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Canals P, Garcia-Tornel A, Requena M, Jabłońska M, Li J, Balocco S, Díaz O, Tomasello A, Ribo M. Deep learning-based model for difficult transfemoral access prediction compared with human assessment in stroke thrombectomy. J Neurointerv Surg 2024:jnis-2024-021718. [PMID: 38702182 DOI: 10.1136/jnis-2024-021718] [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: 03/15/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND In mechanical thrombectomy (MT), extracranial vascular tortuosity is among the main determinants of procedure duration and success. Currently, no rapid and reliable method exists to identify the anatomical features precluding fast and stable access to the cervical vessels. METHODS A retrospective sample of 513 patients were included in this study. Patients underwent first-line transfemoral MT following anterior circulation large vessel occlusion stroke. Difficult transfemoral access (DTFA) was defined as impossible common carotid catheterization or time from groin puncture to first carotid angiogram >30 min. A machine learning model based on 29 anatomical features automatically extracted from head-and-neck computed tomography angiography (CTA) was developed to predict DTFA. Three experienced raters independently assessed the likelihood of DTFA on a reduced cohort of 116 cases using a Likert scale as benchmark for the model, using preprocedural CTA as well as automatic 3D vascular segmentation separately. RESULTS Among the study population, 11.5% of procedures (59/513) presented DTFA. Six different features from the aortic, supra-aortic, and cervical regions were included in the model. Cross-validation resulted in an area under the receiver operating characteristic (AUROC) curve of 0.76 (95% CI 0.75 to 0.76) for DTFA prediction, with high sensitivity for impossible access identification (0.90, 95% CI 0.81 to 0.94). The model outperformed human assessment in the reduced cohort [F1-score (95% CI) by experts with CTA: 0.43 (0.37 to 0.50); experts with 3D segmentation: 0.50 (0.46 to 0.54); and model: 0.70 (0.65 to 0.75)]. CONCLUSIONS A fully automatic model for DTFA prediction was developed and validated. The presented method improved expert assessment of difficult access prediction in stroke MT. Derived information could be used to guide decisions regarding arterial access for MT.
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Affiliation(s)
- Pere Canals
- Stroke Unit, Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Manuel Requena
- Stroke Unit, Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
- Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Magda Jabłońska
- Stroke Unit, Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
- 2nd Department of Radiology, Medical University of Gdansk, Gdansk, Poland
| | - Jiahui Li
- Stroke Unit, Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Simone Balocco
- Department of Mathematics and Computer Science, University of Barcelona, Barcelona, Spain
- Computer Vision Center, Barcelona, Spain
| | - Oliver Díaz
- Department of Mathematics and Computer Science, University of Barcelona, Barcelona, Spain
- Computer Vision Center, Barcelona, Spain
| | | | - Marc Ribo
- Stroke Unit, Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
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Salihu A, Rotzinger DC, Fahrni G, Nowacka A, Antiochos P, Fournier S, Muller O, Kirsch M, Lu H. Transcarotid vascular access for transcatheter aortic valve implantation: is choosing the left side always right? J Cardiothorac Surg 2024; 19:196. [PMID: 38600556 PMCID: PMC11008044 DOI: 10.1186/s13019-024-02661-7] [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] [Accepted: 03/20/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND The transcarotid (TC) vascular access for transcatheter aortic valve implantation (TAVI) has emerged as the first-choice alternative to the transfemoral access, in patients unsuitable for the latter. The use of both the left and right common carotid arteries (CCAs) for TC-TAVI has been described, but the optimal side is subject to debate. We conducted this pilot study to compare the level of vessel tortuosity and plaque burden from either the left CCA to the aortic annulus, or the right CCA to the aortic annulus, considering them as surrogates for technical and procedural complexity. METHODS Consecutive patients who underwent TC-TAVI between 2018 and 2021 in our institution were included. Using three-dimensional reconstruction, pre-TAVI neck and chest computed tomography angiography exams were reviewed to assess the tortuosity index (TI), sum of angles metric, as well as plaque burden, between each CCA and the aortic annulus. RESULTS We included 46 patients who underwent TC-TAVI. No significant difference regarding the mean TIs between the left and right sides (respectively 1.20 and 1.19, p = 0.82), the mean sum of angles (left side: 396°, right side: 384°, p = 0.27), and arterial plaque burden (arterial plaque found in 30% of left CCAs and 45% of right CCAs, p = 0.19) was found. CONCLUSIONS We found no convincing data favoring the use of one particular access side over the other one. The choice of the CCA side in TC-TAVI should to be made on a case-by-case basis, in a multidisciplinary fashion, and may also depend on the operators' experience.
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Affiliation(s)
- Adil Salihu
- Division of Cardiology, Lausanne University Hospital and University Hospital, Rue du Bugnon 46, Lausanne, 1011, Switzerland
| | - David C Rotzinger
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University Hospital, Lausanne, 1011, Switzerland
| | - Guillaume Fahrni
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University Hospital, Lausanne, 1011, Switzerland
| | - Anna Nowacka
- Division of Cardiovascular Surgery, Lausanne University Hospital and University Hospital, Lausanne, 1011, Switzerland
| | - Panagiotis Antiochos
- Division of Cardiology, Lausanne University Hospital and University Hospital, Rue du Bugnon 46, Lausanne, 1011, Switzerland
| | - Stephane Fournier
- Division of Cardiology, Lausanne University Hospital and University Hospital, Rue du Bugnon 46, Lausanne, 1011, Switzerland
| | - Olivier Muller
- Division of Cardiology, Lausanne University Hospital and University Hospital, Rue du Bugnon 46, Lausanne, 1011, Switzerland
| | - Matthias Kirsch
- Division of Cardiovascular Surgery, Lausanne University Hospital and University Hospital, Lausanne, 1011, Switzerland
| | - Henri Lu
- Division of Cardiology, Lausanne University Hospital and University Hospital, Rue du Bugnon 46, Lausanne, 1011, Switzerland.
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Hoshino T, Sato S, Kushi K, Tanaka Y, Mochizuki T, Ishikawa T, Shima S, Ryu B, Inoue T, Okada Y, Niimi Y. Tortuosity of middle cerebral artery M1 segment and outcomes after mechanical thrombectomy. Interv Neuroradiol 2024; 30:154-162. [PMID: 35656743 PMCID: PMC11095343 DOI: 10.1177/15910199221104922] [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: 02/25/2022] [Revised: 05/04/2022] [Accepted: 05/15/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND We aimed to quantify the tortuosity of the middle cerebral artery (MCA) and assess its effects on radiological and clinical outcomes in patients with acute MCA occlusions who received mechanical thrombectomy (MT). METHODS This retrospective study enrolled 53 patients with acute ischemic stroke due to MCA M1 or M2 segment occlusion who underwent MT using stent retrievers (SRs). Tortuosity index (TI) was defined to quantify the tortuosity of the MCA M1 segment using the following formula: (actual distance / straight distance) × 100. For each patient, four TIs were measured in the anteroposterior and caudal views for both ipsilateral and contralateral sides to the occluded site (TI-APi, TI-APc, TI-CAUi, and TI-CAUc, respectively) using magnetic resonance angiography (MRA) or computed tomography angiography (CTA). We defined the first-pass effect (FPE) as first-pass mTICI classification ≥2b reperfusion. RESULTS Patients who did not achieve FPE had significantly higher TI-APi (112 vs. 106; P = 0.004), TI-APc (111 vs. 105; P = 0.005), TI-CAUi (110 vs. 105; P = 0.002), and TI-CAUc (110 vs. 105; P = 0.001) than those who achieved FPE. In multivariable analysis, higher TI-APi, TI-CAUi, and TI-APc were independently associated with an increased rate of unsuccessful FPE (odds ratio (OR) [95% confidence interval (CI)]: 1.25 [1.02-1.61], 1.21 [1.01-1.45], and 1.27 [1.03-1.73], respectively). TI-CAUi, TI-APc, and TI-CAUc were also independent predictors of the occurrence of intracranial hemorrhage after MT (OR [95% CI]: 1.15 [1.01-1.38], 1.14 [1.01-1.38], 1.25 [1.02-1.52], respectively). CONCLUSIONS The TIs of the MCA M1 segment on both ipsilateral and contralateral sides were associated with unfavourable outcomes after MT.
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Affiliation(s)
- Takao Hoshino
- Department of Neuroendovascular Therapy, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurology, Tokyo Women's Medical University, Tokyo, Shinjuku-ku, Tokyo, Japan
| | - Shinsuke Sato
- Department of Neuroendovascular Therapy, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Kazuki Kushi
- Department of Neuroendovascular Therapy, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Yukiko Tanaka
- Department of Neuroendovascular Therapy, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Tatsuki Mochizuki
- Department of Neuroendovascular Therapy, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Tomomi Ishikawa
- Department of Neuroendovascular Therapy, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Shogo Shima
- Department of Neuroendovascular Therapy, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Bikei Ryu
- Department of Neuroendovascular Therapy, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Tatsuya Inoue
- Department of Neuroendovascular Therapy, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Yoshikazu Okada
- Department of Neurosurgery, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Yasunari Niimi
- Department of Neuroendovascular Therapy, St Luke's International Hospital, Chuo-ku, Tokyo, Japan
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Dreyfus R, Boehler Q, Lyttle S, Gruber P, Lussi J, Chautems C, Gervasoni S, Berberat J, Seibold D, Ochsenbein-Kölble N, Reinehr M, Weisskopf M, Remonda L, Nelson BJ. Dexterous helical magnetic robot for improved endovascular access. Sci Robot 2024; 9:eadh0298. [PMID: 38354258 DOI: 10.1126/scirobotics.adh0298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 01/17/2024] [Indexed: 02/16/2024]
Abstract
Treating vascular diseases in the brain requires access to the affected region inside the body. This is usually accomplished through a minimally invasive technique that involves the use of long, thin devices, such as wires and tubes, that are manually maneuvered by a clinician within the bloodstream. By pushing, pulling, and twisting, these devices are navigated through the tortuous pathways of the blood vessels. The outcome of the procedure heavily relies on the clinician's skill and the device's ability to navigate to the affected target region in the bloodstream, which is often inhibited by tortuous blood vessels. Sharp turns require high flexibility, but this flexibility inhibits translation of proximal insertion to distal tip advancement. We present a highly dexterous, magnetically steered continuum robot that overcomes pushability limitations through rotation. A helical protrusion on the device's surface engages with the vessel wall and translates rotation to forward motion at every point of contact. An articulating magnetic tip allows for active steerability, enabling navigation from the aortic arch to millimeter-sized arteries of the brain. The effectiveness of the magnetic continuum robot has been demonstrated through successful navigation in models of the human vasculature and in blood vessels of a live pig.
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Affiliation(s)
- R Dreyfus
- Multi-Scale Robotics Lab, ETH Zurich, Zurich, Switzerland
| | - Q Boehler
- Multi-Scale Robotics Lab, ETH Zurich, Zurich, Switzerland
| | - S Lyttle
- Multi-Scale Robotics Lab, ETH Zurich, Zurich, Switzerland
| | - P Gruber
- Department of Neuroradiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - J Lussi
- Multi-Scale Robotics Lab, ETH Zurich, Zurich, Switzerland
| | - C Chautems
- Multi-Scale Robotics Lab, ETH Zurich, Zurich, Switzerland
| | - S Gervasoni
- Multi-Scale Robotics Lab, ETH Zurich, Zurich, Switzerland
| | - J Berberat
- Department of Neuroradiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - D Seibold
- Multi-Scale Robotics Lab, ETH Zurich, Zurich, Switzerland
| | - N Ochsenbein-Kölble
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
- Institute of Pathology and Molecular Pathology, University of Zurich, Zurich, Switzerland
| | - M Reinehr
- University of Zurich, Zurich, Switzerland
| | - M Weisskopf
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - L Remonda
- Department of Neuroradiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - B J Nelson
- Multi-Scale Robotics Lab, ETH Zurich, Zurich, Switzerland
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Guo L, Yang L, Li C, Zeng Y, Xu R, Wang Z, Jiang C. The clinical outcome of emergency superficial temporal artery-to-middle cerebral artery bypass in acute ischemic stroke with large vessel occlusion. Neurosurg Rev 2024; 47:25. [PMID: 38163848 PMCID: PMC10758367 DOI: 10.1007/s10143-023-02257-0] [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: 07/12/2023] [Revised: 11/27/2023] [Accepted: 12/18/2023] [Indexed: 01/03/2024]
Abstract
The role of superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass in acute ischemic stroke (AIS) is contentious, with no evidence in patients with AIS and large vessel occlusion (AIS-LVO). We conducted a cohort study to assess emergency STA-MCA outcomes in AIS-LVO and a meta-analysis to evaluate STA-MCA outcomes in early AIS treatment. From January 2018 to March 2021, we consecutively recruited newly diagnosed AIS-LVO patients, dividing them into STA-MCA and non-STA-MCA groups. To evaluate the neurological status and outcomes, we employed the National Institutes of Health Stroke Scale (NIHSS) during the acute phase and the modified Rankin Scale (mRS) during the follow-up period. Additionally, we conducted a meta-analysis encompassing all available clinical studies to assess the impact of STA-MCA on patients with AIS. In the cohort study (56 patients), we observed more significant neurological improvement in the STA-MCA group at two weeks (p = 0.030). However, there was no difference in the clinical outcomes between the two groups. Multivariable logistic regression identified the NIHSS at two weeks (OR: 0.840; 95% CI: 0.754-0.936, p = 0.002) as the most critical predictor of a good outcome. Our meta-analysis of seven studies indicated a 67% rate for achieving a good outcome (mRS < 3) at follow-up points (95% CI: 57%-77%, I2 = 44.1%). In summary, while the meta-analysis suggested the potential role of STA-MCA bypass in mild to moderate AIS, our single-center cohort study indicated that STA-MCA bypass does not seem to improve the prognosis of patients who suffer from AIS-LVO.
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Affiliation(s)
- Lei Guo
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Li Yang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Chunling Li
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Yi Zeng
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Ruxiang Xu
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Zhengyu Wang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
| | - Chonggui Jiang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China.
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Webb M, Essibayi MA, Al Kasab S, Maier IL, Psychogios MN, Grossberg JA, Alawieh A, Wolfe SQ, Arthur A, Dumont T, Kan P, Kim JT, De Leacy R, Osbun J, Rai A, Jabbour P, Park MS, Crosa R, Levitt MR, Polifka A, Yoshimura S, Matouk C, Williamson RW, Fragata I, Chowdhry SA, Starke RM, Samaniego EA, Cuellar H, Spiotta A, Mascitelli J. Predictors of Angiographic Outcome After Failed Thrombectomy for Large Vessel Occlusion: Insights from the Stroke Thrombectomy and Aneurysm Registry. Neurosurgery 2023; 93:1168-1179. [PMID: 37377425 DOI: 10.1227/neu.0000000000002560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 04/17/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Mechanical thrombectomy failure (MTF) occurs in approximately 15% of cases. OBJECTIVE To investigate factors that predict MTF. METHODS This was a retrospective review of prospectively collected data from the Stroke Thrombectomy and Aneurysm Registry. Patients who underwent mechanical thrombectomy (MT) for large vessel occlusion (LVO) were included. Patients were categorized by mechanical thrombectomy success (MTS) (≥mTICI 2b) or MTF ( RESULTS A total of 6780 patients were included, and 1001 experienced anterior circulation MTF. Patients in the MTF group were older (73 vs 72, P = .044) and had higher poor premorbid modified Rankin Scale (mRS) (10.8% vs 8.4%, P = .017). Onset to puncture time was greater in the MTF group (273 vs 260 min, P = .08). No significant differences were found between the access site, use of balloon guide catheter, frontline technique, or first-pass devices between the MTF and MTS groups. More complications occurred in the MTF group (14% vs 5.8%), including symptomatic intracerebral hemorrhage (9.4% vs 6.1%) and craniectomies (10% vs 2.8%) ( P < .001). On UVA, age, poor pretreatment mRS, increased number of passes, and increased procedure time were associated with MTF. Internal carotid artery, M1, and M2 occlusions had decreased odds of MTF. Poor preprocedure mRS, number of passes, and procedure time remained significant on MVA. A subgroup analysis of posterior circulation LVO revealed that number of passes and total procedure time correlated with increased odds of MTF ( P < .001) while rescue stenting was associated with less odds of MTF (odds ratio 0.20, 95% CI 0.06-0.63). Number of passes remained significant on MVA of posterior circulation occlusion subgroup analysis. CONCLUSION Anterior circulation MTF is associated with more complications and worse outcomes. No differences were found between techniques or devises used for the first pass during MT. Rescue intracranial stenting may decrease the likelihood of MTF for posterior circulation MT.
