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McKenzie ED, Chaturvedi S, Peters SR. Basilar artery stenting in hyperacute stroke: A systematic review of published cases. Clin Neurol Neurosurg 2024; 242:108327. [PMID: 38761504 DOI: 10.1016/j.clineuro.2024.108327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 04/10/2024] [Accepted: 05/08/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND AND PURPOSE Basilar artery stenting is a rescue therapy in the management of hyperacute stroke. Published data on efficacy and safety are limited. METHODS A systematic review of published studies was performed in accordance with PRISMA guidelines. Inclusion criteria were adult patients with ischemic stroke with permanent basilar artery stent placement within 48 h of onset. Data were extracted by two independent reviewers. Additional cases from our institution were identified via a local stroke registry. RESULTS Of 212 screened articles, patient-level data was reported in 35 studies (87 individuals) and six additional patients were included from our registry. Patients (n = 93, 63 % male; median age 64) most often presented with mid-basilar occlusion (52 %) and 76 % received treatment within 12 hours of onset. Favorable angiographic results occurred in 67 %. The final modified Rankin Scale score (mRS) was 0-3 for 56 % of patients; mortality was 29 %. Those with complete flow post-procedure were more likely to have a final mRS of 0-3 (p = 0.05). CONCLUSIONS In 93 cases of basilar stenting in hyperacute stroke, favourable angiographic and functional outcomes were reported in 67 % and 56 % of patients, respectively. International multicenter registries are required to establish benefit and identify patient and technical factors that predict favorable outcomes.
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Affiliation(s)
- Erica D McKenzie
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Surbhi Chaturvedi
- Department of Neuroscience, Specialist Hospital, Bengaluru, Karnataka, India
| | - Steven R Peters
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Ahmed RA, Dmytriw AA, Patel AB, Stapleton CJ, Vranic JE, Rabinov JD, Leslie-Mazwi TM, Rost NS, Hirsch JA, Regenhardt RW. Basilar artery occlusion: A review of clinicoradiologic features, treatment selection, and endovascular techniques. Interv Neuroradiol 2023; 29:748-758. [PMID: 35695210 PMCID: PMC10680956 DOI: 10.1177/15910199221106049] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/17/2022] [Accepted: 05/15/2022] [Indexed: 12/20/2022] Open
Abstract
Basilar artery occlusion (BAO) is an infrequent but often fatal subtype of stroke. Predicting outcomes and selecting patients for endovascular therapy (EVT) remains challenging. Advances in neuroimaging and the development of prognostic scoring systems have augmented clinical decision-making over time. Recent randomized trials, BEST (Basilar Artery Occlusion Endovascular Intervention vs. Standard Medical Treatment), BASICS (Basilar Artery International Cooperation Study), BAOCHE (Basilar Artery Occlusion CHinese Endovascular Trial) and ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion), compared EVT and medical management for patients with BAO. These trials yielded mixed results. The former two suggested unclear benefit while the latter two supported a benefit of EVT. While all had limitations, most providers agree caution should be exercised when excluding patients from EVT who may stand to benefit. Further studies are therefore needed to determine the effectiveness, safety, selection criteria, and optimal technical approach for EVT among patients with BAO. Hyperacute-phase advanced imaging can offer several benefits to aid decision making. It is reasonable to exclude patients with low National Institutes of Health Stroke Scale (NIHSS), large imaging-proven cores, and evidence of perforator occlusion by branch atheromatous disease. Herein, we review the clinical presentation, imaging work-up, treatments, and clinical outcomes for BAO, while highlighting knowledge gaps in treatment selection and technique.
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Affiliation(s)
- Rashid A Ahmed
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Justin E Vranic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Neurosciences Institute, University of Washington, Seattle, WA, USA
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Gao J, Wen C, Sun J, Chen D, Zhang D, Wang N, Liu Y, Wang J, Zhang B. Prognostic factors for acute posterior circulation cerebral infarction patients after endovascular mechanical thrombectomy: A retrospective study. Medicine (Baltimore) 2022; 101:e29167. [PMID: 35512073 PMCID: PMC9276263 DOI: 10.1097/md.0000000000029167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 03/06/2022] [Indexed: 01/04/2023] Open
Abstract
This article was to analyze the factors influencing the prognosis of posterior circulation cerebral infarction (PCCI) patients, retrospectively.One hundred forty five patients diagnosed with PCCI in Nanyang Central Hospital between June 25, 2016 and October 14, 2019 were included and underwent cerebral vascular mechanical thrombectomy. The clinical data of those patients were collected. The patients were followed up for 3 months to observe the prognostic efficacy and explore the influencing factors for poor prognosis. The potential prognostic factors for PCCI patients after emergency endovascular mechanical thrombectomy were analyzed by univariate and multivariable logistic regression. The thermodynamic diagram was drawn to explore the associations between the prognostic factors.The risk of poor prognosis in PCCI patients receiving emergency endovascular mechanical thrombectomy was reduced by 0.552 time with every 1-point increase of the Alberta Stroke Program Early CT in posterior circulation score (odds ratio [OR] = 0.448, 95% confidence interval [CI]: 0.276-0.727). The risk of poor prognosis was increased by 0.827 time for each additional grade in the digital subtraction angiography-American Society of Intervention and Therapeutic Neuroradiology grading (OR = 1.827, 95% CI: 1.221-2.733, P = .003) and increased by 0.288 time for every 1-point increase in National Institutes of Health Stroke scale at 24 hours (OR = 1.288, 95% CI: 1.161-1.429). All P < .05.Alberta Stroke Program Early CT in posterior circulation score, digital subtraction angiography-American Society of Intervention and Therapeutic Neuroradiology grading, National Institutes of Health Stroke scale score at 24 hours were factors affecting the prognosis of PCCI patients undergoing emergency endovascular mechanical thrombectomy, which might provide evidence for endovascular treatment of PCCI.
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Namioka A, Namioka T, Sasaki M, Kocsis JD, Honmou O. Focal brainstem infarction in the adult rat. Lab Anim (NY) 2021; 50:97-107. [PMID: 33564191 DOI: 10.1038/s41684-021-00722-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 01/12/2021] [Indexed: 11/08/2022]
Abstract
Animal models are required to study the pathogenesis of brainstem ischemia and to develop new therapeutic approaches to promote functional recovery after ischemia in humans. Few models of brainstem ischemia are available, and they show great variability or cause early lethality. New, reliable animal models are therefore needed. By selectively ligating four points of the lower basilar artery, we developed a new focal basilar artery occlusion model that causes a localized brainstem ischemic lesion in female Sprague-Dawley rats. Analysis of ischemic lesion volume and neurological deficits over a period of 28 d showed that the rats present symptoms specific to this type of stroke while the ischemic lesion remains relatively unchanged over time. This procedure allows higher survival rates and extended observation periods compared with other models of brainstem ischemia. The procedure takes ~40 min, can be performed by researchers with basic surgical skills and does not require specialized surgical equipment. This protocol is highly reliable and will be useful to evaluate new therapeutic approaches to promote functional recovery in patients with brainstem ischemia.
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Xun K, Mo J, Ruan S, Dai J, Zhang W, Lv Y, Du N, Chen S, Shen Z, Wu Y. A Meta-Analysis of Prognostic Factors in Patients with Posterior Circulation Stroke after Mechanical Thrombectomy. Cerebrovasc Dis 2020; 50:185-199. [PMID: 33378751 DOI: 10.1159/000512609] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/15/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Posterior circulation stroke is characterized by poor prognosis because its optimal thrombolysis "time window" is always missed. After mechanical thrombectomy (MT), the recanalization rate of posterior circulation obstruction is significantly increased, but prognosis remains poor. To best manage patients, prognostic factors are needed to inform MT triaging after posterior circulation stroke. METHODS A systematic literature search was done for the period through April 2020. Studies included those with posterior circulation stroke cases that underwent MT. The primary outcome measure in this study was the modified Rankin Scale on day 90. RESULTS No outcome differences were found in gender, atrial fibrillation, smoking, and coronary artery disease (OR = 1.07, 95% CI: 0.90-1.28; OR = 1.02, 95% CI: 0.82-1.26; OR = 1.26, 95% CI: 0.94-1.68; and OR = 0.84, 95% CI: 0.58-1.22, respectively). Hypertension, diabetes mellitus, and previous stroke correlated with poorer prognosis (OR = 0.61, 95% CI: 0.48-0.77; OR = 0.60, 95% CI: 0.50-0.73; and OR = 0.74, 95% CI: 0.55-0.99, respectively). However, hyperlipidemia correlated with better prognosis (OR = 1.28, 95% CI: 1.04-1.58). CONCLUSION Our analysis indicates that hypertension, diabetes mellitus, or previous stroke correlate with poorer outcomes. Intriguingly, hyperlipidemia correlates with better prognosis. These factors may help inform triage decisions when considering MT for posterior circulation stroke patients. However, large, multicenter, randomized controlled trials are needed to validate these observations.
