density in patients transferred from a primary stroke center (adjusted β 0.18; 95% CI 0.022–0.35). Conclusion: In our population of acute ischemic stroke patients, we found no clear association between onset-to-imaging time and radiological thrombus characteristics. This suggests that elapsed time from stroke onset plays a limited role in the interpretation of radiological thrombus characteristics and their effect on treatment results, at least in the early time window.
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Affiliation(s)
- Manon L Tolhuisen
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Bruna G Dutra
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | | | - Valeria Guglielmi
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus Medical Center University Medical Center, Rotterdam, Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Center, Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht, University of Maastricht, Maastricht, Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center University Medical Center, Rotterdam, Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Matthan W A Caan
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
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12
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Song K, Yi HJ, Lee DH, Sung JH. Association of blood viscosity with first-pass reperfusion in mechanical thrombectomy for acute ischemic stroke. Clin Hemorheol Microcirc 2021; 77:233-244. [PMID: 33074222 DOI: 10.3233/ch-200979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Elevated blood viscosity has been reported as a risk factor for cerebrovascular disease. OBJECTIVE The relationship between blood viscosity and outcomes of mechanical thrombectomy (MT) for large artery occlusion (LAO) were investigated in the present study. METHODS A total of 238 patients were enrolled and systolic blood viscosity (SBV) and diastolic blood viscosity (DBV) were measured using the scanning capillary tube viscometer. Receiver operating characteristic (ROC) analysis was performed to specify the association of viscosity with the first-pass reperfusion (FPR). Multivariable and regression analyses were performed to evaluate the relationship of viscosity with FPR and various variables. RESULTS Based on ROC analysis, the best DBV cutoff value was 10.55 (cP). In multivariable analysis, high DBV was associated with FPR failure (odds ratio 2.82, 95% confidence interval 1.64-4.22; p = 0.001). Increased DVB could be associated with elevated SBV, hematocrit level, and blood urea nitrogen/creatinine ratio (p = <0.001, 0.004, and 0.002, respectively). CONCLUSIONS Elevated DBV was associated with FPR failure. Patients with high DBV had longer thrombus length and required more stent passages than patients with low DBV.
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Affiliation(s)
- Kyojun Song
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Department of Neurosurgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Jun Yi
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, College of Medicine, Soonchunhyang University, Bucheon, Republic of Korea
| | - Dong Hoon Lee
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae Hoon Sung
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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13
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Guenego A, Fahed R, Sussman ES, Leipzig M, Albers GW, Martin BW, Marcellus DG, Kuraitis G, Marks MP, Lansberg MG, Wintermark M, Heit JJ. Impact of Clot Shape on Successful M1 Endovascular Reperfusion. Front Neurol 2021; 12:642877. [PMID: 33597919 PMCID: PMC7882685 DOI: 10.3389/fneur.2021.642877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives: The susceptibility-vessel-sign (SVS) allows thrombus visualization, length estimation and composition, and it may impact reperfusion during mechanical thrombectomy (MT). SVS can also describe thrombus shape in the occluded artery: in the straight M1-segment (S-shaped), or in an angulated/traversing a bifurcation segment (A-shaped). We determined whether SVS clot shape influenced reperfusion and outcomes after MT for proximal middle-cerebral-artery (M1) occlusions. Methods: Between May 2015 and March 2018, consecutive patients who underwent MT at one comprehensive stroke center and who had a baseline MRI with a T2* sequence were included. Clinical, procedural and radiographic data, including clot shape on SVS [angulated/bifurcation (A-SVS) vs. straight (S-SVS)] and length were assessed. Primary outcome was successful reperfusion (TICI 2b-3). Secondary outcome were MT complication rates, MT reperfusion time, and clinical outcome at 90-days. Predictors of outcome were assessed with univariate and multivariate analyses. Results: A total of 62 patients were included. 56% (35/62) had an A-SVS. Clots were significantly longer in the A-SVS group (19 mm vs. 8 mm p = 0.0002). Groups were otherwise well-matched with regard to baseline characteristics. There was a significantly lower rate of successful reperfusion in the A-SVS cohort (83%) compared to the S-SVS cohort (96%) in multivariable analysis [OR 0.04 (95% CI, 0.002–0.58), p = 0.02]. There was no significant difference in long term clinical outcome between groups. Conclusion: Clot shape as determined on T2* imaging, in patients presenting with M1 occlusion appears to be a predictor of successful reperfusion after MT. Angulated and bifurcating clots are associated with poorer rates of successful reperfusion.