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Affiliation(s)
- Matthew Webb
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
| | | | - Sami Al Kasab
- Medical University of South Carolina, Charleston , South Carolina , USA
| | - Ilko L Maier
- University Medical Center Göttingen, Göttingen , Germany
| | | | | | | | | | - Adam Arthur
- University of Tennessee Health Science Center, Memphis , Tennessee , USA
| | - Travis Dumont
- Bannner University of Arizona Medical Center, Tucson , Arizona , USA
| | - Peter Kan
- University of Texas Medical Branch, Galveston , Texas , USA
| | - Joon-Tae Kim
- Chonnam National University Hospital, Gwangju , South Korea
| | | | - Joshua Osbun
- Washington University in St. Louis, St. Louis , Missouri , USA
| | - Ansaar Rai
- Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Pascal Jabbour
- Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Min S Park
- Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Roberto Crosa
- University of Virginia, Charlottesville , Virginia , USA
| | - Michael R Levitt
- Centro Endovascular Neurológico, Médica Uruguaya, Montevideo , Uruguay
| | - Adam Polifka
- University of Washington, Seattle , Washington , USA
| | | | | | | | - Isabel Fragata
- Allegheny General Hospital, Pittsburgh , Pennsylvania , USA
| | | | - Robert M Starke
- NorthShore University Health System, Evanston , Illinois , USA
| | | | | | - Alejandro Spiotta
- Medical University of South Carolina, Charleston , South Carolina , USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
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7
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Russo R, Mistretta F, Molinaro S, Bergui M. 5F SOFIA intermediate catheter in the treatment of acute ischemic stroke: A retrospective observational study. Interv Neuroradiol 2023; 29:583-588. [PMID: 35929099 PMCID: PMC10549712 DOI: 10.1177/15910199221118145] [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: 06/10/2022] [Revised: 07/08/2022] [Accepted: 07/17/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND We herein report our experience with the 5F SOFIA (Soft Torqueable catheter Optimized for Intracranial Access) intermediate catheter for endovascular treatment of patients with acute ischemic stroke (AIS) both in distal middle vessel occlusions (DMVOs) and in large vessel occlusions (LVOs) with unfavorable anatomy. METHODS Records of forty-seven patients undergoing endovascular thrombectomy with 5F SOFIA between September 2020 and March 2022 were retrospectively reviewed. Patients' demographic data, clinical presentation, treatment details, and complications were recorded from the medical record. The primary outcomes were successful revascularization (modified treatment in cerebral ischemia, mTICI ≥2b) and good clinical outcome at 3 months (modified rankin scale, mRS 0-2). Secondary outcomes were complication rates and switch to alternative techniques. Our institutional review board approved this study. RESULTS Forty-seven patients with AIS treated with 5F SOFIA were examined. In eighteen (38%) cases the occlusion was located on a large vessel while in 29 (61.7%) on a distal-medium vessels. Median national institutes of health strokes scale (NIHSS) score was 16 at admission. Successful revascularization to mTICI 2b-3 was achieved in 14 of 18 patients (77.7%) with LVOs and in 24/29 cases with DMVOs (82.7%) respectively. mRS score 0-2 at three months (3 months-mRS 0-2) was 66.6% for LVOs and 68.9% in DMVOs respectively. Symptomatic intracranial hemorrhage (SICH) occurred in 2 (4.2%) patients. CONCLUSION 5F SOFIA intermediate catheter could be a safe and effective treatment for AIS and a viable alternative to 6 F conventional intermediate catheters in selected cases.
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Affiliation(s)
- Riccardo Russo
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Francesco Mistretta
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Stefano Molinaro
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Mauro Bergui
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
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8
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Nageler G, Gergel I, Fangerau M, Breckwoldt M, Seker F, Bendszus M, Möhlenbruch M, Neuberger U. Deep Learning-based Assessment of Internal Carotid Artery Anatomy to Predict Difficult Intracranial Access in Endovascular Recanalization of Acute Ischemic Stroke. Clin Neuroradiol 2023; 33:783-792. [PMID: 36928398 PMCID: PMC10449951 DOI: 10.1007/s00062-023-01276-0] [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: 07/14/2022] [Accepted: 02/03/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Endovascular thrombectomy (EVT) duration is an important predictor for neurological outcome. Recently it was shown that an angle of ≤ 90° of the internal carotid artery (ICA) is predictive for longer EVT duration. As manual angle measurement is not trivial and time-consuming, deep learning (DL) could help identifying difficult EVT cases in advance. METHODS We included 379 CT angiographies (CTA) of patients who underwent EVT between January 2016 and December 2020. Manual segmentation of 121 CTAs was performed for the aortic arch, common carotid artery (CCA) and ICA. These were used to train a nnUNet. The remaining 258 CTAs were segmented using the trained nnUNet with manual verification afterwards. Angles of left and right ICAs were measured resulting in two classes: acute angle ≤ 90° and > 90°. The segmentations together with angle measurements were used to train a convolutional neural network (CNN) determining the ICA angle. The performance was evaluated using Dice scores. The classification was evaluated using AUC and accuracy. Associations of ICA angle and procedural times was explored using median and Whitney‑U test. RESULTS Median EVT duration for cases with ICA angle > 90° was 48 min and with ≤ 90° was 64 min (p = 0.001). Segmentation evaluation showed Dice scores of 0.94 for the aorta and 0.86 for CCA/ICA, respectively. Evaluation of ICA angle determination resulted in an AUC of 0.92 and accuracy of 0.85. CONCLUSION The association between ICA angle and EVT duration could be verified and a DL-based method for semi-automatic assessment with the potential for full automation was developed. More anatomical features of interest could be examined in a similar fashion.
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Affiliation(s)
- Gregor Nageler
- Dept. of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- mbits imaging GmbH, Heidelberg, Germany
| | | | | | - Michael Breckwoldt
- Dept. of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Fatih Seker
- Dept. of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Martin Bendszus
- Dept. of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Markus Möhlenbruch
- Dept. of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Ulf Neuberger
- Dept. of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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Memon MZ, Ezzeldin M, Biswas A, Ahmad R, Nisar T, Singla A, Muhammad N, Shaltoni H, Kan P, Zaidat OO, Khandelwal P. Novel technique of stent placement via gateway balloon in intracranial atherosclerosis-associated large vessel occlusion. J Neuroimaging 2023; 33:773-780. [PMID: 37391866 DOI: 10.1111/jon.13139] [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: 03/12/2023] [Revised: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND AND PURPOSE Neuroform Atlas stent can be deployed directly via gateway balloon for angioplasty and stent placement without the need for exchange maneuver required for Wingspan stent use. We present our initial experience of this strategy in intracranial atherosclerosis-associated large vessel occlusions. METHODS Patients were identified through mechanical thrombectomy (MT) database from January 2020 to June 2022 at our institutions. Due to reocclusion or impending occlusion, rescue angioplasty with stent placement was performed after initial standard MT. Primary outcomes were good angiographic recanalization with modified thrombolysis in cerebral infarction (mTICI) score of 2b-3, rate of intracranial hemorrhage (ICH), and favorable functional outcome at 3 months, that is, modified Rankin Scale (mRS) score of 0-3. RESULTS We identified 22 patients treated using this technique. Among those, 11 were females with their average age at 66 years (range: 52-85). Initial median National Institute of Health Stroke Scale score was 11 (range: 5-30) and all patients received loading doses of aspirin and P2Y₁₂ inhibitor. After performing submaximal angioplasty and Neuroform Atlas stent deployment through the gateway balloon, we achieved final mTICI of 2b-3 in 20 (90%) patients. One patient had ICH post-op that was asymptomatic. Eight (36%) patients had mRS of 0-3 at 90 days. CONCLUSION Our preliminary experience suggests possible safety and feasibility of deploying Neuroform Atlas stent through a compatible Gateway balloon microcatheter without the need for ICH-associated microcatheter exchange. Further studies with long-term clinical and angiographic follow-up are warranted to corroborate our initial findings.
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Affiliation(s)
- Muhammad Zeeshan Memon
- Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Mohamad Ezzeldin
- Department of Clinical Sciences, College of Medicine, University of Houston, Houston, Texas, USA
| | - Arundhati Biswas
- Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - Rowaid Ahmad
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Taha Nisar
- Department of Neurology, University of South Alabama
| | - Amit Singla
- Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - Nazar Muhammad
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Hashem Shaltoni
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Peter Kan
- Department of Neurology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Osama O Zaidat
- Departments of Endovascular Neurosurgery and Stroke, St. Vincent Mercy Medical Center, Toledo, Ohio, USA
| | - Priyank Khandelwal
- Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
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Bala F, Cimflova P, Singh N, Zhang J, Kappelhof M, Kim BJ, Najm M, Golan R, Elebute I, Benali F, Terreros NA, Marquering H, Majoie C, Almekhlafi M, Goyal M, Hill MD, Qiu W, Menon BK. Impact of vessel tortuosity and radiological thrombus characteristics on the choice of first-line thrombectomy strategy: Results from the ESCAPE-NA1 trial. Eur Stroke J 2023; 8:675-683. [PMID: 37345551 PMCID: PMC10472967 DOI: 10.1177/23969873231183766] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/05/2023] [Indexed: 06/23/2023] Open
Abstract
INTRODUCTION Despite improvements in device technology, only one-third of stroke patients undergoing endovascular thrombectomy (EVT) achieve first-pass effect (FPE). We investigated the effect of arterial tortuosity and thrombus characteristics on the relationship between first-line EVT strategy and angiographic outcomes. PATIENTS AND METHODS Patients with thin-slice baseline CT-angiography from the ESCAPE-NA1 trial (Efficacy and safety of nerinetide for the treatment of acute ischemic stroke) were included. Tortuosity was estimated using the tortuosity index extracted from catheter pathway, and radiological thrombus characteristics were length, non-contrast density, perviousness and hyperdense artery sign. We assessed the association of first-line EVT strategy (stent-retriever [SR] versus contact aspiration [CA] versus combined SR+CA) with FPE (eTICI score 2c/3 after one pass), final eTICI 2b/3, number of passes and procedure duration using multivariable regression. Interaction of tortuosity and thrombus characteristics with first-line technique were assessed using interaction terms. RESULTS Among 520 included patients, SR as a first-line modality was used in 165 (31.7%) patients, CA in 132 (25.4%), and combined SR+CA in 223 (42.9%). FPE was observed in 166 patients (31.9%). First-line strategy was not associated with FPE. Tortuosity had a significant effect on FPE only in the CA group (aOR = 0.90 [95% CI 0.83-0.98]) compared with stent-retrievers and combined first-line approach (p interaction = 0.03). There was an interaction between thrombus length and first-line strategy for number of passes (p interaction = 0.04). Longer thrombi were associated with higher number of passes only in the CA group (acOR 1.03 [95% CI 1.00-1.06]). CONCLUSION Our study suggests that vessel tortuosity and longer thrombi may negatively affect the performance of first-line contact aspiration catheters in acute stroke patients undergoing EVT.
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Affiliation(s)
- Fouzi Bala
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, France
| | - Petra Cimflova
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Department of Medical Imaging, St Anne’s University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Jianhai Zhang
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Mohamed Najm
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Rotem Golan
- Circle Neurovascular Imaging Inc., Calgary, AB, Canada
| | | | - Faysal Benali
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Department of Radiology & Nuclear Medicine, Maastricht University Medical Center+ MUMC+, Maastricht, The Netherlands
| | - Nerea Arrarte Terreros
- Department of Radiology and Nuclear Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Henk Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Wu Qiu
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- School of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Bijoy K Menon
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
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11
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Faizy TD, Broocks G, Heit JJ, Kniep H, Flottmann F, Meyer L, Sporns P, Hanning U, Kaesmacher J, Deb-Chatterji M, Vollmuth P, Lansberg MG, Albers GW, Fischer U, Wintermark M, Thomalla G, Fiehler J, Winkelmeier L. Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion. JAMA Netw Open 2023; 6:e2310213. [PMID: 37126350 PMCID: PMC10152307 DOI: 10.1001/jamanetworkopen.2023.10213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Importance Clinical evidence of the potential treatment benefit of intravenous thrombolysis preceding unsuccessful mechanical thrombectomy (MT) is scarce. Objective To determine whether intravenous thrombolysis (IVT) prior to unsuccessful MT improves functional outcomes in patients with acute ischemic stroke. Design, Setting, and Participants Patients were enrolled in this retrospective cohort study from the prospective, observational, multicenter German Stroke Registry-Endovascular Treatment between May 1, 2015, and December 31, 2021. This study compared IVT plus MT vs MT alone in patients with acute ischemic stroke due to anterior circulation large-vessel occlusion in whom mechanical reperfusion was unsuccessful. Unsuccessful mechanical reperfusion was defined as failed (final modified Thrombolysis in Cerebral Infarction grade of 0 or 1) or partial (grade 2a). Patients meeting the inclusion criteria were matched by treatment group using 1:1 propensity score matching. Interventions Mechanical thrombectomy with or without IVT. Main Outcomes and Measures Primary outcome was functional independence at 90 days, defined as a modified Rankin Scale score of 0 to 2. Safety outcomes were the occurrence of symptomatic intracranial hemorrhage and death. Results After matching, 746 patients were compared by treatment arms (median age, 78 [IQR, 68-84] years; 438 women [58.7%]). The proportion of patients who were functionally independent at 90 days was 68 of 373 (18.2%) in the IVT plus MT and 42 of 373 (11.3%) in the MT alone group (adjusted odds ratio [AOR], 2.63 [95% CI, 1.41-5.11]; P = .003). There was a shift toward better functional outcomes on the modified Rankin Scale favoring IVT plus MT (adjusted common OR, 1.98 [95% CI, 1.35-2.92]; P < .001). The treatment benefit of IVT was greater in patients with partial reperfusion compared with failed reperfusion. There was no difference in symptomatic intracranial hemorrhages between treatment groups (AOR, 0.71 [95% CI, 0.29-1.81]; P = .45), while the death rate was lower after IVT plus MT (AOR, 0.54 [95% CI, 0.34-0.86]; P = .01). Conclusions and Relevance These findings suggest that prior IVT was safe and improved functional outcomes at 90 days. Partial reperfusion was associated with a greater treatment benefit of IVT, indicating a positive interaction between IVT and MT. These results support current guidelines that all eligible patients with stroke should receive IVT before MT and add a new perspective to the debate on noninferiority of combined stroke treatment.
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Affiliation(s)
- Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Vollmuth
- Department of Neuroradiology, University Medical Center Heidelberg, Heidelberg, Germany
| | - Maarten G Lansberg
- Department of Neurology and Neurological Science, Stanford University School of Medicine, Stanford, California
| | - Gregory W Albers
- Department of Neurology and Neurological Science, Stanford University School of Medicine, Stanford, California
| | - Urs Fischer
- Department of Neurology, University Medical Center Basel, Basel, Switzerland
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Cancer Center, Houston, Texas
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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12
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Canals P, Balocco S, Díaz O, Li J, García-Tornel A, Tomasello A, Olivé-Gadea M, Ribó M. A fully automatic method for vascular tortuosity feature extraction in the supra-aortic region: unraveling possibilities in stroke treatment planning. Comput Med Imaging Graph 2023; 104:102170. [PMID: 36634467 DOI: 10.1016/j.compmedimag.2022.102170] [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: 03/23/2022] [Revised: 11/14/2022] [Accepted: 12/24/2022] [Indexed: 12/29/2022]
Abstract
Vascular tortuosity of supra-aortic vessels is widely considered one of the main reasons for failure and delays in endovascular treatment of large vessel occlusion in patients with acute ischemic stroke. Characterization of tortuosity is a challenging task due to the lack of objective, robust and effective analysis tools. We present a fully automatic method for arterial segmentation, vessel labelling and tortuosity feature extraction applied to the supra-aortic region. A sample of 566 computed tomography angiography scans from acute ischemic stroke patients (aged 74.8 ± 12.9, 51.0% females) were used for training, validation and testing of a segmentation module based on a U-Net architecture (162 cases) and a vessel labelling module powered by a graph U-Net (566 cases). Successively, 30 cases were processed for testing of a tortuosity feature extraction module. Measurements obtained through automatic processing were compared to manual annotations from two observers for a thorough validation of the method. The proposed feature extraction method presented similar performance to the inter-rater variability observed in the measurement of 33 geometrical and morphological features of the arterial anatomy in the supra-aortic region. This system will contribute to the development of more complex models to advance the treatment of stroke by adding immediate automation, objectivity, repeatability and robustness to the vascular tortuosity characterization of patients.
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Affiliation(s)
- P Canals
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - S Balocco
- Department of Mathematics and Computer Science, University of Barcelona, Barcelona, Spain; Computer Vision Center, Bellaterra, Spain
| | - O Díaz
- Department of Mathematics and Computer Science, University of Barcelona, Barcelona, Spain
| | - J Li
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - A García-Tornel
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - A Tomasello
- Neuroradiology, Vall d'Hebron Hospital Universitari, Barcelona, Spain
| | - M Olivé-Gadea
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Ribó
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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13
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Liu H, He Y, Zhou T, Zhu L, Zhao Y, Ding Y, He Y, Li T. Evaluation of using a double helical, closed-cell stent-retriever (Skyflow) for thrombectomy procedures in acute arterial occlusion: A preclinical study and a clinical trial. J Interv Med 2022; 5:190-195. [DOI: 10.1016/j.jimed.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/30/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022] Open
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14
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Intravenous thrombolysis prior to endovascular treatment for acute ischemic stroke: a meta-analysis. Neurol Sci 2022; 43:5993-6002. [DOI: 10.1007/s10072-022-06233-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/19/2022] [Indexed: 10/17/2022]
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15
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Sajja KC, Huded V, Prajapati C, Male S, Sharma MK, Shah S, Bohra V, Chakravarthi S, Prasanna LS, Sura PR, Paramasivam S, Gorijala VK, Guntamukkala A, Somasundaram K, Vemuri RT. Rescue Stenting for Refractory Large Vessel Occlusions in the Thrombectomy Era: Intracranial Use of Coronary Stents in Low-mid Economic Settings. Cureus 2022; 14:e23847. [PMID: 35402111 PMCID: PMC8982903 DOI: 10.7759/cureus.23847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/27/2022] Open
Abstract
Background: Failed mechanical thrombectomy due to a refractory emergent large vessel occlusion (RELVO) in patients presenting with an acute stroke poses a major challenge to the outcomes. Objective: We demonstrate the use of coronary stents in the intracranial circulation as rescue stenting for an already expensive mechanical thrombectomy procedure in a mid-low socioeconomic setting. Methods: A retrospective, multicenter study was conducted between December 2015 and January 2021. The studied cohort were patients who required the use of a rescue stenting using a coronary stent for emergent large vessel occlusion to avoid failed recanalization. Failed recanalization was defined as failed vessel recanalization after at least two passes. Patient demographic data, procedure specifics, type of stent used, and procedural outcomes were collected. Results: A total of 26 patients with acute ischemic stroke were included from eight different centers across India. Out of 26 patients, 19 (73.0%) were male and seven were female (26.9%). The mean age was 53.6 years, the youngest patient was 23 years old and the eldest was 68 years old. Seven patients (26.9%) had posterior circulation stroke due to occlusion of the vertebral or basilar artery and 19 patients (73.0%) had anterior circulation stroke median NIHSS at presentation was 16 (range 10 to 28) in anterior circulation stroke and 24 (range 16 to 30) in posterior circulation stroke. Intravenous thrombolysis with tissue plasminogen activator (IV tPA) was given in three patients (11.5%). The hospital course of two patients was complicated by symptomatic intracranial hemorrhage (sICH), which was fatal. Favorable revascularization outcome and favorable functional outcome was achieved in 22 patients (84.6%), three patients passed away (11.5%), and one patient was lost to follow up. Conclusions: Overall, our study finds that rescue stenting using coronary stents can potentially improve outcomes in refractory large vessel occlusions while minimizing costs in low-mid economic settings.