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Affiliation(s)
- Kai Xun
- Department of Emergency, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Jiahang Mo
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China
| | - Shunyi Ruan
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jinyao Dai
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China
| | - Wenting Zhang
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yuqi Lv
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China
| | - Nannan Du
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China
| | - Shengyue Chen
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zefeng Shen
- Department of General Surgery, School of Medicine, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Yuanxi Wu
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China,
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Sang HF, Yin CG, Xia WQ, Huang H, Liu KQ, Chen TW, Si XL, Jiang L. Mechanical Thrombectomy Using Solitaire in Acute Ischemic Stroke Patients with Vertebrobasilar Occlusion: A Prospective Observational Study. World Neurosurg 2019; 128:e355-e361. [DOI: 10.1016/j.wneu.2019.04.152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/17/2019] [Accepted: 04/17/2019] [Indexed: 11/26/2022]
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Bösel J. Ischemic Stroke in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging-based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes.
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Affiliation(s)
- Sonu Bhaskar
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Peter Stanwell
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Dennis Cordato
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
| | - John Attia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
- Centre for Clinical Epidemiology & Biostatistics, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW Australia
| | - Christopher Levi
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
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Luo G, Mo D, Tong X, Liebeskind DS, Song L, Ma N, Gao F, Sun X, Zhang X, Wang B, Jia B, Fernandez-Escobar A, Miao Z. Factors Associated with 90-Day Outcomes of Patients with Acute Posterior Circulation Stroke Treated By Mechanical Thrombectomy. World Neurosurg 2018; 109:e318-e328. [DOI: 10.1016/j.wneu.2017.09.171] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/23/2017] [Accepted: 09/25/2017] [Indexed: 12/22/2022]
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Long J, Qin H, Zhang H. Evaluation of recanalisation treatment on posterior circulation ischemic stroke by Solitaire device—A multicenter retrospective study. Neurol Neurochir Pol 2017; 51:208-213. [DOI: 10.1016/j.pjnns.2017.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 02/17/2017] [Accepted: 02/23/2017] [Indexed: 11/15/2022]
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Abstract
Neurologic complications of cancer are common and are frequently life-threatening events. Certain neurologic emergencies occur more frequently in the cancer population, specifically elevated intracranial pressure, epidural cord compression, status epilepticus, ischemic and hemorrhagic stroke, central nervous system infection, and treatment-associated neurologic dysfunction. These emergencies require early diagnosis and prompt treatment to ensure the best possible outcome and are best managed in the intensive care unit. This article reviews the presentation, pathophysiology, and management of the most common causes of acute neurologic decompensation in the patient with cancer.
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Affiliation(s)
- Andrew L Lin
- 1 Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Edward K Avila
- 1 Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Petrov I, Klissurski M, Halibryam S, Georgieva-kozarova G, Stoynova V. A case of successful interventional treatment in acute basilar artery occlusion. Cor Vasa 2016; 58:e287-e291. [DOI: 10.1016/j.crvasa.2016.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Goehre F, Yanagisawa T, Kamiyama H, Noda K, Ota N, Tsuboi T, Miyata S, Matsumoto T, Ibrahim TF, Andrade-Barazarte H, Ludtka C, Jahromi BR, Tokuda S, Tanikawa R. Direct Microsurgical Embolectomy for an Acute Distal Basilar Artery Occlusion. World Neurosurg 2016; 86:497-502. [DOI: 10.1016/j.wneu.2015.09.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 09/07/2015] [Accepted: 09/08/2015] [Indexed: 11/27/2022]
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Kim SM, Sohn SI, Hong JH, Chang HW, Lee CY, Kim CH. The Effectiveness of Additional Treatment Modalities after the Failure of Recanalization by Thrombectomy Alone in Acute Vertebrobasilar Arterial Occlusion. J Korean Neurosurg Soc 2015; 58:419-25. [PMID: 26713141 PMCID: PMC4688310 DOI: 10.3340/jkns.2015.58.5.419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 11/03/2015] [Accepted: 11/04/2015] [Indexed: 11/27/2022] Open
Abstract
Objective Acute vertebrobasilar artery occlusion (AVBAO) is a devastating disease with a high mortality rate. One of the most important factors affecting favorable clinical outcome is early recanalization. Mechanical thrombectomy is an emerging treatment strategy for achieving a high recanalization rates. However, thrombectomy alone can be insufficient to complete recanalization, especially for acute stroke involving large artery atheromatous disease. The purpose of this study is to investigate the safety and efficacy of mechanical thrombectomy in AVBAO. Methods Fourteen consecutive patients with AVBAO were treated with mechanical thrombectomy. Additional multimodal treatments were intra-arterial (IA) thrombolysis, balloon angioplasty, or permanent stent placement. Recanalization by thrombectomy alone and multimodal treatments were assessed by the Thrombolysis in Cerebral Infarction (TICI) score. Clinical outcome was determined using the National Institutes of Health Stroke Scale (NIHSS) at 7 days and the modified Rankin Scale (mRS) at 3 months. Results Thrombectomy alone and multimodal treatments were performed in 10 patients (71.4%) and 4 patients (28.6%), respectively. Successful recanalization (TICI 2b-3) was achieved in 11 (78.6%). Among these 11 patients, 3 (27.3%) underwent multimodal treatment due to underlying atherosclerotic stenosis. Ten (71.4%) of the 14 showed NIHSS score improvement of >10. Overall mortality was 3 (21.4%) of 14. Conclusion We suggest that mechanical thrombectomy is safe and effective for improving recanalization rates in AVBAO, with low complication rates. Also, in carefully selected patients after the failure of recanalization by thrombectomy alone, additional multimodal treatment such as IA thrombolysis, balloons, or stents can be needed to achieve successful recanalization.
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Affiliation(s)
- Seong Mook Kim
- Department of Neurosurgery, Keimyung University School of Medicine, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Hyuk-Won Chang
- Department of Interventional Neuroradiology, Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Young Lee
- Department of Neurosurgery, Keimyung University School of Medicine, Daegu, Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University School of Medicine, Daegu, Korea
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Sonig A, Krishna C, Natarajan SK, Liu J, Hopkins LN, Snyder KV, Levy EI, Siddiqui AH. Stent Retriever-Assisted Mechanical Thrombectomy for Acute Basilar Artery Occlusion: Single US Institution Experience. Oper Neurosurg (Hagerstown) 2015; 12:250-259. [DOI: 10.1227/neu.0000000000001163] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 10/18/2015] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Acute basilar artery occlusion causes devastating strokes that carry high mortality and morbidity.
OBJECTIVE
To report the outcomes of mechanical thrombectomy in the posterior circulation with a focus on safety and efficacy of stent retrievers.
METHODS
We retrospectively reviewed our endovascular database for all patients treated with stent retrievers for posterior circulation stroke between June 2012 and June 2014. Twelve patients were identified. The following data were analyzed: thrombus location, previous stroke or transient ischemic attack, thrombus etiology, comorbidities, time from presentation to initiation of endovascular treatment, time from start of angiography to revascularization, and whether intravenous tissue plasminogen activator was administered pre-thrombectomy. Outcome was considered poor when modified Rankin Scale score was >2.
