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Mujanovic A, Dobrocky T, Pfeilschifter W, Remonda L, Caroff J, Behme D, Seiffge DJ, Cereda CW, Kägi G, Leyon J, Piechowiak EI, Costalat V, Wagner J, Chabert E, Meinel TR, Jansen O, Alonso A, Loehr C, Liebeskind DS, Gralla J, Fischer U, Kaesmacher J. Value of intravenous alteplase before thrombectomy among patients with tandem lesions and emergent carotid artery stenting: A subgroup analysis of the SWIFT DIRECT trial. Eur J Neurol 2024; 31:e16256. [PMID: 38409874 DOI: 10.1111/ene.16256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/26/2024] [Accepted: 02/07/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND AND PURPOSE The value of intravenous thrombolysis (IVT) in eligible tandem lesion patients undergoing endovascular treatment (EVT) is unknown. We investigated treatment effect heterogeneity of EVT + IVT versus EVT-only in tandem lesion patients. Additional analyses were performed for patients undergoing emergent internal carotid artery (ICA) stenting. METHODS SWIFT DIRECT randomized IVT-eligible patients to either EVT + IVT or EVT-only. Primary outcome was 90-day functional independence (modified Rankin Scale score 0-2) after the index event. Secondary endpoints were reperfusion success, 24 h intracranial hemorrhage rate, and 90-day all-cause mortality. Interaction models were fitted for all predefined outcomes. RESULTS Among 408 included patients, 63 (15.4%) had a tandem lesion and 33 (52.4%) received IVT. In patients with tandem lesions, 20 had undergone emergent ICA stenting (EVT + IVT: 9/33, 27.3%; EVT: 11/30, 36.7%). Tandem lesion did not show treatment effect modification of IVT on rates of functional independence (tandem lesion EVT + IVT vs. EVT: 63.6% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 65.6% vs. 58.2%; p for interaction = 0.77). IVT also did not increase the risk of intracranial hemorrhage among tandem lesion patients (tandem lesion EVT + IVT vs. EVT: 34.4% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 33.5% vs. 26.3%; p for interaction = 0.15). No heterogeneity was noted for other endpoints (p for interaction > 0.05). CONCLUSIONS No treatment effect heterogeneity of EVT + IVT versus EVT-only was observed among tandem lesion patients. Administering IVT in patients with anticipated emergent ICA stenting seems safe, and the latter should not be a factor to consider when deciding to administer IVT before EVT.
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Affiliation(s)
- Adnan Mujanovic
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Waltraud Pfeilschifter
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Luca Remonda
- Department of Neuroradiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Jildaz Caroff
- Department of Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre Hospital, Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - Daniel Behme
- Department for Neuroradiology, Otto von Guericke University Hospital Magdeburg, University of Magdeburg, Magdeburg, Germany
| | - David J Seiffge
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Carlo W Cereda
- Stroke Center, Neurology, Neurocenter of Southern Switzerland (EOC), Lugano, Switzerland
| | - Georg Kägi
- Department of Neurology, Cantonal Hospital St. Gallen, University of St. Gallen, St. Gallen, Switzerland
| | - Joe Leyon
- Department of Neuroradiology, St. George's University Hospital, London, UK
| | - Eike I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Vincent Costalat
- Department of Neuroradiology, University Hospital Montpellier, Montpellier, France
| | - Judith Wagner
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
- Department of Neurology, Evangelisches Klinikum Gelsenkirchen, Academic Hospital University Essen-Duisburg, Gelsenkirchen, Germany
| | - Emmanuel Chabert
- Department of Neuroradiology, University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Thomas R Meinel
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, University of Kiel, Kiel, Germany
| | - Angelika Alonso
- Department of Neurology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christian Loehr
- Department of Radiology and Neuroradiology, Klinikum Vest, Recklinghausen, Germany
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
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Pini R, Faggioli G, Lodato M, Campana F, Vacirca A, Gallitto E, Gargiulo M. Medical and interventional outcome of dissection of the cervical arteries: systematic review and meta-analysis. J Vasc Surg 2024:S0741-5214(24)00999-6. [PMID: 38636608 DOI: 10.1016/j.jvs.2024.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/29/2024] [Accepted: 04/10/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE The management of cervical artery dissections (CADs) is poorly standardized given the scarce number of prospective studies comparing medical and interventional approach to CAD. The aim of the present study is to perform a systematic review and meta-analysis of studies on the treatments of CAD. METHODS Systematic review and meta-analysis (pre-registered on PROSPERO [CRD42022297512] are performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses [PRISMA] guidelines searching in three different databases [PubMed, Embase and Cochrane Database]) of studies on medical or interventional approach to CAD. Only prospective studies were selected to reduce the risk of bias for the primary meta-analysis. Secondarily, retrospective studies were also included. The aim was to assess the rate of stroke and of stroke/death/bleeding (major or intracranial) by Der Simonian-Laird weights of random effects model. RESULTS After screening 456 articles, 6 prospective and 22 retrospective studies were identified. Two randomized controlled trials and five retrospective studies comparing antiplatelet (APT) vs oral anticoagulant therapy (OAC) for CAD were identified, as well as four prospective and 17 retrospective single-arm studies evaluating stenting for CAD. In the meta-analysis of randomized controlled trials comparing APT vs OAC, 444 patients were considered, and a borderline significant association was identified in terms of stroke/death in the APT vs OAC groups (odds ratio [OR], 5.6; 95% confidence interval [CI], 0.94-33.38; P = .06; I2 = 0%). No differences were found for the stroke/death/bleeding outcome (OR, 1.25; 95% CI, 0.19-8.18; P = .81; I2 = 0%) between the two treatments. In the meta-analysis including also retrospective studies, overall risk of bias was considered "serious," and 4104 patients were included with no differences in APT vs OAC for stroke (OR, 1.06; 95% CI, 0.53-2.11; P = .29; I2 = 18%); no other comparisons were possible. The pooled meta-analysis of prospective studies on stenting for CAD included four series, for a total of 68 patients, in whom stenting was adopted primarily after failed medical therapy or after traumatic dissection. The pooled rate of stroke/death was 7% (95% CI, 3%-17%; I2 = 0%). The analysis of moderators identified a significant inverse association between the percentage of traumatic dissection and a reduction in postoperative stroke (Y = -1.60-2.02X; P = .03). The pooled rate of the composite endpoint of stroke/death/ or major bleeding was 8% (95% CI, 3%-18%; I2 = 0%). Secondarily, the meta-analysis also included 17 retrospective studies with overall 457 patients and showed a 2.1% pooled rate of stroke/death (95% CI, 1.0%-3.3%; I2 = 0%) and 3.2% stroke/death/bleeding (95% CI, 1.8%-4.7%; I2 = 0%). CONCLUSIONS Few prospective studies on CAD treatment are present in literature. APT and OAC seem to have similar efficacy in reducing the recurrence of stroke after CAD. No definitive conclusion can be drawn for stenting, due to the low number of studies available. More prospective studies are necessary to evaluate its potential additional value over medical therapy alone in the early phase after CAD.
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Affiliation(s)
- Rodolfo Pini
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy.
| | - Marcello Lodato
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Federica Campana
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Andrea Vacirca
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Enrico Gallitto
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Mauro Gargiulo
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
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Khanafer A, Henkes H, Bücke P, Hennersdorf F, Bäzner H, Forsting M, von Gottberg P. Triple platelet inhibition in intracranial thrombectomy with additional acute cervical stent angioplasty due to tandem lesion: a retrospective single-center analysis. BMC Neurol 2024; 24:99. [PMID: 38500074 PMCID: PMC10946095 DOI: 10.1186/s12883-024-03597-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Acute stroke treatment with intracranial thrombectomy and treatment of ipsilateral carotid artery stenosis/occlusion ("tandem lesion", TL) in one session is considered safe. However, the risk of stent restenosis after TL treatment is high, and antiplatelet therapy (APT) preventing restenosis must be well balanced to avoid intracranial hemorrhage. We investigated the safety and 90-day outcome of patients receiving TL treatment under triple-APT, focused on stent-patency and possible disadvantageous comorbidities. METHODS Patients receiving TL treatment in the setting of acute stroke between 2013 and 2022 were analyzed regarding peri-/postprocedural safety and stent patency after 90 days. All patients received intravenous eptifibatide and acetylsalicylic acid and one of the three drugs prasugrel, clopidogrel, or ticagrelor. Duplex imaging was performed 24 h after treatment, at discharge and 90 days, and digital subtraction angiography was performed if restenosis was suspected. RESULTS 176 patients were included. Periprocedural complications occurred in 2.3% of the patients at no periprocedural death, and in-hospital death in 13.6%. Discharge mRS score was maintained or improved at the 90-day follow-up in 86%, 4.54% had an in-stent restenosis requiring treatment at 90 days. No recorded comorbidity considered disadvantageous for stent patency showed statistical significance, the duration of the endovascular procedure had no significant effect on outcome. CONCLUSION In our data, TL treatment with triple APT resulted in a low restenosis rate, low rates of sICH and a comparably high number of patients with favorable outcome. Aggressive APT in the initial phase may therefore have the potential to prevent recurrent stroke better than restrained platelet inhibition. Comorbidities did not influence stent patency.
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Affiliation(s)
- Ali Khanafer
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Hennersdorf
- Department of Diagnostic and Interventional Neuroradiology, University of Tübingen, Tübingen, Germany
| | - Hansjörg Bäzner
- Neurological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp von Gottberg
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.
- Klinik für Neuroradiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany.
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Yaghi S, Engelter S, Del Brutto VJ, Field TS, Jadhav AP, Kicielinski K, Madsen TE, Mistry EA, Salehi Omran S, Pandey A, Raz E. Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association. Stroke 2024; 55:e91-e106. [PMID: 38299330 DOI: 10.1161/str.0000000000000457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Cervical artery dissection is an important cause of stroke, particularly in young adults. Data conflict on the diagnostic evaluation and treatment of patients with suspected cervical artery dissection, leading to variability in practice. We aim to provide an overview of cervical artery dissection in the setting of minor or no reported mechanical trigger with a focus on summarizing the available evidence and providing suggestions on the diagnostic evaluation, treatment approaches, and outcomes. Writing group members drafted their sections using a literature search focused on publications between January 1, 1990, and December 31, 2022, and included randomized controlled trials, prospective and retrospective observational studies, meta-analyses, opinion papers, case series, and case reports. The writing group chair and vice chair compiled the manuscript and obtained writing group members' approval. Cervical artery dissection occurs as a result of the interplay among risk factors, minor trauma, anatomic and congenital abnormalities, and genetic predisposition. The diagnosis can be challenging both clinically and radiologically. In patients with acute ischemic stroke attributable to cervical artery dissection, acute treatment strategies such as thrombolysis and mechanical thrombectomy are reasonable in otherwise eligible patients. We suggest that the antithrombotic therapy choice be individualized and continued for at least 3 to 6 months. The risk of recurrent dissection is low, and preventive measures may be considered early after the diagnosis and continued in high-risk patients. Ongoing longitudinal and population-based observational studies are needed to close the present gaps on preferred antithrombotic regimens considering clinical and radiographic prognosticators of cervical artery dissection.