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16
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Marnat G, Finistis S, Delvoye F, Sibon I, Desilles JP, Mazighi M, Gariel F, Consoli A, Rosso C, Clarençon F, Elhorany M, Denier C, Chalumeau V, Caroff J, Veunac L, Bourdain F, Darcourt J, Olivot JM, Bourcier R, Dargazanli C, Arquizan C, Richard S, Lapergue B, Gory B. Safety and Efficacy of Cangrelor in Acute Stroke Treated with Mechanical Thrombectomy: Endovascular Treatment of Ischemic Stroke Registry and Meta-analysis. AJNR Am J Neuroradiol 2022; 43:410-415. [PMID: 35241418 PMCID: PMC8910798 DOI: 10.3174/ajnr.a7430] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/23/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Rescue therapies are increasingly used in the setting of endovascular therapy for large-vessel occlusion strokes. Among these, cangrelor, a new P2Y12 inhibitor, offers promising pharmacologic properties to join the reperfusion strategies in acute stroke. We assessed the safety and efficacy profiles of cangrelor combined with endovascular therapy in patients with large-vessel-occlusion stroke. MATERIALS AND METHODS We performed a retrospective patient data analysis in the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France from July 2018 to December 2020 and conducted a systematic review and meta-analysis using several data bases. Indications for cangrelor administration were rescue strategy in case of refractory intracranial occlusion with or without intracranial rescue stent placement, and cervical carotid artery stent placement in case of cervical occlusion (tandem occlusion or isolated cervical carotid occlusion). RESULTS In the clinical registry, 44 patients were included (median initial NIHSS score, 12; prior intravenous thrombolysis, 29.5%). Intracranial stent placement was performed in 54.5% (n = 24/44), and cervical stent placement, in 27.3% (n = 12/44). Adjunctive aspirin and heparin were administered in 75% (n = 33/44) and 40.9% (n = 18/44), respectively. Rates of symptomatic intracerebral hemorrhage, parenchymal hematoma, and 90-day mortality were 9.5% (n = 4/42), 9.5% (n = 4/42), and 24.4% (n = 10/41). Favorable outcome (90-day mRS, 0-2) was reached in 51.2% (n = 21/41), and successful reperfusion, in 90.9% (n = 40/44). The literature search identified 6 studies involving a total of 171 subjects. In the meta-analysis, including our series data, symptomatic intracerebral hemorrhage occurred in 8.6% of patients (95% CI, 5.0%-14.3%) and favorable outcome was reached in 47.6% of patients (95% CI, 27.4%-68.7%). The 90-day mortality rate was 22.6% (95% CI, 13.6%-35.2%). Day 1 artery patency was observed in 89.7% (95% CI, 81.4%-94.6%). CONCLUSIONS Cangrelor offers promising safety and efficacy profiles, especially considering the complex endovascular reperfusion procedures in which it is usually applied. Further large prospective data are required to confirm these findings.
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Affiliation(s)
- G. Marnat
- From the Department of Diagnostic and Interventional Neuroradiology (G.M., F.G.), University Hospital of Bordeaux, Bordeaux, France
| | - S. Finistis
- Aristotle University of Thessaloniki (S.F.), AhepaHospital, Thessaloniki, Greece
| | - F. Delvoye
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - I. Sibon
- Department of Neurology (I.S.), Stroke Center, University Hospital of Bordeaux, Bordeaux, France
| | - J.-P. Desilles
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - M. Mazighi
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - F. Gariel
- From the Department of Diagnostic and Interventional Neuroradiology (G.M., F.G.), University Hospital of Bordeaux, Bordeaux, France
| | - A. Consoli
- Department of Diagnostic and Interventional Neuroradiology (A.C.), Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | | | - F. Clarençon
- Neuroradiology (F.C., M.E.), Centre Hospitalier Universitaire Pitié Salpétrière Hospital, Paris, France
| | - M. Elhorany
- Neuroradiology (F.C., M.E.), Centre Hospitalier Universitaire Pitié Salpétrière Hospital, Paris, France
| | | | - V. Chalumeau
- Neuroradiolology (V.C., J.C.) Centre Hospitalier Universitaire Kremlin Bicêtre, Le Kremlin Bicêtre, France
| | - J. Caroff
- Neuroradiolology (V.C., J.C.) Centre Hospitalier Universitaire Kremlin Bicêtre, Le Kremlin Bicêtre, France
| | - L. Veunac
- Neuroradiolology (L.V.), Centre Hospitalier Cõte Basque, Bayonne, France
| | | | - J. Darcourt
- Neuroradiolology (J.D.), Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | | | - R. Bourcier
- Department of Neuroradiology (R.B.), University Hospital of Nantes, Nantes, France
| | - C. Dargazanli
- Departments of Interventional Neuroradiology (C. Dargazanli)
| | - C. Arquizan
- Neurology (C.A.), Centre Hospitalier Regional Universitaire Gui de Chauliac, Montpellier, France
| | - S. Richard
- Department of Neurology (S.R.), Université de Lorraine, Centre Hospitalier Regional Universitaire Nancy, Nancy, France
| | - B. Lapergue
- Department of Neurology (B.L.), Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - B. Gory
- Department of Diagnostic and Therapeutic Neuroradiology (B.G.), Université de Lorraine, Centre Hospitalier Regional Universitaire Nancy, Nancy, France,Université de Lorraine (B.G.), Imagerie Adaptative Diagnostique et Interventionnelle, Institut National de la Santé et de la Recherche Médicale U1254, Nancy, France
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17
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Holswilder G, Stuart MPME, Dompeling T, Kruyt ND, Goeman JJ, van der Lugt A, Schonewille WJ, Lycklama à Nijeholt GJ, Majoie CBLM, Yo LSF, Meijer FJA, Marquering HA, Wermer MJH, van Walderveen MAA. The prognostic value of extracranial vascular characteristics on procedural duration and revascularization success in endovascularly treated acute ischemic stroke patients. Eur Stroke J 2022; 7:48-56. [PMID: 35300259 PMCID: PMC8921792 DOI: 10.1177/23969873211067662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/01/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction Vascular anatomy might affect endovascular treatment success in acute ischemic stroke patients with large vessel occlusion. We investigated the prognostic value of extracranial vascular characteristics on procedural time and revascularization success in patients with large vessel occlusion in the anterior cerebral circulation. Patients and methods We included 828 patients endovascularly treated within 6.5 hours of symptom onset from the Dutch MR CLEAN-Registry. We evaluated aortic arch configuration, stenosis and tortuosity of supra-aortic arteries, and internal carotid arteries (ICAs) on pre-intervention CTA. We constructed logistic prediction models for outcome variables procedural duration (≥60 minutes) and non-successful revascularization (extended thrombolysis in cerebral infarction (eTICI) of 0–2A) using baseline characteristics and assessed the effect of extracranial vascular characteristics on model performance. Results Cervical ICA tortuosity and stenosis ≥99% improved prediction of long procedural duration compared with baseline characteristics from area under the curve of 0.61 (95% CI: 0.57–0.65) to 0.66 (95% CI: 0.62–0.70) (P < 0.001). Cervical ICA tortuosity was significantly associated with non-successful recanalization. Prediction of non-successful revascularization did not improve after including aortic arch elongation, acute take-off angle, aortic variant, origin stenosis of supra-aortic arteries, and cervical ICA tortuosity, with an area under the curve of 0.63 (95% CI: 0.59–0.67) compared with 0.59 (95% CI: 0.55–0.63) (P = 0.11). Conclusion Extracranial vascular characteristics have additional prognostic value for procedural duration, but not for revascularization success, compared with baseline characteristics. Performance of both prediction models is limited in patients treated for large vessel occlusion.
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Affiliation(s)
| | - Maaike PME Stuart
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Tine Dompeling
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Jelle J Goeman
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Aad van der Lugt
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | | | | - Charles BLM Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Lonneke SF Yo
- Department of Radiology, Catharina Hospital, Eindhoven, Netherlands
| | - Frederick JA Meijer
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Marieke JH Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
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18
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Regenhardt RW, Turner AC, Hirsch JA, Young MJ, Alotaibi NM, Stapleton CJ, Patel AB, Leslie-Mazwi TM, Rost NS, Etherton MR. Sex-specific differences in presentations and determinants of outcomes after endovascular thrombectomy for large vessel occlusion stroke. J Neurol 2022; 269:307-315. [PMID: 34052896 PMCID: PMC8628020 DOI: 10.1007/s00415-021-10628-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/16/2021] [Accepted: 05/26/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Sex-specific differences in ischemic stroke outcomes are prevalent. We sought to investigate sex differences in the determinants of reperfusion and functional outcomes after endovascular thrombectomy (EVT) for emergent large vessel occlusion ischemic stroke (ELVO). METHODS Patients presenting to a single referral center with an anterior circulation ELVO that underwent EVT from 2011 to 2019 were included in this retrospective analysis. Sex differences in history, presentation, adequate reperfusion (TICI 2b-3), and 90-day good outcome [delta modified Rankin Scale (mRS) ≤ 2 from pre-stroke] were examined. Multivariable logistic regression analyses were performed to assess sex-specific associations with outcomes. RESULTS Three hundred and eighty-one consecutive ELVO patients were identified. Women (N = 193) were older (75 vs 64 years, p < 0.0001), had more pre-stroke disability (17% vs 9%, p = 0.032), more atrial fibrillation (41% vs 30%, p = 0.033), but less carotid atherosclerosis (8% vs 16%, p = 0.027). Rates of TICI 2b-3 and good outcome were similar between sexes. Carotid atherosclerosis (OR 0.315, 95% CI 0.130, 0.762) and dissection (OR 0.124, 95% CI 0.027, 0.569) independently decreased the odds of TICI 2b-3 among men but not women. Older age, more severe stroke, and not achieving TICI 2b-3 independently decreased the odds of good outcome among both sexes, while prior stroke (OR 0.258, 95% CI 0.083, 0.797) and hemorrhagic transformation (OR 0.111, 0.021, 0.592) were determinants exclusive to men. CONCLUSION In a real-world analysis of ELVO stroke patients treated with EVT, we found that despite advanced age and more pre-stroke disability, women have comparable reperfusion rates and functional outcomes compared to men. Sex-specific determinants of reperfusion and functional outcome were identified that require further study.
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Affiliation(s)
- Robert W Regenhardt
- Neurology, Massachusetts General Hospital, 55 Fruit St, WAC-7-721, Boston, MA, USA. .,Neurosurgery, Massachusetts General Hospital, 55 Fruit St, WAC-7-721, Boston, MA, USA.
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19
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Dumas V, Kaesmacher J, Ognard J, Forestier G, Dargazanli C, Janot K, Behme D, Shotar E, Chabert E, Velasco S, Bricout N, Ben Hassen W, Veunac L, Geismar M, Eugene F, Detraz L, Darcourt J, L'Allinec V, Eker OF, Consoli A, Maus V, Gariel F, Marnat G, Papanagiotou P, Papagiannaki C, Escalard S, Meyer L, Lobsien D, Abdullayev N, Chalumeau V, Neau JP, Guillevin R, Boulouis G, Rouchaud A, Styczen H, Fauché C. Carotid artery direct access for mechanical thrombectomy: the Carotid Artery Puncture Evaluation (CARE) study. J Neurointerv Surg 2021; 14:1180-1185. [PMID: 34916267 DOI: 10.1136/neurintsurg-2021-017935] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND In acute ischemic stroke due to anterior large vessel occlusion (AIS-LVO), accessing the target occluded vessel for mechanical thrombectomy (MT) is sometimes impossible through the femoral approach. We aimed to evaluate the safety and efficacy of direct carotid artery puncture (DCP) for MT in patients with failed alternative vascular access. METHODS We retrospectively analyzed data from 45 stroke centers in France, Switzerland and Germany through two research networks from January 2015 to July 2019. We collected physician-centered data on DCP practices and baseline characteristics, procedural variables and clinical outcome after DCP. Uni- and multivariable models were conducted to assess risk factors for complications. RESULTS From January 2015 to July 2019, 28 149 MT were performed, of which 108 (0.39%) resulted in DCP due to unsuccessful vascular access. After DCP, 77 patients (71.3%) had successful reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) score ≥2b) and 28 (25.9%) were independent (modified Rankin Scale (mRS) score 0-2) at 3 months. 20 complications (18.5%) attributed to DCP occurred, all of them during or within 1 hour of the procedure. Complications led to extension of the intubation time in the intensive care unit in 7 patients (6.4%) and resulted in death in 3 (2.8%). The absence of use of a hemostatic closure device was associated with a higher complication risk (OR 3.04, 95% CI 1.03 to 8.97; p=0043). CONCLUSION In this large multicentric study, DCP was scantly performed for vascular access to perform MT (0.39%) in patients with AIS-LVO and had a high rate of complications (18.5%). Our results provide arguments for not closing the cervical access by manual compression after MT.
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Affiliation(s)
- Victor Dumas
- Radiology Department, Poitiers University Medical Center, LabCom I3M, DACTIM-MIS team, LMA CNRS 7348, Poitiers, Vienne, France
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | - Julien Ognard
- Interventional Neuroradiology, CHRU de Brest, Brest, Bretagne, France
| | - Géraud Forestier
- Neuroradiology Department, XLIM CNRS, UMR7252, Centre Hospitalier Universitaire de Limoges, Limoges, Limousin, France
| | - Cyril Dargazanli
- Department of Neuroradiology, INSERM U1191, University Hospital Center Montpellier, Montpellier, Occitanie, France
| | - Kevin Janot
- Neuroradiology Department, University Hospital of Tours, Tours, Indre et Loire, France
| | - Daniel Behme
- Institute for Diagnostic and Interventional Neuroradiology, University of Gottingen, Goettingen, Germany
| | - Eimad Shotar
- Neuroradiology Department, Pitié-Salpêtrière Hospital, Paris, France
| | - Emmanuel Chabert
- Neuroradiology Department, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Stéphane Velasco
- Radiology Department, Poitiers University Medical Center, Poitiers, Vienne, France
| | - Nicolas Bricout
- Department of Interventional Neuroradiology, Centre Hospitalier Regional Universitaire de Lille, Lille, France
| | - Wagih Ben Hassen
- Interventional Neuroradiology, CH Sainte-Anne, INSERM UMR 1266, Paris, Île-de-France, France
| | - Louis Veunac
- Department of Radiology, Bayonne Hospital, Bayonne, France
| | - Maxime Geismar
- Neuroradiology Department, Centre Hospitalier Universitaire de Caen, Caen, France
| | | | - Lili Detraz
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Jean Darcourt
- Neuroradiology Department, CHU Toulouse, Toulouse, Midi-Pyrénées, France
| | | | - Omer F Eker
- Neuroradiology Department, Neurologic Hospital, Bron, France
| | - Arturo Consoli
- Interventional Neuroradiology, Hospital Foch, Suresnes, France
| | - Volker Maus
- Institute of Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Bochum, Ruhr-University, Bochum, Germany
| | - Florent Gariel
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, Aquitaine, France
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, Aquitaine, France
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospitals Bremen-Mitte, Bremen-Ost, Germany
| | | | - Simon Escalard
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, Ile de France, France
| | - Lukas Meyer
- Diagnostic and Interventional Neuroradiology, Universitatsklinikum Hamburg Eppendorf Klinik und Poliklinik fur Neuroradiologische Diagnostik und Intervention, Hamburg, Germany
| | - Donald Lobsien
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
| | - Nuran Abdullayev
- Diagnostic and Interventional Radiology Department, University Hospital Cologne, Köln, Germany
| | - Vanessa Chalumeau
- Interventional Neuroradiology, CHU Bicêtre, Le Kremlin-Bicêtre, Paris, France
| | | | - Rémy Guillevin
- Radiology Department, Poitiers University Medical Center, LabCom I3M, DACTIM-MIS team, LMA CNRS 7348, Poitiers, Vienne, France
| | - Gregoire Boulouis
- Neuroradiology Department, University Hospital of Tours, Tours, Indre et Loire, France
| | - Aymeric Rouchaud
- Neuroradiology Department, XLIM CNRS, UMR7252, Centre Hospitalier Universitaire de Limoges, Limoges, Limousin, France
| | - Hanna Styczen
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Cédric Fauché
- Radiology Department, Poitiers University Medical Center, Poitiers, Vienne, France
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20
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Liu R, Jin C, Wang L, Yang Y, Fan Y, Wang W. Simulation of stent retriever thrombectomy in acute ischemic stroke by finite element analysis. Comput Methods Biomech Biomed Engin 2021; 25:740-749. [PMID: 34792427 DOI: 10.1080/10255842.2021.1976761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Stent retriever thrombectomy has become an effective method for treating acute ischemic stroke. Successful recanalization cannot be achieved for all patients. The outcome of mechanical thrombectomy may be associated with some mechanical factors, requiring efficient tools that are able to assess the interaction between stent retrievers and clots. In this study, a simulation by finite element analysis was developed to evaluate the outcome of stent retriever thrombectomy for clots of different sizes and frictional properties. The deployment and retrieval of the stent retriever were conducted in a middle cerebral artery model. The recanalization, deformation of the clot and stent retriever and the stress induced in the clot were assessed. The results showed that higher friction could lead to failed recanalization and increased stress in the clot. The simulation method can be used to characterize the mechanical behaviour of stent retrievers and clots, offering a potential tool for the optimization of device design and the selection of surgical strategies.