RESULTS
Mean patient age was 63.42 years (median, 64.5; range, 28-83 years); 7 were women. Successful recanalization (Thrombolysis in Cerebral Infarction grade 2b or 3) was achieved in 11 of 12 patients (91.7%). Mean discharge modified Rankin Scale score was 2.3 (median, 2.0; standard deviation 1.96; range, 0-6), with a favorable discharge outcome in 9 of 12 (75%) patients. Two patients died as inpatients. Mean follow-up modified Rankin Scale score was 1.4 (median, 1.00; standard deviation 1.075; range, 0-4). Good outcome was achieved in 9 of 10 (90%) patients at last follow-up (mean follow-up duration, 132.42 days [median, 90.50; standard deviation 80.2; range, 8-378 days]).
CONCLUSION
Our single-institution study has shown that good clinical outcomes and successful recanalization with acceptable mortality can be achieved with current stent retrievers.
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Affiliation(s)
- Ashish Sonig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Chandan Krishna
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Sabareesh K Natarajan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Jian Liu
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - L Nelson Hopkins
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York
- Jacobs Institute, Buffalo, New York
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York
- Jacobs Institute, Buffalo, New York
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Jung C, Yoon W, Ahn SJ, Choi BS, Kim JH, Suh SH. The Revascularization Scales Dilemma: Is It Right to Apply the Treatment in Cerebral Ischemia Scale in Posterior Circulation Stroke? AJNR Am J Neuroradiol 2015; 37:285-9. [PMID: 26381554 DOI: 10.3174/ajnr.a4529] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/22/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Although various revascularization scales are used in the angiographic evaluation of acute ischemic stroke, observer reliability tests of these scales have been rarely performed for posterior circulation stroke. We aimed to evaluate inter- and intraobserver variability of 2 scales, the modified Treatment in Cerebral Ischemia and the Arterial Occlusive Lesion, in posterior circulation stroke. MATERIALS AND METHODS Three independent readers interpreted pre- and postthrombolytic angiographies of 62 patients with posterior circulation stroke by using the modified Treatment in Cerebral Ischemia and Arterial Occlusive Lesion scales. The κ statistic was used to measure observer agreement for both scales, and κ > 0.6 was considered substantial agreement. RESULTS For the Arterial Occlusive Lesion scale, inter- and intraobserver agreement was >0.6. While intraobserver agreement of the modified Treatment in Cerebral Ischemia scale was >0.6 except for 1 reader, interobserver agreement was lower in dichotomized and original scales. In 49 cases with solely basilar artery occlusion, inter- and intraobserver agreement of both scales was similar to that in all 62 patients with posterior circulation stroke. In 2 consecutive readings, there was a significant decrease in the proportion of mTICI 2a reads (22.58% in the first versus 13.44% in the second session, P < .03) and a reciprocal increase in the sum of proportions for modified Treatment in Cerebral Ischemia 2b and modified Treatment in Cerebral Ischemia 3 reads (62.37% in the first versus 72.58% in the second session, P < .046). CONCLUSIONS In angiographic assessment of posterior circulation stroke, inter- and intraobserver agreement for the Arterial Occlusive Lesion scale was reliable, while the modified Treatment in Cerebral Ischemia failed to achieve substantial interobserver agreement. The clinical impact of this result needs to be validated in future studies.
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Affiliation(s)
- C Jung
- From the Department of Radiology (C.J., B.S.C., J.H.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - W Yoon
- Department of Radiology (W.Y.), Chonnam National University Medical School, Gwangju, Korea
| | - S J Ahn
- Department of Radiology (S.J.A., S.H.S.), Gangnam Severance Hospital, Yonsei University, Seoul, Korea
| | - B S Choi
- From the Department of Radiology (C.J., B.S.C., J.H.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - J H Kim
- From the Department of Radiology (C.J., B.S.C., J.H.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - S H Suh
- Department of Radiology (S.J.A., S.H.S.), Gangnam Severance Hospital, Yonsei University, Seoul, Korea Severance Institute of Vascular and Metabolic Research (S.H.S.), Yonsei University College of Medicine, Seoul, Korea.
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18
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Abstract
Basilar artery occlusion is one of the most devastating neurological conditions known to man. Though rare, patients with clinical syndromes localized to this anatomical region are often referred to acute stroke and endovascular units. Recent studies evaluating the efficacy of endovascular approaches to stroke have focused on anterior circulation syndromes. In this review, we examine the approaches to stroke syndromes due to basilar artery thrombosis. We share the relevant data for intravenous and intra-arterial tissue plasminogen activator as well as mechanical approaches to restoring perfusion in this critical area of the brain.
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Affiliation(s)
- Jacky T Yeung
- Department of Neurosurgery, Yale School of Medicine, New Haven, Conn., USA
| | - Charles C Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, Conn., USA
| | - Ketan R Bulsara
- Department of Neurosurgery, Yale School of Medicine, New Haven, Conn., USA
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, Conn., USA
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19
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Sairanen T, Strbian D, Ruuskanen R, Silvennoinen H, Salonen O, Lindsberg PJ. Symptomatic intracranial haemorrhage after thrombolysis with adjuvant anticoagulation in basilar artery occlusion. Eur J Neurol 2014; 22:493-9. [PMID: 25482105 DOI: 10.1111/ene.12597] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 09/19/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Our aim was to determine factors associated with symptomatic intracranial haemorrhage (sICH) in basilar artery occlusion patients treated with intravenous thrombolysis (IVT) and adjuvant anticoagulant therapy. METHODS A registry of 176 consecutive patients with angiography-proven basilar artery occlusion who received IVT with alteplase and heparin between 1995 to 2013 was assessed. Post-treatment sICH was evaluated with the European Cooperative Acute Stroke Study II criteria. Unfavourable outcome was defined as a modified Rankin Scale score of 3-6 at 3 months. RESULTS Twenty-four patients developed sICH (13.6%, sICH+), all of whom had unfavourable outcome and only two (8.3%) sICH+ patients survived. On admission, sICH+ patients more frequently had extensive ischaemic changes defined as posterior circulation Acute Stroke Prognosis Early CT Score (PC-ASPECTS) < 8 (50% vs. 27% in sICH-, P = 0.031) and lower platelet counts (183 vs. 218 E9/l; P = 0.011). They also had higher systolic blood pressure (SBP) (median 160 vs. 147 mmHg, P = 0.034) immediately after IVT. In multivariable regression analysis, lower platelet values [odds ratio (OR) 0.99, 95% confidence interval (CI) 0.97-0.996; P = 0.006], PC-ASPECTS < 8 on admission (OR 3.6, 95% CI 1.3-10.3; P = 0.017) and higher SBP after treatment (OR 1.03, 95% CI 1.01-1.05; P = 0.017) were independently associated with sICH. Ninety per cent of the sICHs occurred within 48 h from IVT/anticoagulation treatment. No differences in activated partial thrompoplastin times prior to or after the treatment were observed between sICH+ and sICH- patients. CONCLUSIONS The risk of sICH was largely determined by extension of ischaemic changes on admission computed tomography. Clinically relevantly, also higher post-thrombolytic SBP as described earlier and lower perithrombolytic platelet counts do increase the risk, a finding requiring confirmation in other patient series.
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Affiliation(s)
- T Sairanen
- Department of Neurology, University of Helsinki, Helsinki, Finland
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20
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Eom YI, Hwang YH, Hong JM, Choi JW, Lim YC, Kang DH, Kim YW, Kim YS, Kim SY, Lee JS. Forced arterial suction thrombectomy with the penumbra reperfusion catheter in acute basilar artery occlusion: a retrospective comparison study in 2 Korean university hospitals. AJNR Am J Neuroradiol 2014; 35:2354-9. [PMID: 25034774 DOI: 10.3174/ajnr.a4045] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE A performance of forced arterial suction thrombectomy was not reported for the treatment of acute basilar artery occlusion. This study compared revascularization performance between intra-arterial fibrinolytic treatment and forced arterial suction thrombectomy with a Penumbra reperfusion catheter in patients with acute basilar artery occlusion. MATERIALS AND METHODS Fifty-seven patients with acute basilar artery occlusion were treated with intra-arterial fibrinolysis (n = 25) or forced arterial suction thrombectomy (n = 32). Baseline characteristics, successful revascularization rate, and clinical outcomes were compared between the groups. RESULTS Baseline characteristics, the frequency of patients receiving intravenous recombinant tissue plasminogen activator, and mean time interval between symptom onset and femoral puncture did not differ between groups. The forced arterial suction thrombectomy group had a shorter procedure duration (75.5 minutes versus 113.3 minutes, P = .016) and higher successful revascularization rate (88% versus 60%, P = .017) than the fibrinolysis group. Fair outcome, indicated by a modified Rankin Scale 0-3, at 3 months was achieved in 34% of patients undergoing forced arterial suction thrombectomy and 8% of patients undergoing fibrinolysis (P = .019), and the mortality rate was significantly higher in the fibrinolysis group (25% versus 68%, P = .001). Multiple logistic regression analysis identified the forced arterial suction thrombectomy method as an independent predictor of fair outcome with adjustment for age, sex, initial NIHSS score, and the use of intravenous recombinant tissue plasminogen activator (odds ratio, 7.768; 95% CI, 1.246-48.416; P = .028). CONCLUSIONS In acute basilar artery occlusion, forced arterial suction thrombectomy demonstrated a higher revascularization rate and improved clinical outcome compared with traditional intra-arterial fibrinolysis. Further clinical trials with the newer Penumbra catheter are warranted.
