Arterial Spin Labeling—Can Neurointerventionists Rely on This Novel Technique? A Case Series on Successful Use of Arterial Spin Labeling in Acute Stroke Imaging

AbstractPresence of ischemic penumbra is the principal factor that decides the need for mechanical thrombectomy in acute stroke patients with large vessel occlusion. Our objective was to evaluate the usefulness of arterial spin labeling (ASL) in detecting diffusion perfusion mismatch and directing patients into mechanical thrombectomy. We retrospectively studied all patients with acute nonhemorrhagic stroke in the anterior circulation, who had undergone stroke imaging with ASL followed by mechanical thrombectomy from July 2016 to November 2016. Area of diffusion perfusion mismatch was graded semiquantitatively into three grades: small, medium, and large. Mismatch was compared with 30-day modified Rankin scale (mRS) score. Interpretable PASL-perfusion images were obtained in all patients. Diffusion perfusion mismatches were present in all patients. Out of six patients with good mRS score, five patients had large diffusion perfusion mismatch. Two out of three patients with poor mRS were secondary to failed recanalization, in spite of large mismatch. One out of nine patients had poor outcome as well as a small area of mismatch. ASL is a rapid noninvasive imaging technique in acute stroke that has got the potential to detect ischemic penumbra.

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In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

CardioVascular and Interventional Radiology ◽

10.1007/s00270-020-02727-8 ◽

2020 ◽

Author(s):

Juha-Pekka Pienimäki ◽

Jyrki Ollikainen ◽

Niko Sillanpää ◽

Sara Protto

Keyword(s):

Clinical Outcome ◽

Acute Stroke ◽

Mechanical Thrombectomy ◽

Clinical Laboratory ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Ordinal Logistic Regression Analysis ◽

Stroke Center

Abstract Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

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Mechanical Thrombectomy of Large Vessel Occlusions in COVID-19 Related Stroke: Endovascular and Clinical Outcomes

10.21203/rs.3.rs-49068/v1 ◽

2020 ◽

Author(s):

Anas S. Al-Smadi ◽

Srishti Abrol ◽

Ali Luqman ◽

Parthasarathi Chamiraju ◽

Hani Abujudeh

Keyword(s):

Clinical Outcomes ◽

Mechanical Thrombectomy ◽

Case Series ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Ischemic Disease ◽

Patient Demographics

Abstract Background and PurposeStroke is a drastic complication and a poor prognostic marker of COVID-19 disease which emphasizes the importance of early identification and management of this complication. In this case series, we describe our experience of mechanical thrombectomy of large vessel occlusions (LVO) in patients with COVID-19.MethodsWe performed a retrospective study of a series of confirmed COVID-19 patients who underwent endovascular thrombectomy for acute cerebrovascular ischemic disease with large vessel occlusion. Patient demographics, presentations, lab values, angiographic and clinical outcomes were also reviewed.ResultsThree COVID-19 patients with large vessel occlusion who underwent endovascular thrombectomy were identified in our multi-center institution. Two patients had respiratory symptoms prior presentation and one patient presented initially with clinical deficits. Two patients had anterior circulation occlusion in the middle cerebral artery territory vs one had posterior circulation occlusion in the basilar artery. There was good angiographic outcome post thrombectomy in all patients, however poor clinical outcomes noted with no significant improvement in neurological manifestations in comparison with baseline at presentation. All patients developed critically severe symptoms during hospitalization requiring intubation and one patient died of COVID-19 related respiratory failure.ConclusionIn this small case series, we noted worse clinical outcomes in COVID-19 related LVO stroke despite effective thrombectomy, which may be related to the underlying COVID-19 disease and/or the nature of clot in these patients.

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Iodine-stained fragmented thromboembolism

The Neuroradiology Journal ◽

10.1177/1971400919874508 ◽

2019 ◽

Vol 32 (6) ◽

pp. 445-451

Author(s):

Charlie Chia-Tsong Hsu ◽

Trevor Watkins ◽

Kosuke Kato ◽

Igor Fomin ◽

Sachintha Hapugoda ◽

...