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Affiliation(s)
- Ronghui Liu
- Beijing Advanced Innovation Centre for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, China.,Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
| | - Chang Jin
- Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
| | - Lizhen Wang
- Beijing Advanced Innovation Centre for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yisong Yang
- Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
| | - Yubo Fan
- Beijing Advanced Innovation Centre for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Weidong Wang
- Key Laboratory of Biomedical Engineering and Translational Medicine, Ministry of Industry and Information Technology, Research Center for Biomedical Engineering, Medical Innovation & Research Division, Chinese PLA General Hospital, Beijing, China
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21
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Ajiboye N, Yoo AJ. Biomarkers of Technical Success After Embolectomy for Acute Stroke. Neurology 2021; 97:S91-S104. [PMID: 34785608 DOI: 10.1212/wnl.0000000000012800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/25/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW Stent retrievers and large-bore aspiration catheters have doubled substantial reperfusion rates compared to first-generation devices. This has been accompanied by a 3-fold reduction in procedural time to revascularization. To measure future thrombectomy improvements, new benchmarks for technical efficacy are needed. This review summarizes the recent literature concerning biomarkers of procedural success and harm and highlights future directions. RECENT FINDINGS Expanded Treatment in Cerebral Ischemia (eTICI), which incorporates scores for greater levels of reperfusion, improves outcome prediction. Core laboratory-adjudicated studies show that outcomes following eTICI 2c (90%-99% reperfusion) are superior to eTICI 2b50 and nearly equivalent to eTICI 3. Moreover, eTICI 2c improves scale reliability. Studies also confirm the importance of rapid revascularization, whether measured as first pass effect or procedural duration under 30 minutes. Distal embolization is a complication that impedes the extent and speed of revascularization, but few studies have reported its per-pass occurrence. Distal embolization and emboli to new territory should be measured after each thrombectomy maneuver. Collaterals have been shown to be an important modifier of thrombectomy benefit. A drawback of the currently accepted collateral grading scale is that it does not discriminate among the broad spectrum of partial collateralization. Important questions that require investigation include reasons for failed revascularization, the utility of a global Treatment in Cerebral Ischemia scale, and the optimal grading system for vertebrobasilar occlusions. SUMMARY Emerging data support a lead technical efficacy endpoint that combines the extent and speed of reperfusion. Efforts are needed to better characterize angiographic measures of treatment harm and of collateralization.
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Affiliation(s)
| | - Albert J Yoo
- From the Texas Stroke Institute, Dallas-Fort Worth.
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22
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Penide J, Mirza M, McCarthy R, Fiehler J, Mordasini P, Delassus P, Morris L, Gilvarry M. Systematic Review on Endovascular Access to Intracranial Arteries for Mechanical Thrombectomy in Acute Ischemic Stroke. Clin Neuroradiol 2021; 32:5-12. [PMID: 34642788 DOI: 10.1007/s00062-021-01100-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 09/09/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE In acute ischemic stroke for large vessel occlusions, delayed or failed access to intracranial occlusions has a negative impact on procedural and clinical outcomes. The aim of this review is to identify and quantify access failures and challenges in mechanical thrombectomy. METHODS A systematic literature review of PubMed and Scopus databases from January 2014 to October 2020 was performed. Articles reporting consecutive patients were used to calculate a crude failure rate of femoral and alternative accesses. RESULTS A total of 50 articles met the inclusion criteria, totalling 12,838 interventions. Failure to access the occlusion through transfemoral access occurred in 4.4% of patients, most commonly due to challenging supra-aortic vessel anatomy, decreasing to 3.6% when all alternative access routes were attempted. Failed access from alternative routes (direct carotid, radial and brachial approaches) attempted first-line or after failed femoral attempt were reported in 7.3% of patients. The occurrence rate of potentially challenging features (anatomical, diseases or others) ranged from 4.7% to 47.4%, primarily impacting the access time, procedure time, recanalization and clinical outcomes. CONCLUSION Failure to access the occlusion is a significant contributor to failed recanalization, regardless of access routes. Challenging, but eventually successful access is also a relevant factor in procedural and clinical outcomes; however challenging access requires a universal definition to enable quantification, so that methods for procedural optimization can be critically assessed.
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Affiliation(s)
- Joaquin Penide
- Department of Mechanical and Industrial Engineering, Galway-Mayo Institute of Technology, MET Gateway, Galway, Ireland.
| | - Mahmood Mirza
- Galway Neuro Technology Centre, Cerenovus, Galway, Ireland
| | - Ray McCarthy
- Galway Neuro Technology Centre, Cerenovus, Galway, Ireland
| | - Jens Fiehler
- Klinik und Poliklinik fur Neuroradiologische Diagnostik und Intervention, Universitatsklinikum Hamburg Eppendorf, Hamburg, Germany
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | - Patrick Delassus
- Department of Mechanical and Industrial Engineering, Galway-Mayo Institute of Technology, MET Gateway, Galway, Ireland
| | - Liam Morris
- Department of Mechanical and Industrial Engineering, Galway-Mayo Institute of Technology, MET Gateway, Galway, Ireland
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23
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Hassan AE, Ringheanu VM, Preston L, Tekle WG, Qureshi AI. Acute intracranial stenting with mechanical thrombectomy is safe and efficacious in patients diagnosed with underlying intracranial atherosclerotic disease. Interv Neuroradiol 2021; 28:419-425. [PMID: 34515574 PMCID: PMC9326867 DOI: 10.1177/15910199211039403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate whether significant differences exist in recanalization rates and primary outcomes between patients who undergo mechanical thrombectomy alone versus those who undergo mechanical thrombectomy with acute intracranial stenting. METHODS Through the utilization of a prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2020, variables such as demographics, co-morbid conditions, symptomatic intracerebral hemorrhage, mortality rate at discharge, and good/poor outcomes in regard to modified thrombolysis in cerebral infarction score and modified Rankin Scale were examined. The outcomes between patients receiving acute intracranial stenting + mechanical thrombectomy and patients that underwent mechanical thrombectomy alone were compared. RESULTS There were a total of 420 acute ischemic stroke patients who met criteria for the study (average age 70.6 ± 13.01 years; 46.9% were women). Analysis of 46 patients from the acute stenting + mechanical thrombectomy group (average age 70.34 ± 13.75 years; 37.0% were women), and 374 patients from the mechanical thrombectomy alone group (average age 70.64 ± 12.92 years; 48.1% were women). Four patients (8.7%) in the acute stenting + mechanical thrombectomy group experienced intracerebral hemorrhage versus 45 patients (12.0%) in the mechanical thrombectomy alone group (p = 0.506); no significant increases were noted in the median length of stay (7 vs 8 days; p = 0.208), rates of modified thrombolysis in cerebral infarction 2B-3 recanalization (p = 0.758), or good modified Rankin Scale scores (p = 0.806). CONCLUSION Acute intracranial stenting in addition to mechanical thrombectomy was not associated with an increase in overall length of stay, intracerebral hemorrhage rates, or any change in discharge modified Rankin Scale. Further research is required to determine whether mechanical thrombectomy and acute intracranial stenting in acute ischemic stroke patients is unsafe.
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Affiliation(s)
- Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA.,Department of Clinical Research, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA.,Neuroscience Department, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Victor M Ringheanu
- Department of Clinical Research, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Laurie Preston
- Department of Clinical Research, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA.,Neuroscience Department, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Wondwossen G Tekle
- Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA.,Neuroscience Department, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA.,Department of Neurology, University of Missouri School of Medicine, Columbia, Missouri, USA
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24
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Baik SH, Jung C, Kim JY, Shin DW, Kim BJ, Kang J, Bae HJ, Kim JH. Local Intra-arterial Thrombolysis during Mechanical Thrombectomy for Refractory Large-Vessel Occlusion: Adjunctive Chemical Enhancer of Thrombectomy. AJNR Am J Neuroradiol 2021; 42:1986-1992. [PMID: 34475193 DOI: 10.3174/ajnr.a7264] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/11/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Data on adjunctive intra-arterial thrombolysis during mechanical thrombectomy for refractory thrombus are sparse. The aim of this study was to evaluate the efficacy and safety of local intra-arterial urokinase as an adjunct to mechanical thrombectomy for refractory large-vessel occlusion. MATERIALS AND METHODS We retrospectively evaluated patients with acute ischemic stroke who underwent mechanical thrombectomy for anterior circulation large-vessel occlusion between January 2016 and December 2019. Patients were divided into 2 groups based on the use of intra-arterial urokinase as an adjunctive therapy during mechanical thrombectomy for refractory thrombus: the urokinase and nonurokinase groups. Herein, refractory thrombus was defined as the target occlusion with minimal reperfusion (TICI 0 or 1) despite >3 attempts with conventional mechanical thrombectomy. The baseline characteristics, procedural outcomes, and clinical outcome were compared between the 2 groups. RESULTS One hundred fourteen cases of refractory thrombus were identified. A total of 45 and 69 patients were in the urokinase and the nonurokinase groups, respectively. The urokinase group compared with the nonurokinase group showed a higher rate of successful reperfusion (82.2% versus 63.8%, P = .034), with lower procedural times (54 versus 69 minutes, P = .137). The rates of good clinical outcome, distal embolism, and symptomatic intracranial hemorrhage were similar between the 2 groups. The use of intra-arterial urokinase (OR = 3.682; 95% CI, 1.156-11.730; P = .027) was an independent predictor of successful reperfusion. CONCLUSIONS The use of local intra-arterial urokinase as an adjunct to mechanical thrombectomy may be an effective and safe method that provides better recanalization than the conventional mechanical thrombectomy for refractory thrombus in patients with embolic large-vessel occlusion.
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Affiliation(s)
- S H Baik
- From the Department of Radiology (S.H.B., C.J., D.-W.S., J.H.K.,)
| | - C Jung
- From the Department of Radiology (S.H.B., C.J., D.-W.S., J.H.K.,)
| | - J Y Kim
- Department of Neurology (J.Y.K., B.J.K., J.K., H.-J.B.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - D-W Shin
- From the Department of Radiology (S.H.B., C.J., D.-W.S., J.H.K.,)
| | - B J Kim
- Department of Neurology (J.Y.K., B.J.K., J.K., H.-J.B.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - J Kang
- Department of Neurology (J.Y.K., B.J.K., J.K., H.-J.B.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - H-J Bae
- Department of Neurology (J.Y.K., B.J.K., J.K., H.-J.B.), Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - J H Kim
- From the Department of Radiology (S.H.B., C.J., D.-W.S., J.H.K.,)
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25
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Marnat G, Delvoye F, Finitsis S, Lapergue B, Gariel F, Consoli A, Desilles JP, Mazighi M, Dargazanli C, Bourcier R, Darcourt J, Chalumeau V, Elhorany M, Clarençon F, Richard S, Gory B, Sibon I. A Multicenter Preliminary Study of Cangrelor following Thrombectomy Failure for Refractory Proximal Intracranial Occlusions. AJNR Am J Neuroradiol 2021; 42:1452-1457. [PMID: 34117019 DOI: 10.3174/ajnr.a7180] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/09/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE Rescue endovascular and pharmacologic approaches are increasingly being adopted after recanalization failure of acute large-vessel occlusion strokes with mechanical thrombectomy, with encouraging results. The safety and efficacy of glycoprotein IIb/IIIa inhibitors in ischemic stroke have been investigated, though cangrelor, a recent intravenous P2Y12-receptor inhibitor with a rapid onset/offset of action and a short half-life, may be a valuable option. We compared the safety and efficacy of cangrelor with those of glycoprotein IIb/IIIa inhibitors for refractory occlusions. MATERIALS AND METHODS We performed a retrospective analysis of the ongoing prospective, multicenter, observational Endovascular Treatment in Ischemic Stroke Registry in France between May 2012 and February 2020. Refractory intracranial occlusions of the anterior and posterior circulation were included and defined as recanalization failure of large-vessel occlusion stroke, perioperative target artery reocclusion, or high risk of early reocclusion related to an arterial wall lesion. The primary end point was a favorable outcome, defined as a 90-day mRS of 0-2. Secondary end points were reperfusion, intracranial hemorrhage, and procedural complications. RESULTS Among 69 patients, 15 were treated with cangrelor, and 54, with glycoprotein IIb/IIIa inhibitors. The favorable outcome (adjusted OR = 2.22; 95% CI, 0.42-11.75; P = .348) and mortality (adjusted OR = 0.44; 95% CI, 0.06-3.16; P = .411) rates were similar in both groups. There was no difference in the rates of any intracranial hemorrhage (adjusted OR = 0.40; 95% CI, 0.08-2.09; P = .280), symptomatic intracranial hemorrhage (6.7% versus 0.0%, P = .058), or procedural complications (6.7% versus 20.4%, P = .215). Reperfusion rates were higher in the cangrelor group, though the difference did not reach statistical significance (93.3% versus 75.0% for modified TICI 2b-3; adjusted OR =10.88; 95% CI, 0.96-123.84; P = .054). CONCLUSIONS Cangrelor seems to be as safe as glycoprotein IIb/IIIa inhibitors for managing refractory intracranial occlusion and leads to satisfactory brain reperfusion. Cangrelor is a promising agent in this setting, and additional studies are warranted to confirm our findings.
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Affiliation(s)
- G Marnat
- Neuroradiology Department (G.M., F.G.) and Neurology (I.S.), Bordeaux University Hospital, Bordeaux, France
| | - F Delvoye
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - S Finitsis
- Aristotle University of Thessaloniki (S.F.), Ahepa Hospital, Thessaloniki, Greece
| | - B Lapergue
- Department of Neurology (B.L.), Foch Hospital, Versailles Saint-Quentin-en-Yvelines University, Suresnes, France
| | - F Gariel
- Neuroradiology Department (G.M., F.G.) and Neurology (I.S.), Bordeaux University Hospital, Bordeaux, France
| | - A Consoli
- Department s of Neuroradiology (A.C.) and Neurology (B.L.), Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - J-P Desilles
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - M Mazighi
- Department of Interventional Neuroradiology (F.D., J.-P.D., M.M.), Rothschild Foundation, Paris, France
| | - C Dargazanli
- Department of Neuroradiology (C.D.), Centre Hospitalier Régional Universitaire Gui de Chauliac, Montpellier, France
| | - R Bourcier
- Department of Neuroradiology (R.B.), University Hospital of Nantes, Nantes, France
| | - J Darcourt
- Department of Neuroradiology (J.D.), University Hospital of Toulouse, Toulouse, France
| | - V Chalumeau
- Department of Neuroradiology (M.E., F.C.), Pitié-Salpêtrière Hospital, Paris, France
| | - M Elhorany
- Department of Neuroradiology (M.E., F.C.), Pitié-Salpêtrière Hospital, Paris, France
| | - F Clarençon
- Department of Neuroradiology (M.E., F.C.), Pitié-Salpêtrière Hospital, Paris, France
| | - S Richard
- Department of Neurology (S.R.), Université de Lorraine, Centre Hospitalier Régional Universitaire-Nancy, Stroke Unit, Nancy, France
- Institut national de la santé et de la recherche médicale U1116 (S.R.), Centre Hospitalier Régional Universitaire-Nancy, Nancy, France
| | - B Gory
- Department of Diagnostic and Therapeutic Neuroradiology (B.G.), Université de Lorraine, CHRU-Nancy, Nancy, France
- Institut National de la Santé et de la Recherche Mmédicale U1254 (B.G.), Université de Lorraine, Imagerie Adaptative Diagnostique et Interventionnelle, Nancy, France
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Noh YH, Chung JW, Ko JH, Koo HW, Lee JY, Yoon SM, Song IH, Lee MR, Oh JS. Efficacy and Safety of Emergency Extracranial-Intracranial Bypass for Revascularization within 24 Hours in Resolving Large Artery Occlusion with Intracranial Stenosis. World Neurosurg 2021; 155:e9-e18. [PMID: 34246823 DOI: 10.1016/j.wneu.2021.07.010] [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: 05/12/2021] [Revised: 07/03/2021] [Accepted: 07/03/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Endovascular treatment (EVT) is less effective for intracranial atherosclerosis-induced emergent large vessel occlusion. Extracranial-intracranial (EC-IC) bypass surgery is a possible treatment option to augment cerebral blood flow in the perfusion defect area. We compared the efficacy and safety of EC-IC bypass surgery with those of EVT and maximal medical treatment for acute ischemic stroke. METHODS The data from 39 patients, for whom vessel revascularization had failed despite mechanical thrombectomy, were retrospectively analyzed. Of the 39 patients, 22 had undergone percutaneous transluminal angioplasty or intracranial stenting (PTA/S), 10 had undergone emergency EC-IC bypass surgery within 24 hours of symptom onset, and 7 had received maximal medical treatment (MMT) only. The patency, perfusion status, and postoperative infarct volume were evaluated. The clinical outcomes were assessed at 6 months postoperatively using the modified Rankin scale. RESULTS The mean reperfusion time was significantly longer for the EC-IC bypass group (14.9 hours) compared with that in the PTA/S group (4.1 hours) and MMT group (7.5 hours; P < 0.05). The postoperative infarct volume on diffusion-weighted magnetic resonance imaging was significantly lower in the emergency EC-IC bypass group (11.3 cm3) than in the MMT group (68.0 cm3) but was not significantly different from that of the PTA/S group (14.0 cm3; P < 0.05). The proportion of patients with a modified Rankin scale score of 0-2 at 6 months after surgery was significantly higher in the EC-IC bypass group (80%) than in the PTA/S (59%) and MMT (14%) groups (P < 0.05). CONCLUSIONS Emergency EC-IC bypass surgery is an effective and safe treatment option for intracranial atherosclerosis-induced acute ischemic stroke for which EVT is inadequate.
