Heterogeneity of the Relative Benefits of TICI 2c/3 over TICI 2b50/2b67

Abstract Purpose Incomplete reperfusion after mechanical thrombectomy (MT) is associated with a poor outcome. Rescue therapy would potentially benefit some patients with an expanded treatment in cerebral ischemia score (eTICI) 2b50/2b67 reperfusion but also harbors increased risks. The relative benefits of eTICI 2c/3 over eTICI 2b50/67 in clinically important subpopulations were analyzed. Methods Retrospective analysis of our institutional database for all patients with occlusion of the intracranial internal carotid artery (ICA) or the M1/M2 segment undergoing MT and final reperfusion of ≥eTICI 2b50 (903 patients). The heterogeneity in subgroups of different time metrics, age, National Institutes of Health Stroke Scale (NIHSS), number of retrieval attempts, Alberta Stroke Programme Early CT Score (ASPECTS) and site of occlusion using interaction terms (pi) was analyzed. Results The presence of eTICI 2c/3 was associated with better outcomes in most subgroups. Time metrics showed no interaction of eTICI 2c/3 over eTICI 2b50/2b67 and clinical outcomes (onset to reperfusion pi = 0.77, puncture to reperfusion pi = 0.65, onset to puncture pi = 0.63). An eTICI 2c/3 had less consistent association with mRS ≤2 in older patients (>82 years, pi = 0.038) and patients with either lower NIHSS (≤9) or very high NIHSS (>19, pi = 0.01). Regarding occlusion sites, the beneficial effect of eTICI 2c/3 was absent for occlusions in the M2 segments (aOR 0.73, 95% confidence interval [CI] 0.33–1.59, pi = 0.018). Conclusion Beneficial effect of eTICI 2c/3 over eTICI 2b50/2b67 only decreased in older patients, M2-occlusions and patients with either low or very high NIHSS. Improving eTICI 2b50/2b67 to eTICI 2c/3 in those subgroups may be more often futile.

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Endovascular management of iatrogenic dissection into the petrous segment of the internal carotid artery during mechanical thrombectomy for acute stroke

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2019.11.037 ◽

2020 ◽

Vol 71 ◽

pp. 273-274

Author(s):

David I. Bass ◽

Melanie Walker ◽

Louis J. Kim ◽

Michael R. Levitt

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Acute Stroke ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Endovascular Management

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Extraintracranial Bypass as a Rescue Therapy for Symptomatic Flow Diverter Thrombosis

Case Reports in Neurological Medicine ◽

10.1155/2015/204387 ◽

2015 ◽

Vol 2015 ◽

pp. 1-5

Author(s):

Luigi A. Lanterna ◽

Alessandro Lunghi ◽

Carlo Brembilla ◽

Paolo Gritti ◽

Claudio Bernucci

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Rescue Therapy ◽

Flow Diverter ◽

Minor Stroke ◽

Transient Ischemic Attacks ◽

Postoperative Course ◽

A Minor ◽

Ischemic Events

A 56-year-old female with a giant partially thrombosed unruptured carotid-ophthalmic aneurysm was treated with a Pipeline flow diverter. Three months after the procedure, in concomitance with the discontinuation of one of the antiplatelet medications, the patient suffered from a minor stroke and relapsing transient ischemic attacks. The angiography demonstrated the occlusion of the internal carotid artery, and a perfusion-weighted CT scan showed a condition of hypoperfusion. The patient underwent a double-barrel extraintracranial bypass. The postoperative course was uneventful and she has experienced no further ischemic events to date.