Keyword(s):

Acute Stroke ◽

Mechanical Thrombectomy ◽

Brain Perfusion ◽

Carotid Stenting ◽

Filling Defect ◽

Vessel Occlusion ◽

Imaging Protocol ◽

Stroke Imaging ◽

Iodinated Contrast ◽

Ct Angiogram

Aim Iodine-stained fragmented thromboembolism (ISFT) is a rare phenomenon encountered in the immediate aftermath of mechanical thrombectomy or rarely as a complication of post–carotid stenting. The aim was to describe the imaging appearance and discuss its pathophysiology. Method This is a retrospective review of patients who underwent mechanical thrombectomy for acute stroke at a single institution over the period of one year. All patients underwent the standard acute stroke imaging protocol (CT head, CT angiogram (CTA) and CT brain perfusion) and when clinically appropriate followed by catheter angiogram and mechanical thrombectomy. ISFT was defined as an arterial luminal filling defect with Hounsfield density equal to or greater than iodine seen on the biplanar CT or conventional CT. The presence and location of ISFT were documented. Standard CT angiogram (CTA) or magnetic resonance angiogram (MRA) was performed 24–48 hours after the neurointerventional procedure to assess for recanalization, volume of infarction and the fate of the ISFT. Results ISFTs were identified in eight (five males and three females, age range 18–80 years) out of 49 patients in the following locations: distal M1 ( n = 1), M2 ( n = 4), M3 ( n = 1), A1 ( n = 1), distal A2 ( n = 1). ISFT and vessel recanalization occurred in five patients on follow-up. ISFT and vessel occlusion persisted in two patients. Conclusion ISFT is likely the result of mechanical disruption of a thromboembolus, and porosity of the thromboembolus fragment may transiently retain iodinated contrast. Recognition of this entity may be important to aid detection of residual thromboembolism and avoid misinterpretation as calcified thromboembolism.

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Abstract WP42: Prediction of Blood-brain Barrier Disruption and Intracerebral Hemorrhagic Infarction Using Arterial Spin-labeling MRI

Stroke ◽

10.1161/str.48.suppl_1.wp42 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Takeya Niibo ◽

Hajime Ohta ◽

Shirou Miyata ◽

Ichirou Ikushima ◽

Kazuchika Yonenaga ◽

...

Keyword(s):

Ct Scan ◽

Blood Brain Barrier ◽

Arterial Spin Labeling ◽

Spin Labeling ◽

Hemorrhagic Transformation ◽

Brain Barrier ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Blood Brain Barrier Disruption ◽

Blood Brain

Background and Purpose: Arterial spin-labeling (ASL) MRI is sensitive for detecting hyperemic lesions (HLs) in patients with acute ischemic stroke (AIS). We evaluated whether HLs could predict blood-brain barrier (BBB) disruption and hemorrhagic transformation (HT) in AIS patients. Methods: In a retrospective study, ASL was performed within 6 hours of symptom onset before revascularization treatment in 25 patients with anterior circulation large vessel occlusion on baseline MR angiography. All patients underwent angiographic procedures intended for endovascular therapy and a noncontrast CT scan immediately after treatment. BBB disruption was defined as a hyperdense lesion present on the posttreatment CT scan. A subacute MRI or CT scan was performed during the subacute phase to assess HTs. The relationship between HLs and BBB disruption and HT was examined using the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) locations in the symptomatic hemispheres. Results: A HL was defined as a region where CBF relative ≥1.4 (CBF relative =CBF HL /CBF contralateral ). HLs, BBB disruption and HT were found in 9, 15, and 15 patients, respectively. Compared with the patients without HLs, the patients with HLs had a higher incidence of both BBB disruption (100% versus 37.5%, P=0.003) and HT (100% versus 37.5%, P=0.003). Based on the ASPECTS locations, 21 regions of interests (ROIs) displayed HLs. Compared with the ROIs without HLs, the ROIs with HLs had a higher incidence of both BBB disruption (42.8% versus 3.9%, P<0.001) and HT (85.7% versus 7.8%, P<0.001). Conclusion: HLs detected on pretreatment ASL maps may enable the prediction and localization of subsequent BBB disruption and HT.