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Affiliation(s)
- Adrien Guenego
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - Robert Fahed
- Division of Neurology, Department of Medicine, Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Eric S Sussman
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - Matthew Leipzig
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - Gregory W Albers
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, United States
| | - Blake W Martin
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - David G Marcellus
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - Gabriella Kuraitis
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - Michael P Marks
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - Maarten G Lansberg
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, United States
| | - Max Wintermark
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
| | - Jeremy J Heit
- Interventional and Diagnostic Neuroradiology, Stanford Medical Center, Stanford, CA, United States
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14
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Leker RR, Kasner SE, El Hasan HA, Sacagiu T, Honig A, Gomori JM, Guan S, Choudhry O, Hurst RW, Kung D, Pukenas B, Sedora-Roman N, Ramchand P, Cohen JE. Impact of carotid tortuosity on outcome after endovascular thrombectomy. Neurol Sci 2020; 42:2347-2351. [PMID: 33047199 DOI: 10.1007/s10072-020-04813-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/07/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Endovascular thrombectomy (EVT) is efficacious in patients with large vessel occlusion stroke (LVO). We explored whether internal carotid (ICA) tortuosity increases the technical difficulty of EVT thereby lowering the chances of successful recanalization and favorable outcomes. PATIENTS AND METHODS Consecutive patients with LVO and patent ICAs who underwent EVT were included. Carotid tortuosity was determined on pre-EVT CTA and classified by raters blinded to outcomes into: type 1-straight ICA trunk and type 2-severe tortuosity potentially impeding adequate catheter placement. Thrombolysis in cerebral infarction (TICI) 2b-3 was considered successful recanalization, and 90-day-modified Rankin Scale ≤ 2 was considered favorable functional outcome. RESULTS Among 302 patients (mean age 70 ± 15, median NIHSS 17), 53% had type 1, and 47% type 2 tortuosity. Overall, 85% had successful recanalization. Patients with type 2 tortuosity were significantly older (p < 0.0001) and less frequently achieved successful recanalization (80% vs. 90%; p = 0.019) but had similar outcomes compared with those without tortuosity. On regression analysis, marked tortuosity was associated with lower chances of successful recanalization (OR 0.43 95% CI 0.20-0.92) but had no effect on clinical outcomes. CONCLUSIONS Carotid tortuosity does not appear to impact the likelihood of favorable functional outcome but may influence recanalization.
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Affiliation(s)
- Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel.
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Hosnei Abu El Hasan
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Tzvika Sacagiu
- Department of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel
| | - Asaf Honig
- Department of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel
| | - John M Gomori
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Shaobo Guan
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Omar Choudhry
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert W Hurst
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - David Kung
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian Pukenas
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Neda Sedora-Roman
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Preethi Ramchand
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jose E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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15
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Berndt M, Mück F, Maegerlein C, Wunderlich S, Zimmer C, Wirth S, Mönch S, Kaesmacher J, Friedrich B, Boeckh-Behrens T. Introduction of CTA-index as Simplified Measuring Method for Thrombus Perviousness. Clin Neuroradiol 2020; 31:773-781. [PMID: 32990766 PMCID: PMC8463362 DOI: 10.1007/s00062-020-00957-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 08/27/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Thrombus features on admission CT are useful imaging markers for clot characterization, stroke pathogenesis and outcome prediction. In this context, thrombus perviousness is a promising parameter, but reliable assessment in daily clinical practice is demanding. The aim of the present study was to evaluate an easy to assess measuring method for thrombus permeability at the time of admission. METHODS The CTA-index, which measures relative thrombus attenuation on admission CTA, was compared to the known perviousness parameter in a cohort of 101 patients with large-vessel occlusions of the middle cerebral artery and correlated to clinical outcome parameters (mRS after 90 days, ≤2 rated as favorable). For validation, this correlation was tested in a second independent cohort (n = 87), and possible associations between the CTA-index and outcome measurements (NIHSS/mRS/mTICI) were assessed. RESULTS In the first cohort a coherence between conventional perviousness measurements and the CTA-index was shown. The CTA-index differed significantly between favorable (-0.55 ± 0.16) and non-favorable outcomes (-0.64 ± 0.14, p = 0.01). In the validation cohort this result could be independently reproduced (-0.52 ± 0.13/-0.70 ± 0.09, p < 0.01). The CTA-index showed an association with low NIHSS at discharge (p < 0.01), favorable outcome after 90 days (p < 0.001) and with better reperfusion (measured by mTICI score, p = 0.04). CONCLUSION The CTA-index is an easy to assess imaging parameter on admission CTA in the acute stroke phase and is associated with angiographic and clinical outcome. It can be considered as a simplified measuring method for thrombus perviousness, which is known to provide useful information for further stroke progress and clinical course as well as therapeutic and rehabilitative decisions.
