Successful endovascular treatment of simultaneous acute ischaemic stroke and hyperacute ST elevation myocardial infarction: the first case report of a single-operator cardio-cerebral intervention

Abstract Background The simultaneous management of cardio-cerebral infarctions is an extremely difficult task, as both organs need to receive reperfusion therapy in a limited time to avoid death or permanent disability. The following case is the first published endovascular treatment of synchronous heart & brain infarctions delivered by a single operator with excellent clinical outcome. Case summary A 67-year-old female patient was directly transported to the emergency room of a comprehensive stroke centre with acute onset global aphasia and right hemiplegia. The onset to admission time exceeded the 4,5-hours’ time window of systemic thrombolysis. Head CT excluded extensive early extensive brain damage, CTA documented left middle cerebral artery occlusion (MCA) and mechanical thrombectomy was indicated. Extensive anterior ST elevation was detected on the transport monitor while waiting for in-hospital transfer. The two simultaneously evolving pathologies were handled in a single endovascular procedure that took less than 60 minutes by a dual-trained interventional cardiologist/neurointerventional surgeon. The patient recovered without any major cardiac or neurologic sequela. Discussion Interventional cardiologists, professionally trained through a neuro-interventional fellowship program to perform endovascular stroke interventions according to the latest multi-society position paper, could not only complement stroke teams lacking manpower, but their unique experience could also help the patients suffering from the most devastating forms of cardio-cerebral infarctions.

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Abstract WP33: Reperfusion Therapy in Carotid Artery Occlusion with Collaterals Through the Circle of Willis

Stroke ◽

10.1161/str.48.suppl_1.wp33 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Seong Hwan Ahn ◽

In Sung Choo ◽

Hyun Gu Kang ◽

Ji Yeon Jung ◽

Sang Woo Ha

Keyword(s):

Carotid Artery ◽

Endovascular Treatment ◽

Recurrent Stroke ◽

Reperfusion Therapy ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Circle Of Willis ◽

Carotid Occlusion ◽

Large Artery ◽

Clinical Worsening

Introduction: In large artery occlusion, endovascular treatment shows better recanalization rate than intravenous tPA alone. In reperfusion therapy, excellent collaterals through the circle of Willis has better prognosis. We hypothesized that intravenous tPA only is comparable to endovascular therapy in carotid occlusion with patent ‘T’. Methods: Between January 2010 and December 2015, in acute stroke patients who had received a reperfusion therapy, carotid artery occlusion with good collateral via the circle of Willis were selected. In all patients, non-contrast CT and CT angiography were conducted before reperfusion therapy and at 24 (+/-6) hours and/or clinical worsening. Stroke severity was assessed with NIHSS at baseline and discharge. The prognosis of reperfusion therapy was assessed by modified Rankin Scales at 3 months. Results: In 529 patients treated by reperfusion therapy, 29 patients (5.5%, male 21, median age 76) had internal carotid artery occlusion with patent ‘T’. In tPA alone (24 patients, 82.8%), baseline NIHSS were non-significantly lower than in endovascular treatment (10 vs 15, p=0.224). Recurrent stroke, which was confirmed with follow up angiography, was developed in 8 of tPA alone. In endovascular treatment, one had a distal embolization. In 22 patients who could be assessed by MRS, 10 patients (45.5%, tPA in 9, IA in 1) had good mRS and 6 patients (27.3%) were expired. Conclusions: Carotid occlusion with good collaterals via the circle of Willis was uncommon. tPA alone resulted in recurrent stroke with clinical worsening. Endovascular treatment may be better option in carotid occlusion with patent ‘T’.

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Endovascular Recanalization in Early Recurrent Ischemic Stroke: A Treatment Challenge

Case Reports in Neurology ◽

10.1159/000507185 ◽

2020 ◽

Vol 12 (Suppl. 1) ◽

pp. 49-55

Author(s):