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Mechanical Thrombectomy for Acute Ischemic Stroke in Nepal

Annapurna Journal of Health Sciences ◽

10.52910/ajhs.15 ◽

2021 ◽

Vol 1 (1) ◽

pp. 35-37

Author(s):

Pravesh Rajbhandari ◽

Saujanya Rajbhandari ◽

Anish Neupane ◽

Pritam Gurung

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Time Window ◽

Treatment Strategies ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Stroke Imaging ◽

Number Of Patients ◽

Causes Of Mortality

Stroke is one of the leading causes of mortality and the number one cause of dependency in the world. Endovascular therapy has emerged as promising treatment strategy in the patient with acute ischemic stroke due to large vessel occlusion in anterior circulation. Moreover, the time window for mechanical thrombectomy have also been expanded based on the recent DAWN and DEFUSE-3 trial. It is evident that this trend could dramatically increase the number of potential patients for the treatment. Moreover, advancement in stroke imaging have guided physicians to make wisest decision in identifying suitable patient who can get benefit from the recent treatment strategies. The stroke management is evolving and continues to improve, making better outcome of the patient possible. In context of our country Nepal, it is also necessary to educate and aware medical staffs including physicians, nurses, laboratory/ radiology personnel to design a proper acute stroke team to deliver successful therapy which will eventually make a sound impact in a large number of patients with stroke. Herein, we report a case of a 69-year-old gentleman who presented with right middle cerebral artery territory infarction within 3hours of onset of symptoms and underwent mechanical thrombectomy as a part of the treatment.

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Mechanical Thrombectomy for Acute Stroke Due to Large-Vessel Occlusion Presenting With Mild Symptoms

Frontiers in Neurology ◽

10.3389/fneur.2021.739267 ◽

2021 ◽

Vol 12 ◽

Author(s):

Feifeng Liu ◽

Hao Shen ◽

Chen Chen ◽

Huan Bao ◽

Lian Zuo ◽

...

Keyword(s):

Logistic Regression ◽

Acute Stroke ◽

Mechanical Thrombectomy ◽

Multivariate Logistic Regression Analysis ◽

Functional Independence ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Multivariate Logistic Regression ◽

Anterior Circulation ◽

Vessel Occlusion

Purpose: To evaluate the safety and efficacy of mechanical thrombectomy (MT) for acute stroke due to large vessel occlusion (LVO), presenting with mild symptoms.Methods: A prospective cohort study of patients with mild ischemic stroke and LVO was conducted. Patients were divided into two groups: MT group or best medical management (MM) group. Propensity score matching (PSM) was conducted to reduce the confounding bias between the groups. The primary outcome was functional independence at 90 days. The safety outcome was symptomatic intracranial hemorrhage (sICH). Univariate and multivariate logistic regression analyses were used to identify the independent factors associated with outcomes.Results: Among the 105 included patients, 43 were in the MT group and 62 in the MM group. Forty-three pairs of patients were generated after PSM. There were no significant differences in sICH rates between two groups (p = 1.000). The MT group had a higher proportion of independent outcomes (83.7% MT vs. 67.4% MM; OR 2.483; 95% CI 0.886–6.959; p = 0.079) and excellent outcomes (76.7% MT vs. 51.2% MM; OR 3.150; 95% CI 1.247–7.954; p = 0.013) compared to the MM group, especially in patients with stroke of the anterior circulation (p < 0.05). Multivariate logistic regression analysis showed that small infarct core volume (p = 0.015) and MT treatment (p = 0.013) were independently associated with excellent outcomes.Conclusions: Our results suggest that MT in stroke patients, presenting with mild symptoms, due to acute LVO in the anterior circulation may be associated with satisfactory clinical outcomes.Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT04526756.

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Is a picture-perfect thrombectomy necessary in acute ischemic stroke?