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Affiliation(s)
- Yun Ho Noh
- Department of Neurosurgery, Soonchunhyang University, College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea
| | - Jae Woo Chung
- Department of Neurosurgery, Dankook University, College of Medicine, Dankook University Hospital, Cheonan, Republic of Korea
| | - Jung Ho Ko
- Department of Neurosurgery, Dankook University, College of Medicine, Dankook University Hospital, Cheonan, Republic of Korea
| | - Hae Won Koo
- Department of Neurosurgery, Ilsan Paik Hospital, College of Medicine, Inje University, Goyang, Republic of Korea
| | - Ji Young Lee
- Department of Neurosurgery, Soonchunhyang University, College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea
| | - Seok Mann Yoon
- Department of Neurosurgery, Soonchunhyang University, College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea
| | - In-Hag Song
- Department of Thoracic and Caridovacular Surgery, College of Medicine, Soonchunhyang University, Cheonan Hospital, Cheonan, Republic of Korea
| | - Man Ryul Lee
- Soonchunhyang Institute of Medi-bio Science, Soon Chun Hyang University, Cheonan, Republic of Korea
| | - Jae Sang Oh
- Department of Neurosurgery, Soonchunhyang University, College of Medicine, Cheonan Hospital, Cheonan, Republic of Korea.
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More Retrieval Attempts are Associated with Poorer Functional Outcome After Unsuccessful Thrombectomy. Clin Neuroradiol 2021; 32:361-368. [PMID: 34236443 PMCID: PMC9187527 DOI: 10.1007/s00062-021-01054-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/10/2021] [Indexed: 12/25/2022]
Abstract
Purpose In mechanical thrombectomy, it has been hypothesized that multiple retrieval attempts might the improve reperfusion rate but not the clinical outcome. In order to assess a potential harmful effect of a mechanical thrombectomy on patient outcome, the number of retrieval attempts was analyzed. Only patients with a thrombolysis in cerebral infarction (TICI) score of 0 were reviewed to exclude the impact of eventual successful reperfusion on the mechanical hazardousness of repeated retrievals. Methods In this study 6635 patients who underwent endovascular thrombectomy (EVT) for acute large vessel occlusion (LVO) from the prospectively administered multicenter German Stroke Registry were screened. Insufficient reperfusion was defined as no reperfusion (TICI score of 0), whereas a primary outcome was defined as functional independence (modified Rankin scale [mRS] 0–2 at day 90). Propensity score matching and multivariable logistic regressions were then performed to adjust for confounders. Results A total of 377 patients (7.8%) had a final TICI score of 0 and were included in the study. After propensity score matching functional independence was found to be significantly more frequent in patients who underwent ≤ 2 retrieval attempts (14%), compared to patients with > 2 retrieval attempts (3.9%, OR 0.29, 95% CI 0.07–0.73, p = 0.009). After adjusting for age, sex, admission NIHSS score, and location of occlusion, more than two retrieval attempts remained significantly associated with lower odds of functional independence at 90 days (OR 0.2, 95% CI 0.07–0.52, p = 0.002). Conclusion In patients with failure of reperfusion, more than two retrieval attempts were associated with a worse clinical outcome, therefore indicating a possible harmful effect of multiple retrieval attempts. Supplementary Information The online version of this article (10.1007/s00062-021-01054-w) contains supplementary material, which is available to authorized users.
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Cabral LS, Mont'Alverne F, Silva HC, Passos Filho PE, Magalhães PSC, Bianchin MM, Nogueira RG. Device size selection can enhance Y-stentrieving efficacy and safety as a rescue strategy in stroke thrombectomy. J Neurointerv Surg 2021; 14:558-563. [PMID: 34233944 DOI: 10.1136/neurintsurg-2021-017751] [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: 05/06/2021] [Accepted: 06/17/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Despite advancements in stroke treatment, refractory clots are relatively common, prompting the exploration of alternative techniques. Bifurcation occlusions pose specific intraprocedural challenges, occasionally dealt with by two stentrievers deployed in Y-configuration. Previous studies have portrayed this strategy as feasible, yet little is known about its safety and efficacy, and how to best select retrievers. OBJECTIVE To determine whether device selection influences the efficacy and safety of Y-stentrieving. METHODS We performed a multicentric, retrospective analysis of patients undergoing Y-stentrieving rescue for bifurcation occlusions. Demographics, devices, procedural metrics, neurological severity, reperfusion, disability, and safety were assessed. RESULTS Y-configuration stents were used as a rescue maneuver after 2.16±1.5 failed attempts with other techniques in 20 patients. Successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3) was achieved in 70% of patients after the first Y-stentrieving attempt. The first stentriever more often had a larger diameter (5.15±0.92 vs 3.67±0.57 mm, p=0.017) and longer length (33.12±5.78 vs 20.67±1.15 mm, p=0.002) in successfully reperfused cases. Also, the diameter of the first device was associated with both any parenchymal (6.0 vs 4.71±0.99 mm, p=0.045) and symptomatic (6.0 vs 4.86±1.02 mm, p<0.001) hemorrhages. Exact logistic regression demonstrated that a longer length first stentriever independently predicted better angiographic outcomes (OR=1.26, p=0.036), and a 6 mm diameter first stentriever independently predicted more intracranial hemorrhages (OR=15.28, p=0.044). No periprocedural mortality was recorded. CONCLUSION Y-stentrieving is an effective and safe bail-out strategy for refractory bifurcation clots. Longer stents may promote better angiographic outcomes, whereas avoidance of disproportionately large retrievers may mitigate intracranial hemorrhage. Future studies should account for these factors when evaluating alternative stentriever techniques.
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Affiliation(s)
- Lucas Scotta Cabral
- Department of Neurology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Francisco Mont'Alverne
- Department of Interventional Neuroradiology, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Henrique Coelho Silva
- Department of Interventional Neuroradiology, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | | | | | - Marino Muxfeldt Bianchin
- Graduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,B.R.A.I.N., Division of Neurology, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Raul G Nogueira
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, and the Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
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29
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Al Kasab S, Almallouhi E, Alawieh A, Wolfe S, Fargen KM, Arthur AS, Goyal N, Dumont T, Kan P, Kim JT, De Leacy R, Maier I, Osbun J, Rai A, Jabbour P, Grossberg JA, Park MS, Starke RM, Crosa R, Spiotta AM. Outcomes of Rescue Endovascular Treatment of Emergent Large Vessel Occlusion in Patients With Underlying Intracranial Atherosclerosis: Insights From STAR. J Am Heart Assoc 2021; 10:e020195. [PMID: 34096337 PMCID: PMC8477850 DOI: 10.1161/jaha.120.020195] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Some emergent large vessel occlusions (ELVOs) are refractory to reperfusion because of underlying intracranial atherosclerosis (ICAS), often requiring rescue therapy (RT) with balloon angioplasty, stenting, or both. In this study, we investigate the safety, efficacy, and long‐term outcomes of RT in the setting of mechanical thrombectomy for ICAS‐related ELVO. Methods and Results We queried the databases of 10 thrombectomy‐capable centers in North America and Europe included in STAR (Stroke Thrombectomy and Aneurysm Registry). Patients with ELVO who underwent ICAS‐related RT were included. A matched sample was produced for variables of age, admission National Institute of Health Stroke Scale, Alberta Stroke Program Early CT Score, onset to groin puncture time, occlusion site, and final recanalization. Out of 3025 patients with MT, 182 (6%) patients required RT because of underlying ICAS. Balloon angioplasty was performed on 122 patients, and 117 patients had intracranial stenting. In the matched analysis, 141 patients who received RT matched to a similar number of controls. The number of thrombectomy passes was higher (3 versus 1, P<0.001), and procedural time was longer in the RT group (52 minutes versus 36 minutes, P=0.004). There was a higher rate of symptomatic hemorrhagic transformation in the RT group (7.8% versus 4.3%, P=0.211), however, the difference was not significant. There was no difference in 90‐day modified Rankin scale of 0 to 2 (44% versus 47.5%, P=0.543) between patients in the RT and control groups. Conclusions In patients with ELVO with underlying ICAS requiring RT, despite longer procedure time and a more thrombectomy passes, the 90 days favorable outcomes were comparable with patients with embolic ELVO.
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Affiliation(s)
- Sami Al Kasab
- Department of Neurology Medical University of South Carolina Charleston SC.,Department of Neurosurgery Medical University of South Carolina Charleston SC
| | - Eyad Almallouhi
- Department of Neurology Medical University of South Carolina Charleston SC.,Department of Neurosurgery Medical University of South Carolina Charleston SC
| | - Ali Alawieh
- Department of Neurosurgery Emory University School of Medicine Atlanta GA
| | - Stacey Wolfe
- Department of Neurosurgery Wake Forest School of Medicine Winston Salem NC
| | - Kyle M Fargen
- Department of Neurosurgery Wake Forest School of Medicine Winston Salem NC
| | - Adam S Arthur
- Department of Neurosurgery Semmes-Murphey Neurologic and Spine Clinic University of Tennessee Health Science Center Memphis TN
| | - Nitin Goyal
- Department of Neurosurgery Semmes-Murphey Neurologic and Spine Clinic University of Tennessee Health Science Center Memphis TN.,Department of Neurology University of Tennessee Health Science Center Memphis TN
| | - Travis Dumont
- Department of Neurosurgery University of Arizona Health Sciences Tucson AZ
| | - Peter Kan
- Department of Neurosurgery Baylor School of Medicine Houston TX
| | - Joon-Tae Kim
- Department of Neurology Chonnam National University Hospital Seoul South Korea
| | - Reade De Leacy
- Department of Neurosurgery Mount Sinai Health System New York NY
| | - Ilko Maier
- Department of Neurology University Medical Center Göttingen Göttingen Germany
| | - Joshua Osbun
- Department of Neurosurgery Washington University of School of Medicine St. Louis MO
| | - Ansaar Rai
- Department of Radiology West Virginia School of Medicine Morgantown WV
| | - Pascal Jabbour
- Department of Neurosurgery Thomas Jefferson University Hospitals Philadelphia PA
| | | | - Min S Park
- Department of Neurosurgery University of Virginia Charlottesville VA
| | - Robert M Starke
- Department of Neurosurgery University of Miami Health System Miami FL
| | - Roberto Crosa
- Department of Neurosurgery Endovascular Neurological Center Médica Uruguaya Montevideo Uruguay
| | - Alejandro M Spiotta
- Department of Neurosurgery Medical University of South Carolina Charleston SC
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30
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Factors associated with early reperfusion improvement after intra-arterial fibrinolytics as rescue for mechanical thrombectomy. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2021. [DOI: 10.1177/2514183x211017363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To identify factors associated with early angiographic reperfusion improvement (EARI) following intra-arterial fibrinolytics (IAF) after failed or incomplete mechanical thrombectomy (MT). Methods: A subset of patients treated with MT and IAF rescue after incomplete reperfusion included in the INFINITY (INtra-arterial FIbriNolytics In ThrombectomY) multicenter observational registry was analyzed. Multivariable logistic regression was used to identify factors associated with EARI. Heterogeneity of the clinical effect of EARI on functional independence (defined as modified Rankin Score ≤2) was tested with interaction terms. Results: A total of 228 patients (median age: 72 years, 44.1% female) received IAF as rescue for failed or incomplete MT and had a post-fibrinolytic angiographic control run available (50.9% EARI). A cardioembolic stroke origin (adjusted odds ratio (aOR) 3.72, 95% confidence interval (CI) 1.39–10.0) and shorter groin puncture to IAF intervals (aOR 0.82, 95% CI 0.71–0.95 per 15-min delay) were associated with EARI, while pre-interventional thrombolysis showed no association (aOR 1.15, 95% CI 0.59–2.26). The clinical benefit of EARI after IAF seemed more pronounced in patients without or only minor early ischemic changes (Alberta Stroke Program Early Computed Tomography Score (ASPECTS) ≥9, aOR 4.00, 95% CI 1.37–11.61) and was absent in patients with moderate to severe ischemic changes (ASPECTS ≤8, aOR 0.94, 95% CI 0.27–3.27, p for interaction: 0.095). Conclusion: Early rescue and a cardioembolic stroke origin were associated with more frequent EARI after IAF. The clinical effect of EARI seemed reduced in patients with already established infarcts. If confirmed, these findings can help to inform patient selection and inclusion criteria for randomized-controlled trials evaluating IAF as rescue after MT.
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31
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Ospel JM, Hill MD, Demchuk A, Menon BK, Thornton J, Rempel J, Almekhlafi MA, Ganesh A, Kappelhof M, Singh N, Cimflova P, Kashani N, Bala F, Kim BJ, McTaggart R, Poppe A, Nogueira RG, Tymianski M, Goyal M. Clinical impact of EVT with failed reperfusion in patients with acute ischemic stroke: results from the ESCAPE and ESCAPE-NA1 trials. Neuroradiology 2021; 63:1883-1889. [PMID: 33914135 DOI: 10.1007/s00234-021-02723-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular treatment (EVT) is a powerful treatment for large vessel occlusion (LVO) stroke if reperfusion can be achieved, while in cases with failed reperfusion, EVT may cause harm, as procedure-related complications may occur. We hypothesized that EVT with failed recanalization does not result in worse outcomes compared to best medical management and compared clinical outcomes of LVO stroke patients who underwent EVT with failed reperfusion to those who were treated with best medical management. METHODS We included patients with failed reperfusion from the control (EVT-only) arm of the ESCAPE-NA1 trial and the EVT arm of the ESCAPE trial and patients of the ESCAPE control arm who were treated with best medical management. Failed reperfusion following EVT was defined as modified thrombolysis in cerebral infarction score 0-2a. Proportions of good outcome (modified Rankin scale 0-2) were compared between patients who did and did not undergo EVT, and adjusted effect size estimates for EVT on outcomes were obtained. RESULTS We included 260 patients (110 failed EVT and 150 non-EVT patients). Proportions of good outcome were 38/110 (34.6%) with failed EVT vs.43/147 (29.3%) without EVT (adjusted odds ratio[aOR]: 1.48 [95%CI: 0.81-2.68]). Mortality and proportions of sICH in the failed EVT group vs. patients treated with best medical management were 26/110 (23.6%) vs. 28/147 (19.1%), aOR: 1.12 (95%CI: 0.56-2.24), and 7/110 (6.4%) vs. 4/150 (2.7%), aOR: 2.34 (95%CI: 0.00-22.97). CONCLUSION Clinical outcomes of EVT patients with failed reperfusion did not differ significantly from patients treated with best medical management.
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Affiliation(s)
- Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University Hospital of Basel, Basel, Switzerland
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Andrew Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | | | | | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Manon Kappelhof
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Nishita Singh
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Petra Cimflova
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Nima Kashani
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Fouzi Bala
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Beom Joon Kim
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Ryan McTaggart
- Warren Alpert School of Medicine, Brown University, Providence, USA
| | - Alexandre Poppe
- Centre Hospitalier de L'Université de Montréal, Montreal, Canada
| | - Raul G Nogueira
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, USA
| | | | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.
- Department of Radiology, University of Calgary, Calgary, Canada.
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Farooq J, Lee JY. Vascular tortuosity in endovascular mechanical thrombectomy. Brain Circ 2021; 7:3-7. [PMID: 34084969 PMCID: PMC8057096 DOI: 10.4103/bc.bc_5_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/02/2020] [Accepted: 12/15/2020] [Indexed: 12/11/2022] Open
Abstract
Endovascular mechanical thrombectomy effectively removes occlusive thrombi from the arterial lumen; however, there is little literature supporting the relevance of vascular geometry on surgical outcomes. Critical vessel characteristics including the degree of angulation and tortuosity influence the ability to advance stent retriever devices toward the site of occlusion. Therefore, it is crucial to evaluate the impact of carotid artery catheter pathway accessibility on the thrombectomy outcomes in acute ischemic stroke (AIS) patients. Traditional imaging modalities generate incomplete pictures of the vascular tortuosity and are prone to clinical judgment errors. Recent three-dimensional computed tomography angiography image analysis techniques circumvent these limitations to calculate accurate tortuosity and angulation measurements. These novel images facilitate classifying common anatomical variant patients into groups that may be treated with specially designed catheter devices. Importantly, this image analysis method reveals significant angulation in the common carotid artery and extracranial internal carotid artery that correlates with delays in reaching the occlusion site. Increased age, which is associated with increased risk of stroke, also increases the incidence of severe tortuosity. The semi-automated measurements technique also demonstrate that full 360° arterial loops are present in nearly 3% of catheter pathways and that the overall degree of angulation differs bilaterally. In this review, we examine the utility of this novel image analysis procedure and evaluate the recent literature relevant to neuroendovascular thrombectomy in AIS patients. Three literature databases – PubMed, Embase, and Web of Science were queried for original articles investigating both preclinical and clinical thrombectomy applications.
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Affiliation(s)
- Jeffrey Farooq
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Jea Young Lee
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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33
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Soize S, Eymard JB, Cheikh-Rouhou S, Manceau PF, Gelmini C, Sahnoun M, Gawlitza M, Zuber M, Pierot L, Touzé E. Fast Stent Retrieval during Mechanical Thrombectomy Improves Recanalization in Patients with the Negative Susceptibility Vessel Sign. AJNR Am J Neuroradiol 2021; 42:726-731. [PMID: 33574100 DOI: 10.3174/ajnr.a6989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/02/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND PURPOSE In acute ischemic stroke, the negative susceptibility vessel sign on T2*-weighted images traditionally highlights fibrin-rich clots, which are particularly challenging to remove. In vitro, fast stent retrieval improves fibrin-rich clot extraction. We aimed to evaluate whether the speed of stent retrieval influences the recanalization and clinical outcome of patients presenting with the negative susceptibility vessel sign. MATERIALS AND METHODS Patients were identified from a registry of patients with ischemic stroke receiving mechanical thrombectomy between January 2016 and January 2020. Inclusion criteria were the following: 1) acute ischemic stroke caused by an isolated occlusion of the anterior circulation involving the MCA (Internal Carotid Artery-L, M1, M2) within 8 hours of symptom onset; 2) a negative susceptibility vessel sign on prethrombectomy T2*-weighted images; and 3) treatment with a combined technique (stent retriever + contact aspiration). Patients were dichotomized according to retrieval speed (fast versus slow). The primary outcome was the first-pass recanalization rate. RESULTS Of 68 patients who met inclusion criteria, 31 (45.6%) were treated with fast retrieval. Patients receiving a fast retrieval had greater odds of first-pass complete (relative risk and 95% confidence interval [RR 95% CI], 4.30 [1.80-10.24]), near-complete (RR 95% CI, 3.24 [1.57-6.68]), and successful (RR 95% CI, 2.60 [1.53-4.43]) recanalization as well as greater odds of final complete (RR 95% CI, 4.18 [1.93-9.04]), near-complete (RR 95% CI, 2.75 [1.55-4.85]), and successful (RR 95% CI, 1.52 [1.14-2.03]) recanalization. No significant statistical differences in procedure-related serious adverse events, distal embolization, or symptomatic intracranial hemorrhage were reported. No differences were noted in terms of functional independence (RR 95% CI, 1.01 [0.53-1.93]) and all-cause mortality (RR 95% CI, 0.90 [0.35-2.30]) at 90 days. CONCLUSIONS A fast stent retrieval during mechanical thrombectomy is safe and improves the retrieval of clots with the negative susceptibility vessel sign.