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Perrin G, Molinier E, Gory B, Kyheng M, Labreuche J, Pasi M, Janot K, Bourcier R, Sibon I, Consoli A, Desilles JP, Olivot JM, Papagiannaki C, Soize S, Gentric JC, Dargazanli C, Caroff J, Pop R, Naggara O, Moulin S, Eker O, Alias Q, Clarençon F, Lapergue B, Marnat G. Impact of Day 1 carotid patency on outcome in dissection-related tandem occlusions treated with mechanical thrombectomy. J Neuroradiol 2024; 51:196-203. [PMID: 38309578 DOI: 10.1016/j.neurad.2024.01.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND The clinical benefit of mechanical thrombectomy(MT) for stroke patients with tandem occlusion is similar to that of isolated intracranial occlusions. However, the management of cervical internal carotid artery(ICA) occlusion during the MT, particularly in the setting of carotid dissection, remains controversial. We aimed to investigate the clinical impact of cervical ICA patency at day 1 on 3-month functional outcome. METHODS We collected data from the Endovascular Treatment in Ischemic Stroke, a prospective national registry in 30 French centers performing MT between January 2015 and January 2022. Inclusion criteria were consecutive tandem occlusions related to cervical ICA dissection treated with MT. Tandem occlusions of other etiology, isolated cervical ICA occlusions without intracranial thrombus and patients without day-1 ICA imaging were excluded. Primary endpoint was the 3-month functional outcome. Secondary endpoints included intracranial hemorrhage(ICH), excellent outcome, mortality and early neurological improvement. A sensitivity analysis was performed in patients with intracranial favorable recanalization after MT. RESULTS During the study period, 137 patients were included of which 89(65%) presented ICA patency at day 1. The odds of favorable outcome did not significantly differ between patients with patent and occluded ICA at day 1(68.7 vs 59.1%;aOR=1.30;95%CI 0.56-3.00,p=0.54). Excellent outcome, early neurological improvement, mortality and ICH were also comparable between groups. Sensitivity analysis showed similar results. CONCLUSION ICA patency at day 1 in patients with tandem occlusions related to dissection did not seem to influence functional outcome. Endovascular recanalization of the cervical ICA including stenting might not be systematically required in this setting.
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Affiliation(s)
| | | | - Benjamin Gory
- Neuroradiology Department, Nancy University Hospital, INSERM 1254, IADI, Université de Loraine, Nancy, France
| | - Maeva Kyheng
- Biostatistic Department - Lille University Hospital, Lille, France
| | - Julien Labreuche
- Biostatistic Department - Lille University Hospital, Lille, France
| | - Marco Pasi
- Neurology department, Tours University Hospital, Tours, France
| | - Kevin Janot
- Neuroradiology department, Tours University Hospital, Tours, France
| | - Romain Bourcier
- Neuroradiology Department, Nantes University Hospital, Nantes, France
| | - Igor Sibon
- Neurology Department, Bordeaux University Hospital, Bordeaux, France
| | - Arturo Consoli
- Neuroradiology Department, Foch Hospital, Suresnes, France
| | | | - Jean-Marc Olivot
- Neurology Department, Toulouse University Hospital, Toulouse, France
| | | | - Sebastien Soize
- Neuroradiology Department, Reims University Hospital, Reims, France
| | | | - Cyril Dargazanli
- Neuroradiology Department, Montpellier University Hospital, Montpellier, France
| | - Jildaz Caroff
- Neuroradiology Department, Kremlin-Bicêtre University Hospital, Kremlin-Bicêtre, France
| | - Raoul Pop
- Neuroradiology Department, Strabsourg University Hospital, Strasbourg, France
| | - Olivier Naggara
- Neuroradiology Department, Sainte-Anne University Hospital, Paris, France
| | - Solene Moulin
- Neurology Department, Reims University Hospital, Reims, France
| | - Omer Eker
- Neuroradiology Department, Lyon University Hospital, Lyon, France
| | - Quentin Alias
- Neuroradiology Department, Rennes University Hospital, Rennes, France
| | - Frederic Clarençon
- Neuroradiology Department, Pitié-Salpêtriere University Hospital, Paris, France
| | | | - Gaultier Marnat
- Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France.
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Marnat G, Lapergue B, Gory B, Kyheng M, Labreuche J, Turc G, Olindo S, Sibon I, Caroff J, Smadja D, Chausson N, Clarençon F, Seners P, Bourcier R, Pop R, Olivot JM, Mazighi M, Moulin S, Janot K, Cognard C, Alamowitch S, Gerschenfeld G. Intravenous thrombolysis with tenecteplase versus alteplase combined with endovascular treatment of anterior circulation tandem occlusions: A pooled analysis of ETIS and TETRIS. Eur Stroke J 2024; 9:124-134. [PMID: 37837202 PMCID: PMC10916828 DOI: 10.1177/23969873231206894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Tandem occlusions are a singular large vessel occlusion entity involving specific endovascular and perioperative antithrombotic management. In this context, data on safety and efficacy of prior intravenous thrombolysis (IVT) with tenecteplase is scarce. We aimed to compare IVT with tenecteplase or alteplase in patients with acute tandem occlusions intended for endovascular treatment. PATIENTS AND METHODS A retrospective pooled analysis of two large observational registries (ETIS (Endovascular Treatment of Ischemic Stroke) and TETRIS (Tenecteplase Treatment in Ischemic Stroke)) was performed on consecutive patients presenting with anterior circulation tandem occlusion treated with IVT using either alteplase (ETIS) or tenecteplase (TETRIS) followed by endovascular treatment between January 2015 and June 2022. Sensitivity analyses on atherosclerosis related tandem occlusions and on patient treated with emergent carotid stenting were conducted. Propensity score overlap weighting analyses were performed. RESULTS We analyzed 753 patients: 124 in the tenecteplase and 629 in the alteplase group. The overall odds of favorable outcome (3-month modified Rankin score 0-2) were comparable between both groups (49.4% vs 47.1%; OR = 1.10, 95%CI 0.85-1.41). Early recanalization, final successful recanalization and mortality favored the use of tenecteplase. The occurrence of any intracranial hemorrhage (ICH) was more frequent after tenecteplase use (OR = 2.24; 95%CI 1.75-2.86). However, risks of symptomatic ICH and parenchymal hematoma remained similar. In atherosclerotic tandems, favorable outcome, mortality, parenchymal hematoma, early recanalization, and final successful recanalization favored the tenecteplase group. In the carotid stenting subgroup, PH were less frequent in the tenecteplase group (OR = 0.18; 95%CI 0.05-0.69). CONCLUSION In patients with tandem occlusions, IVT with tenecteplase seemed reasonably safe in particular with increased early recanalization rates. These findings remain preliminary and should be further confirmed in randomized trials.
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Affiliation(s)
- Gaultier Marnat
- Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | | | - Benjamin Gory
- Neuroradiology, Nancy University Hospital, Université de Lorraine, IADI, INSERM U1254, Nancy, France
| | - Maeva Kyheng
- Biostatistics, Lille University Hospital, Lille, France
| | | | - Guillaume Turc
- Neurology, GHU Paris Psychiatrie et Neurosciences, INSERM U1266, Université Paris Cité, FHU NeuroVasc, Paris, France
| | | | - Igor Sibon
- Neurology, Bordeaux University Hospital, Bordeaux, France
| | - Jildaz Caroff
- Interventional Neuroradiology − NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Didier Smadja
- Unité Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes, France
| | - Nicolas Chausson
- Unité Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes, France
| | | | - Pierre Seners
- Neurology, Fondation Rothschild, Paris, Île-de-France, France
| | | | - Raoul Pop
- Neuroradiology, Strasbourg University Hospital, Strasbourg, France
| | | | - Mikael Mazighi
- Neurology, Lariboisiere Hospital, and Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris Cité, INSERM 1144, FHU Neurovasc, Paris, France
| | - Solène Moulin
- Neurology, Stroke Unit; Reims University Hospital, Reims, France
| | - Kevin Janot
- Neuroradiology, Tours University Hospital, Tours, France
| | | | - Sonia Alamowitch
- Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, AP-HP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France; STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Gaspard Gerschenfeld
- Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, AP-HP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France; STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
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Long B, Pelletier J, Koyfman A, Bridwell RE. High risk and low prevalence diseases: Spontaneous cervical artery dissection. Am J Emerg Med 2024; 76:55-62. [PMID: 37995524 DOI: 10.1016/j.ajem.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/05/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Spontaneous cervical artery dissection (sCAD) is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of sCAD, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION sCAD is a condition affecting the carotid or vertebral arteries and occurs as a result of injury and compromise to the arterial wall layers. The dissection most commonly affects the extracranial vessels but may extend intracranially, resulting in subarachnoid hemorrhage. Patients typically present with symptoms due to compression of local structures, and the presentation depends on the vessel affected. The most common symptom is headache and/or neck pain. Signs and symptoms of ischemia may occur, including transient ischemic attack and stroke. There are a variety of risk factors for sCAD, including underlying connective tissue or vascular disorders, and there may be an inciting event involving minimal trauma to the head or neck. Diagnosis includes imaging, most commonly computed tomography angiography of the head and neck. Ultrasound can diagnose sCAD but should not be used to exclude the condition. Treatment includes specialist consultation (neurology and vascular specialist), consideration of thrombolysis in appropriate patients, symptomatic management, and administration of antithrombotic medications. CONCLUSIONS An understanding of sCAD can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Rachel E Bridwell
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA, USA
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Pagano S, Ricciuti V, Mancini F, Barbieri FR, Chegai F, Marini A, Marruzzo D, Paracino R, Ricciuti RA. Eagle syndrome: An updated review. Surg Neurol Int 2023; 14:389. [PMID: 38053694 PMCID: PMC10695462 DOI: 10.25259/sni_666_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/16/2023] [Indexed: 12/07/2023] Open
Abstract
Background This work aims to review the current literature and our experience on vascular Eagle syndrome (ES) that can present misleading clinical presentations and better understand the possible therapeutic strategies. Methods We reviewed the existing literature on PubMed from January 1, 2017, to December 31, 2022, including the sequential keywords "vascular AND Eagle syndrome," "vascular AND styloid syndrome," "vascular AND elongated styloid process," "vascular AND stylocarotid syndrome," and "Eagle syndrome AND carotid artery dissection." Results 38 vascular ES cases, including our experience, were analyzed. The most frequent clinical onset was hemiparesis (n 21, 57%), but other regular clinical presentations were aphasia, loss of consciousness, amaurosis, headache, or a combination of the latter. Massive oral bleeding was reported only once in the literature before our case. Twelve patients were treated with only antiplatelet therapy, either single or double. Nine patients were treated with anticoagulation therapy only. In 14 patients, a carotid artery stent was used, associated with anticoagulation or antiplatelet therapy. In 17 cases, a styloid process (SP) resection was performed. Conclusion ES has many clinical presentations, and carotid artery dissection resulting in oral bleeding seems rare. Literature results and our experience make us believe that when dealing with vascular ES, the best treatment strategy is endovascular internal carotid artery stenting with antiplatelet therapy, followed by surgical removal of the elongated SP to prevent stent fracture.