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Affiliation(s)
- Y-I Eom
- From the Departments of Neurology (Y.-I.E., J.M.H., J.S.L.)
| | - Y-H Hwang
- Departments of Neurology (Y.-H.H., Y.-W.K.)
| | - J M Hong
- From the Departments of Neurology (Y.-I.E., J.M.H., J.S.L.)
| | - J W Choi
- Radiology (J.W.C., S.Y.K.), Ajou University Medical Center, Suwon, South Korea
| | - Y C Lim
- Department of Neurosurgery (Y.C.L.), Ajou University Hospital, Daegu, South Korea
| | - D-H Kang
- Neurosurgery (D.-H.K.) Radiology (D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, South Korea
| | - Y-W Kim
- Departments of Neurology (Y.-H.H., Y.-W.K.) Radiology (D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, South Korea
| | - Y-S Kim
- Radiology (D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, South Korea
| | - S Y Kim
- Radiology (J.W.C., S.Y.K.), Ajou University Medical Center, Suwon, South Korea
| | - J S Lee
- From the Departments of Neurology (Y.-I.E., J.M.H., J.S.L.)
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21
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Abstract
In face of any severe stroke, the questions for health professionals in charge of the patient are: will the handicap be acceptable for the patient? But can we predict an acceptable handicap for the patient? For his family? When we know that the cognitive disorders, consequences of severe stroke often modify, in a major way, the behaviour of these patients? Given these difficulties for estimate vital and functional prognosis and even more the quality of life of patients with severe stroke, collective reflexions between physicians and nurses are essential, reflexions taking into account preferences and values of patients. Use of resuscitation resources for severe stroke patients implies to offer them the best rehabilitation. So, questions about health pathways for severe stroke are essential: which structures for these patients, which technologies, which medical, medico-social and social supports, which human accompaniment the society can propose to the patients and to their family, so that they have an acceptable quality of life.
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Affiliation(s)
- F Woimant
- Service de neurologie, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; Agence régionale de santé Île-de-France, 35, rue de la Gare, 75019 Paris, France.
| | - Y Biteye
- Agence régionale de santé Île-de-France, 35, rue de la Gare, 75019 Paris, France
| | - P Chaine
- Service de neurologie, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France
| | - S Crozier
- Service des urgences cérébrovasculaires, groupe hospitalier Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
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22
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Möhlenbruch M, Stampfl S, Behrens L, Herweh C, Rohde S, Bendszus M, Hametner C, Nagel S, Ringleb PA, Pham M. Mechanical thrombectomy with stent retrievers in acute basilar artery occlusion. AJNR Am J Neuroradiol 2013; 35:959-64. [PMID: 24287087 DOI: 10.3174/ajnr.a3796] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Basilar artery occlusion remains one of the most devastating subtypes of ischemic stroke. The prognosis is poor if early recanalization is not achieved. The purpose of this study was to evaluate the safety and technical feasibility of self-expanding retrievable stents in the endovascular treatment of acute basilar artery occlusion. MATERIALS AND METHODS Twenty-four patients with acute basilar artery occlusion were treated with Solitaire FR or Revive SE devices between December 2009 and May 2012. Additional treatment included intravenous and/or intra-arterial thrombolysis (21/24) and percutaneous transluminal angioplasty/permanent stent placement (7/24). Recanalization was assessed by means of the TICI score. Clinical outcome was determined at discharge (NIHSS), and at 3 months (mRS). RESULTS Median NIHSS score on admission was 24; median duration of symptoms was 254 minutes. Successful recanalization (TICI 2b +3) by thrombectomy only was achieved in 18 patients (75%). Intracranial stent deployment after thrombectomy caused by underlying atherosclerotic stenosis was performed in 7 patients. If these patients with intracranial stent placement are included, successful recanalization was achieved in 21 of 24 patients (87.5%). NIHSS improvement ≥10 points was reached in 54% of patients (n = 13/24). Mortality during the first 3 months was 29% (7/24). After 3 months, 8 patients (33%) had a favorable clinical outcome (mRS 0-2). CONCLUSIONS In our series, application of self-expanding retrievable stents in acute basilar artery occlusion resulted in a high recanalization rate without procedural complications and good clinical outcome in one-third of patients.
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Affiliation(s)
- M Möhlenbruch
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)
| | - S Stampfl
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)
| | - L Behrens
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)
| | - C Herweh
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)
| | - S Rohde
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)
| | - M Bendszus
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)
| | - C Hametner
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)Neurology (C.H., S.N., P.A.R.), University of Heidelberg Medical Center, Heidelberg, Germany
| | - S Nagel
- Neurology (C.H., S.N., P.A.R.), University of Heidelberg Medical Center, Heidelberg, Germany
| | - P A Ringleb
- Neurology (C.H., S.N., P.A.R.), University of Heidelberg Medical Center, Heidelberg, Germany
| | - M Pham
- From the Departments of Neuroradiology (M.M., S.S., L.B., C.H., S.R., M.B., M.P.)
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23
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Park BS, Kang CW, Kwon HJ, Choi SW, Kim SH, Koh HS, Youm JY, Song SH. Endovascular mechanical thrombectomy in basilar artery occlusion: initial experience. J Cerebrovasc Endovasc Neurosurg 2013; 15:137-44. [PMID: 24167791 PMCID: PMC3804649 DOI: 10.7461/jcen.2013.15.3.137] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 07/11/2013] [Accepted: 08/01/2013] [Indexed: 12/19/2022] Open
Abstract
Objective This study was conducted to assess the efficacy and safety of endovascular mechanical thrombectomy (EMT) for patients diagnosed with basilar artery (BA) occlusion. Materials and Methods We retrospectively analyzed clinical and imaging data of 16 patients diagnosed with BA occlusion who were treated with endovascular intervention from July 2012 to February 2013. Direct suction using the Penumbra system and thrombus retrieval by the Solitaire stent were the main endovascular techniques used to restore BA flow. The outcomes were evaluated based on rate of angiographic recanalization, rate of improvement of National Institutes of Health Stroke Scale (NIHSS) score, rate of modified Rankin Scale (mRS) at discharge and after 3 months, and rate of cerebral hemorrhagic complications. Successful recanalization was defined as achieving Thrombolysis In Cerebral Infarction (TICI) of II or III. Results Sixteen patients received thrombectomy. The mean age was 67.8 ± 11 years and the mean NIHSS score was 12.3 ± 8.2. Eight patients treated within 6 hours of symptom onset were grouped as A and the other 8 patients treated beyond 6 hours (range, 6-120) were grouped as B. Successful recanalization was met in six patients (75%) for group A and 7 (87.5%) for group B. Favorable outcome occurred in 4 patients (50%) for group A and 5 (62.5%) for group B. Conclusion Our study supports the effectiveness and safety of endovascular mechanical thrombectomy in treating BA occlusion even 6 hours after symptom onset.
