Thrombolysis and angioplasty for acute occlusion of intracranial vertebrobasilar arteries. Report of three cases

Acute vertebrobasilar occlusion: current treatment strategies

Acute vertebrobasilar occlusion (VBO) remains a disease with a high mortality. Local intraarterial fibrinolysis (LIF) can reduce the mortality rate from about 90 to 60%. The combined therapy of i.v. Abciximab and i.a. rt-PA with additional PTA/stenting may improve neurological outcome and significantly reduce mortality, despite an increase of overall bleeding complications. Additional PTA/stenting is an important treatment factor in cases of atherothrombotic occlusion. In embolic occlusions, mechanical catheter devices, such as basket or snare devices or rheolytic systems, are promising therapies for the near future. This article describes diagnostic criteria and treatment factors in acute VBO. Different treatment strategies, such as i.v. and i.a. fibrinolysis, adjunctive application of GP IIb/IIIa inhibitors, PTA/stenting and mechanical embolectomy are addressed in detail.

Endovascular Recanalization of the Subacute to Chronically Occluded Basilar Artery

INTRODUCTION

Occlusion of the basilar artery (BA) has a poor prognosis. We evaluated technical considerations and complications associated with reopening subacute to chronically occluded BAs.

METHODS

Duration of BA occlusion before revascularization, symptoms and medical management before treatment, and postprocedural antiplatelet regimen and anticoagulation protocols of 9 patients were analyzed. All patients underwent endovascular low-volume balloon angioplasty followed by Wingspan stenting.

RESULTS

The median time between onset of symptoms and treatment was 5 days (range, 2 days to 3.5 years). The median time between documentation of BA occlusion by cerebral angiography or computed tomography angiography and treatment was 3 days (range, 1 day to 8 months). Recanalization was successful in 8 of the 9 patients. Immediately after the procedure, 4 patients were stable, 3 patients improved, and 2 patients were worse. Four patients had periprocedural complications. Four of the 9 patients died, 2 from periprocedural complications. The mean clinical duration of follow-up was 11 months. At latest follow-up, the modified Rankin Scale scores for the 5 surviving patients were 0, 0, 2, 2, and 3, respectively. During the follow-up period, 4 patients improved, 1 patient remained stable, and 1 patient died. The mean angiographic follow-up was 8.6 months. Two patients developed significant in-stent stenosis during this period.

CONCLUSION

With current endovascular techniques, recanalization of chronically occluded BAs is feasible. The procedure carries substantial risks and should be reserved for patients with medically refractory symptoms. Careful postprocedural medical management and radiographic follow-up are warranted to prevent in-stent restenosis.

Neuroimaging of ischemic stroke with CT and MRI: advancing towards physiology-based diagnosis and therapy

Acute ischemic stroke is the third leading cause of death and the major cause of significant disability in adults in the USA and Europe. The number of patients who are actually treated for acute ischemic stroke is disappointingly low, despite availability of effective treatments. A major obstacle is the short window of time following stroke in which therapies are effective. Modern imaging is able to identify the ischemic penumbra, a key concept in stroke physiology. Evidence is accumulating that identification of a penumbra enhances patient management, resulting in significantly improved outcomes. Moreover, unexpectedly large proportions of patients have a substantial ischemic penumbra beyond the traditional time window and are suitable for therapy. The widespread availability of modern MRI and computed tomography systems presents new opportunities to use physiology to guide ischemic stroke therapy in individual patients. This article suggests an evidence-based alternative to contemporary acute ischemic stroke therapy.

Primary endovascular therapy with clot retrieval and balloon angioplasty for acute basilar artery occlusion

This case report demonstrates that mechanical clot disruption and retrieval may be performed safely and successfully in a child with basilar artery (BA) thrombosis. A 16-year-old boy presented to our institution with locked-in syndrome 20 h after symptom onset. Brain MRI and cerebral angiography findings were consistent with BA occlusion. The child underwent endovascular therapy with clot retrieval followed by balloon angioplasty achieving immediate recanalization and clinical recovery on 3-month follow-up. This case highlights the use of primary neurointerventional devices in children with BA occlusion presenting beyond the conventional therapeutic window for other interventions.