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Affiliation(s)
- Serena Pagano
- Department of Neurosurgery, Ospedale Belcolle, Viterbo, Italy
| | - Vittorio Ricciuti
- Department of Neurosurgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Gerardo dei Tintori, Monza, Italy
| | - Fabrizio Mancini
- Department of Neurosurgery, Azienda Ospedaliera Di Perugia, Perugia, Italy
| | | | - Fabrizio Chegai
- Department of Vascular and Interventional Radiology, Unit of Radiology, Ospedale Belcolle, Viterbo, Italy
| | - Alessandra Marini
- Department of Neurosurgery, Azienda Ospedaliera Di Perugia, Perugia, Italy
| | | | - Riccardo Paracino
- Department of Neurosurgery, Azienda Ospedaliera Di Perugia, Perugia, Italy
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9
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Marnat G, Finistis S, Moreno R, Sibon I, Pop R, Mazighi M, Clarençon F, Rosso C, Dargazanli C, Darcourt J, Olivot JM, Boulouis G, Janot K, Moulin S, Bourcier R, Consoli A, Richard S, Arquizan C, Vannier S, Richter S, Gentric JC, Papagiannaki C, Naggara O, Eker OF, Lapergue B, Caroff J, Gory B. Aspirin versus aggressive antiplatelet therapy for acute carotid stenting plus thrombectomy in tandem occlusions: ETIS Registry results. J Neurointerv Surg 2023; 15:e248-e254. [PMID: 36357169 DOI: 10.1136/jnis-2022-019527] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/24/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Patients treated with acute carotid stenting (CAS) may have higher odds of a favorable outcome than those treated without CAS during thrombectomy in tandem occlusions. Antiplatelet therapy is associated with CAS to avoid stent thrombosis, which occurs in around 20% of patients and negatively impacts outcomes. In this study we compared two antiplatelet strategies in tandem occlusion strokes treated with CAS and intracranial thrombectomy in clinical practice. METHODS The Endovascular Treatment in Ischemic Stroke Registry is an ongoing prospective observational study involving 21 comprehensive stroke centers performing thrombectomy in France. We analyzed patients with atherosclerotic tandem occlusions treated with acute CAS and intracranial thrombectomy who received at least one antiplatelet agent. Aggressive antiplatelet therapy included oral or intravenous glycoprotein (GP) IIb/IIIa or P2Y12 inhibitors. The primary outcome was cervical carotid artery patency at day 1 imaging follow-up. RESULTS Among the 187 included patients, 124 (66.3%) received aspirin alone and 63 (33.7%) received aggressive antiplatelet therapy. There was no significant difference regarding safety outcomes, especially in symptomatic intracerebral hemorrhage, parenchymal hematoma, and procedural complications. There was a significantly higher rate of carotid stent patency at day 1 in the aggressive antiplatelet therapy group (81.7% vs 97.1%, aOR 17.49, 95% CI 1.10 to 277.2, p=0.042). Odds of favorable functional outcome (90-day modified Rankin Scale score 0-2) were similar between the groups (OR 3.04, 95% CI 0.64 to 14.25, p=0.158). CONCLUSIONS In tandem occlusions treated with CAS plus thrombectomy, an aggressive antiplatelet regimen was associated with an increased rate of carotid stent patency at day 1 without safety concerns. Randomized trials are warranted to confirm these findings.
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Affiliation(s)
- Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, France
| | - Stefanos Finistis
- Neurosurgery, Aristotle University of Thessaloniki, Thessaloniki, Central Macedonia, Greece
| | - Ricardo Moreno
- Neuroradiology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Igor Sibon
- Neurology, CHU de Bordeaux, Bordeaux, France
| | - Raoul Pop
- Neuroradiolology, CHU Strasbourg, Strasbourg, France
| | - Mikaël Mazighi
- Interventional Neuroradiology, Fondation Rothschild, Paris, France
- Neurology, GH Lariboisiere Fernand-Widal, Paris, France
| | - Frédéric Clarençon
- Neuroradiology, Hopital Universitaire Pitie Salpetriere, Paris, France
- Sorbonne University, Paris, France
| | - Charlotte Rosso
- Neurology, Hopital Universitaire Pitie Salpetriere, Paris, France
| | - Cyril Dargazanli
- Neuroradiology, University Hospital Centre Montpellier, Montpellier, France
| | | | | | | | | | - Solène Moulin
- Neurology, University Hospital Centre Reims, Reims, France
| | | | | | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | | | | | | | | | | | | | - Omer F Eker
- Neuroradiology, Hospices Civils de Lyon, Bron, France
| | | | - Jildaz Caroff
- Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Benjamin Gory
- Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
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10
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Liu C, Liu M, Yang X, Wang J, Li G. Efficacy and safety of bridging therapy versus direct thrombectomy for tandem lesions in acute stroke: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 234:108005. [PMID: 37837908 DOI: 10.1016/j.clineuro.2023.108005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Current studies have concluded that MT (Mechanical Thrombectomy) is safe and effective for tandem lesions (TL). However, The benefit of bridging therapy for TL is controversial. OBJECTIVE To compare efficacy and safety between bridging therapy and direct thrombectomy of tandem lesions. METHOD We conducted a systematic review and meta-analysis of studies comparing bridging therapy versus direct thrombectomy among TL patients with regards to symptomatic intracerebral hemorrhage(sICH), Parenchymal hemorrhage (PH), 3-month mortality, modified Rankin Scale (mRS) score within 3 months, successful reperfusion, and excellent reperfusion. The meta-analysis of proportions was conducted with a common effects model. RESULT Five studies (n = 1198 patients) were identified for the systematic review. For safety outcomes, the bridging group had no significant difference in the rate of symptomatic intracranial hemorrhage (OR = 0.78, 95% CI = 0.49-1.25, P = 0.31) and the rate of PH (OR = 0.67, 95% CI = 0.39-1.13, P = 0.13) but significantly lower rate of 3-month mortality (OR = 0.53, 95% CI = 0.37-0.75, P = 0.0004) compared to the direct thrombectomy group. In terms of efficacy outcomes, the bridging therapy group had a significantly higher rate of 3- month good functional outcome (mRS 0-2) (OR = 1.76, 95% CI = 1.38-2.24, P < 0.00001) and successful recanalization (OR = 1.69, 95% CI = 1.27-2.25, P = 0.0003) but no significant difference in the rate of excellent recanalization(OR = 1.21, 95% CI = 0.91-1.59, P = 0.19) in patients with TL compared to direct thrombectomy group. CONCLUSION Bridging therapy is effective in improving the 3-month functional prognosis and increasing the rate of arterial recanalization without increasing the risk of intracranial hemorrhage in patients with TL compared to direct thrombectomy. A large multicentre clinical RCT is expected, as are advanced intravenous thrombolysis and endovascular thrombectomy techniques.
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Affiliation(s)
- Chenxi Liu
- Department of Neurology, The Frist Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Mingsu Liu
- Department of Neurology, Zhongshan Hospital Affiliated to Fudan University, Shanghai 200032, China
| | - Xun Yang
- Department of Neurology, Hechuan District People's Hospital, Chongqing 401500, China
| | - Jinping Wang
- Department of Neurology, Chongqing University Central Hospital, Chongqing 400050, China
| | - Guangqin Li
- Department of Neurology, The Frist Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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11
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Ifergan H, Reiner P, Simonato D, Polara GF, Mazighi M, Houdart E, Jouvent E, Labeyrie MA. Early ischemic recurrence in acute spontaneous cervical artery dissection. J Neuroradiol 2023; 50:523-529. [PMID: 36907266 DOI: 10.1016/j.neurad.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/07/2023] [Accepted: 03/07/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND AND PURPOSE Early ischemic recurrence (EIR) following the diagnosis of acute spontaneous cervical artery dissection (CeAD) has been little investigated. We aimed to determine the prevalence and determinants on admission of EIR in a large single-center retrospective cohort study of patients with CeAD. METHODS EIR was defined as any ipsilateral clinical or radiological cerebral ischemia or intracranial artery occlusion, not present on admission and occurring within 2 weeks. CeAD location, degree of stenosis, circle of Willis support, presence of intraluminal thrombus, intracranial extension, and intracranial embolism were analyzed on initial imaging by 2 independent observers. Uni- and multivariate logistic regression was used to determine their association with EIR. RESULTS Two hundred thirty-three consecutive patients with 286 CeAD were included. EIR was observed in 21 patients (9%,95%CI=5-13%) with a median time from diagnosis of 1.5 days (range:0.1-14.0 days). No EIR was observed in CeAD without ischemic presentation or with less than 70% stenosis. In the remaining cases, poor circle of Willis (OR=8.5, CI95%=2.0-35.4, p = 0.003), CeAD extending to other intracranial arteries than just V4 (OR=6.8, CI95%=1.4-32.6, p = 0.017), cervical artery occlusion (OR=9.5, CI95%=1.2- 39.0, p = 0.031), and cervical intraluminal thrombus (OR=17.5, CI95%=3.0-101.7, p = 0.001) were independently associated with EIR. CONCLUSIONS Our results suggests that EIR is more frequent than previously reported, and that its risk might be stratified on admission with a standard workup. In particular, the presence of a poor circle of Willis, intracranial extension (other than just V4), cervical occlusion, or cervical intraluminal thrombus are associated with high risk of EIR, for which specific management should be further evaluated.
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Affiliation(s)
- Héloïse Ifergan
- Neurointerventional Unit, Tours Hospital, Tours, Paris, France
| | - Peggy Reiner
- Vascular Neurology Unit, Lariboisière Hospital, APHP, F-75475, Paris, France; FHU NeuroVasc, Paris, France
| | - Davide Simonato
- Neurointerventional Unit, Lariboisière Hospital, APHP, F-75475, Paris, France; Université de Paris, Paris, France
| | - Giulia Frasca Polara
- Vascular Neurology Unit, Lariboisière Hospital, APHP, F-75475, Paris, France; FHU NeuroVasc, Paris, France
| | - Mikael Mazighi
- Vascular Neurology Unit, Lariboisière Hospital, APHP, F-75475, Paris, France; FHU NeuroVasc, Paris, France; Université de Paris, Paris, France
| | - Emmanuel Houdart
- Neurointerventional Unit, Lariboisière Hospital, APHP, F-75475, Paris, France; Université de Paris, Paris, France
| | - Eric Jouvent
- Vascular Neurology Unit, Lariboisière Hospital, APHP, F-75475, Paris, France; FHU NeuroVasc, Paris, France; Université de Paris, Paris, France; INSERM U1141, Paris, France
| | - Marc-Antoine Labeyrie
- Neurointerventional Unit, Lariboisière Hospital, APHP, F-75475, Paris, France; Université de Paris, Paris, France; INSERM U942, Paris, France.
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12
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Salehi Omran S. Cervical Artery Dissection. Continuum (Minneap Minn) 2023; 29:540-565. [PMID: 37039409 DOI: 10.1212/con.0000000000001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Cervical artery dissection is a common cause of stroke in young adults. This article reviews the pathophysiology, etiology and risk factors, evaluation, management, and outcomes of spontaneous cervical artery dissection. LATEST DEVELOPMENTS Cervical artery dissection is believed to be a multifactorial disease, with environmental factors serving as possible triggers in patients who have a genetic predisposition to dissection formation. Cervical artery dissection can cause local symptoms or ischemic events, such as ischemic stroke or transient ischemic attack. Neuroimaging is used to confirm the diagnosis; classic findings include a long tapered arterial stenosis or occlusion, dissecting aneurysm, intimal flap, double lumen, or intramural hematoma. Patients with cervical artery dissection who present with an acute ischemic stroke should be evaluated for IV thrombolysis, endovascular therapy eligibility, or both. Antithrombotic therapy with either anticoagulation or antiplatelet treatment is used to prevent stroke from cervical artery dissection. The risk of recurrent ischemia appears low and is mostly limited to the first two weeks after symptom onset. ESSENTIAL POINTS Cervical artery dissection is a known cause of ischemic strokes. Current data show no difference between the benefits and risks of anticoagulation versus antiplatelet therapy in the acute phase of symptomatic extracranial cervical artery dissection, thereby supporting the recommendation that clinicians can prescribe either treatment. Further research is warranted to better understand the pathophysiology and long-term outcomes of cervical artery dissection.