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Affiliation(s)
- Bum-Soo Park
- Department of Neurosurgery, School of Medicine, Chungnam National University, Daejeon, Korea
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24
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Pellerin O, Delorme L, Bellmann L, Sapoval M. Clinical presentation and percutaneous endovascular management of acute left subclavian artery thrombosis: report of two cases. Diagn Interv Imaging 2013; 95:95-9. [PMID: 24012286 DOI: 10.1016/j.diii.2013.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- O Pellerin
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Interventional Radiology Department, Georges Pompidou European Hospital, AP-HP, 20, rue Leblanc, 75015 Paris, France.
| | - L Delorme
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Interventional Radiology Department, Georges Pompidou European Hospital, AP-HP, 20, rue Leblanc, 75015 Paris, France
| | - L Bellmann
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Interventional Radiology Department, Georges Pompidou European Hospital, AP-HP, 20, rue Leblanc, 75015 Paris, France
| | - M Sapoval
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Interventional Radiology Department, Georges Pompidou European Hospital, AP-HP, 20, rue Leblanc, 75015 Paris, France
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25
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Duffis EJ, Tank V, Gandhi CD, Prestigiacomo CJ. Recent advances in neuroendovascular therapy. Clin Neurol Neurosurg 2013; 115:853-8. [DOI: 10.1016/j.clineuro.2013.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 01/11/2013] [Accepted: 01/20/2013] [Indexed: 11/29/2022]
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26
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Broussalis E, Hitzl W, McCoy M, Trinka E, Killer M. Comparison of Endovascular Treatment Versus Conservative Medical Treatment in Patients With Acute Basilar Artery Occlusion. Vasc Endovascular Surg 2013; 47:429-37. [DOI: 10.1177/1538574413488458] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Basilar artery occlusion (BAO) causes mortality up to 90%. Methods: A total of 99 patients with BAO received either endovascular (endovascular mechanical recanalization and/or intra-arterial with optional intravenous thrombolysis [IVT] as bridging concept) or conservative medical treatment (IVT and/or medical oral therapy). Outcome parameters were measured in accordance with the thrombolysis in cerebral infarction (TICI), National Institutes of Health Stroke Scale (NIHSS), and modified Rankin Scale (mRS) scores. Results: In all, 78% underwent endovascular and 22% conservative medical treatment. The NIHSS at admission was 20 in both the groups. Postprocedurally, 36% (95% confidence interval: 26%-48%) of the endovascular group and 9% (21%-64%) of the conservative group reached TICI 3 ( P = .017). In all, 30% of the endovascular group and 9% of the conservative group were documented with TICI 2b ( P = .057). At 90 days follow-up, 45% (31%-60%) of the endovascular-treated patientsand no patient (0%-25%) of the conservative-treated group reached mRS ≤2 ( P = .012). Conclusion: Endovascular treatment of BAO provides a better chance to survive this severe condition with good clinical outcome.
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Affiliation(s)
- E. Broussalis
- Department of Neuroradiology, Paracelsus Medical University, Christian Doppler Clinic, Salzburg, Austria
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - W. Hitzl
- Research Office, Paracelsus Medical University, Salzburg, Austria
| | - M. McCoy
- Department of Neuroradiology, Paracelsus Medical University, Christian Doppler Clinic, Salzburg, Austria
| | - E. Trinka
- Department of Neurology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - M. Killer
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
- Department of Neurology, Paracelsus Medical University Hospital, Salzburg, Austria
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Sanyal R, Barrick J, Bhalla A, Cassidy T, Collas D, Cloud G, Fearon P, Gompertz P, Keir S, Khanna P, Power M, White P, Roffe C. The 2010 British Association of Stroke Physicians Survey of interventional treatments for stroke in the United Kingdom. Int J Stroke 2013; 8 Suppl A100:62-8. [PMID: 23294913 DOI: 10.1111/j.1747-4949.2012.00931.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The UK National Stroke Strategy (Department of Health 2007) states that patients should have access to a stroke service with neurointerventional capacity. This survey was conducted by the Clinical Standards Committee of the British Association of Stroke Physicians to get a snapshot of the availability of interventional treatments for stroke in the United Kingdom. METHODS Questionnaires covering availability of endovascular treatments for stroke, e.g. intra-arterial thrombolysis and mechanical thrombectomy, were emailed to all British Association of Stroke Physicians members in October 2010. Where more than one response was received from the same hospital, the data were only entered once. If there was a discrepancy between different respondents for the same hospital, details were cross-checked with the respondents to ensure accuracy. RESULTS Responses were received from 58 hospitals in England, Scotland, Wales, and Northern Ireland. Intra-arterial thrombolysis and/or mechanical thrombectomy were available in 23 hospitals. Of these, three had not performed any procedures in 2010. Twenty centres had conducted a mean (range) of eight (2-20) procedures during the 10-month period. Thirty-five hospitals were not offering endovascular treatments. Sixteen of these were not referring patients to centres which could provide interventional treatments. Hospitals offering endovascular treatments had a mean (range) of 5.2 (2-12) stroke physicians, 2.3 (0-4) interventional neuroradiologists, and 3.6 (0-9) noninterventional neuroradiologists. Only two hospitals providing interventions had four or more interventional neuroradiologists. CONCLUSIONS Only a small number of hospitals in the United Kingdom provide interventional treatments for stroke. Almost 50% of hospitals not providing interventions had no processes in place for referral to providers.
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Affiliation(s)
- R Sanyal
- Department of Stroke Medicine, Lyme Building, University Hospital of North Staffordshire, UK
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28
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Abstract
OPINION STATEMENT Mechanical clot retrieval is increasingly used for flow-restoration and thrombectomy in acute embolic stroke. Emerging as a treatment option in addition to intravenous or intra-arterial thrombolysis, it is currently being further developed and investigated as a potential first-line and stand-alone treatment. The ability to rapidly restore flow and effectively retrieve clots from large intracranial arteries is reflected by angiographic data and preliminary clinical results. This article reviews the principles and technical aspects of this new technique, its emergence from the spectrum of intravenous and endovascular stroke treatment, and summarizes the first clinical results for acute ischemic anterior and posterior circulation stroke. Clot retrieval devices are a very promising option for treatment of acute ischemic stroke in the setting of large vessel occlusion. However, there currently exists a reported discrepancy between excellent recanalization rates and less satisfactory clinical outcomes. This problem urgently needs to be addressed in a prospective randomized fashion and improvements of treatment be recognized and implemented before clot retrieval can be considered an established form of acute stroke treatment.
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Affiliation(s)
- Julian Bösel
- Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany,
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29
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Tan ML, Mitchell P, Dowling R, Tacey M, Yan B. Shorter time to intervention improves recanalization success and clinical outcome post intra-arterial intervention for basilar artery thrombosis. J Clin Neurosci 2012; 19:1397-400. [DOI: 10.1016/j.jocn.2012.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 03/07/2012] [Indexed: 11/21/2022]
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30
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Lazzaro MA, Novakovic RL, Alexandrov AV, Darkhabani Z, Edgell RC, English J, Frei D, Jamieson DG, Janardhan V, Janjua N, Janjua RM, Katzan I, Khatri P, Kirmani JF, Liebeskind DS, Linfante I, Nguyen TN, Saver JL, Shutter L, Xavier A, Yavagal D, Zaidat OO. Developing practice recommendations for endovascular revascularization for acute ischemic stroke. Neurology 2012; 79:S243-55. [PMID: 23008406 PMCID: PMC4109230 DOI: 10.1212/wnl.0b013e31826959fc] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Accepted: 02/23/2012] [Indexed: 11/15/2022] Open
Abstract
Guidelines have been established for the management of acute ischemic stroke; however, specific recommendations for endovascular revascularization therapy are lacking. Burgeoning investigation of endovascular revascularization therapies for acute ischemic stroke, rapid device development, and a diverse training background of the providers performing the procedures underscore the need for practice recommendations. This review provides a concise summary of the Society of Vascular and Interventional Neurology endovascular acute ischemic stroke roundtable meeting. This document was developed to review current clinical efficacy of pharmacologic and mechanical revascularization therapy, selection criteria, periprocedure management, and endovascular time metrics and to highlight current practice patterns. It therefore provides an outline for the future development of multisociety guidelines and recommendations to improve patient selection, procedural management, and organizational strategies for revascularization therapies in acute ischemic stroke.