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Management of Mobile Thrombus With Distal Protection Devices During Carotid Artery Angioplasty: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opab131 ◽

2021 ◽

Author(s):

Salomon Cohen-Cohen ◽

Giuseppe Lanzino ◽

Waleed Brinjikji ◽

Adam Arthur ◽

Mark Bain ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Standard Of Care ◽

Video Production ◽

Left Internal Carotid Artery ◽

Left Middle Cerebral Artery ◽

Cerebral Angiogram ◽

Protection Devices

Abstract Embolic protection devices (EPDs) have become a standard of care during internal carotid artery revascularization.1,2 This video is about a 57-yr-old-male who presented with a wake-up stroke with a left hemispheric syndrome. Head computed tomography angiography (CTA) revealed tandem occlusions of the proximal left internal carotid artery (ICA) and of the distal left middle cerebral artery (MCA) with an ASPECT (Alberta Stroke Program Early CT Score) score of 6. The patient underwent a cerebral angiogram and was treated with balloon angioplasty with a distal EPD and mechanical thrombectomy. The EPD became occluded with thrombus from the ICA and was retrieved through a 6-Fr Sofia (MicroVention) under continuous aspiration. Successful revascularization of the proximal ICA and distal MCA was achieved. No procedure-related complications occurred, and the patient's neurological exam improved. Tandem occlusions can occur in up to 15% of strokes. The optimal treatment can be controversial, but mechanical thrombectomy and ICA revascularization with a distal EPD appear to be safe and effective in selected patients.3 Consent was obtained for the procedure and for the video production.

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Carotid Artery Stenting to Prevent Stroke in a Patient with Bilateral Extracranial Internal Carotid Dissection and Vasospasm following Rupture of an Intracranial Aneurysm

Interventional Neuroradiology ◽

10.1177/159101990300900311 ◽

2003 ◽

Vol 9 (3) ◽

pp. 305-310 ◽

Cited By ~ 3

Author(s):

J. Sedat ◽

M. Dib ◽

J. Szapiro ◽

P. Paquis

Keyword(s):

Cerebral Ischemia ◽

Carotid Artery ◽

Intracranial Aneurysm ◽

Carotid Artery Stenting ◽

Internal Carotid ◽

Anticoagulation Therapy ◽

Clinical Grade ◽

Carotid Dissection ◽

Aneurysmal Rupture ◽

Therapeutic Anticoagulation

The stenting of carotid dissection has been described for the prevention of cerebral ischemia in patients who remain symptomatic despite therapeutic anticoagulation, in those who present contraindications for anticoagulation therapy, or who present a local or extensive stenosis, with an associated pseudoaneurysm. We here report a case associating a high clinical grade aneurysmal rupture with a bilateral extracranial carotid dissection. Because of the haemodynamic risk due to the acute bilateral stenosis-induced dissection and the occurrence of a vasospasm, the carotid dissections were treated with self-expendable stents.

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Efficacy of Stenting for High Cervical Internal Carotid Artery Dissection Presenting with Cerebral Ischemia: A Report of Three Cases

Journal of Neuroendovascular Therapy ◽

10.5797/jnet.cr.2016-0058 ◽

2016 ◽

Vol 10 (3) ◽

pp. 144-151 ◽

Cited By ~ 1

Author(s):

Mai Azumi ◽

Shunji Matsubara ◽

Keita Kinoshita ◽

Satoshi Hirai ◽

Nobuhisa Matsushita ◽

...

Keyword(s):

Cerebral Ischemia ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Carotid Artery Dissection ◽

Artery Dissection ◽

Internal Carotid Artery Dissection ◽

High Cervical ◽

Cervical Internal Carotid Artery

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Bilateral mechanical thrombectomy for internal carotid artery occlusion and contralateral middle cerebral artery occlusion during transvenous thrombolysis: Case report

Nosotchu ◽

10.3995/jstroke.10941 ◽

2021 ◽

Author(s):

Satoshi Inoue ◽

Atsushi Fujita ◽

Koji Shinoda ◽

Takashi Mizowaki ◽

Te Jin Lee ◽

...

