Delayed Stenosis in the Intracranial Vessels following Endovascular Treatment for Acute Stroke

Extracranial ultrasound following mechanical thrombectomy in patients with acute stroke

BACKGROUND AND PURPOSE

Mechanical thrombectomy (MT) is standard care for patients suffering from an ischemic stroke due to a large vessel occlusion. Immediate and follow-up transcranial ultrasound examinations after MT were shown to have a diagnostic benefit. However, it is unclear whether repeated extracranial ultrasound after MT has an additional diagnostic yield, that is, depicts new findings.

METHODS

Retrospectively, from our prospective database we identified all patients after MT who presented for a follow-up examination between January 2017 and March 2020 and who had received an ultrasound examination after MT and at follow-up. Clinical data were extracted from our database. Ultrasound images of all patients were revisited to identify new findings at follow-up compared to examination after MT.

RESULTS

Ninety-one patients were identified appropriate for further analysis, with a mean age of 67.8 ± 16 years. Median National Institute of Health Stroke Scale at admission was 11 ± 8.5 points. At baseline ultrasound, 18 patients (19.8%) had no atherosclerotic alterations and 73 patients (82.2%) had a plaque burden of ≥1 plaque. During follow-up, in 5 patients (5.5%) a pathological finding presented in first examination evolved dynamically, that is, normalized. Vessel status of all other patients was stable, especially, in no patient a new relevant pathological finding occurred.

CONCLUSIONS

Although sonographic normalization of pathologic findings was observed, pathologic new findings were not detected during follow-up. This study provides first data for a discussion of the role of ultrasound in a structured stroke care after MT. However, larger studies are required to improve the understanding.

Repeated Endovascular Thrombectomy in Patients With Acute Ischemic Stroke

Background and Purpose—

Patients with acute ischemic stroke treated with endovascular thrombectomy may be treated with repeat endovascular thrombectomy (rEVT) in case of recurrent large vessel occlusion. Data on safety and efficacy of these interventions is scarce. Our aim is to report on frequency, timing, and outcome of rEVT in a large nation-wide multicenter registry.

Methods—

In the Netherlands, all patients with endovascular thrombectomy have been registered since 2002 (MR CLEAN Pretrial registry, MR CLEAN Trial [Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands], and MR CLEAN Registry). We retrospectively reviewed these databases for anterior circulation rEVT cases. Patient characteristics, procedural data, and functional outcome (modified Rankin Scale at 90 days) were analyzed.

Results—

Of 3928 patients treated between 2002 and 2017, 27 (0.7%) underwent rEVT. Median time between first and second procedure was 78 (1–1122) days; 11/27 patients were re-treated within 30 days. Cardioembolism was the most common etiology (18 patients [67%]). In 19 patients (70%), recurrent occlusion occurred ipsilateral to previous occlusion. At 90 days after rEVT procedure, 44% of the patients had achieved functional independence (modified Rankin Scale score of 0–2), and 33% had died. Adverse events were 2/27 (7.4%) intracranial hemorrhage, 1/27 (3.7%) stroke progression, and 1/27 (3.7%) pneumonia.

Conclusions—

In this large nationwide cohort of patients with acute ischemic stroke treated with endovascular thrombectomy, rEVT was rare. Stroke cause was mainly cardio-embolic, and most recurrent large vessel occlusions in which rEVT was performed occurred ipsilateral. Although there probably is a selection bias on repeated treatment in case of recurrent large vessel occlusion, rEVT appears safe, with similar outcome as in single-treated cases.

Neurosonography After Mechanical Thrombectomy for Acute Stroke Treatment

BACKGROUND AND PURPOSE

Mechanical thrombectomy has been shown to be effective for acute stroke treatment, but lesions of cerebral vessels can develop thereafter. Such lesions of recanalized vessels and altered cerebral hemodynamics after mechanical thrombectomy are poorly investigated. In particular for neurosonography, data are sparse. We aimed to describe hemodynamic changes and incidence of de-novo stenosis after mechanical thrombectomy with neurosonography.

METHODS

Retrospective analysis of patients after successful mechanical thrombectomy for acute stroke therapy who received one neurosonography at baseline and during follow up. Peak systolic velocity (PSV) of all intracranial recanalized and reference vessels was extracted for analysis. Patients with an isolated increase or decrease of PSV (50% or 50 cm/second for anterior and 30% or 30 cm/second for posterior circulation) were identified and characterized.

RESULTS

Eighty-eight patients (mean age 64.4; 34.1% female) were included in this study. In 9 (10.2%) patients, the vessel occlusion was located in the posterior, and in 79 (89.9%) patients the vessel occlusion was located in the anterior circulation. With predominance to the recanalized vessel, mean PSV decreased at both, the recanalized and the reference vessel during follow up. In 3 (3.4%) patients, an isolated increase of PSV was observed in the recanalized vessel, and in 6 (6.8%) patients an isolated decrease of PSV was observed in the recanalized vessel.

CONCLUSION

Sonographic incidence of de-novo stenosis following mechanical thrombectomy seems to be low, in line with prior angiographic studies. However, as measured by neurosonography, cerebral hemodynamic in the recanalized vessel is dynamic after thrombectomy. This result is of interest for further prospective analysis.