Huong Bich Thi Nguyen ◽

Thang Huy Nguyen

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Time Window ◽

Recurrent Stroke ◽

Reperfusion Therapy ◽

Artery Occlusion ◽

Large Artery ◽

Limited Information ◽

Anterior Circulation ◽

Endovascular Recanalization

Reperfusion therapy is the most effective treatment for acute ischemic stroke. At present, many clinical studies have shown that mechanical thrombectomy is efficient and safe for acute ischemic stroke of large artery occlusion disease in the time window of 24 h. However, there is limited information on the safety and effectiveness of this technique in cases of recurrent ischemic stroke. We report a case of early recurrent stroke of the anterior circulation after a week of the first stroke. Imaging examinations showed that there existed occlusion of corresponding vessels and obvious ischemic penumbra. Symptoms of the patient were progressive worsening and medical treatment failed; therefore, the corresponding vessel was opened. The low perfusion status in brain tissue and clinical defect symptoms of the patients have improved a lot. In conclusion, thrombectomy for early recurrent ischemic stroke may be effective. Moreover, there may be a wider reperfusion time window for ischemic stroke patients.

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Simultaneous treatment of ischaemic bowel and ischaemic stroke with intravenous thrombolysis therapy

BMJ Case Reports ◽

10.1136/bcr-2018-227126 ◽

2018 ◽

Vol 11 (1) ◽

pp. e227126

Author(s):

Lucia Y Chen ◽

Charlotte Ainscough ◽

Mohamed Sayed ◽

Maneesh Bhargava

Keyword(s):

Ischaemic Stroke ◽

Intravenous Thrombolysis ◽

Abdominal Distension ◽

Artery Occlusion ◽

Left Middle Cerebral Artery ◽

Simultaneous Treatment ◽

Systemic Thrombolysis ◽

Ct Angiogram ◽

Stroke Team ◽

Left Middle

Novel treatment of simultaneous mesenteric and cerebral ischaemia with systemic thrombolysis. A 75-year-old man presented to the acute stroke team with aphasia, right-sided weakness and distressed with a pain he was unable to localise. He was treated with intravenous thrombolysis with tissue plasminogen activator for a left middle cerebral artery stroke. Decompensation on the ward during thrombolysis with worsening abdominal distension and pain, hypotension and tachycardia prompted a CT angiogram scan, which displayed proximal inferior mesenteric artery occlusion. Thrombolysis treatment resulted in excellent improvement of both his dysphasia and weakness from the left cerebral ischaemic stroke and reperfusion of the ischaemic bowel, without surgical intervention.

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Endovascular Treatment in Patients with Cerebral Artery Occlusion of Three Different Etiologies

Journal of Stroke ◽

10.5853/jos.2019.02404 ◽

2020 ◽

Vol 22 (2) ◽

pp. 234-244

Author(s):

Dongwhane Lee ◽

Deok Hee Lee ◽

Dae Chul Suh ◽

Bum Joon Kim ◽

Sun U. Kwon ◽

...

Keyword(s):

Endovascular Treatment ◽

Time Window ◽

Arterial Occlusion ◽

Hemorrhagic Transformation ◽

Artery Occlusion ◽

Related Factors ◽

Nihss Score ◽

Artery Embolism ◽

Shift Analysis ◽

Common Etiology

Background and Purpose The outcome of endovascular treatment (EVT) may differ depending on the etiology of arterial occlusion. This study aimed to assess the differences in EVT outcomes in patients with intracranial arterial steno-occlusion (ICAS-O), artery-to-artery embolism (AT-O), and cardiac embolism (CA-O).<br/>Methods We retrospectively analyzed 330 patients with ischemic stroke who underwent EVT between January 2012 and August 2017. Patients were classified according to the etiology. The clinical data, EVT-related factors, and clinical outcomes were compared. The modified Rankin Scale (mRS) score at 3 months, determined using ordinal logistic regression (shift analysis), was the primary outcome.<br/>Results CA-O (n=149) was the most common etiology, followed by ICAS-O (n=63) and AT-O (n=49). Age, initial National Institutes of Health Stroke Scale (NIHSS) score, and rate of hemorrhagic transformation were significantly higher in patients with CA-O compared to AT-O and ICAS-O. The time from onset-to-recanalization was the shortest in the CA-O (356.0 minutes) groups, followed by the AT-O (847.0 minutes) and ICAS-O (944.0 minutes) groups. The rates of successful recanalization, mRS distribution, and favorable outcomes at 3 months (mRS 0–2; CA-O, 36.9%, AT-O, 53.1%; and ICAS-O, 41.3%) did not differ among the three groups. Baseline NIHSS score (odds ratio, 0.87; 95% confidence interval, 0.83 to 0.91) could independently predict a favorable shift in mRS distribution.<br/>Conclusions The functional outcomes of ICAS-O and AT-O were similar to those of CA-O, despite the delay in symptom onset-to-recanalization, suggesting that the therapeutic time window may be extended in these patients.