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Affiliation(s)
- Maria Berndt
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany.
| | - Fabian Mück
- Department of Radiology, Helios Klinikum München West, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Stefan Wirth
- Clinic and Polyclinic for Radiology, Ludwig-Maximilians-University of Munich, Munich, Germany
- Department of Radiology and Nuclear Medicine, Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany
| | - Sebastian Mönch
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Johannes Kaesmacher
- Department of Neuroradiology, Inselspital, University Hospital Bern, University Bern, Bern, Switzerland
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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16
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Large Vessel Occlusion Secondary to COVID-19 Hypercoagulability in a Young Patient: A Case Report and Literature Review. J Stroke Cerebrovasc Dis 2020; 29:105307. [PMID: 32992201 PMCID: PMC7832635 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105307] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 12/11/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) initially most appreciated for its pulmonary symptoms, is now increasingly recognized for causing multi-organ disease and stroke in the setting of a hypercoagulable state. We report a case of 33-year-old African American woman with COVID-19 who developed acute malignant middle cerebral artery infarction due to thromboembolic occlusion of the left terminal internal carotid artery and middle cerebral artery stem. Mechanical thrombectomy was challenging and ultimately unsuccessful resulting in limited reperfusion of <67% of the affected vascular territory, and thrombectomized clot was over 50 mm in length, at least three times the average clot length. The final stroke size was estimated at 224 cubic centimeters. On admission her D-dimer level was 94,589 ng/mL (normal 0-500 ng/ml). Throughout the hospitalization D-dimer decreased but never reached normal values while fibrinogen trended upward. Hypercoagulability panel was remarkable for mildly elevated anticardiolipin IgM of 16.3 MPL/mL (normal: 0-11.0 MPL/mL). With respect to remaining stroke workup, there was no evidence of clinically significant stenosis or dissection in the proximal internal carotid artery or significant cardioembolic source including cardiomyopathy, atrial fibrillation, cardiac thrombus, cardiac tumor, valvular abnormality, aortic arch atheroma, or patent foramen ovale. She developed malignant cytotoxic cerebral edema and succumbed to complications. This case underscores the importance of recognizing hypercoagulability as a cause of severe stroke and poor outcome in young patients with COVID-19 and highlights the need for further studies to define correlation between markers of coagulopathy in patients with COVID-19 infection and outcome post stroke.
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17
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Weyland CS, Neuberger U, Potreck A, Pfaff JAR, Nagel S, Schönenberger S, Bendszus M, Möhlenbruch MA. Reasons for Failed Mechanical Thrombectomy in Posterior Circulation Ischemic Stroke Patients. Clin Neuroradiol 2020; 31:745-752. [PMID: 32894352 PMCID: PMC8463404 DOI: 10.1007/s00062-020-00950-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/06/2020] [Indexed: 01/18/2023]
Abstract
Background and Purpose To determine reasons for failed recanalization in mechanical thrombectomy (MT) of the posterior circulation. Methods Retrospective single center analysis of reasons for MT failure in the posterior circulation. Failed MTs were categorized according to the reason for procedure failure in failed vascular access, failed passage of the target vessel occlusion and MT failure after passing the occluded target vessel. Patient characteristics were compared between failed and successful MT. Results Patients with failed MT (30/218 patients, 13.8%) were categorized into futile vascular access (13/30, 43.3%), abortive passage of the target vessel occlusion (6/30, 20.0%) and MT failure after passing the vessel occlusion (11/30, 36.7%). In 188/218 (86.2%) successful MTs alternative vascular access, local intra-arterial (i.a.) thrombolysis and emergency stent-assisted PTA prevented 65 MT failures. Patients with failed MT showed a higher NIHSS at discharge, a higher pc-ASPECTS in follow-up imaging, a higher mRS 90 days after stroke onset and a high mortality rate of 77.0% (mRS at 90 days, median (IQR): 6 (6–6) vs. 4 (2–6) for successful MT, p-value < 0.001). Co-morbidities and stroke etiology were not different compared to sufficient recanalization with atherosclerotic disease as the leading stroke etiology in both groups. Conclusion Failure of MT in posterior circulation ischemic stroke patients is associated with a high mortality rate. Reasons for MT failure are diverse with futile vascular access and MT failure after passing the vessel occlusion as the leading causes. Alternative vascular access, local i.a. thrombolysis and stent-assisted PTA can prevent MT failure.