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Affiliation(s)
- S Soize
- From the Unité Mixte de recherche-S U1237 (S.S., M.Z., E.T.), Institut National de la Santé et de la Recherche Médicale, Normandie University , Université Caen-Normandie, Cyceron, Caen, France .,Department of Neuroradiology (S.S., J.-B.E., S.C.-R., P.-F.M., C.G., M.S., M.G., L.P.), Hôpital Maison Blanche, Centre Hospitalier Universitaire de Reims, Université de Champagne-Ardenne, Reims, France
| | - J-B Eymard
- Department of Neuroradiology (S.S., J.-B.E., S.C.-R., P.-F.M., C.G., M.S., M.G., L.P.), Hôpital Maison Blanche, Centre Hospitalier Universitaire de Reims, Université de Champagne-Ardenne, Reims, France
| | - S Cheikh-Rouhou
- Department of Neuroradiology (S.S., J.-B.E., S.C.-R., P.-F.M., C.G., M.S., M.G., L.P.), Hôpital Maison Blanche, Centre Hospitalier Universitaire de Reims, Université de Champagne-Ardenne, Reims, France
| | - P-F Manceau
- Department of Neuroradiology (S.S., J.-B.E., S.C.-R., P.-F.M., C.G., M.S., M.G., L.P.), Hôpital Maison Blanche, Centre Hospitalier Universitaire de Reims, Université de Champagne-Ardenne, Reims, France
| | - C Gelmini
- Department of Neuroradiology (S.S., J.-B.E., S.C.-R., P.-F.M., C.G., M.S., M.G., L.P.), Hôpital Maison Blanche, Centre Hospitalier Universitaire de Reims, Université de Champagne-Ardenne, Reims, France
| | - M Sahnoun
- Department of Neuroradiology (S.S., J.-B.E., S.C.-R., P.-F.M., C.G., M.S., M.G., L.P.), Hôpital Maison Blanche, Centre Hospitalier Universitaire de Reims, Université de Champagne-Ardenne, Reims, France
| | - M Gawlitza
- Department of Neuroradiology (S.S., J.-B.E., S.C.-R., P.-F.M., C.G., M.S., M.G., L.P.), Hôpital Maison Blanche, Centre Hospitalier Universitaire de Reims, Université de Champagne-Ardenne, Reims, France
| | - M Zuber
- From the Unité Mixte de recherche-S U1237 (S.S., M.Z., E.T.), Institut National de la Santé et de la Recherche Médicale, Normandie University , Université Caen-Normandie, Cyceron, Caen, France.,Department of Neurology (M.Z.), Université de Paris, Hôpital Saint-Joseph, Paris, France
| | - L Pierot
- Department of Neuroradiology (S.S., J.-B.E., S.C.-R., P.-F.M., C.G., M.S., M.G., L.P.), Hôpital Maison Blanche, Centre Hospitalier Universitaire de Reims, Université de Champagne-Ardenne, Reims, France
| | - E Touzé
- From the Unité Mixte de recherche-S U1237 (S.S., M.Z., E.T.), Institut National de la Santé et de la Recherche Médicale, Normandie University , Université Caen-Normandie, Cyceron, Caen, France.,Department of Neurology (E.T.), Centre Hospitalier Universitaire Caen Normandie, Caen, France
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Kaesmacher J, Bellwald S, Dobrocky T, Meinel TR, Piechowiak EI, Goeldlin M, Kurmann CC, Heldner MR, Jung S, Mordasini P, Arnold M, Mosimann PJ, Schroth G, Mattle HP, Gralla J, Fischer U. Safety and Efficacy of Intra-arterial Urokinase After Failed, Unsuccessful, or Incomplete Mechanical Thrombectomy in Anterior Circulation Large-Vessel Occlusion Stroke. JAMA Neurol 2021; 77:318-326. [PMID: 31816018 DOI: 10.1001/jamaneurol.2019.4192] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance Achieving complete reperfusion is a key determinant of good outcome in patients treated with mechanical thrombectomy (MT). However, data on treatments geared toward improving reperfusion after incomplete MT are sparse. Objective To determine whether administration of intra-arterial urokinase is safe and improves reperfusion after failed or incomplete MT. Design, Setting, and Participants This observational cohort study included a consecutive sample of patients treated with second-generation MT from January 1, 2010, through August 4, 2017. Data were collected from the prospective registry of a tertiary care stroke center. Of 1274 patients screened, 69 refused to participate, and 993 met the observational studies inclusion criteria of a large vessel occlusion in the anterior circulation. Data were analyzed from September 1, 2017, through September 20, 2019. Intervention One hundred patients received intra-arterial urokinase after failed or incomplete MT using manual microcatheter injections. Main Outcomes and Measures Primary safety outcome was the occurrence of symptomatic intracranial hemorrhage (sICH) according to the Prolyse in Acute Cerebral Thromboembolism II criteria. Secondary end points included 90-day mortality and 90-day functional independence (defined as modified Rankin Scale score of ≤2). Efficacy was evaluated angiographically, applying the Thrombolysis in Cerebral Infarction (TICI) scale. Results After exclusion of patients with posterior circulation strokes and those treated with intra-arterial thrombolytics only, 993 patients were included in the final analyses (median age, 74.6 [interquartile range, 62.6-82.2] years; 505 [50.9%] women). Additional intra-arterial urokinase was administered in 100 patients (10.1%). The most common reason for administering intra-arterial urokinase was incomplete reperfusion (TICI<3) after MT (53 [53.0%]). After adjusting for baseline characteristics underlying case selection, intra-arterial urokinase was not associated with an increased risk of sICH (adjusted odds ratio [aOR], 0.81; 95% CI, 0.31-2.13) or 90-day mortality (aOR, 0.78; 95% CI, 0.43-1.40). Among 53 cases of partial or near-complete reperfusion and treated with intra-arterial urokinase, 32 (60.4%) had early reperfusion improvement, and 18 of 53 (34.0%) had an improvement in TICI grade. Correspondingly, patients treated with intra-arterial urokinase had higher rates of functional independence after adjusting for the selection bias favoring a priori poor TICI grades in the intra-arterial urokinase group (aOR, 1.93; 95% CI, 1.11-3.37). Conclusions and Relevance In selected patients, adjunctive treatment with intra-arterial urokinase during or after MT was safe and improved angiographic reperfusion. Systemic evaluation of this approach in a multicenter prospective registry or a randomized clinical trial seems warranted.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland.,University Institute of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Sebastian Bellwald
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Eike I Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Martina Goeldlin
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland.,Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Christoph C Kurmann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pascal J Mosimann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Gerhard Schroth
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Heinrich P Mattle
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute 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
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Kaesmacher J, Abdullayev N, Maamari B, Dobrocky T, Vynckier J, Piechowiak EI, Pop R, Behme D, Sporns PB, Styczen H, Virtanen P, Meyer L, Meinel TR, Cantré D, Kabbasch C, Maus V, Pekkola J, Fischer S, Hasiu A, Schwarz A, Wildgruber M, Seiffge DJ, Langner S, Martinez-Majander N, Radbruch A, Schlamann M, Mihoc D, Beaujeux R, Strbian D, Fiehler J, Mordasini P, Gralla J, Fischer U. Safety and Angiographic Efficacy of Intra-Arterial Fibrinolytics as Adjunct to Mechanical Thrombectomy: Results from the INFINITY Registry. J Stroke 2021; 23:91-102. [PMID: 33600706 PMCID: PMC7900401 DOI: 10.5853/jos.2020.01788] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/04/2020] [Indexed: 01/10/2023] Open
Abstract
Background and Purpose Data on safety and efficacy of intra-arterial (IA) fibrinolytics as adjunct to mechanical thrombectomy (MT) are sparse.
Methods INtra-arterial FIbriNolytics In ThrombectomY (INFINITY) is a retrospective multi-center observational registry of consecutive patients with anterior circulation large-vessel occlusion ischemic stroke treated with MT and adjunctive administration of IA fibrinolytics (alteplase [tissue plasminogen activator, tPA] or urokinase [UK]) at 10 European centers. Primary outcome was the occurrence of symptomatic intracranial hemorrhage (sICH) according to the European Cooperative Acute Stroke Study II definition. Secondary outcomes were mortality and modified Rankin Scale (mRS) scores at 3 months.
Results Of 5,612 patients screened, 311 (median age, 74 years; 44.1% female) received additional IA after or during MT (194 MT+IA tPA, 117 MT+IA UK). IA fibrinolytics were mostly administered for rescue of thrombolysis in cerebral infarction (TICI) 0-2b after MT (80.4%, 250/311). sICH occurred in 27 of 308 patients (8.8%), with an increased risk in patients with initial TICI0/1 (adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.1 to 5.0 per TICI grade decrease) or in those with intracranial internal carotid artery occlusions (aOR, 3.7; 95% CI, 1.2 to 12.5). In patients with attempted rescue of TICI0-2b and available angiographic follow-up, 116 of 228 patients (50.9%) showed any angiographic reperfusion improvement after IA fibrinolytics, which was associated with mRS ≤2 (aOR, 3.1; 95% CI, 1.4 to 6.9).
Conclusions Administration of IA fibrinolytics as adjunct to MT is performed rarely, but can improve reperfusion, which is associated with better outcomes. Despite a selection bias, an increased risk of sICH seems possible, which underlines the importance of careful patient selection.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland.,University Institute of Diagnostic and Interventional and Pediatric Radiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Nuran Abdullayev
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Basel Maamari
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Jan Vynckier
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Eike I Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Raoul Pop
- Department of Interventional Neuroradiology, University Hospital Strasbourg, Strasbourg, France
| | - Daniel Behme
- Department of Neuroradiology, University Hospital Göttingen, Göttingen, Germany
| | - Peter B Sporns
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanna Styczen
- Department of Neuroradiology, University Hospital Essen, Essen, Germany
| | - Pekka Virtanen
- Department of Neuroradiology, University Hospital Helsinki, Helsinki, Finland
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas R Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Daniel Cantré
- Department of Radiology, University Hospital Rostock, Rostock, Germany
| | - Christoph Kabbasch
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Volker Maus
- Department of Neuroradiology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Johanna Pekkola
- Department of Neuroradiology, University Hospital Helsinki, Helsinki, Finland
| | - Sebastian Fischer
- Department of Neuroradiology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Anca Hasiu
- Department of Interventional Neuroradiology, University Hospital Strasbourg, Strasbourg, France
| | - Alexander Schwarz
- Department of Neuroradiology, University Hospital Göttingen, Göttingen, Germany
| | - Moritz Wildgruber
- Institute of Clinical Radiology University Hospital of Muenster, Muenster, Germany.,Department of Radiology, University Hospital Munich, Ludwig Maximilian University, Munich, Germany
| | - David J Seiffge
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Sönke Langner
- Department of Radiology, University Hospital Rostock, Rostock, Germany
| | | | - Alexander Radbruch
- Department of Neuroradiology, University Hospital Essen, Essen, Germany.,Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Marc Schlamann
- Institute for Diagnostic and Interventional Radiology, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Dan Mihoc
- Department of Interventional Neuroradiology, University Hospital Strasbourg, Strasbourg, France
| | - Rémy Beaujeux
- Department of Interventional Neuroradiology, University Hospital Strasbourg, Strasbourg, France
| | - Daniel Strbian
- Department of Neurology, University Hospital Helsinki, Helsinki, Finland
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute 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
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36
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Kaesmacher J, Meinel TR, Kurmann C, Zaidat OO, Castonguay AC, Zaidi SF, Mueller-Kronast N, Kappelhof M, Dippel DWJ, Soudant M, Bracard S, Hill MD, Goyal M, Strbian D, Heiferman DM, Ashley W, Anadani M, Spiotta AM, Dobrocky T, Piechowiak EI, Arnold M, Goeldlin M, Seiffge D, Mosimann PJ, Mordasini P, Gralla J, Fischer U. Safety and efficacy of intra-arterial fibrinolytics as adjunct to mechanical thrombectomy: a systematic review and meta-analysis of observational data. J Neurointerv Surg 2021; 13:1073-1080. [PMID: 33514609 PMCID: PMC8606438 DOI: 10.1136/neurintsurg-2020-016680] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/17/2020] [Accepted: 12/01/2020] [Indexed: 12/22/2022]
Abstract
Background Achieving the best possible reperfusion is a key determinant of clinical outcome after mechanical thrombectomy (MT). However, data on the safety and efficacy of intra-arterial (IA) fibrinolytics as an adjunct to MT with the intention to improve reperfusion are sparse. Methods We performed a PROSPERO-registered (CRD42020149124) systematic review and meta-analysis accessing MEDLINE, PubMed, and Embase from January 1, 2000 to January 1, 2020. A random-effect estimate (Mantel-Haenszel) was computed and summary OR with 95% CI were used as a measure of added IA fibrinolytics versus control on the risk of symptomatic intracranial hemorrhage (sICH) and secondary endpoints (modified Rankin Scale ≤2, mortality at 90 days). Results The search identified six observational cohort studies and three observational datasets of MT randomized-controlled trial data reporting on IA fibrinolytics with MT as compared with MT alone, including 2797 patients (405 with additional IA fibrinolytics (100 urokinase (uPA), 305 tissue plasminogen activator (tPA)) and 2392 patients without IA fibrinolytics). Of 405 MT patients treated with additional IA fibrinolytics, 209 (51.6%) received prior intravenous tPA. We did not observe an increased risk of sICH after administration of IA fibrinolytics as adjunct to MT (OR 1.06, 95% CI 0.64 to 1.76), nor excess mortality (0.81, 95% CI 0.60 to 1.08). Although the mode of reporting was heterogeneous, some studies observed improved reperfusion after IA fibrinolytics. Conclusion The quality of evidence regarding peri-interventional administration of IA fibrinolytics in MT is low and limited to observational data. In highly selected patients, no increase in sICH was observed, but there is large uncertainty.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland .,University Institute of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Raphael Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Christoph Kurmann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Osama O Zaidat
- Neuroscience, St Vincent Mercy Hospital, Toledo, Ohio, USA
| | | | - Syed F Zaidi
- Neurology, University of Toledo Health Science Campus, Toledo, Ohio, USA
| | - Nils Mueller-Kronast
- Neurology, St. Mary's Medical Center, Delray Medical Center, Boynton Beach, Florida, USA
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Diederik W J Dippel
- Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marc Soudant
- Clinical Investigation Centre-Clinical Epidemiology 1433, INSERM, University Hospital Centre Nancy, Université de Lorraine, Nancy, France
| | - Serge Bracard
- Neuroradiology, CHRU-Nancy, University de Lorraine, Nancy, France
| | - Michael D Hill
- Clinical Neurosciences, University Of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | | | | | - William Ashley
- Neurosurgery, The Sandra and Malcolm Berman Brain and Spine Institute, Sinai Hospital and LifeBridge Health System, Baltimore, Maryland, USA
| | - Mohammad Anadani
- Neurology, Washington University School of Medicine, Saint Louis, Missouri, USA.,Neurology, Medical University of South Carolina - College of Medicine, Charleston, South Carolina, USA
| | - Alejandro M Spiotta
- Neurology, Medical University of South Carolina - College of Medicine, Charleston, South Carolina, USA
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Eike I Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Martina Goeldlin
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - David Seiffge
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pascal J Mosimann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland.,Neuroradiology, Alfried Krupp Krankenhaus, Essen, Germany
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute 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
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Flottmann F, Brekenfeld C, Broocks G, Leischner H, McDonough R, Faizy TD, Deb-Chatterji M, Alegiani A, Thomalla G, Mpotsaris A, Nolte CH, Fiehler J, Maros ME. Good Clinical Outcome Decreases With Number of Retrieval Attempts in Stroke Thrombectomy: Beyond the First-Pass Effect. Stroke 2021; 52:482-490. [PMID: 33467875 PMCID: PMC7834657 DOI: 10.1161/strokeaha.120.029830] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Endovascular therapy is the standard of care in the treatment of acute ischemic stroke due to large-vessel occlusion. Often, more than one retrieval attempt is needed to achieve reperfusion. We aimed to quantify the influence of endovascular therapy on clinical outcome depending on the number of retrievals needed for successful reperfusion in a large multi-center cohort. Methods: For this observational cohort study, 2611 patients from the prospective German Stroke Registry included between June 2015 and April 2018 were analyzed. Patients who received endovascular therapy for acute anterior circulation stroke with known admission National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT Score, final Thrombolysis in Cerebral Infarction score, and number of retrievals were included. Successful reperfusion was defined as a Thrombolysis in Cerebral Infarction score of 2b or 3. The primary outcome was defined as functional independence (modified Rankin Scale score of 0–2) at day 90. Multivariate mixed-effects models were used to adjust for cluster effects of the participating centers and confounders. Results: The inclusion criteria were met by 1225 patients. The odds of good clinical outcome decreased with every retrieval attempt required for successful reperfusion: the first retrieval had the highest odds of good clinical outcome (adjusted odds ratio, 6.45 [95% CI, 4.0–10.4]), followed by the second attempt (adjusted odds ratio, 4.56 [95% CI, 2.7–7.7]), and finally the third (adjusted odds ratio, 3.16 [95% CI, 1.8–5.6]). Conclusions: Successful reperfusion within the first 3 retrieval attempts is associated with improved clinical outcome compared with patients without reperfusion. We conclude that at least 3 retrieval attempts should be performed in endovascular therapy of anterior circulation strokes. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03356392.