Keyword(s):

Case Report ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Middle Cerebral Artery ◽

Middle Cerebral Artery Occlusion ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Cerebral Artery Occlusion

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Endovascular repair of an acute symptomatic carotid artery dissection through the false dissecting carotid lumen

Interventional Neuroradiology ◽

10.1177/1591019918798154 ◽

2018 ◽

Vol 25 (1) ◽

pp. 51-53

Author(s):

Nicholas Befera ◽

Andrew S Griffin ◽

Erik F Hauck

Keyword(s):

Carotid Artery ◽

Internal Carotid ◽

False Lumen ◽

Carotid Artery Dissection ◽

National Institutes Of Health ◽

Artery Dissection ◽

True Lumen ◽

Duplex Scan ◽

Symptomatic Carotid ◽

Flow Diverting Stent

A 48-year-old woman presented with an acute ischemic stroke (National Institutes of Health Stroke Scale (NIHSS) 21) six hours after symptom onset. Workup revealed a left cervical internal carotid artery (ICA) occlusive dissection, which was emergently reconstructed with a flow-diverting stent. A routine Duplex scan one hour later suggested reocclusion of the ICA, confirmed by angiography. The true lumen of the ICA could not be accessed and therefore the “false lumen” of the ICA dissection was entered proximally. The true lumen and ultimately the flow-diverting stent were accessed via the false lumen. In analogy to the subintimal arterial flossing with antegrade-retrograde intervention technique described for peripheral vascular disease, several stents were placed in telescoping fashion from the true common carotid lumen through the “false dissecting” lumen of the proximal ICA into the distal true lumen. The stent construct remained patent, and the patient recovered clinically to an NIHSS of 1.

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Abstract WP20: Efficacy and Safety of Mechanical Thrombectomy in Emergent Large Vessel Occlusions with Concomitant Cervical Internal Carotid Artery Occlusion

Stroke ◽

10.1161/str.48.suppl_1.wp20 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Nitin Goyal ◽

Georgios Tsivgoulis ◽

Abhi Pandhi ◽

Yasser M Khorchid ◽

Abhishek Ojha ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Large Vessel ◽

Efficacy And Safety ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Aspiration Thrombectomy ◽

Cervical Internal Carotid Artery

Introduction: Recently, five published major randomized controlled clinical trials have demonstrated that timely mechanical thrombectomy (MT) of acute ischemic strokes (AIS) with emergent large vessel occlusion (ELVO) is safe and improves functional outcomes. However, data evaluating the efficacy and safety of MT in ELVO patients with concomitant cervical internal carotid artery (cICA) occlusion is limited. The purpose of this study is to evaluate efficacy and safety of MT in ELVO patients with concomitant cICA occlusion Methods: We prospectively analyzed consecutive AIS patients with anterior circulation ELVO who underwent stent-retriever or primary aspiration thrombectomy at two tertiary stroke centers. Outcome measures in our study were 3-month mortality and modified ranking scale (mRS), as well as symptomatic intracranial hemorrhage (sICH). Safety and efficacy outcomes were compared between ELVO patients with and without concomitant cICA occlusion. Results: A total of 137 AIS patients had anterior circulation ELVO and underwent MT (age 63 ± 14, 49% male, median NIHSS 17, IQR [13-20]). ELVO patients with concomitant cICA occlusion (n=19) did not differ in terms of rates of sICH (0% versus 11%, p=0.21), complete recanalization (68 % versus 68%, p=1.00), onset to groin puncture time (minutes [IQR] 268 [211-379] versus 225 [165-312], p=0.47), 3-month mortality (35% versus 26 %, p=0.55), and mRS of 0-2 at 3 months (41% versus 45%, p=0.80) when compared with ELVO patients without concomitant cICA occlusion (n=118). Admission NIHSS was higher among ELVO patients with concomitant cICA occlusion (median [IQR], 18 [15-22] versus 16 [12-19], p=0.01), and they tended to have higher groin puncture to recanalization time (minutes [IQR] 74 [42-97] versus 49 [38-78], p=0.09). The ordinal shift analysis did not show any difference in favorable outcomes in two groups in unadjusted analyses or after adjustment for admission NIHSS and groin to recanalization time (common OR=0.78 [95% CI: 0.27-2.29, p=0.66]). Angioplasty was performed in 11 of 19 ELVO patients with concomitant cICA occlusion. Three patients required stent placement. Discussion: Our study indicates that MT can be performed safely and effectively in ELVO patients with concomitant cICA occlusion.

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