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Affiliation(s)
- Charlotte S Weyland
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Ulf Neuberger
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Arne Potreck
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Johannes A R Pfaff
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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18
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Byrne D, Walsh JP, Sugrue G, Nicolaou S, Rohr A. CT Imaging of Acute Ischemic Stroke [Formula: see text]. Can Assoc Radiol J 2020; 71:266-280. [PMID: 32157894 DOI: 10.1177/0846537120902068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Although acute ischemic stroke remains one of the most common causes of death and disability worldwide, it is a potentially treatable condition if appropriately managed in a timely manner. The goals of acute stroke imaging include establishing a diagnosis as fast as possible with (1) accurate infarct quantification, (2) intracranial and cervical vasculature assessment, and (3) brain perfusion analysis for detection of infarct core and potentially salvageable penumbra allowing optimal patient selection for appropriate therapy. Given the extensive number of images generated from acute stroke imaging studies and as "time is brain," this article aims to highlight a logical approach for the radiologist in acute stroke computed tomography imaging in order to accurately interpret and communicate results in a timely manner.
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Affiliation(s)
- D Byrne
- Division of Neuroradiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,University of British Columbia, Vancouver, British Columbia, Canada
| | - J P Walsh
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Emergency Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - G Sugrue
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Emergency Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - S Nicolaou
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Emergency Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - A Rohr
- Division of Neuroradiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,University of British Columbia, Vancouver, British Columbia, Canada
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19
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Mönch S, Boeckh-Behrens T, Berndt M, Maegerlein C, Wunderlich S, Zimmer C, Friedrich B. Angiographic Baseline Proximal Thrombus Appearance of M1/M2 Occlusions in Mechanical Thrombectomy. Clin Neuroradiol 2019; 31:189-196. [PMID: 31807811 DOI: 10.1007/s00062-019-00863-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/19/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Analyzing stroke thrombi has proven to be valuable in prognostication and risk stratification of stroke etiology, reperfusion success and outcomes. The aim of this study was to test if the baseline appearance of the proximal thrombus on digital subtraction angiography (DSA) can predict these parameters in acute ischemic stroke patients treated with mechanical thrombectomy. METHODS The appearance of the most proximal part of the thrombus was determined based on DSA. Thrombus perviousness, density, and histology were measured beforehand as described previously. Baseline, technical, and outcome variables were compared using the χ2-test, analysis of variance and the Kruskal-Wallis test. RESULTS A total of 144 stroke patients with M1 and M2 occlusions could be included in this present study. Of the patients 60.4% had a cutoff, 27.1% a tapered, and 12.5% a meniscus/tram-track appearance of the thrombus on baseline DSA. The number of maneuvers was higher in the cutoff cohort (P = 0.003). Age (P = 0.777), female sex (P = 0.936), administration of intravenous thrombolysis (P = 0.364), percentage of M1 occlusions (P = 0.194), Alberta Stroke Program early computed tomography score (ASPECTS, P = 0.256), usage of balloon guide catheters (P = 0.367), general anesthesia (P = 0.184), procedure time (P = 0.214) and symptom onset to groin puncture time (P = 0.114) did not significantly differ. Alongside a lower National Institutes of Health scale (NIHSS) score on admission (P = 0.085), good functional outcome was favorable for the meniscus/tram-track cohort (P = 0.030). Stroke etiology according to the trial of Org 10172 in acute stroke treatment (TOAST) criteria as well as thrombus perviousness, density, and histology showed no association with the thrombus appearance. CONCLUSION Baseline cut off thrombus appearance predicts a higher number of thrombectomy maneuvers. In day to day practice this may prepare the neurointerventionalist for a more challenging endovascular procedure ahead. Stroke etiology, clinical outcomes and thrombus-specific characteristics did not show any associations with the thrombus appearance.
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Affiliation(s)
- Sebastian Mönch
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Maria Berndt
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Ismaninger Straße 22, 81675, Munich, Germany
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20
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Li G, Wu G, Qin Z, Li H, Cheng X, Cai Y. Prognostic Value of Clot Burden Score in Acute Ischemic Stroke after Reperfusion Therapies: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2019; 28:104293. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 06/12/2019] [Accepted: 07/10/2019] [Indexed: 01/08/2023] Open
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21
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Dutra BG, Tolhuisen ML, Alves HC, Treurniet KM, Kappelhof M, Yoo AJ, Jansen IG, Dippel DW, van Zwam WH, van Oostenbrugge RJ, da Rocha AJ, Lingsma HF, van der Lugt A, Roos YB, Marquering HA, Majoie CB. Thrombus Imaging Characteristics and Outcomes in Acute Ischemic Stroke Patients Undergoing Endovascular Treatment. Stroke 2019; 50:2057-2064. [DOI: 10.1161/strokeaha.118.024247] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background and Purpose—
Thrombus imaging characteristics have been reported to be useful to predict functional outcome and reperfusion in acute ischemic stroke. However, conflicting data about this subject exist in patients undergoing endovascular treatment. Therefore, we aimed to evaluate whether thrombus imaging characteristics assessed on computed tomography are associated with outcomes in patients with acute ischemic stroke treated by endovascular treatment.