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Affiliation(s)
- Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Milani Deb-Chatterji
- Department of Neurology (M.D.-C., A.A., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Anna Alegiani
- Department of Neurology (M.D.-C., A.A., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Götz Thomalla
- Department of Neurology (M.D.-C., A.A., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Anastasios Mpotsaris
- University Clinic for Neuroradiology, Otto-von-Guericke-University Magdeburg, Germany (A.M.)
| | - Christian H Nolte
- Department of Neurology (C.H.N.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin (C.H.N.), Charité-Universitätsmedizin Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Máté E Maros
- Department of Neuroradiology (M.E.M.), Heidelberg University, Mannheim, Germany.,Department of Biomedical Informatics at the Center for Preventive Medicine and Digital Health (M.E.M.), Heidelberg University, Mannheim, Germany
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Lee SJ, Park SY, Hong JM, Choi JW, Kang DH, Kim YW, Kim YS, Hong JH, Kim CH, Yoo J, Nogueira RG, Hwang YH, Sohn SI, Lee JS. Etiological Approach to Understanding Recanalization Failure in Intracranial Large Vessel Occlusion and Thrombectomy: Close to Embolism but Distant From Atherosclerosis. Front Neurol 2021; 11:598216. [PMID: 33536994 PMCID: PMC7848124 DOI: 10.3389/fneur.2020.598216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/10/2020] [Indexed: 12/28/2022] Open
Abstract
Introduction: In patients with intracranial large vessel occlusion (LVO) who undergo endovascular treatment (EVT), recanalization failure may be related to intracranial atherosclerotic stenosis (ICAS). We evaluated whether the risk factors of recanalization failure could possibly be a marker of ICAS among various types of LVO. Methods: From a multicenter registry, patients with middle cerebral artery M1 segment occlusions who underwent thrombectomy within 24 h were included. Based on the on-procedure and post-procedure angiographic findings, patients were classified into embolic, ICAS-related, tandem occlusion, and recanalization failure groups. Recanalization failure was defined if the occluded vessel could not be recanalized by stent retrieval, contact aspiration, or local lytics treatment. Risk factors, imaging markers, and EVT methods were compared between groups. Results: Among 326 patients, 214 were classified as embolism, 76 as ICAS, 16 as tandem, and 20 as recanalization failure. The group with recanalization failure showed higher scores on the National Institutes of Health Stroke Scale (NIHSS) (median, 16.0 vs. 14.5 vs. 14.0 vs. 17.0, p = 0.097), frequent atrial fibrillation (59.3 vs. 18.4 vs. 0 vs. 40.0% p < 0.001), and elevation in erythrocyte sedimentation rate (ESR) (14.5 ± 15.7 vs. 15.0 ± 14.1 vs. 21.2 ± 19.5 vs. 36.0 ± 32.9, p < 0.001) among the groups. The rate of computed tomography angiography-based truncal-type occlusion in recanalization failure group was not as high as that in the ICAS group (8.1 vs. 37.5 vs. 0 vs. 16.7%, p < 0.001). Balloon guide catheters (BGC) were less frequently utilized in the recanalization failure group as compared to their use in the other groups (72.0 vs. 72.4 vs. 62.5 vs. 30.0%, p = 0.001). In the multivariable analysis, initial higher NIHSS [odds ratio (OR), 1.11 95% confidence interval (CI), 1.01–1.22 p = 0.027], higher ESR (OR, 1.03 CI, 1.01–1.05 p = 0.006), and non-use of BGCs (OR, 3.41 CI, 1.14–10.17 p = 0.028) were associated with recanalization failure. In M1 occlusions, the predominant mechanism of recanalization failure was presumed to be embolic in 80% and due to ICAS in 20%. Conclusion: The analysis of recanalization failures does not suggest an underlying predominant ICAS mechanism. Sufficient utilization of thrombectomy devices and procedures may improve the rates of recanalization.
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Affiliation(s)
- Seong-Joon Lee
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - So Young Park
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Jin Wook Choi
- Department of Radiology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Dong-Hun Kang
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, South Korea.,Department of Radiology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yong-Won Kim
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, South Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yong-Sun Kim
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Joonsang Yoo
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea.,Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Raul G Nogueira
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, United States
| | - Yang-Ha Hwang
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Ajou University Medical Center, Suwon, South Korea
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Abstract
Endovascular therapy (EVT) has become the standard treatment for large-vessel occlusion (LVO) acute ischemic stroke (AIS). EVT is now indicated in patients up to 24h from their last known well, provided that the patient meets specific clinical and imaging criteria. Improvements in thrombectomy devices, techniques, and operator experience have allowed successful EVT of ICA terminus, M1-MCA occlusions as well as proximal M2-MCA, basilar artery occlusions, and revascularization of tandem lesions. Mechanical thrombectomy failures still occur due to several factors, however, highlighting the need for further device and technical improvements. An ongoing debate exists regarding the need for pre-EVT thrombolytic agents, thrombectomy techniques, distal occlusions, anesthesia methods, the role of advanced neuroimaging, the treatment of patients with larger infarct core, and those presenting with milder stroke symptoms. Many of these questions are the subject of current or upcoming clinical trials. This review aims to provide an outline and discussion about the established recommendations and emerging topics regarding EVT for LVO AIS.
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Affiliation(s)
- Fabio Settecase
- Neuroradiology Division, Department of Radiology, University of British Columbia, Vancouver, BC, Canada; Diagnostic and Interventional Neuroradiology Division, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada; Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States.
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40
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Rosa JA, Roberts R, Wareham J, Crossley R, Cox A, Mortimer A. Aortic and supra-aortic arterial tortuosity and access technique: Impact on time to device deployment in stroke thrombectomy. Interv Neuroradiol 2020; 27:419-426. [PMID: 33215558 DOI: 10.1177/1591019920974183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Longer intervals to reperfusion in patients treated with mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) stroke are associated with worse outcomes and influenced by the operator's ability to navigate individual anatomy. Our aims were to assess the impact of time from puncture to first deployment of the MT device (DT) on technical and clinical outcomes, develop an Anatomical Assessment for Mechanical Thrombectomy Score (ASMETS) that could predict DT and assess how different methods of intracranial access (coaxial-direct or exchange) influence this. METHODS Retrospective review of a prospective database of patients treated with MT for ELVO between November 2015 and August 2018. CTAs were assessed for ASMETS. Intracranial access technique was at the discretion of the operator. Technical and clinical outcomes and complications were recorded. Linear and logistic regression analysis was performed. RESULTS 92 patients were included. The impact of DT on clinical outcomes was significant. An unfavourable ASMET score is significantly associated with longer DT (p = 0.002) and linear regression showed DT time can be predicted by ASMETS - F(1,90) = 6.182, p = 0.015. No difference was demonstrated between different access techniques. CONCLUSION CTA-based ASMETS can predict time between arterial puncture and deployment of the mechanical thrombectomy device in stroke patients, irrespective of the technique used to catheterise the target ICA. This could inform the operator in preparing appropriate strategies to overcome challenging vascular anatomy in patients undergoing MT.
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Affiliation(s)
- Joao Alves Rosa
- Neuroradiology Department, 159003Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Rachel Roberts
- Neuroradiology Department, 159003Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - James Wareham
- Neuroradiology Department, 159003Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Robert Crossley
- Neuroradiology Department, 159003Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Anthony Cox
- Neuroradiology Department, 159003Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Alex Mortimer
- Neuroradiology Department, 159003Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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41
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Jin X, Shi F, Chen Y, Zheng X, Zhang J. Jet-Like Appearance in Angiography as a Predictive Image Marker for the Occlusion of Intracranial Atherosclerotic Stenosis. Front Neurol 2020; 11:575567. [PMID: 33193024 PMCID: PMC7661688 DOI: 10.3389/fneur.2020.575567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/31/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Identifying intracranial atherosclerotic stenosis-related occlusion (ICAS-O) in acute ischemic stroke has important clinical significance. Correct identification would help operators devise an optimal recanalization strategy. However, it is often hard to make accurate judgments in emergency situations before thrombectomy. Here, we propose a new image marker for ICAS-O based on the appearance of occluded vessels on baseline digital subtraction angiography. Materials and Methods: We retrospectively reviewed patients with acute ischemic stroke who underwent endovascular therapy from August 2017 to February 2020 at our center. ICAS-O was identified by residual focal stenosis at occluded vessels after successful recanalization. The jet-like appearance was defined as appearance of pencil-tip-like or line-linked contrast filling of the occlusion edge. A non-jet-like appearance was defined as appearance of convex, concave, or flat edge contrast filling. The proportion of jet-like appearance in different occlusion etiologies and occluded vessels was determined. The diagnostic value of jet-like appearance for ICAS-O was assessed. Results: A total of 164 patients diagnosed with ICAS-O were enrolled. Jet-like appearance was detected in 34 (20.7%) patients with younger age (68.0 ± 11.9 years vs. 62.7 ± 10.2, p = 0.019), patients with lower baseline NIHSS scores (16.6 ± 7.1 vs. 12.4 ± 6.5, p = 0.002) and patients with more past stroke or transit ischemic events (31.4 vs. 13.2%, p = 0.011). ICAS-O rate was higher in the jet-like appearance group (82.9 vs. 8.5%, p < 0.001), and rescue methods were more frequently used (74.3 vs. 12.4%, p < 0.001). Jet-like appearance was mostly found at the origin of the middle cerebral artery (MCA) (44.1%), followed by the first segment trunk of MCA (20.6%) and internal carotid artery (ICA) supraclinoid (11.8%). Logistic regression showed that jet-like appearance was independently associated with ICAS-O [OR 180.813, 95% CI (17.966, 1,819.733), p < 0.001]. The sensitivity, specificity, and accuracy values for predicting ICAS-O was 96, 78, and 83%. Conclusion: The jet-like appearance on the angiogram was an image marker for ICAS-O, with relatively high sensitivity and specificity, which could help operators predict underlying intracranial atherosclerotic stenosis in a timely manner and choose the optimal intervention strategy during endovascular therapy.
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Affiliation(s)
- Xing Jin
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Feina Shi
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yigang Chen
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xu Zheng
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jinhua Zhang
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Allard J, Ghazanfari S, Mahmoudi M, Labreuche J, Escalard S, Delvoye F, Ciccio G, Smajda S, Redjem H, Hebert S, Consoli A, Costalat V, Desilles JP, Mazighi M, Piotin M, Dargazanli C, Lapergue B, Blanc R, Maïer B. Rescue carotid puncture for ischemic stroke treated by endovascular therapy: a multicentric analysis and systematic review. J Neurointerv Surg 2020; 13:809-815. [PMID: 33077577 DOI: 10.1136/neurintsurg-2020-016725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/22/2020] [Accepted: 09/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endovascular therapy (EVT) for acute ischemic stroke (AIS) can be challenging in older patients with supra-aortic tortuosity. Rescue carotid puncture (RCP) can be an alternative in case of supra-aortic catheterization failure by femoral access, but data regarding RCP are scarce. We sought to investigate the feasibility, effectiveness and safety of RCP for AIS treated by EVT. METHODS Patients treated by EVT with RCP were included from January 2012 to December 2019 in the Endovascular Treatment in Ischemic Stroke (ETIS) multicentric registry. Main outcomes included reperfusion rates ( ≥ TICI2B), 3 month functional outcome (modified Rankin Scale) and 3 month mortality. We also performed an additional systematic review of the literature according to the PRISMA checklist to summarize previous studies on RCP. RESULTS 25 patients treated by EVT with RCP were included from the ETIS registry. RCP mainly concerned elderly patients (median age 85 years, range 73-92) with supra-aortic tortuosity (n=16 (64%)). Intravenous thrombolysis (IVT) was used for nine patients (36%). Successful reperfusion was achieved in 64%, 87.5% of patients were dependent at 3 months, and 3 month mortality was 45.8%. The systematic review yielded comparable results. In pooled individual data, there was a shift toward better functional outcome in patients with successful reperfusion (median (IQR) 4 (2-6) vs 6 (4-6), p=0.011). CONCLUSION RCP mainly concerned elderly patients admitted for AIS with anterior LVO with supra-aortic tortuosity. The procedure seemed feasible, notably for patients treated with IVT, and led to significant reperfusion rates at the end of procedure, but with pronounced unfavorable outcomes at 3 months. RCP should be performed under general anesthesia to avoid life-threatening complications and ensure airways safety. Finally, RCP led to low rates of closure complications, emphasizing that this concern should not withhold RCP, if indicated.
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Affiliation(s)
- Julien Allard
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Sam Ghazanfari
- Stroke Center, Hôpital Foch, Suresnes, Île-de-France, France
| | - Mehdi Mahmoudi
- Neuroradiology, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Julien Labreuche
- ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille University Hospital Center, Lille, Hauts-de-France, France
| | - Simon Escalard
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - François Delvoye
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Gabriele Ciccio
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Stanislas Smajda
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Hocine Redjem
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Solène Hebert
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Arturo Consoli
- Neuroradiology, Hopital Foch, Suresnes, Île-de-France, France
| | - Vincent Costalat
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, Occitanie, France
| | - Jean-Philippe Desilles
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Université de Paris, Paris, France.,Laboratory of Vascular Translational Science, U1148, Paris, France
| | - Mikael Mazighi
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Université de Paris, Paris, France.,Laboratory of Vascular Translational Science, U1148, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Laboratory of Vascular Translational Science, U1148, Paris, France
| | - Cyril Dargazanli
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, Occitanie, France
| | | | - Raphaël Blanc
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France
| | - Benjamin Maïer
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, Île-de-France, France.,Université de Paris, Paris, France.,Laboratory of Vascular Translational Science, U1148, Paris, France
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43
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Weyland CS, Neuberger U, Potreck A, Pfaff JAR, Nagel S, Schönenberger S, Bendszus M, Möhlenbruch MA. Reasons for Failed Mechanical Thrombectomy in Posterior Circulation Ischemic Stroke Patients. Clin Neuroradiol 2020; 31:745-752. [PMID: 32894352 PMCID: PMC8463404 DOI: 10.1007/s00062-020-00950-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/06/2020] [Indexed: 01/18/2023]
Abstract
Background and Purpose To determine reasons for failed recanalization in mechanical thrombectomy (MT) of the posterior circulation. Methods Retrospective single center analysis of reasons for MT failure in the posterior circulation. Failed MTs were categorized according to the reason for procedure failure in failed vascular access, failed passage of the target vessel occlusion and MT failure after passing the occluded target vessel. Patient characteristics were compared between failed and successful MT. Results Patients with failed MT (30/218 patients, 13.8%) were categorized into futile vascular access (13/30, 43.3%), abortive passage of the target vessel occlusion (6/30, 20.0%) and MT failure after passing the vessel occlusion (11/30, 36.7%). In 188/218 (86.2%) successful MTs alternative vascular access, local intra-arterial (i.a.) thrombolysis and emergency stent-assisted PTA prevented 65 MT failures. Patients with failed MT showed a higher NIHSS at discharge, a higher pc-ASPECTS in follow-up imaging, a higher mRS 90 days after stroke onset and a high mortality rate of 77.0% (mRS at 90 days, median (IQR): 6 (6–6) vs. 4 (2–6) for successful MT, p-value < 0.001). Co-morbidities and stroke etiology were not different compared to sufficient recanalization with atherosclerotic disease as the leading stroke etiology in both groups. Conclusion Failure of MT in posterior circulation ischemic stroke patients is associated with a high mortality rate. Reasons for MT failure are diverse with futile vascular access and MT failure after passing the vessel occlusion as the leading causes. Alternative vascular access, local i.a. thrombolysis and stent-assisted PTA can prevent MT failure.
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Affiliation(s)
- Charlotte S Weyland
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Ulf Neuberger
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Arne Potreck
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Johannes A R Pfaff
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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Lu CJ, Lin YH, Chu HJ, Tang SC, Lee CW. Safety and efficacy of the transbrachial approach for endovascular thrombectomy in patients with acute large vessel occlusion stroke. J Formos Med Assoc 2020; 120:705-712. [PMID: 32819794 DOI: 10.1016/j.jfma.2020.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The transbrachial approach (TBA) is an alternative method to the transfemoral approach (TFA). We herein aimed to evaluate the safety and efficacy of the TBA for endovascular thrombectomy (EVT) in patients with acute large vessel occlusion stroke. METHODS We reviewed the records of 297 patients who had undergone EVT from January 2015 to July 2019. Eighteen patients who had undergone 19 procedures were included. Indications for arterial access, devices, recanalization rates, complication rates, and clinical outcomes were evaluated. RESULTS There were 15 and 4 cases of anterior and posterior circulation stroke, respectively. The mean patient age was 80.1 years. Eight patients were male. The median National Institutes of Health Stroke Scale score was 18. The total procedure duration tended to be longer when the TBA was used after failure of the TFA (n = 6, 32%, median: 60.5 min) than when the TBA was used as the first treatment approach (n = 13, 68%, median: 22 min). Optimal recanalization (a modified Thrombolysis in Cerebral Infarction score of 2b or 3) was achieved for 15 procedures. Local complications were observed in two cases: one with brachial artery pseudoaneurysm and another with brachial artery occlusion. Three patients with anterior circulation stroke exhibited good clinical outcomes (modified Rankin score ≤ 2) at 90 days. Symptomatic intracranial hemorrhage occurred in one patient. Mortality was noted in four patients. CONCLUSION The TBA for EVT is a suitable alternative when adoption of the TFA is difficult or impossible.
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Affiliation(s)
- Chi-Ju Lu
- Department of Medical Imaging, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan; Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Hai-Jui Chu
- Department of Neurology, En Chu Kong Hospital, New Taipei City, Taiwan; Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan.