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13
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Da Ros V, Pusceddu F, Lattanzi S, Scaggiante J, Sallustio F, Marrama F, Bandettini di Poggio M, Toscano G, Di Giuliano F, Rolla-Bigliani C, Ruggiero M, Haznedari N, Sgreccia A, Sanfilippo G, Finocchi C, Diomedi M, Tomasi SO, Palmisciano P, Umana GE, Strigari L, Griessenauer CJ, Pitocchi F, Garaci F, Floris R. Endovascular treatment of patients with acute ischemic stroke and tandem occlusion due to internal carotid artery dissection: A multicenter experience. Neuroradiol J 2023. [PMID: 35699167 DOI: 10.1177/19714009221089026]] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND The optimal management of patients with acute ischemic stroke (AIS) due to tandem occlusion (TO) and underlying carotid dissection (CD) remains unclear. OBJECTIVE We present our multicenter-experience of endovascular treatment (EVT) approach used and outcomes for AIS patients with CD-related TO (CD-TO). METHODS Consecutive AIS patients underwent EVT for CD-TO at five Italian Neuro-interventional Tertiary Stroke Centers were retrospectively identified. TO from atherosclerosis and other causes of, were excluded from the final analysis. Primary outcome was successful (mTICI 2b-3) and complete reperfusion (mTICI 3); secondary outcome was patients' 3-months functional independence (mRS≤2). RESULTS Among 214 AIS patients with TO, 45 presented CD-TO. Median age was 54 years (range 29-86), 82.2% were male. Age <65 years (p < 0.0001), lower baseline NIHSS score (p = 0.0002), and complete circle of Willis (p = 0.0422) were associated with mRS ≤ 2 at the multivariate analysis. Comparisons between antegrade and retrograde approaches resulted in differences for baseline NIHSS scores (p = 0.001) and number of EVT attempts per-procedure (p = 0.001). No differences in terms of recanalization rates were observed between antegrade and retrograde EVT approaches (p = 0.811) but higher rates of mTICI3 revascularization was observed with the retrograde compared to the antegrade approach (78.6% vs 73.3%), anyway not statistically significant. CD management technique (angioplasty vs aspiration vs emergent stenting) did not correlate with 3-months mRS≤2. CONCLUSION AIS patients with CD-TO were mostly treated with the retrograde approach with lower number of attempts per-procedure but it offered similar recanalization rates compared with the antegrade approach. Emergent carotid artery stenting (CAS) proved to be safe for CD management but it does not influence 3-months patients' clinical outcomes.
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Affiliation(s)
- Valerio Da Ros
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, 9318University of Rome Tor Vergata, Italy
| | - Federica Pusceddu
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, 9318University of Rome Tor Vergata, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Italy
| | - Jacopo Scaggiante
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, USA
| | | | - Federico Marrama
- Comprehensive Stroke Center, 9318University of Rome Tor Vergata, Italy
| | | | - Gianpaolo Toscano
- Stroke Unit University Policlinico San Matteo, IRCCS Mondino Fundation, Italy
| | - Francesca Di Giuliano
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, 9318University of Rome Tor Vergata, Italy
| | - Claudia Rolla-Bigliani
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, San Martino, Italy
| | | | | | - Alessandro Sgreccia
- Clinic of Neuroradiology and Interventional Neuroradiology, 18494AOU Ospedali Riuniti di Ancona, Italy
| | - Giuseppina Sanfilippo
- Department of Diagnostic and Interventional Radiology and Neuroradiology, IRCCS Policlinico San Matteo, Italy
| | - Cinzia Finocchi
- Department of Neurosciences, Policlinico Hospital San Martino, University of Genova, Italy
| | - Marina Diomedi
- Department of Systemic Medicine, 9318University of Rome Tor Vergata, Italy
| | - Santino O Tomasi
- Department of Neurological Surgery, Christian Doppler Klinik, 31507Paracelsus Medical University, Salzburg, Austria.,Laboratory for Microsurgical Neuroanatomy, Christian Doppler Klinik, 31507Paracelsus Medical University, Salzburg, Austria
| | - Paolo Palmisciano
- Department of Neurosurgery, Trauma and Gamma-Knife Center, 18531Cannizzaro Hospital, Italy
| | - Giuseppe E Umana
- Department of Neurosurgery, Trauma and Gamma-Knife Center, 18531Cannizzaro Hospital, Italy
| | - Lidia Strigari
- Department of Medical Physics, 18494IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Christoph J Griessenauer
- Department of Neurological Surgery, Christian Doppler Klinik, 31507Paracelsus Medical University, Salzburg, Austria.,Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.,Research Institute of Neurointervention, 31507Paracelsus Medical University, Salzburg, Austria
| | - Francesca Pitocchi
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, 9318University of Rome Tor Vergata, Italy
| | - Francesco Garaci
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, 9318University of Rome Tor Vergata, Italy
| | - Roberto Floris
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, 9318University of Rome Tor Vergata, Italy
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14
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Zhang L, Trippier S, Banerjee S, Xu T, Leyon J, Taylor E, Shtaya A, Sim CH, Gargalas S, Khan U, Cluckie G, Holt P, Lobotesis K, Clifton A, Markus HS, Goyal M, Ogungbemi A. Dissection-related tandem occlusion may be different from atherothrombotic tandem occlusion. J Stroke Cerebrovasc Dis 2023; 32:106910. [PMID: 36473397 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 11/10/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The optimal endovascular treatment for tandem occlusion in anterior circulation ischaemic stroke remains unknown. The aim of this study was to examine how the aetiology of carotid pathology, dissection versus atherothrombosis, affects clinical outcomes. MATERIALS AND METHODS Data was obtained from prospectively collected registries from two stroke centres between April 2016 and December 2020. Tandem cases with complete cervical internal carotid artery (ICA) occlusion or near-total occlusion (≥90% stenosis) were included. Patients were divided into two groups based on carotid pathology: dissection versus atherothrombosis. RESULTS A total of 134 patients were included: 36 were dissection and 98 were atherothrombosis. The dissection group had better clinical outcomes compared to the atherothrombosis group, although after adjusting for age and stroke risk factors differences were non-significant. In the non-stented cohort, the dissection patients achieved a better outcome (modified Rankin scale 0-2) than atherothrombotic patients (57% vs. 34%, p=0.04) at 90-days. CONCLUSION Dissection-related tandem occlusions appear to have different clinical features from atherothrombotic tandem occlusions which suggests different management strategies are needed.
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Affiliation(s)
- Liqun Zhang
- Department of Neurology, St George's University Hospital, UK.
| | - Sarah Trippier
- Department of Research and Development, The Royal United Hospitals Bath NHS Foundation Trust, UK
| | - Soma Banerjee
- Department of Stroke Medicine, Imperial College Healthcare NHS Trust, UK
| | - Tian Xu
- Department of Neurology, Affiliated Hospital of Nantong University, China
| | - Joe Leyon
- Department of Neuroradiology, St George's University Hospital, UK
| | - Eleanor Taylor
- Imaging Department, Imperial College Healthcare NHS Trust, UK
| | - Anan Shtaya
- Wessex Spinal Unit, University Hospital Southampton NHS Foundation Trust, UK
| | - Cai Hua Sim
- Department of Neurology, St George's University Hospital, UK
| | - Sergios Gargalas
- Department of Neuroradiology, St George's University Hospital, UK
| | - Usman Khan
- Department of Neurology, St George's University Hospital, UK
| | - Gillian Cluckie
- Department of Neurology, St George's University Hospital, UK
| | - Peter Holt
- Department of Vascular Surgery, St George's University Hospital, UK
| | | | - Andrew Clifton
- Department of Neuroradiology, St George's University Hospital, UK
| | - Hugh S Markus
- Department of Clinical Neuroscience, University of Cambridge, UK
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15
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Da Ros V, Pusceddu F, Lattanzi S, Scaggiante J, Sallustio F, Marrama F, Bandettini di Poggio M, Toscano G, Di Giuliano F, Rolla-Bigliani C, Ruggiero M, Haznedari N, Sgreccia A, Sanfilippo G, Finocchi C, Diomedi M, Tomasi SO, Palmisciano P, Umana GE, Strigari L, Griessenauer CJ, Pitocchi F, Garaci F, Floris R. Endovascular treatment of patients with acute ischemic stroke and tandem occlusion due to internal carotid artery dissection: A multicenter experience. Neuroradiol J 2023; 36:86-93. [PMID: 35699167 PMCID: PMC9893158 DOI: 10.1177/19714009221108673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The optimal management of patients with acute ischemic stroke (AIS) due to tandem occlusion (TO) and underlying carotid dissection (CD) remains unclear. OBJECTIVE We present our multicenter-experience of endovascular treatment (EVT) approach used and outcomes for AIS patients with CD-related TO (CD-TO). METHODS Consecutive AIS patients underwent EVT for CD-TO at five Italian Neuro-interventional Tertiary Stroke Centers were retrospectively identified. TO from atherosclerosis and other causes of, were excluded from the final analysis. Primary outcome was successful (mTICI 2b-3) and complete reperfusion (mTICI 3); secondary outcome was patients' 3-months functional independence (mRS≤2). RESULTS Among 214 AIS patients with TO, 45 presented CD-TO. Median age was 54 years (range 29-86), 82.2% were male. Age <65 years (p < 0.0001), lower baseline NIHSS score (p = 0.0002), and complete circle of Willis (p = 0.0422) were associated with mRS ≤ 2 at the multivariate analysis. Comparisons between antegrade and retrograde approaches resulted in differences for baseline NIHSS scores (p = 0.001) and number of EVT attempts per-procedure (p = 0.001). No differences in terms of recanalization rates were observed between antegrade and retrograde EVT approaches (p = 0.811) but higher rates of mTICI3 revascularization was observed with the retrograde compared to the antegrade approach (78.6% vs 73.3%), anyway not statistically significant. CD management technique (angioplasty vs aspiration vs emergent stenting) did not correlate with 3-months mRS≤2. CONCLUSION AIS patients with CD-TO were mostly treated with the retrograde approach with lower number of attempts per-procedure but it offered similar recanalization rates compared with the antegrade approach. Emergent carotid artery stenting (CAS) proved to be safe for CD management but it does not influence 3-months patients' clinical outcomes.