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Atypical electrocardiographic presentations of myocardial infarction with ST elevation - ST elevation myocardial infarction equivalents

Medicinski pregled ◽

10.2298/mpns1808241d ◽

2018 ◽

Vol 71 (7-8) ◽

pp. 241-246

Author(s):

Jadranka Dejanovic ◽

Anastazija Stojsic-Milosavljevic ◽

Milos Trajkovic ◽

Tanja Popov ◽

Aleksandra Ilic

Keyword(s):

Myocardial Infarction ◽

Clinical Symptoms ◽

Coronary Artery Occlusion ◽

Reperfusion Therapy ◽

Artery Occlusion ◽

St Elevation Myocardial Infarction ◽

St Segment Elevation ◽

St Segment ◽

St Elevation ◽

T Waves

Introduction. Some patients with clinical symptoms and signs of acute myocardial and coronary artery occlusion have atypical electrocardiographic presentations - ST elevation myocardial infarction equivalents. Rapid recognition of these patterns is imperative, because the condition requires prompt reperfusion therapy following actual guidelines. De Winter pattern. Diagnostic criteria are: tall, prominent, symmetrical T-waves in the precordial leads, upsloping ST segment depression > 1 mm at the J-point in the precordial leads, absence of ST elevation in the precordial leads, ST segment elevation (0.5 mm - 1 mm) in aVR. ST Elevation in aVR. Electrocardiographic criteria include ST segment elevation in aVR ? 1 mm, ST segment elevation in aVR ? V1, and diffuse ST segment depression in lateral leads. Wellens syndrome. Wellens syndrome describes deeply inverted or bi?phasic T-waves in leads V2 - V3, highly specific for significant stenosis of the left anterior descending artery. Posterior infarction. Posterior infarction is confirmed with ST segment depression ? 0,5 mm in leads V1 - 3 and ST segment elevation ? 0.5 mm in posterior leads (V7 - V9). Conclusion. There are many electrocardiographic patterns that physicians should promptly recognize as clinical myocardial infarction with ST segment elevation equivalents in order to perform urgent reperfusion therapy for better prognosis and survival in these patients.

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Retriever first embolectomy (ReFirE): An alternative approach for challenging cervical access

Interventional Neuroradiology ◽

10.1177/1591019917701114 ◽

2017 ◽

Vol 23 (4) ◽

pp. 412-415 ◽

Cited By ~ 2

Author(s):

Daniel Behme ◽

Michael Knauth ◽

Marios-Nikos Psychogios

Keyword(s):

Endovascular Treatment ◽

Standard Of Care ◽

Artery Occlusion ◽

Exclusion Criterion ◽

Large Artery ◽

Direct Puncture ◽

First Case ◽

Guide Catheter ◽

Number Of Patients ◽

Diagnostic Catheter

After endovascular treatment became the standard of care procedure for acute ischaemic stroke with large artery occlusion in 2015 the number of performed interventions has increased dramatically. Especially because age is no exclusion criterion for endovascular treatment, a relevant number of patients with difficult to access carotid arteries has to be treated. In these patients a direct puncture of the carotid is a valuable tool but is associated with severe complications and an initial learning curve. We therefore developed the so called retriever first embolectomy (ReFirE) technique in which a stentretriever is deployed over a 5F diagnostic catheter and a microcatheter to establish a stable anchor prior to accessing the internal carotid artery/intracranial vasculature with an 8F guide catheter and a 5F/6F intermediate catheter. We hereby report the first case in which we performed a thrombectomy applying our novel technique.

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Abstract T P4: Impact of Extended IV rt-PA Time Window and Immediate Endovascular Therapy on the Outcome in Patients with Major Artery Occlusion

Stroke ◽

10.1161/str.45.suppl_1.tp4 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Hiroshi Yamagami ◽

Mikito Hayakawa ◽

Masatoshi Koga ◽

Shoichiro Sato ◽

Tomoyuki Ohara ◽

...