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Affiliation(s)
- Marc A Lazzaro
- Medical College of Wisconsin/Froedtert Hospital, Milwaukee, WI, USA
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Jung C, Kwon BJ, Han MH. Evidence-based changes in devices and methods of endovascular recanalization therapy. Neurointervention 2012; 7:68-76. [PMID: 22970415 PMCID: PMC3429847 DOI: 10.5469/neuroint.2012.7.2.68] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 07/12/2012] [Indexed: 12/03/2022] Open
Abstract
The devices and methods of endovascular recanalization therapy (ERT) have been rapidly developed and changed since PROACT II trial. Emerging as a treatment option in addition to intravenous or intra-arterial thrombolysis, mechanical thrombectomy is currently being further developed and investigated as a potential first-line and stand-alone treatment. This review highlights and summarizes the recent clinical series and trials of the available devices and methods of ERT focusing on the multimodal approach.
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Affiliation(s)
- Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Bae Ju Kwon
- Department of Radiology, Kwandong University Myongji Hospital, Goyang, Korea
| | - Moon Hee Han
- Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea
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Ottomeyer C, Zeller J, Fesl G, Holtmannspötter M, Opherk C, Bender A, Dichgans M, Brückmann H, Pfefferkorn T. Multimodal Recanalization Therapy in Acute Basilar Artery Occlusion. Stroke 2012; 43:2130-5. [DOI: 10.1161/strokeaha.112.651281] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Caroline Ottomeyer
- From the Departments of Neurology (C.O., J.Z., A.B., T.P.) and Neuroradiology (G.F., M.H., H.B.) and the Institute for Stroke and Dementia Research (Ch.O., M.D.), Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Judith Zeller
- From the Departments of Neurology (C.O., J.Z., A.B., T.P.) and Neuroradiology (G.F., M.H., H.B.) and the Institute for Stroke and Dementia Research (Ch.O., M.D.), Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Gunther Fesl
- From the Departments of Neurology (C.O., J.Z., A.B., T.P.) and Neuroradiology (G.F., M.H., H.B.) and the Institute for Stroke and Dementia Research (Ch.O., M.D.), Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Markus Holtmannspötter
- From the Departments of Neurology (C.O., J.Z., A.B., T.P.) and Neuroradiology (G.F., M.H., H.B.) and the Institute for Stroke and Dementia Research (Ch.O., M.D.), Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Christian Opherk
- From the Departments of Neurology (C.O., J.Z., A.B., T.P.) and Neuroradiology (G.F., M.H., H.B.) and the Institute for Stroke and Dementia Research (Ch.O., M.D.), Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Andreas Bender
- From the Departments of Neurology (C.O., J.Z., A.B., T.P.) and Neuroradiology (G.F., M.H., H.B.) and the Institute for Stroke and Dementia Research (Ch.O., M.D.), Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Martin Dichgans
- From the Departments of Neurology (C.O., J.Z., A.B., T.P.) and Neuroradiology (G.F., M.H., H.B.) and the Institute for Stroke and Dementia Research (Ch.O., M.D.), Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Hartmut Brückmann
- From the Departments of Neurology (C.O., J.Z., A.B., T.P.) and Neuroradiology (G.F., M.H., H.B.) and the Institute for Stroke and Dementia Research (Ch.O., M.D.), Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Thomas Pfefferkorn
- From the Departments of Neurology (C.O., J.Z., A.B., T.P.) and Neuroradiology (G.F., M.H., H.B.) and the Institute for Stroke and Dementia Research (Ch.O., M.D.), Klinikum Grosshadern, University of Munich, Munich, Germany
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Yun JS, Kwak HS, Hwang SB, Chung GH. Endovascular management in patients with acute basilar artery obstruction: low-dose intra-arterial urokinase and mechanical clot disruption. Interv Neuroradiol 2011; 17:435-41. [PMID: 22192547 DOI: 10.1177/159101991101700407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Accepted: 10/01/2011] [Indexed: 11/15/2022] Open
Abstract
Mechanical clot disruption for the treatment of acute basilar artery occlusion (BAO) is known to provide a benefit. We aimed to determine the safety, recanalization rate and time-to-flow restoration of mechanical clot disruption and low dose urokinase (UK) infusions for the treatment of patients with acute BAO. Between June 2006 and June 2010, 21 patients with acute BAO underwent endovascular treatment that included angioplasty or stent placement. The time to treatment, duration of the procedure, dose of urokinase (UK), recanalization rates and symptomatic hemorrhages were analyzed. Clinical outcome measures were assessed at admission and at the time of discharge using the National Institutes of Health Stroke Scale (NIHSS) score and at three months after treatment using the modified Rankin Score (mRS). On admission, the median NIHSS score was 13.2. Median time from symptom onset to arrival at hospital was 356 minutes, and median time from symptom onset to intraarterial thrombolysis (IAT) was 49 minutes. We used the following interventional treatment regimens: Intra-arterial (IA) UK and a minimal mechanical procedure (n=14), IA UK with angioplasty (n=1), IA UK with angioplasty and stent placement (n=3) and IA UK with HyperForm (n=3). The recanalization (thrombolysis in cerebral ischemia grade II or III) rate was 90.5% (19/21). There was symptomatic hemorrhage in one patient (4.8%). The median NIHSS score at discharge was 6.3. The three-month outcome was favorable (mRS: 0-2) for 14 patients (66.7%) and poor (mRS: 3-6) for seven patients (33.3%). The overall mortality at three months was 14.3% (three patients died). Low-dose IAT with mechanical clot disruption is a safe and effective treatment for treatment for acute BAO.
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Affiliation(s)
- J S Yun
- Radiology Department, Chonbuk National University Medical School and Hospital, Jeonju, Jeonbuk, Korea
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Pfefferkorn T, Holtmannspötter M, Patzig M, Brückmann H, Ottomeyer C, Opherk C, Dichgans M, Fesl G. Preceding Intravenous Thrombolysis Facilitates Endovascular Mechanical Recanalization in Large Intracranial Artery Occlusion. Int J Stroke 2011; 7:14-8. [DOI: 10.1111/j.1747-4949.2011.00639.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background and aims Acute occlusions of the large intracranial arteries are relatively resistant to intravenous thrombolysis. Therefore, multimodal approaches combining intravenous thrombolysis with endovascular mechanical recanalization are increasingly being applied. In this setting, intravenous thrombolysis may facilitate subsequent mechanical thrombectomy. To test this hypothesis, we analyzed the influence of intravenous thrombolysis on net intervention time in subsequent endovascular mechanical recanalization. Methods In this retrospective single-center analysis, we compared net intervention time with and without preceding intravenous thrombolysis in patients treated by endovascular mechanical recanalization between 01/2003 and 06/2010. The net intervention time was defined as the interval between the onset of endovascular thrombus manipulation and successful vessel recanalization. Results We identified 65 eligible patients, 35 of whom were treated by intravenous thrombolysis before mechanical therapy. Recanalization was achieved in 26 patients with (74%) and 23 patients without preceding intravenous thrombolysis (77%). In the case of successful recanalization, the net intervention time was significantly shorter in patients with preceding intravenous thrombolysis (24·8 ± 22·8 vs. 44·2 ± 40·5 min; P<0·05). This difference remained significant after restricting the analysis to the patients treated by the Penumbra Stroke System© ( n=32). After three-months, patients with preceding intravenous thrombolysis were more likely to be functionally independent (modified Rankin Scale≤2) than those without ( P<0·05). Conclusions Our findings suggest that preceding intravenous thrombolysis may reduce the intervention time in patients treated by endovascular mechanical recanalization. However, due to the retrospective design of our study, these findings have to be interpreted with caution and need confirmation in a larger patient population.