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Affiliation(s)
- Valerio Da Ros
- Diagnostic Imaging Unit, Department
of Biomedicine and Prevention, University of Rome Tor
Vergata, Italy
| | - Federica Pusceddu
- Diagnostic Imaging Unit, Department
of Biomedicine and Prevention, University of Rome Tor
Vergata, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of
Experimental and Clinical Medicine, Marche Polytechnic
University, Italy
| | - Jacopo Scaggiante
- Department of Radiology and
Radiological Science, Medical University of South
Carolina, Charleston, USA
| | | | - Federico Marrama
- Comprehensive Stroke Center, University of Rome Tor
Vergata, Italy
| | | | - Gianpaolo Toscano
- Stroke Unit University Policlinico
San Matteo, IRCCS Mondino Fundation, Italy
| | - Francesca Di Giuliano
- Diagnostic Imaging Unit, Department
of Biomedicine and Prevention, University of Rome Tor
Vergata, Italy
| | - Claudia Rolla-Bigliani
- Department of Diagnostic and
Interventional Neuroradiology, University Hospital, San Martino, Italy
| | | | | | - Alessandro Sgreccia
- Clinic of Neuroradiology and
Interventional Neuroradiology, AOU Ospedali Riuniti di
Ancona, Italy
| | - Giuseppina Sanfilippo
- Department of Diagnostic and
Interventional Radiology and Neuroradiology, IRCCS Policlinico San
Matteo, Italy
| | - Cinzia Finocchi
- Department of Neurosciences,
Policlinico Hospital San Martino, University of Genova, Italy
| | - Marina Diomedi
- Department of Systemic Medicine, University of Rome Tor
Vergata, Italy
| | - Santino O Tomasi
- Department of Neurological
Surgery, Christian Doppler Klinik, Paracelsus Medical
University, Salzburg, Austria
- Laboratory for Microsurgical
Neuroanatomy, Christian Doppler Klinik, Paracelsus Medical
University, Salzburg, Austria
| | - Paolo Palmisciano
- Department of Neurosurgery,
Trauma and Gamma-Knife Center, Cannizzaro Hospital, Italy
| | - Giuseppe E Umana
- Department of Neurosurgery,
Trauma and Gamma-Knife Center, Cannizzaro Hospital, Italy
| | - Lidia Strigari
- Department of Medical Physics, IRCCS Azienda
Ospedaliero-Universitaria di Bologna, Italy
| | - Christoph J Griessenauer
- Department of Neurological
Surgery, Christian Doppler Klinik, Paracelsus Medical
University, Salzburg, Austria
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
- Research Institute of
Neurointervention, Paracelsus Medical
University, Salzburg, Austria
| | - Francesca Pitocchi
- Diagnostic Imaging Unit, Department
of Biomedicine and Prevention, University of Rome Tor
Vergata, Italy
| | - Francesco Garaci
- Diagnostic Imaging Unit, Department
of Biomedicine and Prevention, University of Rome Tor
Vergata, Italy
| | - Roberto Floris
- Diagnostic Imaging Unit, Department
of Biomedicine and Prevention, University of Rome Tor
Vergata, Italy
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16
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Courret T, Tourdias T, Papaxanthos J, Labreuche J, Gariel F, Liegey JS, Olindo S, Renou P, Berge J, Barreau X, Sagnier S, Menegon P, Lucas L, Briau P, Poli M, Debruxelles S, Rouanet F, Dousset V, Sibon I, Marnat G. Etiologic and prognostic value of external carotid artery thrombus detection during endovascular therapy for anterior circulation proximal occlusions. Eur J Neurol 2023; 30:380-388. [PMID: 36325682 PMCID: PMC10100328 DOI: 10.1111/ene.15623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/23/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND PURPOSE An early understanding of stroke mechanism may improve treatment and outcome in patients presenting with large vessel occlusion stroke (LVOS) treated with mechanical thrombectomy (MT). We aimed to investigate whether spontaneous external carotid artery (ECA) embolism detection during MT is associated with stroke etiology and clinical outcome. METHODS We retrospectively reviewed our prospectively maintained institutional database including consecutive patients with anterior circulation LVOS treated with MT between January 2015 and August 2020. RESULTS An ECA embolus was detected in 68 of 1298 patients (5.2%). The kappa coefficient for interobserver agreement was 0.89 (95% confidence interval [CI] 0.82-0.95). ECA embolism was significantly associated with intracranial internal carotid artery (ICA) occlusion (p < 0.001), cardioembolic etiology (p < 0.001) and a lower clot burden score (p < 0.001). Day-1 variation of National Institutes of Health Stroke Scale score (adjusted odds ratio [OR] -2.7, 95% CI -4.9 to 0.3; p = 0.021) and delta Alberta Stroke Program Early Computed Tomography Score (adjusted OR 0.9, 95% CI 0.2 to 1.5; p = 0.004) were worse among patients with ECA emboli. There was no significant difference in 90-day functional outcome between groups (adjusted OR 0.8, 95% CI 0.42 to 1.52; p = 0.50). CONCLUSION In patients with anterior circulation LVOS treated with MT, ECA embolism was significantly associated with cardioembolic etiology, high thrombus burden and proximal intracranial ICA occlusions. This underexplored angiographic pattern might provide a valuable etiologic clue to the underlying cause of anterior circulation LVOS and may also help determine the appropriate revascularization strategy.
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Affiliation(s)
- Thomas Courret
- Neuroradiology Department, CHU Bordeaux, Bordeaux, France
| | - Thomas Tourdias
- Neuroradiology Department, CHU Bordeaux, Bordeaux, France
- INSERM-U862, Neurocentre Magendie, Bordeaux, France
| | | | - Julien Labreuche
- Department of Biostatistics, Université de Lille, CHU de Lille, Lille, France
| | - Florent Gariel
- Neuroradiology Department, CHU Bordeaux, Bordeaux, France
| | | | | | - Pauline Renou
- Neurology Department, CHU Bordeaux, Bordeaux, France
| | - Jerome Berge
- Neuroradiology Department, CHU Bordeaux, Bordeaux, France
| | - Xavier Barreau
- Neuroradiology Department, CHU Bordeaux, Bordeaux, France
| | - Sharmila Sagnier
- Neurology Department, CHU Bordeaux, Bordeaux, France
- UMR-5287-CNRS, Université de Bordeaux, EPHE PSL Research University, Bordeaux, France
| | | | - Ludovic Lucas
- Neurology Department, CHU Bordeaux, Bordeaux, France
| | - Pierre Briau
- Neurology Department, CHU Bordeaux, Bordeaux, France
| | - Mathilde Poli
- Neurology Department, CHU Bordeaux, Bordeaux, France
| | | | | | - Vincent Dousset
- Neuroradiology Department, CHU Bordeaux, Bordeaux, France
- INSERM-U862, Neurocentre Magendie, Bordeaux, France
| | - Igor Sibon
- Neurology Department, CHU Bordeaux, Bordeaux, France
- UMR-5287-CNRS, Université de Bordeaux, EPHE PSL Research University, Bordeaux, France
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17
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Masoud HE, Nguyen TN, Broderick JP. Early Stent Patency After Endovascular Therapy for Tandem or Isolated Carotid Steno-Occlusive Disease. Stroke 2023; 54:132-134. [PMID: 36542069 DOI: 10.1161/strokeaha.122.040879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Hesham E Masoud
- Department of Neurology, Neurosurgery and Radiology, Upstate Medical University, Syracuse, NY (H.E.M.)
| | - Thanh N Nguyen
- Department of Neurology and Radiology, Boston Medical Center, MA (T.N.N.)
| | - Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH (J.P.B.)
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18
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Allard J, Delvoye F, Pop R, Labreuche J, Maier B, Marnat G, Sibon I, Zhu F, Lapergue B, Consoli A, Spelle L, Denier C, Richard S, Piotin M, Gory B, Mazighi M, Redjem H, Escalard S, Dessilles JP, Delvoye F, Smajda S, Maier B, Solène H, Mazighi M, Obadia M, Sabben C, Pierre S, Igor R, Corabianu O, de Broucker T, Manchon E, Taylor G, Maacha MB, Thion LA, Augustin L, Julien S, Wang A, Evrard S, Tchikviladze M, Ajili N, WeisenburgerLile D, Gorza L, Buard G, Coskun O, Di Maria F, Rodesh G, Zimatore S, Leguen M, Gratieux J, Pico F, Rakotoharinandrasana H, Tassan P, Poll R, Marinier S, Barreau X, Berge J, Menegon P, Lucas L, Olindo S, Renou P, Sagnier S, Poli M, Debruxelles S, Rouanet F, Tourdias T, Liegey JS, Briau P, Pangon N, Coussy A, Papillon L, Papaxanthos J, Detraz L, Daumas-Duport B, Alexandre PL, Roy M, Lenoble C, Desal H, Guillon B, de Gaalon S, Preterre C, Bracard S, Anxionnat R, Braun M, Derelle AL, Tonnelet R, Liao L, Zhu F, Schmitt E, Planel S, Humbertjean L, Lacour JC, Riou-Comte N, Voicu M, Alb L, Reitter M, Brezeanu M, Masson A, Tabarna A, Podar I, Macian-Montoro F, Saleme S, Mounayer C, Rouchaud A, Costalat V, Arquizan C, Dargazanli C, Gascou G, Lefèvre PH, Derraz I, Riquelme C, Gaillard N, Mourand I, Corti L, Cagnazzo F, Ter Schiphorst A, Ferre JC, Raoult H, Ronziere T, Lassale M, Paya C, Gauvrit JY, Tracol C, Langnier-Lemercier S. 24-Hour Carotid Stent Patency and Outcomes After Endovascular Therapy: A Multicenter Study. Stroke 2023; 54:124-131. [PMID: 36542074 DOI: 10.1161/strokeaha.122.039797] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Management of extracranial internal carotid artery steno-occlusive lesion during endovascular therapy remains debated. Stent occlusion within 24 hours of endovascular therapy is a frequent event after acute carotid artery stenting, and we currently lack large population results. We investigated the incidence, predictors, and clinical impact of stent occlusion after acute carotid artery stenting in current clinical practice. METHODS Patients treated by endovascular therapy with acute carotid artery stenting between 2015 and 2019 in 5 large-volume endovascular-capable centers were retrospectively analyzed. Patients were separated in 2 groups according to the stent patency at 24 hours after carotid artery stenting. We compared baseline characteristics, treatment modalities, and clinical outcome depending on 24-hour stent patency. Primary end point was favorable outcome, defined as a modified Rankin Scale score 0-2 at 3 months. RESULTS A stent occlusion was observed in 47/225 patients (20.9%). Patients with stent patency had a lower baseline National Institutes of Health Stroke Scale (median [interquartile range]: 13 [7-17] versus 18 [12-21]) and had more often stroke of atherothrombotic origin (77.0% versus 53.2%). A higher stent patency rate was found for patients treated with P2Y12 antagonists at the acute phase (odds ratio [OR]' 2.95 [95% CI' 1.10-7.91]; P=0.026) and treated with angioplasty (OR' 2.42 [95% CI' 1.24-4.67]; P=0.008). A better intracranial angiographic reperfusion was observed in patients with 24-hour stent patency compared with patients without stent patency (OR' 8.38 [95% CI' 3.07-22.78]; P<0.001). Patients with a stent patency at 24 hours had a higher chance of favorable outcome (OR' 3.29 [95% CI, 1.66-6.52]; P<0.001) and a lower risk of death (OR' 0.32 [95% CI, 0.13-0.76]; P=0.009). CONCLUSIONS One out of 5 patients treated with carotid artery stenting during endovascular therapy presented a stent occlusion within 24 hours. This event was associated with worse functional outcome. Stroke etiology, P2Y12 antagonist administration, quality of intracranial reperfusion, and angioplasty were associated with 24-hour stent patency.
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Affiliation(s)
- Julien Allard
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.).,University of Paris' France (J.A., M.M.)
| | - François Delvoye
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.)
| | - Raoul Pop
- Department of Neuroradiolology, CHU Strasbourg, France (R.P.).,Institut de Chirurgie Minime Invasive Guidée par l'Image, Strasbourg, France (R.P.).,University of Strasbourg, INSERM UMR-S1255, France (R.P.)
| | - Julien Labreuche
- Department of Biostatistics, CHU Lille, University of Lille, France (J.L.)
| | - Benjamin Maier
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.).,LVTS, INSERM U1148, University of Paris, France (BM., M.M.)
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, France (G.M.)
| | - Igor Sibon
- Department of Neurology, Stroke Center, University Hospital of Bordeaux, France (I.S.)
| | - François Zhu
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, France (B.G., F.Z.)
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France (B.L.)
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France (A.C.)
| | - Laurent Spelle
- Department of Neuroradiolology, CHU Kremlin-Bicêtre, Le Kremlin Bicêtre, France (L.S.)
| | - Christian Denier
- Department of Neurology, CHU Kremlin-Bicêtre, Le Kremlin Bicêtre, France (C.D.)
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, Université de Lorraine, CHRU-Nancy, France (S.R.).,CIC-P 1433, INSERM U1116, CHRU-Nancy, France (S.R.)
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.)
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, France (B.G., F.Z.).,IADI, INSERM U1254, Université de Lorraine, Nancy, France (B.G.)
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France (J.A., F.D., B.M., MP, M.M.).,LVTS, INSERM U1148, University of Paris, France (BM., M.M.).,University of Paris' France (J.A., M.M.)