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-017193 ◽

2021 ◽

pp. neurintsurg-2020-017193

Author(s):

Ching-Jen Chen ◽

Reda Chalhoub ◽

Dale Ding ◽

Jeyan S Kumar ◽

Natasha Ironside ◽

...

Keyword(s):

Primary Outcome ◽

Mechanical Thrombectomy ◽

National Institutes Of Health ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Symptomatic Intracerebral Hemorrhage ◽

History Of ◽

Multivariable Models ◽

Secondary Outcomes

BackgroundThe benefit of complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 3) over near-complete reperfusion (≥90%, mTICI 2c) remains unclear. The goal of this study is to compare clinical outcomes between mechanical thrombectomy (MT)-treated stroke patients with mTICI 2c versus 3.MethodsThis is a retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) comprising 33 centers. Adults with anterior circulation arterial vessel occlusion who underwent MT yielding mTICI 2c or mTICI 3 reperfusion were included. Patients were categorized based on reperfusion grade achieved. Primary outcome was modified Rankin Scale (mRS) 0–2 at 90 days. Secondary outcomes were mRS scores at discharge and 90 days, National Institutes of Health Stroke Scale score at discharge, procedure-related complications, and symptomatic intracerebral hemorrhage.ResultsThe unmatched mTICI 2c and mTICI 3 cohorts comprised 519 and 1923 patients, respectively. There was no difference in primary (42.4% vs 45.1%; p=0.264) or secondary outcomes between the unmatched cohorts. Reperfusion status (mTICI 2c vs 3) was also not predictive of the primary outcome in non-imputed and imputed multivariable models. The matched cohorts each comprised 191 patients. Primary (39.8% vs 47.6%; p=0.122) and secondary outcomes were also similar between the matched cohorts, except the 90-day mRS which was lower in the matched mTICI 3 cohort (p=0.049). There were increased odds of the primary outcome with mTICI 3 in patients with baseline mRS ≥2 (36% vs 7.7%; p=0.011; pinteraction=0.014) and a history of stroke (42.3% vs 15.4%; p=0.027; pinteraction=0.041).ConclusionsComplete and near-complete reperfusion after MT appear to confer comparable outcomes in patients with acute stroke.

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Inadvertent Stent Retriever Detachment: A Multicenter Case Series and Review of Device Experience FDA Reports

Interventional Neurology ◽

10.1159/000441920 ◽

2015 ◽

Vol 4 (3-4) ◽

pp. 75-82 ◽

Cited By ~ 9

Author(s):

Hesham Masoud ◽

Thanh N. Nguyen ◽

Coleman O. Martin ◽

William E. Holloway ◽

Sudheer Ambekar ◽

...

Keyword(s):

First Generation ◽

Mechanical Thrombectomy ◽

Rare Complication ◽

Case Series ◽

Standard Of Care ◽

Stent Retriever ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

The Us ◽

Solitaire Fr

Mechanical thrombectomy using retrievable stents or stent retriever devices has become the mainstay of intra-arterial therapy for acute ischemic stroke. The recent publication of a series of positive trials supporting intra-arterial therapy as standard of care for the treatment of large vessel occlusion will likely further increase stent retriever use. Rarely, premature stent detachment during thrombectomy may be encountered. In our multicenter case series, we found a rate of detachment of less than 1% (n = 7/1,067), and all were first-generation Solitaire FR devices. A review of the US Food and Drug Administration database of device experience yielded 90 individual adverse reports of detachment. There were 82, 1 and 7 detachments of Solitaire FR (first generation), Solitaire FR2 (second generation) and Trevo devices, respectively. We conclude with a brief overview of the technical and procedural considerations which may be helpful in avoiding this rare complication.