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Affiliation(s)
- Thomas Pfefferkorn
- Department of Neurology, Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Markus Holtmannspötter
- Department of Neuroradiology, Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Maximilian Patzig
- Department of Neuroradiology, Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Hartmut Brückmann
- Department of Neuroradiology, Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Caroline Ottomeyer
- Department of Neurology, Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Christian Opherk
- Department of Neurology, Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Martin Dichgans
- Department of Neurology, Klinikum Grosshadern, University of Munich, Munich, Germany
| | - Gunther Fesl
- Department of Neuroradiology, Klinikum Grosshadern, University of Munich, Munich, Germany
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Tanaka K, Koga M, Miyashita F, Kajimoto K, Matsushige T, Sato T, Ishibashi-Ueda H, Iihara K, Toyoda K. [Successful thrombectomy for basilar artery occlusion with Merci(®) retrieval system: a case report]. Rinsho Shinkeigaku 2011; 51:706-9. [PMID: 21946430 DOI: 10.5692/clinicalneurol.51.706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 66-year old hypertensive man having a prostate cancer was admitted to our hospital with sudden onset right hemiparesis. On admission, he showed left hemiplegia, hypesthesia, right limb ataxia, and dysarthria. The NIHSS score was 16. Diffusion weighted magnetic resonance imaging showed an acute infarct in the middle pons and magnetic resonance angiography (MRA) revealed basilar artery (BA) occlusion. Carotid Doppler ultrasonography showed distal occlusion pattern of the bilateral vertebral artery. He was treated with intravenous rt-PA at 116 minutes after symptom onset. One hour later, his symptom was not improved and BA was still occluded on follow-up MRA. Therefore, we performed mechanical thrombectomy with Merci(®) Retrieval System. At 323 minutes after onset, BA was successfully recanalized and NIHSS score decreased to 4 without hemorrhagic complication. Medication of oral warfarin was started on day 19 because paroxysmal atrial fibrillation was detected by electrocardiogram. The retrieved thrombus was pathologically diagnosed as a organizing mixed thrombus probable cardiac origin. On day 27, he was discharged home without any neurological deficit. Additional thrombectomy with Merci(®) Retrieval System is a promising treatment strategy for BA occlusion which is resistant to intravenous rt-PA thrombolysis.
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Affiliation(s)
- Koji Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
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Masjuan J, Álvarez-sabín J, Arenillas J, Calleja S, Castillo J, Dávalos A, Díez Tejedor E, Freijo M, Gil-núñez A, López Fernández J, Maestre J, Martínez-vila E, Morales A, Purroy F, Ramírez J, Segura T, Serena J, Tejada J, Tejero C. Stroke health care plan (ICTUS II. 2010). Neurología (English Edition) 2011; 26:383-96. [DOI: 10.1016/j.nrleng.2010.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Masjuan J, Álvarez-Sabín J, Arenillas J, Calleja S, Castillo J, Dávalos A, Tejedor ED, Freijo M, Gil-Núñez A, Fernández JL, Maestre J, Martínez-Vila E, Morales A, Purroy F, Ramírez J, Segura T, Serena J, Tejada J, Tejero C. Plan de asistencia sanitaria al ICTUS II. 2010. Neurologia 2011; 26:383-96. [DOI: 10.1016/j.nrl.2010.05.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 05/07/2010] [Indexed: 10/18/2022] Open
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Kwon JH, Shin SH, Weon YC, Hwang JC, Baik SK. Intra-arterial adjuvant tirofiban after unsuccessful intra-arterial thrombolysis of acute ischemic stroke: preliminary experience in 16 patients. Neuroradiology 2011; 53:779-85. [PMID: 21808986 DOI: 10.1007/s00234-011-0939-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 07/19/2011] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Intra-arterial (IA) thrombolysis with plasminogen activator is well-known, but the use of IA tirofiban as an adjuvant for IA thrombolysis is not well-known. We investigated the feasibility of IA tirofiban as an adjuvant after unsuccessful IA recanalization with urokinase (UK) for acute ischemic stroke. METHODS We retrospectively analyzed all 16 consecutive patients (11 men and five women; mean age, 61.3 years; range, 36-85 years) who were treated with IA tirofiban after isolated IA thrombolysis with UK or bridging therapy with systemic recombinant tissue plasminogen activator (rt-PA; 0.6 mg/Kg) and IA UK for acute ischemic stroke. Outcome measures included angiographic recanalization (thrombolysis in cerebral infarction, TICI), symptomatic and asymptomatic intracerebral hemorrhage (ICH), mortality, and functional independence at 3 months (modified Rankin Scale, 0-2). RESULTS Among the 16 patients treated with IA tirofiban as an adjuvant, 10 patients had conventional dose (<25 ug/kg, bolus) and six patients had high dose (≥25 ug/kg, bolus) of IA tirofiban after unsuccessful IA thrombolysis whether systemic rt-PA used or not. Successful angiographic recanalization (TICI grade 2b or 3) was achieved in 13 patients (13/16) and a functional independence at 3 months in eight patients (8/16). Three months after therapy, three patients had died. There were two patients of symptomatic ICH and four asymptomatic ICH. CONCLUSION Conventional dose of IA tirofiban as an adjuvant during IA thrombolysis for acute ischemic stroke seems feasible. However, further dose escalation studies should be performed regarding the IA use of tirofiban for acute ischemic stroke.
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Kamper L, Meyn H, Rybacki K, Nordmeyer S, Kempkes U, Piroth W, Isenmann S, Haage P. Workflow Optimization in Vertebrobasilar Occlusion. Cardiovasc Intervent Radiol 2011; 35:491-7. [DOI: 10.1007/s00270-011-0222-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 06/16/2011] [Indexed: 11/29/2022]
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Hussein HM, Qureshi AI. Editorial: Endovascular Treatment of Basilar Artery Occlusion: When a Pretty Picture Is Not Enough. J Neuroimaging 2011; 22:107-8. [DOI: 10.1111/j.1552-6569.2011.00587.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Barlinn K, Becker U, Puetz V, Dzialowski I, Kunz A, Kepplinger J, von Kummer R, Gahn G. Combined Treatment with Intravenous Abciximab and Intraarterial tPA Yields High Recanalization Rate in Patients with Acute Basilar Artery Occlusion. J Neuroimaging 2011; 22:167-71. [DOI: 10.1111/j.1552-6569.2011.00584.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Chandra RV, Law CP, Yan B, Dowling RJ, Mitchell PJ. Glasgow coma scale does not predict outcome post-intra-arterial treatment for basilar artery thrombosis. AJNR Am J Neuroradiol 2011; 32:576-80. [PMID: 21349965 DOI: 10.3174/ajnr.a2325] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Evidence to guide patient selection for IA therapy in acute basilar artery thrombosis is lacking. The GCS is frequently used as a selection criterion, based on the view that higher GCS correlates with better neurologic outcome. This view has not been systematically studied. We hypothesize that low GCS does not correlate with poor outcome and that it should not preclude IA therapy. MATERIALS AND METHODS We included 40 consecutive patients with basilar artery thrombosis treated with IA therapy. Clinical characteristics, GCS, time to intervention, and postprocedural TIMI scores were collected. Recanalization was defined as TIMI grade 2 or 3; clinical outcome was measured by 90-day mRS. RESULTS Median patient age was 63.5 years. Most presented with gaze palsies (67.5%) or hemiparesis (45%). Median GCS was 9, the median time to intervention was 7.2 hours, and recanalization rate was 82.5%. Good neurologic outcome (mRS ≤ 1) occurred in 30%. There was no correlation between GCS and 90-day mRS (Spearman ρ - 0.174, P = .283). Equal numbers of patients with good neurologic outcome of mRS ≤ 1 (n = 12) had a GCS of ≤6 or >6. In those with GCS ≤ 6 for >3 hours, 33.3% had good neurologic outcome-a similar rate to that of the overall cohort. Statistical significance was demonstrated between time to IA therapy within 6 hours and mRS ≤ 2. CONCLUSIONS Low GCS score did not correlate with poor neurologic outcome in patients with acute basilar artery thrombosis managed with IA therapy. It is not appropriate to exclude patients from IA therapy on the basis of low GCS.
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Affiliation(s)
- R V Chandra
- Department of Radiology, The Royal Melbourne Hospital, Australia
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Roth C, Mielke A, Siekmann R, Ferbert A. First Experiences with a New Device for Mechanical Thrombectomy in Acute Basilar Artery Occlusion. Cerebrovasc Dis 2011; 32:28-34. [DOI: 10.1159/000324948] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Accepted: 02/07/2011] [Indexed: 11/19/2022] Open
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Abstract
Acute basilar artery thrombosis (ABT) has been largely considered a neurological catastrophe. With conventional treatment, only around 20% of patients achieve functional independence. An early presumptive diagnosis is essential to avoid treatment delay. Either multiparametric magnetic resonance imaging or computed tomography angiography source images may represent valid non-invasive tools to confirm ABT and evaluate ischemic tissue viability. The main determinant of ABT outcome is early recanalization but the most effective therapeutic option remains to be clarified. The BASICS prospective registry showed no superiority of intra-arterial over intravenous thrombolysis. Therefore, in the absence of contraindications, intravenous thrombolysis should be started as soon as possible and can be used as the main therapy when interventional procedures are not available. However, recent case series have reported high rates of functional independence (50%) after staged escalation therapy (ultra-early intravenous thrombolysis followed by on-demand endovascular mechanical thrombectomy). These results represent a hope for patients and neurologists and reinforce the need for innovation and research in this field.