Rescue angioplasty after failed intra-arterial thrombolysis in acute middle cerebral artery stroke: A case report

Intra-arterial thrombolysis is increasingly being used in the treatment of acute ischemic stroke with a failure rate of recanalization as high as 66%. We describe a case of acute ischemic stroke secondary to occlusion of the middle cerebral artery that failed intra-arterial thrombolytic therapy but responded to rescue balloon angioplasty.

Retrospective analysis of neurological outcome after intra-arterial thrombolysis in basilar artery occlusion

BACKGROUND

Basilar artery occlusion usually has a very poor outcome and is associated with a high mortality rate. Local intra-arterial thrombolysis may improve the clinical outcome and reduce mortality in the treatment of acute basilar artery occlusion. We evaluated the possible variables affecting recanalization and clinical outcome in patients with basilar artery occlusions undergoing thrombolytic therapy.

METHODS

We analyzed retrospectively the clinical course and outcome of a series of 26 patients between 1998 and 2001. All patients who were examined within 24 hours after onset of symptoms underwent emergency cerebral angiography and subsequent intra-arterial thrombolysis. Three patients additionally received percutaneous transluminal angioplasty of underlying stenosis at the site of thrombosis.

RESULTS

Outcome was good in 9 patients (34.6%) and poor in 17 (65.4%). Recanalization could be achieved in 24 patients (92.3%) and was not affected by age, sex, site of occlusion, etiology, thrombolytic drugs, or time interval. Good outcome was associated with younger age, good initial clinical condition, and no evidence of brain stem infarction. There was no association between the interval (greater or less than 6 hours) from the onset of symptoms until the end of thrombolysis and survival.

CONCLUSIONS

We confirm that intra-arterial thrombolysis reduces mortality in basilar artery occlusion. Young patients (<75 years) without any infarct in brain stem before the start of treatment seem to be the ideal candidates for thrombolysis. Basilar artery thrombosis could and should be reopened, even late (after 6 hours) after symptom onset.

Successful endovascular therapy for acute basilar thrombosis in an adolescent

Pediatric stroke is an underrecognized, potentially treatable cause of childhood neurologic disease. Acute basilar artery thrombosis is a devastating disease rarely encountered in children. Acute interventions with both chemical and mechanical thrombolysis techniques can improve outcomes in adults with arterial thrombosis of the posterior cerebral circulation. We report a case of intervention with both intra-arterial alteplase (tissue plasminogen activator) and cerebral balloon angioplasty to treat a prolonged basilar artery occlusion secondary to idiopathic thrombosis in an adolescent. Despite the patient being clinically locked-in and intervention being delayed at least 20 hours from symptom onset, he obtained complete neurologic recovery. Issues of pediatric stroke, late therapeutic intervention, chemical thrombolysis, and cerebral angioplasty are discussed. This case highlights the underrecognition and subsequent delay in diagnosis of pediatric stroke and how acute intervention may cure otherwise catastrophic strokes in children.

Cerebrovascular angioplasty and stenting for the prevention of stroke

Until recently, stroke preventive strategies have focused on either medical regimens aimed at antagonizing or reversing atherosclerosis, or surgical intervention for revascularization of the cerebrovascular system. However, with the advent of rapidly emerging microcatheterization techniques and technology, endovascular surgical revascularization of the brain is rapidly emerging as a powerful therapeutic modality. In particular, significant advances already have been made in revascularization of the extracranial carotid artery and many common anatomic sites of intracranial athero-occlusive disease, using special adaptations of conventional percutaneous angioplasty and stenting techniques. This paper reviews the cumulative experience with these emerging techniques, with a particular emphasis on clinical outcomes and future directions. It also reports the substantial cumulative institutional experience of the authors over the past 18 months with both extracranial carotid and intracranial artery stent-assisted carotid angioplasty.