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19
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Scopelliti G, Karam A, Labreuche J, Bricout N, Marrama F, Diomedi M, Ben Hassen W, Leclerc X, Cordonnier C, Henon H, Casolla B. Internal carotid artery patency after mechanical thrombectomy for stroke due to occlusive dissection: Impact on outcome. Eur Stroke J 2022; 8:199-207. [PMID: 37021179 PMCID: PMC10069197 DOI: 10.1177/23969873221140649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/04/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction: Internal carotid artery dissection (ICAD) is a rare cause of acute ischemic stroke with large vessel occlusion (AIS-LVO). We aimed investigating the impact on outcome of internal carotid artery (ICA) patency after mechanical thrombectomy (MT) for AIS-LVO due to occlusive ICAD. Patients and methods: We included consecutive patients with AIS-LVO due to occlusive ICAD treated with MT from January 2015 to December 2020 in three European stroke centers. We excluded patients with unsuccessful intracranial reperfusion after MT (modified Thrombolysis in Cerebral Infarction (mTICI) score < 2b). We compared 3-month favorable clinical outcome rate, defined as a modified Rankin scale (mRS) score ⩽2, according to ICA status (patency vs occlusion) at the end of MT and at 24-h follow-up imaging, using univariate and multivariable models. Results: Among 70 included patients, ICA was patent in 54/70 (77%) at the end of MT, and in 36/66 (54.5%) patients with 24-h follow-up imaging. Among patients with ICA patency at the end of MT, 32% presented ICA occlusion at 24-h control imaging. Favorable 3-month outcome occurred in 41/54 (76%) patients with ICA patency post-MT and in 9/16 (56%) patients with occluded ICA post-MT ( p = 0.21). Rates of favorable outcome were significantly higher in patients with 24-h ICA patency compared to patients with 24-h ICA occlusion (32/36 [89%] vs 15/30 [50%]), with an adjusted odds ratio of 4.67 (95% CI: 1.26–17.25). Discussion and conclusion: Obtaining sustained (24-h) ICA patency after MT could be a therapeutic target for improving functional outcome in patients with AIS-LVO due to ICAD.
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Affiliation(s)
- Giuseppe Scopelliti
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | - Arnaud Karam
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
- Department of Neuroradiology, Roger Salengro Hospital, CHU Lille, University of Lille, Lille, France
| | | | - Nicolas Bricout
- Department of Neuroradiology, Roger Salengro Hospital, CHU Lille, University of Lille, Lille, France
| | - Federico Marrama
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Marina Diomedi
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Wagih Ben Hassen
- Department of Neuroradiology, GHU Paris, Université de Paris, INSERM UMR 1266, Paris, France
| | - Xavier Leclerc
- Department of Neuroradiology, Roger Salengro Hospital, CHU Lille, University of Lille, Lille, France
| | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | - Hilde Henon
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
| | - Barbara Casolla
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Lille, France
- UR2CA-URRIS, Stroke Unit, CHU Pasteur 2, Nice Cote d’Azur University, Nice, France
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20
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Keser Z, Chiang CC, Benson JC, Pezzini A, Lanzino G. Cervical Artery Dissections: Etiopathogenesis and Management. Vasc Health Risk Manag 2022; 18:685-700. [PMID: 36082197 PMCID: PMC9447449 DOI: 10.2147/vhrm.s362844] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/19/2022] [Indexed: 11/23/2022] Open
Abstract
Cervical Artery Dissection (CeAD) is a frequent stroke etiology for patients younger than 50 years old. The most common immediate complications related to CeAD are headache and neck pain (65–95%), TIA/ischemic stroke (>50%), and partial Horner’s syndrome (25%). The prevailing hypothesis regarding the pathogenesis of sCeAD is that the underlying constitutional vessel wall weakness of patients with sCeAD is genetically determined and that environmental factors could act as triggers. The stroke prevention treatment of CeAD remains controversial, involving anticoagulation or antiplatelet therapy and potentially emergent stenting and/or thrombectomy or angioplasty for selected cases of carotid artery dissection with occlusion. The treatment of headache associated with CeAD depends on the headache phenotype and comorbidities. Radiographically, more than 75% of CeAD cases present with occlusion or non-occlusive stenosis. Many patients demonstrate partial and complete healing, more commonly in the carotid arteries. One-fifth of the patients develop dissecting pseudoaneurysm, but this is a benign clinical entity with an extremely low rupture and stroke recurrence risk. Good recovery is achieved in many CeAD cases, and mortality remains low. Family history of CeAD, connective tissue disorders like Ehlers-Danlos syndrome type IV, and fibromuscular dysplasia are risk factors for recurrent CeAD, which can occur in 3–9% of the cases. This review serves as a comprehensive, updated overview of CeAD, emphasizing etiopathogenesis and management.
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Affiliation(s)
- Zafer Keser
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Correspondence: Zafer Keser, Department of Neurology – Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA, Email
| | | | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
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21
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Bontinis V, Antonopoulos CN, Bontinis A, Koutsoumpelis A, Zymvragoudakis V, Rafailidis V, Giannopoulos A, Stoiloudis P, Ktenidis K. A systematic review and meta-analysis of carotid artery stenting for the treatment of cervical carotid artery dissection. Eur J Vasc Endovasc Surg 2022; 64:299-308. [PMID: 35961627 DOI: 10.1016/j.ejvs.2022.07.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of carotid artery stenting for the treatment of extracranial carotid artery dissection (CAD). DATA SOURCES Systematic review using Medline, Scopus, EMBASE and Cochrane Library. REVIEW METHODS A systematic search was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) statement. Data from the eligible studies were extracted and meta-analyzed. Primary endpoints included postoperative mortality, cerebrovascular events (CE) and modified Rankin Score for neurologic disability (mRS) at 90 days. We performed subgroup analyses between stenting of spontaneous and traumatic CAD, primary stenting versus stenting after failed medical therapy (FMT) and stenting of CAD in the presence of tandem occlusions versus stenting of isolated extracranial CAD. RESULTS Twenty-four studies with 1,224 patients were included. Pooled post-operative mortality, CE and mRS 0-2 rates were 1.71% (95%CI:0.83-2.80), 6.45% (95%CI:2.80-11.10) and 76.13% (95%CI:64.15-86.50), respectively. The pooled stroke rate was 2.16% (95%CI:0.0-6.64). Spontaneous versus traumatic CAD mortality rates were 3.20% (95%CI:1.80-4.88) and 0.00% (95%CI:0.00-1.59) while CE rates were 14.26% (95%CI:6.28-24.36) and 1.64% (95%CI:0.0-6.08). Primary stenting and stenting after FMT mortality rates were 0.63% (95%CI:0.0-5.63) and 0.0% (95%CI:0.0-2.24), while CE rates were 5.02% (95%CI:0.38-12.63) and 3.33% (95%CI:0.12-9.03). Mortality rates for tandem occlusions and isolated extracranial CAD were 5.62% (95%CI:1.76-10.83) and 0.23% (95%CI:0.0-1.88) respectively, while CE rates were 15.28% (95%CI:6.23-26.64) and 1.88% (95%CI:0.23-4.51). The methodological index for non-randomized studies (MINORS) score was 8.66 (low). CONCLUSION Both primary stenting and stenting of spontaneous CAD yielded unfavorable results regarding stent thrombosis and stroke rates. Conversely, stenting following FMT displayed acceptable mortality and complication rates corroborating the use of stenting in the setting of CAD as a second line treatment. Due to the low quality of the included studies, definite conclusions cannot be drawn necessitating further research.
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Affiliation(s)
- Vangelis Bontinis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece.
| | - Constantine N Antonopoulos
- Department of Vascular Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Alkis Bontinis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Andreas Koutsoumpelis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Vassilios Zymvragoudakis
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Vasileios Rafailidis
- Department of Radiology, Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Argirios Giannopoulos
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Panagiotis Stoiloudis
- 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki
| | - Kiriakos Ktenidis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
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22
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Zhong YL, Feng JP, Luo H, Gong XH, Wei ZH. Spontaneous internal carotid artery pseudoaneurysm complicated with ischemic stroke in a young man: A case report and review of literature. World J Clin Cases 2022; 10:8025-8033. [PMID: 36158486 PMCID: PMC9372827 DOI: 10.12998/wjcc.v10.i22.8025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/04/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Carotid artery pseudoaneurysm (PSA) is infrequently encountered in clinical settings. Internal carotid artery (ICA) PSA complicated with ischemic stroke is rare. PSAs are typically caused by iatrogenic injury, trauma, or infection. The underlying mechanisms of spontaneous PSA formation are not well characterized. We report a healthy young man who presented with stroke as a complication of spontaneous PSA of the left ICA.
CASE SUMMARY A 30-year-old man working as a ceiling decoration worker was hospitalized due to sudden-onset speech disorder and right lower extremity weakness. Medical history was unremarkable. Brain computed tomography revealed ischemic stroke. Digital subtraction angiography showed a left ICA PSA with mild stenosis. The patient was conservatively managed with oral anticoagulation and antiplatelet therapy. He recovered well and was discharged. The patient was in good condition during follow-up.
CONCLUSION The occupational history of patient should be taken into consideration while evaluating the etiology of spontaneous ICA PSA in young people with stroke.
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Affiliation(s)
- Yu-Lin Zhong
- Department of Ultrasound, The Second Clinical College of Jinan University, Shenzhen People's Hospital, Shenzhen 518020, Guangdong Province, China
- Department of Ultrasound, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen People's Hospital, Shenzhen 518020, Guangdong Province, China
| | - Jia-Ping Feng
- Department of Ultrasound, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen 518035, Guangdong Province, China
- Graduate School, Guangzhou Medical University, Guangzhou 510180, Guangdong Province, China
| | - Hui Luo
- Department of Ultrasound, The Second Clinical College of Jinan University, Shenzhen People's Hospital, Shenzhen 518020, Guangdong Province, China
- Department of Ultrasound, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen People's Hospital, Shenzhen 518020, Guangdong Province, China
| | - Xue-Hao Gong
- Department of Ultrasound, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen 518035, Guangdong Province, China
- Graduate School, Guangzhou Medical University, Guangzhou 510180, Guangdong Province, China
| | - Zhang-Hong Wei
- Department of Ultrasound, The Second Clinical College of Jinan University, Shenzhen People's Hospital, Shenzhen 518020, Guangdong Province, China
- Department of Ultrasound, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen People's Hospital, Shenzhen 518020, Guangdong Province, China
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23
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Marnat G, Sibon I, Bourcier R, Anadani M, Gariel F, Labreuche J, Kyheng M, Mazighi M, Dargazanli C, Piotin M, Consoli A, Blanc R, Anxionnat R, Audibert G, Richard S, Lapergue B, Gory B. Thrombolysis Improves Reperfusion and the Clinical Outcome in Tandem Occlusion Stroke Related to Cervical Dissection: TITAN and ETIS Pooled Analysis. J Stroke 2021; 23:411-419. [PMID: 34649385 PMCID: PMC8521253 DOI: 10.5853/jos.2020.04889] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 09/08/2021] [Indexed: 11/23/2022] Open
Abstract
Background and Purpose Despite the widespread adoption of mechanical thrombectomy (MT) for the treatment of large vessel occlusion stroke (LVOS) in the anterior circulation, the optimal strategy for the treatment tandem occlusion related to cervical internal carotid artery (ICA) dissection is still debated. This individual patient pooled analysis investigated the safety and efficacy of prior intravenous thrombolysis (IVT) in anterior circulation tandem occlusion related to cervical ICA dissection treated with MT.
Methods We performed a retrospective analysis of two merged prospective multicenter international real-world observational registries: Endovascular Treatment in Ischemic Stroke (ETIS) and Thrombectomy In TANdem occlusions (TITAN) registries. Data from MT performed in the treatment of tandem LVOS related to cervical ICA dissection between January 2012 and December 2019 at 24 comprehensive stroke centers were analyzed. The primary endpoint was a favorable outcome defined as 90-day modified Rankin Scale (mRS) score of 0–2.