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Impact of Repeated Clot Retrieval Attempts on Infarct Growth and Outcome After Ischemic Stroke

Neurology ◽

10.1212/wnl.0000000000012321 ◽

2021 ◽

pp. 10.1212/WNL.0000000000012321

Author(s):

Wagih Ben Hassen ◽

Caroline Touloupas ◽

Joseph Benzakoun ◽

Gregoire Boulouis ◽

Martin Bretzner ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Functional Outcome ◽

Mechanical Thrombectomy ◽

Binary Logistic Regression ◽

Unfavorable Outcome ◽

Binary Logistic Regression Analysis ◽

Strongly Correlated ◽

Vessel Occlusion

Objective:To determine whether the association between increasing number of clot retrieval attempts (CRA) and unfavorable outcome is due to an increase in emboli to new territory (ENT) and greater infarct growth (IG) in successfully recanalized patients with acute ischemic stroke due to large vessel occlusion (AIS LVO).Methods:Data were extracted from two pooled multicentric prospective registries of consecutive anterior AIS-LVO patients treated with mechanical thrombectomy (MT) between January 2016-2019. Patients with pretreatment and 24 hours post-treatment diffusion-weighted imaging (DWI) achieving successful recanalization, defined as expanded Thrombolysis in Cerebral Infarction Scale (eTICI) scores 2b, 2C or 3 were included. ENT were assessed and IG measured by voxel-based segmentation after DWI co-registration. Associations between number of CRA, ENT, IG and 3-month outcome were analyzed.Results:Four hundred nineteen patients achieving successful recanalization were included. ENT occurrence was strongly correlated with increasing CRA (ρ=0.73, p=10-4). In multivariable linear analysis, IG was independently associated with CRA (β=1.6 per retrieval attempt, 95% CI = [0.97–9.74], p=0.03) and ENT (β=2.7, [1.21-4.1], p=0.03). Unfavorable functional outcome (3-month modified Rankin Score >2) increased with each additional CRA. IG was an independent predictor of unfavorable outcome (OR=1.05 [1.02-1.07] per 1 mL IG increase, p=10-4) in binary logistic regression analysis.Conclusion:Increasing number of CRA in acute stroke is correlated with an increased ENT rate and increased IG volume, affecting functional outcome even when successful recanalization is achieved.Classification of evidence:This study provides Class II evidence that, for patients with acute stroke undergoing successful recanalization, an increasing number of clot retrieval attempts is associated with poorer functional outcome.

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Abstract 1122‐000022: Delays in Care for Patients with Acute Stroke During Hospitalization for Other Reasons

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000022 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Nicholas Vigilante ◽

Parth Patel ◽

Prasanth Romiyo ◽

Lauren Thau ◽

Mark Heslin ◽

...

Keyword(s):

Acute Stroke ◽

Acute Care ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Single Center ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Symptom Recognition ◽

Risk Patients ◽

Recognition Imaging

Introduction : In‐hospital stroke (IHS) is defined as stroke that occurs during hospitalization for non‐stroke conditions. We aimed to understand the timing of symptom recognition for patients who experienced IHS and its impact on the care they receive. Methods : A prospective, single center registry of adult patients (9/20/19‐2/28/21) was queried for acute anterior circulation IHS. Indications for hospitalization, delays from last known well (LKW) to symptom recognition, imaging, and treatment were explored. Results : Of 928 consecutively evaluated adults with acute stroke, 85 (9%) developed an anterior circulation IHS, 39 (46%) of whom were female, with a median age of 67 years (IQR 60–76) and median NIHSS of 15 (IQR 4–22). Sixty‐eight (80%) had a >1 hour delay from last known well to symptom recognition. Two patients (2%) received IV thrombolysis, although another 38 (45%) would have been eligible if not for a delay in symptom recognition. An ICA, M1, or M2 occlusion was observed in 18 patients (21%), 7 of whom were treated at a median of 174 minutes after LKW (IQR 65–219). Compared to the 11 patients who did not undergo thrombectomy with large vessel occlusion, those who underwent thrombectomy had non‐significantly shorter delays from LKW until neuroimaging (median 85 [IQR 65‐162] vs. 216 [IQR 133‐507], p = 0.12). Conclusions : While uncommon, patients with IHS experience delays in symptom recognition and treatment, which lead to exclusion from acute care treatment such as thrombolysis and thrombectomy. Earlier detection with more frequent nursing assessments or advanced neuromonitoring devices in at‐risk patients may reduce delays in care.

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