Methods—
The MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry is an ongoing, prospective, and observational study in all centers performing endovascular treatment in the Netherlands. We evaluated associations of thrombus imaging characteristics with the functional outcome (modified Rankin Scale at 90 days), mortality, reperfusion, duration of endovascular treatment, and symptomatic intracranial hemorrhage using univariable and multivariable regression models. Thrombus characteristics included location, clot burden score (CBS), length, relative and absolute attenuation, perviousness, and distance from the internal carotid artery terminus to the thrombus. All characteristics were assessed on thin-slice (≤2.5 mm) noncontrast computed tomography and computed tomography angiography, acquired within 30 minutes from each other.
Results—
In total, 408 patients were analyzed. Thrombus with distal location, higher CBS, and shorter length were associated with better functional outcome (adjusted common odds ratio, 3.3; 95% CI, 2.0–5.3 for distal M1 occlusion compared with internal carotid artery occlusion; adjusted common odds ratio, 1.15; 95% CI, 1.07–1.24 per CBS point; and adjusted common odds ratio, 0.96; 95% CI, 0.94–0.99 per mm, respectively) and reduced duration of endovascular procedure (adjusted coefficient B, −14.7; 95% CI, −24.2 to −5.1 for distal M1 occlusion compared with internal carotid artery occlusion; adjusted coefficient B, −8.5; 95% CI, −14.5 to −2.4 per CBS point; and adjusted coefficient B, 7.3; 95% CI, 2.9–11.8 per mm, respectively). Thrombus perviousness was associated with better functional outcome (adjusted common odds ratio, 1.01; 95% CI, 1.00–1.02 per Hounsfield units increase). Distal thrombi were associated with successful reperfusion (adjusted odds ratio, 2.6; 95% CI, 1.4–4.9 for proximal M1 occlusion compared with internal carotid artery occlusion).
Conclusions—
Distal location, higher CBS, and shorter length are associated with better functional outcome and faster endovascular procedure. Distal thrombus is strongly associated with successful reperfusion, and a pervious thrombus is associated with better functional outcome.
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Affiliation(s)
- Bruna G. Dutra
- From the Departments of Radiology and Nuclear Medicine (B.G.D., H.C.B.R.A., K.M.T., M.K., I.G.H.J., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
- Biomedical Engineering and Physics (B.G.D., M.L.T., H.C.B.R.A., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands
- Department of Radiology, Irmandade Santa Casa de Misericórdia de São Paulo, Brazil (B.G.D., H.C.B.R.A., A.J.d.R.)
| | - Manon L. Tolhuisen
- Biomedical Engineering and Physics (B.G.D., M.L.T., H.C.B.R.A., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - Heitor C.B.R. Alves
- From the Departments of Radiology and Nuclear Medicine (B.G.D., H.C.B.R.A., K.M.T., M.K., I.G.H.J., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
- Biomedical Engineering and Physics (B.G.D., M.L.T., H.C.B.R.A., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands
- Department of Radiology, Irmandade Santa Casa de Misericórdia de São Paulo, Brazil (B.G.D., H.C.B.R.A., A.J.d.R.)
| | - Kilian M. Treurniet
- From the Departments of Radiology and Nuclear Medicine (B.G.D., H.C.B.R.A., K.M.T., M.K., I.G.H.J., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - Manon Kappelhof
- From the Departments of Radiology and Nuclear Medicine (B.G.D., H.C.B.R.A., K.M.T., M.K., I.G.H.J., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - Albert J. Yoo
- Division of Interventional Neuroradiology, Department of Radiology, Texas Stroke Institute, Plano (A.J.Y.)
| | - Ivo G.H. Jansen
- From the Departments of Radiology and Nuclear Medicine (B.G.D., H.C.B.R.A., K.M.T., M.K., I.G.H.J., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - Diederik W.J. Dippel
- Neurology (D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Wim H. van Zwam
- Departments of Radiology (W.H.v.Z), Maastricht University Medical Center, the Netherlands
- Cardiovascular Research Institute Maastricht (W.H.v.Z., R.J.v.O.), Maastricht University Medical Center, the Netherlands
| | - Robert J. van Oostenbrugge
- Neurology (R.J.v.O.), Maastricht University Medical Center, the Netherlands
- Cardiovascular Research Institute Maastricht (W.H.v.Z., R.J.v.O.), Maastricht University Medical Center, the Netherlands
| | - Antônio J. da Rocha
- Department of Radiology, Irmandade Santa Casa de Misericórdia de São Paulo, Brazil (B.G.D., H.C.B.R.A., A.J.d.R.)