Results The study included 144 patients with tandem occlusion LVOS due to cervical ICA dissection, of whom 94 (65.3%) received IVT before MT. Prior IVT was significantly associated with a better clinical outcome considering the mRS shift analysis (common odds ratio, 2.59; 95% confidence interval [CI], 1.35 to 4.93; P=0.004 for a 1-point improvement) and excellent outcome (90-day mRS 0–1) (adjusted odds ratio [aOR], 4.23; 95% CI, 1.60 to 11.18). IVT was also associated with a higher rate of intracranial successful reperfusion (83.0% vs. 64.0%; aOR, 2.70; 95% CI, 1.21 to 6.03) and a lower rate of symptomatic intracranial hemorrhage (4.3% vs. 14.8%; aOR, 0.21; 95% CI, 0.05 to 0.80).
Conclusions Prior IVT before MT for the treatment of tandem occlusion related to cervical ICA dissection was safe and associated with an improved 90-day functional outcome.
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Affiliation(s)
- Gaultier Marnat
- Department of Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Igor Sibon
- Department of Neurology, University Hospital of Bordeaux, Bordeaux, France
| | - Romain Bourcier
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Mohammad Anadani
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Florent Gariel
- Department of Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | | | - Maeva Kyheng
- Department of Biostatistics, University of Lille, Lille, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Cyril Dargazanli
- Department of Neuroradiology, CHRU Gui-de-Chauliac, Montpellier, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Arturo Consoli
- Department of Neuroradiology, Foch Hospital, Versailles Saint-Quentin-en-Yvelines University, Suresnes, France
| | - Raphaël Blanc
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - René Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, University of Lorraine, CHRU-Nancy, Nancy, France.,Université de Lorraine, IADI, INSERM U1254, Nancy, France
| | - Gérard Audibert
- Department of Anesthesiology and Intensive Care, University of Lorraine, University Hospital of Nancy, Nancy, France
| | - Sébastien Richard
- Stroke Unit, Department of Neurology, University of Lorraine, University Hospital of Nancy, and INSERM U1116, Nancy, France
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin-en-Yvelines University, Suresnes, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, University of Lorraine, CHRU-Nancy, Nancy, France.,Université de Lorraine, IADI, INSERM U1254, Nancy, France
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- Department of Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
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24
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Debette S, Mazighi M, Bijlenga P, Pezzini A, Koga M, Bersano A, Kõrv J, Haemmerli J, Canavero I, Tekiela P, Miwa K, J Seiffge D, Schilling S, Lal A, Arnold M, Markus HS, Engelter ST, Majersik JJ. ESO guideline for the management of extracranial and intracranial artery dissection. Eur Stroke J 2021; 6:XXXIX-LXXXVIII. [PMID: 34746432 PMCID: PMC8564160 DOI: 10.1177/23969873211046475] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 08/26/2021] [Indexed: 11/15/2022] Open
Abstract
The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of extracranial artery dissection (EAD) and intracranial artery dissection (IAD). EAD and IAD represent leading causes of stroke in the young, but are uncommon in the general population, thus making it challenging to conduct clinical trials and large observational studies. The guidelines were prepared following the Standard Operational Procedure for European Stroke Organisation guidelines and according to GRADE methodology. Our four recommendations result from a thorough analysis of the literature comprising two randomized controlled trials (RCTs) comparing anticoagulants to antiplatelets in the acute phase of ischemic stroke and twenty-six comparative observational studies. In EAD patients with acute ischemic stroke, we recommend using intravenous thrombolysis (IVT) with alteplase within 4.5 hours of onset if standard inclusion/exclusion criteria are met, and mechanical thrombectomy in patients with large vessel occlusion of the anterior circulation. We further recommend early endovascular or surgical intervention for IAD patients with subarachnoid hemorrhage (SAH). Based on evidence from two phase 2 RCTs that have shown no difference between the benefits and risks of anticoagulants versus antiplatelets in the acute phase of symptomatic EAD, we strongly recommend that clinicians can prescribe either option. In post-acute EAD patients with residual stenosis or dissecting aneurysms and in symptomatic IAD patients with an intracranial dissecting aneurysm and isolated headache, there is insufficient data to provide a recommendation on the benefits and risks of endovascular/surgical treatment. Finally, nine expert consensus statements, adopted by 8 to 11 of the 11 experts involved, propose guidance for clinicians when the quality of evidence was too low to provide recommendations. Some of these pertain to the management of IAD (use of IVT, endovascular treatment, and antiplatelets versus anticoagulation in IAD with ischemic stroke and use of endovascular or surgical interventions for IAD with headache only). Other expert consensus statements address the use of direct anticoagulants and dual antiplatelet therapy in EAD-related cerebral ischemia, endovascular treatment of the EAD/IAD lesion, and multidisciplinary assessment of the best therapeutic approaches in specific situations.
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Affiliation(s)
- Stephanie Debette
- Bordeaux Population Health research
center, INSERM U1219, University of Bordeaux, Bordeaux, France
- Department of Neurology and
Institute for Neurodegenerative Diseases, Bordeaux University
Hospital, France
| | - Mikael Mazighi
- Department of Neurology, Hopital Lariboisière, Paris, France
- Interventional Neuroradiology
Department, Hôpital Fondation Ophtalmologique
Adolphe de Rothschild, Paris, France
- Université de Paris, Paris, France
- FHU NeuroVasc, Paris, France
- Laboratory of Vascular Translational
Science, INSERM U1148, Paris, France
| | - Philippe Bijlenga
- Neurosurgery, Département de
Neurosciences Cliniques, Hôpitaux Universitaires et Faculté de
Médecine de Genève, Switzerland
| | - Alessandro Pezzini
- Department of Clinical and
Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Masatoshi Koga
- Department of Cerebrovascular
Medicine, National Cerebral and Cardiovascular
Center, Suita, Osaka, Japan
| | - Anna Bersano
- Fondazione IRCCS Istituto Neurologico
'Carlo Besta', Milano
| | - Janika Kõrv
- Department of Neurology and
Neurosurgery, University of Tartu, Tartu, Estonia
- Department of Neurology, Tartu University
Hospital, Tartu, Estonia
| | - Julien Haemmerli
- Neurosurgery, Département de
Neurosciences Cliniques, Hôpitaux Universitaires et Faculté de
Médecine de Genève, Switzerland
| | | | - Piotr Tekiela
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Kaori Miwa
- Department of Cerebrovascular
Medicine, National Cerebral and Cardiovascular
Center, Suita, Osaka, Japan
| | - David J Seiffge
- University Hospital
Bern, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Sabrina Schilling
- Guidelines Methodologist, European Stroke
Organization, Basel, Switzerland
| | - Avtar Lal
- Guidelines Methodologist, European Stroke
Organization, Basel, Switzerland
| | - Marcel Arnold
- University Hospital
Bern, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Hugh S Markus
- Department of Clinical
Neurosciences, University of Cambridge, Cambridge, UK
| | - Stefan T Engelter
- Department of Neurology and
Stroke Center, University Hospital and University of
Basel, Basel, Switzerland
- Neurology and
Neurorehabilitation, University Department of Geriatric
Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
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25
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Engelter ST, Lyrer P, Traenka C. Cervical and intracranial artery dissections. Ther Adv Neurol Disord 2021; 14:17562864211037238. [PMID: 34408787 PMCID: PMC8366117 DOI: 10.1177/17562864211037238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/19/2021] [Indexed: 12/26/2022] Open
Abstract
This review summarizes recent therapeutic advances in cervical (CeAD) and intracranial artery dissection (IAD) research. Despite unproven benefits, but in the absence of any signal of harm, in patients, with acute ischemic stroke attributable to CeAD, intravenous thrombolysis and, in case of large-vessel occlusion, endovascular revascularization should be considered. Future research will clarify which patients benefit most from either treatment modality. For stroke prevention, the recently published randomized controlled TREAT-CAD study showed that, against the initial hypothesis, aspirin was not shown non-inferior to anticoagulation with vitamin K antagonists (VKAs). With the results of two randomized controlled trials (CADISS and TREAT-CAD) available now, the evidence to consider aspirin as the standard therapy of CeAD is weak. Further analyses might clarify whether the assumption supports, in particular, that patients presenting with cerebral ischemia, clinical or subclinical with magnetic resonance imaging surrogates, might benefit most from VKA treatment. In turn, it remains to be shown, whether in CeAD patients presenting with pure local symptoms and without hemodynamic compromise, antiplatelets are sufficient, and whether a dual antiplatelet therapy during the first weeks of treatment is recommendable. The observation that ischemic strokes occurred (or recurred) very early after CeAD diagnosis, consistently across randomized and observational studies, supports the recommendation to start antithrombotic treatment immediately, whatever antithrombotic agent is chosen in each individual case. The lack of a license for the use in CeAD patients and the paucity of data are still arguments against the use of direct oral anticoagulants in CeAD. Nevertheless, due to their beneficial safety and efficacy profile proven in atrial fibrillation, these agents are a worthwhile treatment option to be tested in further CeAD treatment trials. In IAD, the experience with the use of antithrombotic agents is limited. As the risk of suffering intracranial hemorrhage is higher in IAD than in CeAD, the use of antithrombotic therapy in IAD remains controversial.
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Affiliation(s)
- Stefan T Engelter
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Petersgraben 4, Basel 4031, Switzerland
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26
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Anadani M, Marnat G, Consoli A, Papanagiotou P, Nogueira RG, Siddiqui A, Ribo M, Spiotta AM, Bourcier R, Kyheng M, Labreuche J, de Havenon A, Sibon I, Dargazanli C, Arquizan C, Cognard C, Olivot JM, Anxionnat R, Audibert G, Mazighi M, Blanc R, Lapergue B, Richard S, Gory B. Endovascular Therapy of Anterior Circulation Tandem Occlusions: Pooled Analysis From the TITAN and ETIS Registries. Stroke 2021; 52:3097-3105. [PMID: 34372671 DOI: 10.1161/strokeaha.120.033032] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular therapy for tandem occlusion strokes of the anterior circulation is an effective and safe treatment. The best treatment approach for the cervical internal carotid artery (ICA) lesion is still unknown. In this study, we aimed to compare the functional and safety outcomes between different treatment approaches for the cervical ICA lesion during endovascular therapy for acute ischemic strokes due to tandem occlusion in current clinical practice. METHODS Individual patients' data were pooled from the French prospective multicenter observational ETIS (Endovascular Treatment in Ischemic Stroke) and the international TITAN (Thrombectomy in Tandem Lesions) registries. TITAN enrolled patients from January 2012 to September 2016, and ETIS from January 2013 to July 2019. Patients with acute ischemic stroke due to anterior circulation tandem occlusion who were treated with endovascular therapy were included. Patients were divided based on the cervical ICA lesion treatment into stent and no-stent groups. Outcomes were compared between the two treatment groups using propensity score methods. RESULTS A total of 603 patients were included, of whom 341 were treated with acute cervical ICA stenting. In unadjusted analysis, the stent group had higher rate of favorable outcome (90-day modified Rankin Scale score, 0-2; 57% versus 45%) and excellent outcome (90-day modified Rankin Scale score, 0-1; 40% versus 27%) compared with the no-stent group. In inverse probability of treatment weighting propensity score-adjusted analyses, stent group had higher odds of favorable outcome (adjusted odds ratio, 1.09 [95% CI, 1.01-1.19]; P=0.036) and successful reperfusion (modified Thrombolysis in Cerebral Ischemia score, 2b-3; adjusted odds ratio, 1.19 [95% CI, 1.11-1.27]; P<0.001). However, stent group had higher odds of any intracerebral hemorrhage (adjusted odds ratio, 1.10 [95%, 1.02-1.19]; P=0.017) but not higher rate of symptomatic intracerebral hemorrhage or parenchymal hemorrhage type 2. Subgroup analysis demonstrated heterogeneity according to the lesion type (atherosclerosis versus dissection; P for heterogeneity, 0.01), and the benefit from acute carotid stenting was only observed for patients with atherosclerosis. CONCLUSIONS Patients treated with acute cervical ICA stenting for tandem occlusion strokes had higher odds of 90-day favorable outcome, despite higher odds of intracerebral hemorrhage; however, most of the intracerebral hemorrhages were asymptomatic.