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Mokin M, Waqas M, Chin F, Rai H, Senko J, Sparks A, Ducharme RW, Springer M, Borlongan CV, Levy EI, Ionita C, Siddiqui AH. Semi-automated measurement of vascular tortuosity and its implications for mechanical thrombectomy performance. Neuroradiology 2020; 63:381-389. [PMID: 32816090 DOI: 10.1007/s00234-020-02525-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Few studies have examined the geometry of endovascular mechanical thrombectomy pathways. Here we examine the tortuosity and angulations of catheter pathways from the aortic arch to the termination of the internal carotid artery (ICA) and its association with thrombectomy performance. METHODS We included 100 consecutive anterior circulation large vessel occlusion thrombectomy patients over 12 months. Computed tomography angiograms (CTA) were used for 3D segmentation of catheter pathway from the aortic arch to ICA termination. Tortuosity index (TI) and angulations of the catheter pathway were measured in a semi-automated fashion. TI and angulation degree were compared between sides and correlated with age and procedural measures. RESULTS We analyzed 188 catheter pathways in 100 patients. Severe angulation (≤ 30°) was present in 5.8% and 39.4% of common carotid artery (CCA) and extracranial ICA segments, respectively. Five pathways (2.6%) had 360° loop. CCA and extracranial ICA tortuosity had a weak but significant correlation with age (r = 0.17, 0.21, p value = 0.05, 0.02 respectively), time from groin puncture to the site of occlusion (r = 0.29, 0.25, p values = 0.008, 0.026 respectively), and fluoroscopy time (r = 0.022, 0.31, p values = 0.016, 0.001 respectively). There was a significant difference in the pattern of angulation (p value = 0.04) and tortuosity between right and left side in CCA segment (TI = 0.20 ± 0.086 vs. 0.15 ± 0.82, p value < 0.001). CONCLUSIONS There was a significant difference in CCA angulation between right and left sides. TI of extracranial CCA and ICA correlated with age and influenced time from groin puncture to the occlusion site and total fluoroscopy time.
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Affiliation(s)
- Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Felix Chin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Hamid Rai
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | | | | | | | | | - Cesario V Borlongan
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Ciprian Ionita
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA. .,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA.
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Bourcier R, Marnat G, Labreuche J, Desal H, Maria FD, Consoli A, Eugène F, Gory B, Dargazanli C, Blanc R, Lapergue B. Balloon Guide Catheter is Not Superior to Conventional Guide Catheter when Stent Retriever and Contact Aspiration are Combined for Stroke Treatment. Neurosurgery 2020; 88:E83-E90. [DOI: 10.1093/neuros/nyaa315] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 05/02/2020] [Indexed: 01/10/2023] Open
Abstract
Abstract
BACKGROUND
The effectiveness of balloon guide catheter (BGC) use has not been prospectively studied and its added value for improving reperfusion in acute ischemic stroke (AIS) treatment has only been reported in studies in which no contact aspiration was combined with the stent retriever (CA + SR).
OBJECTIVE
To compare the reperfusion results and clinical outcomes with and without BGC use when a combined CA + SR strategy is employed in first line to treat AIS.
METHODS
From January 2016 to April 2019, data from the ETIS registry (Endovascular Treatment in Ischemic Stroke) were reviewed. We included patients having undergone endovascular treatment with a combined CA + SR strategy and use or not of a BGC according to the operator's discretion. We compared BGC and nonBGC populations with matching and inverse probability of treatment weighting propensity scores. Primary outcome was the final near-complete/complete revascularization (mTICI2c/3) rate. Secondary outcomes included clinical outcomes and safety considerations.
RESULTS
Among 607 included patients, BGC was used in 32.9% (n = 200), and 190 matched pairs could be found. We found no significant difference in final mTICI2c/3 between patients with and without BGC (60.1% in BGC group compared to 62.7% in nonBGC group (matched RR, 0.92; 95%CI, 0.80 to 1.14)), first-pass mTICI2c/3 (35.1% vs 37.3%, matched RR, 0.94; 95%CI, 0.68 to 1.30), clinical outcome (matched RR of 1.12 (95%CI, 0.85 to 1.47) for favorable outcome.
CONCLUSION
The reperfusion and clinical results with and without BGC use are not significantly different when combined CA + SR are used as a first-line strategy for large vessel occlusion in the setting of AIS.
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Affiliation(s)
- Romain Bourcier
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Julien Labreuche
- University of Lille, CHU Lille, EA 2694 - Santé Publique: Épidémiologie et Qualité des Soins, Lille, France
| | - Hubert Desal
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Federico Di Maria
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Foch Suresnes FR, University of Versailles Saint Quentin-en-Yvelines, Versailles, France
| | - Arturo Consoli
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Foch Suresnes FR, University of Versailles Saint Quentin-en-Yvelines, Versailles, France
| | | | - Benjamin Gory
- University of Lorraine, INSERM U1254, IADI, F-54000, Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Guy de Chauliac University Hospital, Montpellier, France
| | - Raphaël Blanc
- Department of Interventional Neuroradiology, Fondation Ophtalmologique A. De Rothschild, Paris, France
| | - Bertrand Lapergue
- Department of Neurology, Hôpital Foch Suresnes FR, University of Versailles Saint Quentin-en-Yvelines, Versailles, France
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Hofmeister J, Bernava G, Rosi A, Vargas MI, Carrera E, Montet X, Burgermeister S, Poletti PA, Platon A, Lovblad KO, Machi P. Clot-Based Radiomics Predict a Mechanical Thrombectomy Strategy for Successful Recanalization in Acute Ischemic Stroke. Stroke 2020; 51:2488-2494. [PMID: 32684141 PMCID: PMC7382538 DOI: 10.1161/strokeaha.120.030334] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Mechanical thrombectomy (MTB) is a reference treatment for acute ischemic stroke, with several endovascular strategies currently available. However, no quantitative methods are available for the selection of the best endovascular strategy or to predict the difficulty of clot removal. We aimed to investigate the predictive value of an endovascular strategy based on radiomic features extracted from the clot on preinterventional, noncontrast computed tomography to identify patients with first-attempt recanalization with thromboaspiration and to predict the overall number of passages needed with an MTB device for successful recanalization. Methods: We performed a study including 2 cohorts of patients admitted to our hospital: a retrospective training cohort (n=109) and a prospective validation cohort (n=47). Thrombi were segmented on noncontrast computed tomography, followed by the automatic computation of 1485 thrombus-related radiomic features. After selection of the relevant features, 2 machine learning models were developed on the training cohort to predict (1) first-attempt recanalization with thromboaspiration and (2) the overall number of passages with MTB devices for successful recanalization. The performance of the models was evaluated on the prospective validation cohort. Results: A small subset of radiomic features (n=9) was predictive of first-attempt recanalization with thromboaspiration (receiver operating characteristic curve–area under the curve, 0.88). The same subset also predicted the overall number of passages required for successful recanalization (explained variance, 0.70; mean squared error, 0.76; Pearson correlation coefficient, 0.73; P<0.05). Conclusions: Clot-based radiomics have the ability to predict an MTB strategy for successful recanalization in acute ischemic stroke, thus allowing a potentially better selection of the MTB strategy, as well as patients who are most likely to benefit from the intervention.
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Affiliation(s)
- Jeremy Hofmeister
- Radiology Unit, Department of Diagnostic (J.H., X.M., S.B., P.-A.P., A.P.), Geneva University Hospitals, Switzerland.,Department of Radiology and Medical Informatics, University of Geneva, Switzerland (J.H., M.I.V., X.M., P.-A.P., A.P., K.-O.L., P.M.)
| | - Gianmarco Bernava
- Diagnostic and Interventional Neuroradiology Unit, Department of Diagnostic (G.B., A.R., M.I.V., K.-O.L., P.M.), Geneva University Hospitals, Switzerland
| | - Andrea Rosi
- Diagnostic and Interventional Neuroradiology Unit, Department of Diagnostic (G.B., A.R., M.I.V., K.-O.L., P.M.), Geneva University Hospitals, Switzerland
| | - Maria Isabel Vargas
- Diagnostic and Interventional Neuroradiology Unit, Department of Diagnostic (G.B., A.R., M.I.V., K.-O.L., P.M.), Geneva University Hospitals, Switzerland.,Department of Radiology and Medical Informatics, University of Geneva, Switzerland (J.H., M.I.V., X.M., P.-A.P., A.P., K.-O.L., P.M.)
| | - Emmanuel Carrera
- Neurology Unit, Department of Neurosciences (E.C.), Geneva University Hospitals, Switzerland
| | - Xavier Montet
- Radiology Unit, Department of Diagnostic (J.H., X.M., S.B., P.-A.P., A.P.), Geneva University Hospitals, Switzerland.,Department of Radiology and Medical Informatics, University of Geneva, Switzerland (J.H., M.I.V., X.M., P.-A.P., A.P., K.-O.L., P.M.)
| | - Simon Burgermeister
- Radiology Unit, Department of Diagnostic (J.H., X.M., S.B., P.-A.P., A.P.), Geneva University Hospitals, Switzerland
| | - Pierre-Alexandre Poletti
- Radiology Unit, Department of Diagnostic (J.H., X.M., S.B., P.-A.P., A.P.), Geneva University Hospitals, Switzerland.,Department of Radiology and Medical Informatics, University of Geneva, Switzerland (J.H., M.I.V., X.M., P.-A.P., A.P., K.-O.L., P.M.)
| | - Alexandra Platon
- Radiology Unit, Department of Diagnostic (J.H., X.M., S.B., P.-A.P., A.P.), Geneva University Hospitals, Switzerland.,Department of Radiology and Medical Informatics, University of Geneva, Switzerland (J.H., M.I.V., X.M., P.-A.P., A.P., K.-O.L., P.M.)
| | - Karl-Olof Lovblad
- Diagnostic and Interventional Neuroradiology Unit, Department of Diagnostic (G.B., A.R., M.I.V., K.-O.L., P.M.), Geneva University Hospitals, Switzerland.,Department of Radiology and Medical Informatics, University of Geneva, Switzerland (J.H., M.I.V., X.M., P.-A.P., A.P., K.-O.L., P.M.)
| | - Paolo Machi
- Diagnostic and Interventional Neuroradiology Unit, Department of Diagnostic (G.B., A.R., M.I.V., K.-O.L., P.M.), Geneva University Hospitals, Switzerland.,Department of Radiology and Medical Informatics, University of Geneva, Switzerland (J.H., M.I.V., X.M., P.-A.P., A.P., K.-O.L., P.M.)
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Soize S, Pierot L, Mirza M, Gunning G, Gilvarry M, Gawlitza M, Vivien D, Zuber M, Touzé E. Fast Stent Retrieval Improves Recanalization Rates of Thrombectomy: Experimental Study on Different Thrombi. AJNR Am J Neuroradiol 2020; 41:1049-1053. [PMID: 32409312 DOI: 10.3174/ajnr.a6559] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/02/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE About 20% of patients with acute ischemic stroke due to large-artery occlusion do not achieve recanalization with mechanical thrombectomy. We aimed to determine whether the speed of retrieval of the stent retriever influences the efficacy in removing different clot types. MATERIALS AND METHODS Sixty mechanical thrombectomies were performed using an in vitro pulsatile cerebrovascular circulation model with controlled pressure and flow rate. Experiments were dichotomized into fast and slow retrieval using a wedging technique, in which the stent retriever and distal catheter are retrieved together. We used 3 different clot types: erythrocyte-rich, fibrin-rich, and friable clots. Primary end points were complete (TICI 3) and successful (TICI 2b-3) recanalizations. Secondary measures were distal and new territory embolizations. RESULTS Fast retrieval was more frequently associated with complete (RR = 1.83; 95% CI, 1.12-2.99) and successful recanalization (RR = 1.50; 95% CI, 1.03-2.19) than slow retrieval, without a difference in distal embolization (RR = 0.75; 95% CI, 0.29-1.90). There were no emboli in a new territory. The advantage of fast retrieval over slow retrieval differed according to the clot composition, with a stronger effect with fibrin-rich clots with regard to complete (RR = 4.00; 95% CI, 1.11-14.35; Pint = .04) and successful (Pint = .10) recanalization. CONCLUSIONS In our experimental model, a fast removal improved recanalization rates of mechanical thrombectomy, especially in the case of fibrin-rich clots. An in vivo confirmation is warranted to see whether our findings can have an impact in clinical practice.
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Affiliation(s)
- S Soize
- From the Department of Neuroradiology (S.S., L.P., M. Gawlitza), Hôpital Maison Blanche, Champagne-Ardenne University, Reims, France .,Unité Mixte de Recherche (UMR)-S 1237 Physiopathology and Imaging of Neurological Disorders (S.S., D.V., E.T.), National Institute for Health and Medical Research, Normandie University, Université Caen Normandie, Cyceron, Caen, France
| | - L Pierot
- From the Department of Neuroradiology (S.S., L.P., M. Gawlitza), Hôpital Maison Blanche, Champagne-Ardenne University, Reims, France
| | - M Mirza
- Neuravi/Cerenovus (M.M., G.G., M. Gilvarry), Galway, Ireland
| | - G Gunning
- Neuravi/Cerenovus (M.M., G.G., M. Gilvarry), Galway, Ireland
| | - M Gilvarry
- Neuravi/Cerenovus (M.M., G.G., M. Gilvarry), Galway, Ireland
| | - M Gawlitza
- From the Department of Neuroradiology (S.S., L.P., M. Gawlitza), Hôpital Maison Blanche, Champagne-Ardenne University, Reims, France
| | - D Vivien
- Unité Mixte de Recherche (UMR)-S 1237 Physiopathology and Imaging of Neurological Disorders (S.S., D.V., E.T.), National Institute for Health and Medical Research, Normandie University, Université Caen Normandie, Cyceron, Caen, France
| | - M Zuber
- Department of Neurology (M.Z.), Hôpital Saint-Joseph, Paris Descartes University, Paris, France
| | - E Touzé
- Unité Mixte de Recherche (UMR)-S 1237 Physiopathology and Imaging of Neurological Disorders (S.S., D.V., E.T.), National Institute for Health and Medical Research, Normandie University, Université Caen Normandie, Cyceron, Caen, France
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49
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Alverne FJAM, Lima FO, Rocha FDA, Bandeira DDA, de Lucena AF, Silva HC, Lee JS, Nogueira RG. Unfavorable Vascular Anatomy during Endovascular Treatment of Stroke: Challenges and Bailout Strategies. J Stroke 2020; 22:185-202. [PMID: 32635684 PMCID: PMC7341011 DOI: 10.5853/jos.2020.00227] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/05/2020] [Accepted: 05/06/2020] [Indexed: 12/11/2022] Open
Abstract
The benefit of mechanical thrombectomy (MT) in acute ischemic stroke (AIS) due to large vessel intracranial occlusions is directly related to the technical success of the procedures in achieving fast and complete reperfusion. While a precise definition of refractoriness is lacking in the literature, it may be considered when there is reperfusion failure, long procedural times, or high number of passes with the MT devices. Detailed knowledge about the causes for refractory MT in AIS is limited; however, it is most likely a multifaceted problem including factors related to the vascular anatomy and the underlying nature of the occlusive lesion amongst other factors. We aim to review the impact of several key unfavorable anatomical factors that may be encountered during endovascular AIS treatment and discuss potential bail-out strategies to these challenging situations.
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Affiliation(s)
| | | | - Felipe de Araújo Rocha
- Interventional Neuroradiology Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
- Neurology Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Diego de Almeida Bandeira
- Interventional Neuroradiology Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
- Neurology Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Adson Freitas de Lucena
- Interventional Neuroradiology Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
- Neurology Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Henrique Coelho Silva
- Interventional Neuroradiology Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
- Neurology Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Raul Gomes Nogueira
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
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50
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Factors Associated with Failure of Reperfusion in Endovascular Therapy for Acute Ischemic Stroke : A Multicenter Analysis. Clin Neuroradiol 2020; 31:197-205. [PMID: 32067055 PMCID: PMC7943507 DOI: 10.1007/s00062-020-00880-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/23/2020] [Indexed: 11/21/2022]
Abstract
Aim In acute large vessel occlusions, endovascular therapy (EVT) achieves flow restoration in the majority of cases; however, EVT fails to achieve sufficient reperfusion in a substantial minority of patients. This study aimed to identify predictors of failed reperfusion. Methods In this study 2211 patients from the German Stroke Registry who received EVT for anterior circulation stroke were retrospectively analyzed. Failure of reperfusion was defined as thrombolysis in cerebral infarction (TICI) grades 0/1/2a, and sufficient reperfusion as TICI 2b/3. In 1629 patients with complete datasets, associations between failure of reperfusion and baseline clinical data, comorbidities, location of occlusion, and procedural data were assessed with multiple logistic regression. Results Failure of reperfusion occurred in 371 patients (16.8%) and was associated with the following locations of occlusion: cervical internal carotid artery (ICA, adjusted odds ratio, OR 2.01, 95% confidence interval, CI 1.08–3.69), intracranial ICA without carotid T occlusion (adjusted OR 1.79, 95% CI 1.05–2.98), and M2 segment (adjusted OR 1.86, 95% CI 1.21–2.84). Failed reperfusion was also associated with cervical ICA stenosis (>70% stenosis, adjusted OR 2.90, 95% CI 1.69–4.97), stroke of other determined etiology by TOAST (Trial of ORG 10172 in acute stroke treatment) criteria (e.g. nonatherosclerotic vasculopathies, adjusted OR 2.73, 95% CI 1.36–5.39), and treatment given outside the usual working hours (adjusted OR 1.41, 95% CI 1.07–1.86). Successful reperfusion was associated with higher Alberta stroke program early CT score (ASPECTS) on initial imaging (adjusted OR 0.85, 95% CI 0.79–0.92), treatment with the patient under general anesthesia (adjusted OR 0.72, 95% CI 0.54–0.96), and concomitant ICA stenting in patients with ICA stenosis (adjusted OR 0.20, 95% CI 0.11–0.38). Conclusion Several factors are associated with failure of reperfusion, most notably occlusions of the proximal ICA and low ASPECTS on admission. Conversely, stent placement in the proximal ICA was associated with reperfusion success. Electronic supplementary material The online version of this article (10.1007/s00062-020-00880-8) contains supplementary material, which is available to authorized users.
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