| | - Hester F. Lingsma
- Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Aad van der Lugt
- Departments of Radiology (A.v.d.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Yvo B.W.E.M. Roos
- Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands
| | - Henk A. Marquering
- Biomedical Engineering and Physics (B.G.D., M.L.T., H.C.B.R.A., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - Charles B.L.M. Majoie
- From the Departments of Radiology and Nuclear Medicine (B.G.D., H.C.B.R.A., K.M.T., M.K., I.G.H.J., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
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22
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Shu L, Salehi Ravesh M, Jansen O, Jensen-Kondering U. Stent Retriever Thrombectomy Potentially Increases the Recanalization Rate, Improves Clinical Outcome, and Decreases Mortality in Acute Basilar Occlusion: A Systematic Review and Meta-Analysis. Cerebrovasc Dis Extra 2019; 9:46-56. [PMID: 31167189 PMCID: PMC6587203 DOI: 10.1159/000499665] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/17/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Acute basilar artery occlusion (BAO) is a devastating condition if untreated. The optimal treatment strategy, however, is unknown. Historically, interventional approaches have been favored over intravenous thrombolysis (IVT), although this is not supported by good evidence. The aim of this systematic review and meta-analysis was to summarize and compare the results for treatment modalities of BAO, namely, IVT and interventional stent retriever thrombectomy (SRT). METHODS Studies on IVT and SRT in BAO were systematically searched. Successful recanalization (TICI ≥2b), favorable clinical outcome (modified Rankin Scale score ≤2), mortality, and the rate of symptomatic intracranial hemorrhage (SICH) were the target parameters. Only studies with ≥15 patients were included. IVT prior to SRT was allowed. Studies were excluded (1) if >1 thrombectomy device was used in >50% of the patients and (2) when data on outcome or treatment could not be parsed (e.g. registries). Odds ratios (ORs) were calculated using Mantel-Haenszel risk ratio estimation. Results are given as OR and the 95% confidence interval (95% CI). The χ2 test was used to compare the outcome parameters clinical outcome, recanalization, mortality, and SICH. RESULTS A total of 17 studies (4 on IVT and 13 on SRT) with a total of 672 patients (IVT, n = 314; SRT, n = 358) were identified. Cumulatively, we found a highly significantly improved clinical outcome (43 vs. 31%, p = 0.004, OR [95% CI] = 1.66 [1.21, 2.76]), increased recanalization rate (88 vs. 60%, p < 0.00001, OR [95% CI] = 3.99 [2.73, 5.84]), and decreased mortality (26 vs. 41%, p = 0.0004, OR [95% CI] = 1.86 [1.33, 2.61]), as well as an equal rate of SICH (5 vs. 7%, p = 0.15, OR [95% CI] = 1.68 [0.82, 3.43]), in patients treated with SRT compared to those treated with IVT alone. CONCLUSIONS The data from this meta-analysis suggest a possible superiority of SRT over IVT, pending positive results of randomized controlled trials. According to international recommendations, patients with BAO should preferentially be treated with SRT; if no contraindications exist, IVT should not be withheld.
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Affiliation(s)
- Liang Shu
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Mona Salehi Ravesh
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ulf Jensen-Kondering
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany,
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23
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An acute stroke CT imaging algorithm incorporating automated perfusion analysis. Emerg Radiol 2019; 26:319-329. [PMID: 30706257 DOI: 10.1007/s10140-019-01675-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/15/2019] [Indexed: 12/16/2022]
Abstract
In this paper, we propose a CT imaging algorithm for patients presenting with suspected acute stroke that incorporates automated CT perfusion (CTP) imaging. The algorithm details evaluation of the non-contrast CT (NCCT) for hemorrhage and acute ischemia, calculation of ASPECTS, with performance and interpretation of CTP if appropriate. In particular, we consider the key steps in expeditious interpretation of non-contrast CT and CT angiography in the context of suspected acute ischemic stroke. Given the recent expansion of the "imaging based" treatment window for thrombectomy from 6 to 24 h in the 2018 American Heart Association stroke guidelines, we consider the key criteria in the decision to perform CT perfusion and the patient cohorts in which this might be most helpful. We also describe how imaging findings might be incorporated into the treatment paradigm for suspected with acute ischemic stroke and we allude to some of the most frequently encountered pitfalls associated with CTP which we think will be particularly helpful for radiologists and stroke physicians who are considering adding CT perfusion to their work-up for acute stroke.