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Affiliation(s)
- Mohammad Anadani
- Department of Neurology, Washington University School of Medicine, St. Louis (M.A., A.d.H.).,Department of Neurosurgery, Medical University of South Carolina, Charleston (A.M.S., M.A.)
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, France. (G.M.)
| | - Arturo Consoli
- Department of Diagnostic and Interventional Neuroradiology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France. (A.C.)
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Germany (P.P.)
| | - Raul G Nogueira
- Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta (R.G.N.)
| | - Adnan Siddiqui
- Department of Neurosurgery, State University of New York, Buffalo (A.S.)
| | - Marc Ribo
- Department of Neurology, Hospital Vall D'Hebron, Barcelona, Spain (M.R.)
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston (A.M.S., M.A.)
| | - Romain Bourcier
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, L'institut du thorax, INSERM 1087, CNRS, Université de Nantes, France (R.B.)
| | - Maeva Kyheng
- University Lille, CHU Lille, EA 2694, Santé Publique: épidémiologie et Qualité des Soins, France (M.K., J.L.)
| | - Julien Labreuche
- University Lille, CHU Lille, EA 2694, Santé Publique: épidémiologie et Qualité des Soins, France (M.K., J.L.)
| | - Adam de Havenon
- Department of Neurology, Washington University School of Medicine, St. Louis (M.A., A.d.H.)
| | - Igor Sibon
- Department of Neurology, Stroke Center, University Hospital of Bordeaux, France. (I.S.)
| | - Cyril Dargazanli
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, Montpellier, France. (C.D.)
| | - Caroline Arquizan
- Department of Neurology, CHRU Gui de Chauliac, Montpellier, France. (C.A.)
| | - Christophe Cognard
- Department of Neuroradiology, University Hospital of Toulouse, France. (C.C.)
| | - Jean-Marc Olivot
- Department of Stroke Unit, Department of Neurology, University Hospital of Toulouse, France. (J.-M.O.)
| | - René Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, France. (R.A., B.G.).,IADI, INSERM U1254, Université de Lorraine, Nancy, France (R.A., B.G.)
| | - Gérard Audibert
- Department of Anesthesiology and Surgical Intensive Care, Université de Lorraine, CHRU-Nancy, France. (G.A.)
| | - Mikaël Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, University of Paris, INSERM U1148, France (M.M., R.B.)
| | - Raphaël Blanc
- Department of Interventional Neuroradiology, Rothschild Foundation, University of Paris, INSERM U1148, France (M.M., R.B.)
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France. (B.L.)
| | - Sébastien Richard
- Stroke Unit, Department of Neurology, Université de Lorraine, CHRU-Nancy, France. (S.R.).,INSERM U1116, CHRU-Nancy, France. (S.R.)
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, France. (R.A., B.G.).,IADI, INSERM U1254, Université de Lorraine, Nancy, France (R.A., B.G.)
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27
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Da Ros V, Scaggiante J, Pitocchi F, Sallustio F, Lattanzi S, Umana GE, Chaurasia B, Bandettini di Poggio M, Toscano G, Rolla Bigliani C, Ruggiero M, Haznedari N, Sgreccia A, Sanfilippo G, Diomedi M, Finocchi C, Floris R. Mechanical thrombectomy in acute ischemic stroke with tandem occlusions: impact of extracranial carotid lesion etiology on endovascular management and outcome. Neurosurg Focus 2021; 51:E6. [PMID: 34198245 DOI: 10.3171/2021.4.focus21111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/07/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Different etiologies of extracranial internal carotid artery steno-occlusive lesions (ECLs) in patients with acute ischemic stroke (AIS) and tandem occlusion (TO) have been pooled together in randomized trials. However, carotid atherosclerosis (CA) and carotid dissection (CD), the two most common ECL etiologies, are distinct nosological entities. The authors aimed to determine if ECL etiology has impacts on the endovascular management and outcome of patients with TO. METHODS A multicenter, retrospective study of prospectively collected data was conducted. AIS patients were included who had TO due to internal CA or CD and ipsilateral M1 middle cerebral artery occlusion and underwent endovascular treatment (EVT). Comparative analyses including demographic data, safety, successful recanalization rates, and clinical outcome were performed according to EVT and ECL etiology. RESULTS In total, 214 AIS patients with TOs were included (77.6% CA related, 22.4% CD related). Patients treated with a retrograde approach were more often functionally independent at 3 months than patients treated with an antegrade approach (OR 0.6, 95% CI 0.4-0.9). Patients with CD-related TOs achieved 90-day clinical independence more often than patients with CA-related TOs (OR 1.4, 95% CI 1.1-2.0). Emergency stenting use was associated with good 3-month clinical outcome only in patients with CA-related TOs (OR 1.4, 95% CI 1.1-2.1). Symptomatic intracranial hemorrhage (sICH) occurred in 10.7% of patients, without differences associated with ECL etiology. CONCLUSIONS ECL etiology impacts both EVT approach and clinical outcome in patients with TOs. Patients with CD-related TO achieved higher 3-month functional independence rates than patients with CA-related TOs. A retrograde approach can be desirable for both CA- and CD-related TOs, and emergency stenting is likely better justified in CA-related TOs.
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Affiliation(s)
- Valerio Da Ros
- 1Department of Biomedicine, Interventional Neuroradiology Unit, University of Rome Tor Vergata, Rome
| | - Jacopo Scaggiante
- 1Department of Biomedicine, Interventional Neuroradiology Unit, University of Rome Tor Vergata, Rome.,13Medical University of South Carolina, Division of Neuroradiology, Charleston, South Carolina
| | - Francesca Pitocchi
- 1Department of Biomedicine, Interventional Neuroradiology Unit, University of Rome Tor Vergata, Rome
| | | | - Simona Lattanzi
- 3Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona
| | - Giuseppe Emmanuele Umana
- 4Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Bipin Chaurasia
- 5Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Monica Bandettini di Poggio
- 6Ospedale Policlinico San Martino, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova
| | | | - Claudia Rolla Bigliani
- 8Department of Diagnostic and Interventional Neuroradiology, Policlinico Universitario San Martino, Genova
| | | | | | - Alessandro Sgreccia
- 10Department of Clinical Neuroradiology and Interventional Neuroradiology, AOU Ospedali Riuniti, Ancona
| | - Giuseppina Sanfilippo
- 11Department of Diagnostic and Interventional Radiology and Neuroradiology, IRCCS Policlinico San Matteo, Pavia
| | - Marina Diomedi
- 12Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy; and
| | - Cinzia Finocchi
- 6Ospedale Policlinico San Martino, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova
| | - Roberto Floris
- 1Department of Biomedicine, Interventional Neuroradiology Unit, University of Rome Tor Vergata, Rome
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28
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Safety and outcome of mechanical thrombectomy in ischaemic stroke related to carotid artery dissection. J Neurol 2021; 269:772-779. [PMID: 34184125 DOI: 10.1007/s00415-021-10656-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/30/2021] [Accepted: 06/09/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The net clinical benefit of mechanical thrombectomy (MT) in patients with anterior circulation ischaemic stroke associated with large vessel occlusion (AIS-LVO) related to carotid artery dissection (CAD) is uncertain. The aim of the study was to investigate the safety and clinical outcomes of patients treated by MT for a CAD-related stroke. METHODS We included consecutive patients with AIS-LVO treated by MT between 1st 2015 and January 1st 2020 at Lille University Hospital. We compared the safety and clinical outcomes, including successful recanalisation, defined as a modified thrombolysis in cerebral infarction (mTICI) ≥ 2b and favourable functional outcome at 3 months (defined as a modified Rankin Scale (mRS) ≤ 2 or equal to pre-stroke), in patients with CAD-related stroke versus patients with other aetiologies. RESULTS We included 1422 patients, among them, 43 patients with CAD-related AIS-LVO were matched to 86 patients with other aetiologies. Procedural complications, sICH (ECASS-3 criteria) and mortality rates were similar in the two groups (OR 0.85, 95% CI 0.21-3.49, p = 0.82; OR 1.54 95% CI 0.33-2.79, p = 0.58; OR 0.18 95% CI 0.02-1.46, p = 0.11, respectively), as well as the rates of intracranial angiographic successful recanalisation and favourable functional outcome (OR 0.67 (95% CI 0.26-1.73, p = 0.41; OR 1.26 (95% CI 0.61-2.64, p = 0.53). In patients with CAD-related stroke, intracranial angiographic success after MT was significantly associated with favourable functional outcome. CONCLUSIONS In patients with AIS-LVO related to CAD, safety profiles and clinical outcomes after MT are similar compared to matched patients with other stroke aetiologies.
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29
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Gigliotti MJ, Sweid A, El Naamani K, Patel N, Cockroft KM, Park C, Kanekar S, Church EW, Tjoumakaris SI, Simon SD. Management of Internal Carotid Artery and Intracranial Anterior Circulation Tandem Occlusion with Stenting versus No Stenting: A Multicenter Study. World Neurosurg 2021; 153:e237-e243. [PMID: 34175489 DOI: 10.1016/j.wneu.2021.06.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tandem occlusion (TO) describes not only occlusion of the middle cerebral artery but a contemporaneous occlusion of the cervical internal carotid artery. There is a paucity of data over whether mechanical thrombectomy (MT) alone, MT with angioplasty, or MT with carotid artery stent placement is superior. We aim to address a gap in the literature comparing carotid stenting with mechanical thrombectomy (CSMT) and carotid angioplasty with mechanical thrombectomy (CAMT) in patients presenting with acute anterior circulation TOs. METHODS This is a multicenter, retrospective study from 2012 to 2020 comparing CSMT and CAMT presenting with acute anterior circulation TOs. Primary outcomes of interest were functional status, perioperative stroke, mortality, and symptomatic intracranial hemorrhage (sICH). A total of 92 patients (66 vs. 26 in CSMT and CAMT, respectively) met inclusion criteria for analysis. RESULTS There was no statistically significant difference in functional outcomes at 90-day follow-up (adjusted odds ratio [aOR] 0.82; 95% confidence interval [CI] 0.20-3.5; P = 0.46). In addition, there was no statistically significant difference in 90-day mortality (aOR 0.361; 95% CI 0.016-2.92; P = 0.532) and perioperative stroke rate (aOR 1.76; 95% CI 0.160-15.6; P = 0.613). However, sICH risk was significantly greater in the stent-treated cohort (aOR 3.94; 95% CI 0.529-37.4; P = 0.003). CONCLUSIONS Functional outcomes, mortality, and perioperative stroke rates do not significantly differ in CSMT and CAMT procedures in the acute setting. However, CSMT-treated patients do appear to have an increased risk of sICH, potentially due to the use of additional antiplatelet agents following stent placement.
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Affiliation(s)
- Michael J Gigliotti
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Neel Patel
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Christian Park
- Department of Radiology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Sangam Kanekar
- Department of Radiology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Ephraim W Church
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | | | - Scott D Simon
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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