Keyword(s):

Time Window ◽

Phase 1 ◽

Reperfusion Therapy ◽

Artery Occlusion ◽

Phase 2 ◽

Total Period ◽

Nihss Score ◽

Poor Outcome ◽

Two Phases ◽

The Impact

Background and Purpose: In Japan, indication of intravenous recombinant tissue plasminogen activator (IV rt-PA) therapy for acute ischemic stroke (AIS) has been extended to 4.5 hours after the onset from Aug, 2012. Additionally, we have modified our institutional strategy of endovascular treatment (EVT) to start immediately after IV rt-PA in patients with occlusions of internal carotid artery (ICA), proximal portion of middle cerebral artery (MCA), or basilar artery (BA) from Oct, 2012. This study aimed to clarify the impact of these changes on the outcome in patients with major artery occlusion. Methods: We investigated the AIS patients with ICA, MCA or BA occlusion admitted to our hospital within 24 hours after the onset. They were divided into two phases according to admission date: phase 1 (Oct, 2011 to Sept, 2012) or phase 2 (Oct, 2012 to Apr, 2013). Backgrounds, treatments, and outcomes were compared between two phases. Favorable outcomes were defined as modified Rankin Scale (mRS) ≦2 or equal to premorbid mRS, and poor outcome as mRS 5 or 6 at 90 days after the onset. Results: Among 248 patients (130 men, 76.1±12.4 years old, National Institute of Health Stroke Scale [NIHSS] score on admission: median 18 [IQR 11-24]), 152 patients were admitted in phase 1 and 96 in phase 2. Age, sex, onset to admission time, stroke subtype, and sites of occluded arteries were similar in two phases, while NIHSS score on admission was higher in phase 1 than 2 (median 19 vs 17, P=0.046). Compared to phase 1, IV rt-PA (36.8 vs 44.8%), EVT (12.5 vs 26.0%), and either reperfusion therapy (42.8 vs 54.2%) were more frequently performed, and door to IV rt-PA time (71 vs 61min.) and door to EVT time (148 vs 127min.) were shorter in phase 2. The rate of favorable outcome significantly increased (27.0 vs 40.6%, P=0.027) and that of poor outcome decreased (44.1 vs 30.2%, P=0.033) in phase 2. With multivariate analysis in total period, reperfusion therapy was associated to favorable outcomes (OR 2.24, 95% CI 1.05-4.80) and inversely associated with poor outcome (OR 0.29, 95%CI 0.13-0.64). Conclusions: Increased frequency of reperfusion therapy by extended IV rt-PA time window and rapid EVT may contribute to the improvement of outcome in AIS patients with major artery occlusion.

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A Narrative Review of Contemporary Global Perspectives into Epidemiology, Treatment, and Prognosis of Vertebrobasilar Strokes

Rwanda Journal of Medicine and Health Sciences ◽

10.4314/rjmhs.v4i3.12 ◽

2021 ◽

Vol 4 (3) ◽

pp. 418-429

Author(s):

Samwel Msigwa

Keyword(s):

Time Window ◽

Reperfusion Therapy ◽

Artery Occlusion ◽

Narrative Review ◽

Basilar Artery Occlusion ◽

Management Options ◽

Significant Disabilities ◽

Global Perspectives ◽

Stent Restenosis ◽

Standard Medical Therapy

Blood flow interruptions to the posterior cerebral circulation hallmark vertebrobasilar strokes (VBS), leading to mortality and significant disabilities, yet optimal therapy prevails unpublished. Recent epidemiological evidence indicates that VBS account for nearly 1/5 of all ischemic strokes globally, with acute basilar artery occlusion (BAO) contributing significant disabilities in nearly 1/3 of the victims. The prevalence of VBS in Africa is close to 5%, majorly in large intracranial vessels. Etiologically, Stenosis accounts for 20% of all VBS, while aneurysms face up to a 3% rupture rate. Furthermore, intravenous alteplase is the gold standard medical therapy for the cases presenting within 3 to 4.5 hours post-baseline regarding management options. Nevertheless, there is no consensus for BAO beyond 4.5 hours post-onset. Stent retrievers are the first-line endovascular reperfusion therapy device proposed. However, an 18% risk of in-stent restenosis is a significant drawback. Comprehensive prognostic factors are addressed in this review. However, prospective, multicenter, controlled studies are needed to clarify the time window dilemmas facing posterior circulation strokes. This narrative review explores recent VBS epidemiology, management advances, and prognosis.Rwanda J Med Health Sci 2021;4(3):418-429

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