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24
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Gavriliuc P, Kharouba R, Cohen J, Gomori J, Yaghmour N, Leker R. Clot length does not impact outcome following thrombectomy. J Neurol Sci 2018; 395:91-94. [DOI: 10.1016/j.jns.2018.09.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/23/2018] [Accepted: 09/25/2018] [Indexed: 10/28/2022]
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25
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Thrombus Permeability in Admission Computed Tomographic Imaging Indicates Stroke Pathogenesis Based on Thrombus Histology. Stroke 2018; 49:2674-2682. [DOI: 10.1161/strokeaha.118.021873] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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26
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Kaesmacher J, Gralla J, Mosimann PJ, Zibold F, Heldner MR, Piechowiak E, Dobrocky T, Arnold M, Fischer U, Mordasini P. Reasons for Reperfusion Failures in Stent-Retriever-Based Thrombectomy: Registry Analysis and Proposal of a Classification System. AJNR Am J Neuroradiol 2018; 39:1848-1853. [PMID: 30166434 DOI: 10.3174/ajnr.a5759] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 06/25/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE In 5%-10% of patients with acute ischemic stroke with an intention to treat with mechanical thrombectomy, no reperfusion can be achieved (Thrombolysis in Cerebral Infarction score = 0/1). Purpose of this analysis was a systematic assessment of underlying reasons for reperfusion failures. MATERIALS AND METHODS An intention-to-treat single-center cohort (n = 592) was re-evaluated for all patients in whom no reperfusion could be achieved (n = 63). Baseline characteristics of patients were compared between patients with and without reperfusion failures. After qualitative review of all cases with reperfusion failures, a classification system was proposed and relative frequencies were reported. In a second step, occurrence of delayed recanalization at 24 hours after reperfusion failure and dependency on IV-tPA were evaluated. RESULTS In 63/592 patients with an intention to perform stent-retriever thrombectomy, no reperfusion was achieved (TICI 0/1, 10.6%, 95% CI, 8.2%-13.1%). Older patients (adjusted OR per yr = 1.03; 95% CI, 1.01-1.05) and patients with M2 occlusion (adjusted OR = 3.36; 95% CI, 1.82-6.21) were at higher risk for reperfusion failure. In most cases, no reperfusion was a consequence of technical difficulties (56/63, 88.9%). In one-third of these cases, reperfusion failures were due to the inability to reach the target occlusion (20/63, 31.7%), while "stent-retriever failure" occurred in 39.7% (25/63) of patients. Delayed recanalization was very rare (18.2%), without dependence on IV-tPA pretreatment status. CONCLUSIONS Reasons for reperfusion failure in stent-retriever thrombectomy are heterogeneous. The failure to establish intracranial or cervical access is almost as common as stent-retriever failure after establishing intracranial access. Systematic reporting standards of reasons may help to further estimate relative frequencies and thereby guide priorities for technical development and scientific effort.
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Affiliation(s)
- J Kaesmacher
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini)
- Department of Neurology (J.K., M.R.H., M.A., U.F.), University Hospital Bern and University of Bern, Inselspital, Bern, Switzerland
| | - J Gralla
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini)
| | - P J Mosimann
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini)
| | - F Zibold
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini)
| | - M R Heldner
- Department of Neurology (J.K., M.R.H., M.A., U.F.), University Hospital Bern and University of Bern, Inselspital, Bern, Switzerland
| | - E Piechowiak
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini)
| | - T Dobrocky
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini)
| | - M Arnold
- Department of Neurology (J.K., M.R.H., M.A., U.F.), University Hospital Bern and University of Bern, Inselspital, Bern, Switzerland
| | - U Fischer
- Department of Neurology (J.K., M.R.H., M.A., U.F.), University Hospital Bern and University of Bern, Inselspital, Bern, Switzerland
| | - P Mordasini
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini)
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Acute basilar thrombosis: Recanalization following intravenous thrombolysis is dependent on thrombus length. PLoS One 2018; 13:e0193051. [PMID: 29466399 PMCID: PMC5821367 DOI: 10.1371/journal.pone.0193051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 02/02/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction We investigated whether thrombus length measured in Computed Tomography Angiography (CTA) is predictive of the success rate of intravenous thrombolysis (IVT) in acute basilar occlusion and whether recanalization can be achieved by additional mechanical endovascular thrombectomy. Methods In 51 patients with acute basilar thrombosis thrombus length was measured on CTA images before intravenous thrombolysis (IVT) with rt-PA was started. After 114 minutes on average success of IVT was evaluated either by CTA or DSA. Patients with persistent basilar occlusion and no major brainstem infarction on CT underwent endovascular recanalization. Results 87% of patients had no recanalization of basilar artery after IVT alone. The average thrombus length was 15 mm in patients with persistent basilar occlusion after IVT and 7 mm in patients with recanalization after IVT. Thrombi longer than 13 mm did not resolve after IVT alone and 80% of thrombi shorter than 13 mm did not resolve either. 41 patients were transferred to endovascular recanalization; endovascular therapy was performed successfully in 90% (37 / 41). Conclusions Recanalization rates in acute basilar occlusion after IVT alone are low and dependent on thrombus length. Additional mechanical endovascular thrombectomy showed to be a very successful recanalization therapy.