Imaging and interventional neuroradiology

Technical innovations in neuroimaging have improved diagnosis and prognosis, whereas developments in interventional neuroradiology have extended the range of therapy to different patient populations. These changes in service demand the identification of those clinical and technical factors distinguishing feasibility from futility, in order to increase population efficiency and reduce the harm associated with inappropriate therapy.

Intra-arterial thrombolysis for vertebrobasilar circulation ischemia

Acute basilar artery occlusion is usually associated with a poor prognosis despite therapy with antiplatelet and anticoagulant agents. The natural history of this disorder should be fully understood before clinicians make decisions on therapy. Recent advances in angiography technique and the use of newer mobile microcatheters have made intra-arterial thrombolysis therapy feasible. There have been several small, uncontrolled series of intra-arterial thrombolysis in basilar artery occlusion with promising results.

Superiority of platelet integrin GPIIb-IIIa receptor antagonist over aspirin in preventing cyclic flow reductions in the guinea pig middle cerebral artery

We established a photothrombotic occlusion model in the guinea pig middle cerebral artery. In this model, the middle cerebral artery was recanalized within 10 to 20 min after thrombotic occlusion, with subsequent cyclic flow reductions. Cyclic flow reductions in the middle cerebral artery are expected to manage cerebral infarction by modulating arterial patency. Therefore, we evaluated the effect of several antiplatelet agents on the frequency of cyclic flow reductions and subsequent cerebral infarction using this model. A platelet integrin GPIIb-IIIa receptor antagonist, ME3277 (sodium hydrogen [4-[(4,5,6,7-tetrahydrothieno[3,2c]pyridin-2-yl) carbonylamino] acetyl-o-phenylene] dioxydiacetate, 0.3, 1 and 3 mg/kg i.v.) dose-dependently inhibited the ex vivo platelet aggregation induced by ADP (5 microM), collagen (0.8 and 20 microg/ml) and arachidonic acid (100 microM). While the same doses of ME3277 reduced the frequency of the cyclic flow reductions and increased the total patency time of the middle cerebral artery, time to thrombotic occlusion was prolonged only at the highest dose, 3 mg/kg. ME3277 (0.3-3 mg/kg) significantly reduced the infarct volume and improved the neurological deficit at 24 h. In contrast, aspirin (30 mg/kg) did not affect these variables in spite of complete inhibition of platelet aggregation induced by arachidonic acid and collagen (0.8 microg/ml). A thromboxane A2 synthetase inhibitor, sodium ozagrel, significantly increased the total patency time and reduced the infarct volume at 30 mg/kg. Inhibition of prostaglandin I2 generation could explain the effectiveness of sodium ozagrel but not aspirin in this model. These results suggest that platelet integrin GPIIb-IIIa receptor antagonists are more beneficial than aspirin for the treatment of cerebral thrombosis.

Increased cerebral infarction by cyclic flow reductions: studies in the guinea pig MCA thrombosis model

We have developed a photochemical model of thrombotic middle cerebral artery (MCA) occlusion in the guinea pig for investigating factors contributing to the development of cerebral infarction. In this model, cyclic flow reductions (CFRs) after recanalization of the MCA are a common observation and might contribute to the development of cerebral infarction. Therefore, we sought to measure the time course of recanalization of the guinea pig MCA after the artery had been occluded by a thrombus. Thrombotic occlusion of the MCA was induced by photochemical reaction between intravenously administered rose bengal and transluminal green light for 10, 15, 20, or 30 min. After the thrombotic occlusion of MCA and subsequent spontaneous thrombolysis, blood flow in the MCA gradually recovered to preocclusion level but with frequent CFRs. The recovery of MCA blood flow or duration of CFRs was dependent on the duration of photochemical reaction (extent of endothelial injury); thus, for a 30-min photochemical reaction, CFRs were still observed 24 h after photochemical reaction. In separate experiments, we also investigated the effect of permanent occlusion of the MCA, which was induced by electrocoagulation in the vessel on cerebral infarction. The infarct volume in the permanent occlusion model was smaller than the maximum value in the thrombotic occlusion model (12.5 vs. 17.4%; P < 0.05, n = 6). CFRs may constitute an important factor contributing to the extent of cerebral infarction.