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Affiliation(s)
- J F Arenillas Lara
- Unidad de Ictus, Servicio de Neurología, Hospital Clínico Universitario, Valladolid, España.
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Kamper L, Winkler SB, Meyn H, Scharwächter C, Piroth W, Haage P. [Targeted diagnosis of basilar artery thrombosis]. Med Klin (Munich) 2010; 105:501-502. [PMID: 20676953 DOI: 10.1007/s00063-010-1085-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Lars Kamper
- Klinik für diagnostische und interventionelle Radiologie, HELIOS Klinikum Wuppertal, Universitätsklinik Witten/Herdecke, Witten/Herdecke, Germany.
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Shi ZS, Loh Y, Walker G, Duckwiler GR. Endovascular thrombectomy for acute ischemic stroke in failed intravenous tissue plasminogen activator versus non-intravenous tissue plasminogen activator patients: revascularization and outcomes stratified by the site of arterial occlusions. Stroke 2010; 41:1185-92. [PMID: 20431084 DOI: 10.1161/strokeaha.109.568451] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Intracranial mechanical thrombectomy is a therapeutic option for acute ischemic stroke patients failing intravenous tissue plasminogen activator (IV tPA). We compared patients treated by mechanical embolus removal in cerebral ischemia (MERCI) thrombectomy after failed IV tPA with those treated with thrombectomy alone. METHODS We pooled MERCI and Multi MERCI study patients, grouped them either as failed IV tPA or non-IV tPA, and assessed revascularization rates, procedural complications, symptomatic hemorrhage rates, clinical outcomes, and mortality. We also evaluated outcomes stratified by the occlusion site and final revascularization. RESULTS Among 305 patients, 48 failed, and 257 were ineligible for IV tPA. Nonresponders to IV tPA trended toward a higher revascularization rate (73% versus 63%) and less mortality (27.7% versus 40.1%) and had similar rates of symptomatic hemorrhage and procedural complications. Favorable 90-day outcomes were similar in failed and non-IV tPA patients (38% versus 31%), with no difference according to occlusion site. Among patients failing IV tPA, good outcomes tended to occur more frequently in revascularized patients (47.1% versus 15.4%), although this relationship was attributable solely to middle cerebral artery and not internal carotid artery occlusions, with no difference in mortality. Among IV tPA-ineligible patients, revascularization correlated with good outcome (47.4% versus 4.4%) and less mortality (28.5% versus 59.6%). CONCLUSIONS The risks of hemorrhage and procedure-related complications after mechanical thrombectomy do not differ with respect to previous IV tPA administration. Thrombectomy after IV tPA achieves similar rates of good outcomes, a tendency toward lower mortality, and similar revascularization rates when stratified by clot location. Good outcomes correlate with successful revascularization except with internal carotid artery occlusions in tPA-nonresponders.
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Affiliation(s)
- Zhong-Song Shi
- Division of Interventional Neuroradiology, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA 90095-7437, USA
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Pfefferkorn T, Holtmannspötter M, Schmidt C, Bender A, Pfister HW, Straube A, Mayer TE, Brückmann H, Dichgans M, Fesl G. Drip, Ship, and Retrieve. Stroke 2010; 41:722-6. [DOI: 10.1161/strokeaha.109.567552] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thomas Pfefferkorn
- From the Departments of Neurology (T.P., C.S., A.B., H.-W.P., A.S., H.B., M.D.) and Neuroradiology (M.H., T.E.M., G.F.), Klinikum Grosshadern, University of Munich, Germany
| | - Markus Holtmannspötter
- From the Departments of Neurology (T.P., C.S., A.B., H.-W.P., A.S., H.B., M.D.) and Neuroradiology (M.H., T.E.M., G.F.), Klinikum Grosshadern, University of Munich, Germany
| | - Caroline Schmidt
- From the Departments of Neurology (T.P., C.S., A.B., H.-W.P., A.S., H.B., M.D.) and Neuroradiology (M.H., T.E.M., G.F.), Klinikum Grosshadern, University of Munich, Germany
| | - Andreas Bender
- From the Departments of Neurology (T.P., C.S., A.B., H.-W.P., A.S., H.B., M.D.) and Neuroradiology (M.H., T.E.M., G.F.), Klinikum Grosshadern, University of Munich, Germany
| | - Hans-Walter Pfister
- From the Departments of Neurology (T.P., C.S., A.B., H.-W.P., A.S., H.B., M.D.) and Neuroradiology (M.H., T.E.M., G.F.), Klinikum Grosshadern, University of Munich, Germany
| | - Andreas Straube
- From the Departments of Neurology (T.P., C.S., A.B., H.-W.P., A.S., H.B., M.D.) and Neuroradiology (M.H., T.E.M., G.F.), Klinikum Grosshadern, University of Munich, Germany
| | - Thomas E. Mayer
- From the Departments of Neurology (T.P., C.S., A.B., H.-W.P., A.S., H.B., M.D.) and Neuroradiology (M.H., T.E.M., G.F.), Klinikum Grosshadern, University of Munich, Germany
| | - Hartmut Brückmann
- From the Departments of Neurology (T.P., C.S., A.B., H.-W.P., A.S., H.B., M.D.) and Neuroradiology (M.H., T.E.M., G.F.), Klinikum Grosshadern, University of Munich, Germany
| | - Martin Dichgans
- From the Departments of Neurology (T.P., C.S., A.B., H.-W.P., A.S., H.B., M.D.) and Neuroradiology (M.H., T.E.M., G.F.), Klinikum Grosshadern, University of Munich, Germany
| | - Gunther Fesl
- From the Departments of Neurology (T.P., C.S., A.B., H.-W.P., A.S., H.B., M.D.) and Neuroradiology (M.H., T.E.M., G.F.), Klinikum Grosshadern, University of Munich, Germany
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Connors JJ, Sacks D, Black CM, McIff EB, Stallmeyer MJB, Cole JW, Rowley HA, Wojak JC, Mericle RA, Murphy KJ, Cardella JF. Training guidelines for intra-arterial catheter-directed treatment of acute ischemic stroke: a statement from a special writing group of the Society of Interventional Radiology. J Vasc Interv Radiol 2010; 20:1507-22. [PMID: 19944980 DOI: 10.1016/j.jvir.2009.10.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 10/11/2009] [Accepted: 10/13/2009] [Indexed: 10/20/2022] Open
Affiliation(s)
- J J Connors
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Schulte-Altedorneburg G, Liebig T, Brückmann H, Jansen O. Treatment of basilar artery occlusion: a prospective randomised therapeutic study is needed. Lancet Neurol 2009; 8:1084-5; author reply 1085. [PMID: 19909904 DOI: 10.1016/S1474-4422(09)70310-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Oster JM, Aggarwal P. Spontaneous recanalization of the basilar artery with conservative management months after symptom onset. Neurol Int 2009; 1:e17. [PMID: 21577354 PMCID: PMC3093223 DOI: 10.4081/ni.2009.e17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 10/19/2009] [Indexed: 11/23/2022] Open
Abstract
Basilar artery occlusion may be associated with a poor prognosis in the absence of recanalization. Choices in aggressive treatment for this potentially fatal condition vary from intra-arterial or intravenous thrombolysis, endovascular removal, or a combination of the two, with adjunct anti-coagulation therapy. These therapies have proven to be effective in recanalization, whereas conservative management with anti-coagulants alone has had more limited success in the literature. We report a case of basilar artery occlusion managed conservatively with unfractionated heparin, resulting in complete recanalization 3.5 months after symptom onset. Conservative management of basilar artery occlusion with unfractionated heparin was associated with complete recanalization long after symptom onset.
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Affiliation(s)
- Joel M Oster
- Department of Neurology, Lahey Clinic, Burlington, MA, USA
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