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Seker F, Pfaff J, Wolf M, Ringleb PA, Nagel S, Schönenberger S, Herweh C, Möhlenbruch MA, Bendszus M, Pham M. Correlation of Thrombectomy Maneuver Count with Recanalization Success and Clinical Outcome in Patients with Ischemic Stroke. AJNR Am J Neuroradiol 2017; 38:1368-1371. [PMID: 28473346 DOI: 10.3174/ajnr.a5212] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 03/03/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In the treatment of acute thromboembolic stroke, the effectiveness and success of thrombus removal when using stent retrievers is variable. In this study, we analyzed the correlation of thrombectomy maneuver count with a good clinical outcome and recanalization success. MATERIALS AND METHODS One hundred and four patients with acute occlusion of the middle cerebral artery or the terminal internal carotid artery who were treated with thrombectomy were included in this retrospective study. A good clinical outcome was defined as a 90-day mRS of ≤2, and successful recanalization was defined as TICI 2b-3. RESULTS The maneuver count ranged between 1-10, with a median of 2. Multivariate logistic regression analyses identified an increasing number of thrombectomy maneuvers as an independent predictor of poor outcome (adjusted OR, 0.59; 95% CI, 0.38-0.87; P = .011) and unsuccessful recanalization (adjusted OR, 0.48; 95% CI, 0.32-0.66; P < .001). A good outcome was significantly more likely if finished within 2 maneuvers compared with 3 or 4 maneuvers, or even more than 4 maneuvers (P < .001). CONCLUSIONS An increasing maneuver count correlates strongly with a decreasing probability of both good outcome and recanalization. The probability of successful recanalization decreases below 50% if not achieved within 5 thrombectomy maneuvers. Patients who are recanalized within 2 maneuvers have the best chance of achieving a good clinical outcome.
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Affiliation(s)
- F Seker
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - J Pfaff
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - M Wolf
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - P A Ringleb
- Neurology (P.A.R., S.N., S.S.), Heidelberg University Hospital, Heidelberg, Germany
| | - S Nagel
- Neurology (P.A.R., S.N., S.S.), Heidelberg University Hospital, Heidelberg, Germany
| | - S Schönenberger
- Neurology (P.A.R., S.N., S.S.), Heidelberg University Hospital, Heidelberg, Germany
| | - C Herweh
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - M A Möhlenbruch
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - M Bendszus
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.)
| | - M Pham
- From the Departments of Neuroradiology (F.S., J.P., M.W., C.H., M.A.M., M.B., M.P.).,Department of Neuroradiology (M.P.), Würzburg University Hospital, Würzburg, Germany
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29
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Alotaibi NM, Sarzetto F, Boyle K, Howard P, Yang VXD. Single-pass endovascular thrombectomy for massive carotid-cerebral occlusion. Br J Neurosurg 2017; 33:92-93. [PMID: 28436277 DOI: 10.1080/02688697.2017.1319909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Acute concomitant occlusions of the extracranial internal carotid artery and intracranial vessels frequently require multiple passes with stent-retrievers for mechanical thrombectomy. Due to the large clot burden associated with these occlusions, their response to intravenous thrombolysis is poor. We herein report a successful case of evacuating a massive clot (>14 cm) in a single-pass using a stent-retrieval device.
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Affiliation(s)
- Naif M Alotaibi
- a Division of Neurosurgery, Department of Surgery , Sunnybrook Health Sciences Centre, and Institute of Medical Science, Faculty of Medicine, University of Toronto , Toronto , Ontario , Canada
| | - Francesca Sarzetto
- a Division of Neurosurgery, Department of Surgery , Sunnybrook Health Sciences Centre, and Institute of Medical Science, Faculty of Medicine, University of Toronto , Toronto , Ontario , Canada
| | - Karl Boyle
- b Division of Neurology, Department of Medicine , Sunnybrook Health Sciences Centre, University of Toronto , Toronto , Ontario , Canada
| | - Peter Howard
- c Department of Radiology , Sunnybrook Health Sciences Centre, University of Toronto , Toronto , Ontario , Canada
| | - Victor X D Yang
- a Division of Neurosurgery, Department of Surgery , Sunnybrook Health Sciences Centre, and Institute of Medical Science, Faculty of Medicine, University of Toronto , Toronto , Ontario , Canada
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