Intracranial mechanical thrombectomy without extracranial revascularization for a tandem occlusion with robust Circle of Willis: Case report

Introduction: Despite level 1a evidence demonstrating the clinical benefit of mechanical thrombectomy in selected large vessel ischemic stroke patients, a gender disparity exists. Women not only have less favorable clinical outcomes after all stroke types, but the causes of this disparity remain elusive. Gender differences in cerebral vascular anatomy have been previously published. We hypothesize that differences in circle of Willis diameters may contribute to the gender disparity seen in clinical outcomes after mechanical thrombectomy for acute ischemic stroke. Methods: Clinical and radiographic data from a consecutive series undergoing mechanical thrombectomy for anterior circulation large vessel ischemic strokes were reviewed. Measurements of the proximal middle cerebral artery (M1) segment and supraclinoid internal carotid artery (ICA) diameters were obtained in a standardized fashion from the thrombectomy procedure angiogram. All M1 measurements were recorded at 3 mm of the vessel origin while ICA measurements were taken 3 mm proximal to the ICA terminus. Covariates included age, occlusion location, vascular risk factors, admission NIHSS score and final TICI grade. Modified Rankin score (mRS) at 90 days was the dependent variable. Variable significance between male and female cohorts was determined using student T-Tests. Multivariate regression analysis was also performed. Results: Ninety-four patients (41 female) between 6/2013 and 6/2016 fit the inclusion criteria. ICA terminus measurements for men and women were 3.07 mm (SD=0.46) and 2.88 mm (SD=0.47), respectively. M1 origin measurements for men and women were 2.46 mm (SD=0.31) and 2.21 mm (SD=0.37), respectively. Male ICA terminus and M1 origin measurements were larger than female (p = 0.05 and p < 0.001, respectively). 61% of men vs. 25% of women had 90-day mRS ≤ 2. Multivariate analysis indicated that only age was significantly associated with 90-day mRS ≤ 2. Conclusions: Our single center series suggests that differences in intracranial vessel diameter may contribute to the gender disparity in outcomes after mechanical thrombectomy. Smaller circle of Willis arterial diameters may compromise collateral blood flow and increase the difficulty in achieving sufficient reperfusion.

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Mechanical thrombectomy beyond the circle of Willis: efficacy and safety of different techniques for M2 occlusions

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017425 ◽

2021 ◽

pp. neurintsurg-2021-017425

Author(s):

Leonardo Renieri ◽

Iacopo Valente ◽

Adam A Dmytriw ◽

Ajit S Puri ◽

Jasmeet Singh ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Mechanical Thrombectomy ◽

Circle Of Willis ◽

Stent Retriever ◽

National Institutes Of Health ◽

Neurological Deficits ◽

Stent Retrievers ◽

Subarachnoid Hemorrhages ◽

Combined Technique

BackgroundM2 segment occlusions represent approximately one-third of non-lacunar ischemic stroke and can lead to permanent neurological deficits. Various techniques are available for mechanical thrombectomy beyond the circle of Willis, but data evaluating their effectiveness and safety are lacking.MethodsA retrospective review of patients with ischemic stroke undergoing mechanical thrombectomy for M2 occlusions from 13 centers in North American and Europe was performed. Tandem or multiple-territory occlusions were excluded. The primary outcome was 90-day modified Rankin Scale and reperfusion rates across stent-retriever, direct aspiration and combined techniques.ResultsThere were 465 patients (mean age 71.48±14.03 years, 53.1% female) with M2 occlusions who underwent mechanical thrombectomy. Stent-retriever alone was used in 133 (28.6%), direct aspiration alone in 93 (20.0%) and the combined technique in 239 (51.4%) patients. Successful reperfusion was achieved with the combined technique in 198 (82.2%; OR 2.6 (1.1–6.9)), with stent-retriever alone in 112 (84.2%; OR 9.2 (1.9–44.6)) and with direct aspiration alone in 62 (66.7%; referencecategory). Intraprocedural subarachnoid hemorrhages (iSAH) were 36 (7.7%) and were more likely to occur in patients treated with the stent-retrievers (OR 5.0 (1.1–24.3)) and combined technique (OR 4.6 (1.1–20.9)). Good clinical outcome was achieved in 260 (61.8%) patients, while 59 (14.0%) patients died. Older age, higher baseline NIHSS (National Institutes of Health Stroke Scale), parenchymal hemorrhage and iSAH were associated with poor outcome while successful recanalization and higher baseline ASPECTS (Alberta Stroke Program Early CT Score) were associated with good outcome. No differences were found among the three techniques in terms of clinical outcome.ConclusionStent-retrievers and a combined approach for M2 occlusions seem more effective than direct aspiration, but with higher rates of iSAH. This leads to no detectable difference in clinical outcome at 3 months.

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Hemorrhagic Acquired Pial Arteriovenous Fistula Occurring after Mechanical Thrombectomy: A Case Report

Journal of Neuroendovascular Therapy ◽

10.5797/jnet.cr.2018-0054 ◽

2019 ◽

Vol 13 (2) ◽

pp. 66-71

Author(s):

Koichiro Shindo ◽

Tatsuya Ogino ◽

Tomoki Fuchizaki ◽

Hideki Endo ◽

Yohei Maruga ◽

...

Keyword(s):

Case Report ◽

Arteriovenous Fistula ◽

Mechanical Thrombectomy ◽

Pial Arteriovenous Fistula

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First attempt recanalization with ADAPT: rate, predictors, and outcome

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014294 ◽

2018 ◽

Vol 11 (7) ◽

pp. 641-645 ◽

Cited By ~ 11

Author(s):

Mohammad Anadani ◽

Ali Alawieh ◽

Jan Vargas ◽

Arindam Rano Chatterjee ◽

Aquilla Turk ◽

...

Keyword(s):

Functional Outcome ◽

Mechanical Thrombectomy ◽

Functional Independence ◽

Hemorrhagic Transformation ◽

Lower Mortality ◽

Anterior Circulation ◽

Tandem Occlusion ◽

First Pass ◽

Baseline Characteristics ◽

Iv Tpa

IntroductionThe rate of first-attempt recanalization (FAR) with the newer-generation thrombectomy devices, and more specifically with aspiration devices, is not well known. Moreover, the effect of FAR on outcomes after mechanical thrombectomy is not properly understood.ObjectiveTo report the rate of FAR using a direct aspiration first pass technique (ADAPT), investigate the association between FAR and outcomes, and identify the predictors of FAR.MethodsThe ADAPT database was used to identify a subgroup of patients in whom FAR was achieved. Baseline characteristics, procedural, and postprocedural variables were collected. Outcome measures included 90-day modified Rankin scale (mRS) score, mortality, and hemorrhagic complications. Multivariate logistic regression was used to identify FAR predictors.ResultsA total of 524 patients was included of whom 178 (34.0%) achieved FAR. More patients in the FAR group than in the non-FAR group received IV tPA (46.6% vs 37.6%; p<0.05). For the functional outcome, higher proportions of patients in the FAR group achieved functional independence (mRS score 0–2; 53% vs 37%; p<0.05). Additionally, we observed lower mortality and hemorrhagic transformation rates in the FAR group than the non-FAR group. Independent predictors of FAR in the anterior circulation were pretreatment IV tPA, non-tandem occlusion, and use of larger reperfusion catheters (Penumbra, ACE 64–68). Independent predictors of FAR in the posterior circulation were diabetes, onset-to-groin time, and cardioembolic etiology.ConclusionFAR was associated with better functional outcome and lower mortality rate. When ADAPT is used, a larger aspiration catheter and pretreatment IV tPA should be employed when indicated.

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