Middle Cerebral Artery Thrombectomy: Clinical Findings and Technical Pearls: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Shivani D Rangwala ◽  
Pradeep Selvan ◽  
Matthew Tenser ◽  
William Mack ◽  
Adam Arthur ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Ct Perfusion ◽  
Sensory Loss ◽  
Acute Hemorrhage ◽  
Presenting Symptoms ◽  
Mca Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Ct Head

Abstract Mechanical thrombectomy as a treatment for large vessel occlusion to achieve rapid revascularization is supported in the literature.1-3 The presenting symptoms will localize to functions of the ischemic area. The middle cerebral artery (MCA) supplies areas of the frontal, temporal, and parietal cortices, as well as the basal ganglia. Occlusion of the MCA will present with contralateral hemiplegia, sensory loss, and, if the dominant hemisphere is involved, language deficits. We present a right-hand-dominant 79-yr-old female with right MCA syndrome—her last known well time was 1.5 h prior to presentation. Her NIH (National Institutes of Health) Stroke Scale was 16, most notable for left hemiplegia. Although the patient presented early in the clinical time course, as part of our institution protocol, a computed tomography (CT) head, CT perfusion, and CT angiogram (CTA) were performed. CT head did not demonstrate acute hemorrhage, so she received intravenous tissue plasminogen activator. CTA demonstrated a right MCA occlusion and CT perfusion suggested a large area of salvageable tissue, so she was taken to the angiography suite for mechanical thrombectomy. Angiography of the right internal carotid artery (ICA) showed MCA occlusion (insular segment). A thrombectomy device was deployed over the area of occlusion and allowed to engage for 5 min. An aspiration catheter was advanced over the stentriever up against the clot. The stentriever device was withdrawn under continuous aspiration and follow-up angiography showed complete reperfusion. The patient demonstrated improvement and was eventually discharged to an inpatient rehabilitation center. Patient provided consent for photography per university protocol. Institutional review board (IRB) approval was not needed for the single-patient data included in this report.

scholarly journals Main Trunk and Division Middle Cerebral Artery Occlusions: Differences in Recanalization Times, Number of Stent Retriever Passes and Clinical Outcomes: A Single-Center Experience

2015 ◽  
Vol 4 (3-4) ◽  
pp. 83-89
Author(s):  
Ihtesham A. Qureshi ◽  
Alberto Maud ◽  
Salvador Cruz-Flores ◽  
Gustavo J. Rodriguez
Keyword(s):  
Middle Cerebral Artery ◽  
Clinical Outcomes ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Univariate Analysis ◽  
Stent Retriever ◽  
Main Trunk ◽  
Single Center Experience ◽  
Mca Occlusion ◽  
Complex Anatomy

Background and Purpose: In this article, we present our experience with the recanalization of the middle cerebral artery (MCA), we hypothesize that there are higher rates of recanalization with fewer stent retriever passes and better clinical outcomes in patients with division MCA occlusions. A more complex anatomy at the bifurcation may prevent a faster recanalization in main trunk MCA occlusions. Methods: We retrospectively identified consecutive patients admitted with MCA occlusions who underwent mechanical thrombectomy using stent retrievers. We categorized patients into division MCA and main trunk MCA occlusions based on angiography. Variables were compared between the groups. We further analyzed patients with trunk MCA occlusions to identify reasons for delays in recanalization. Results: There were 32 MCA occlusions that underwent mechanical thrombectomy and eligible for the analysis during the study period. Of those, 11 were main trunk MCA occlusions. Univariate analysis disclosed a trend toward a lower GP-to-recanalization time (p = 0.05) and a lower number of passes required for recanalization in division MCA occlusions. However, there was a significantly better outcome in patients with division MCA occlusion after multivariate analysis. Analyzing main trunk MCA occlusion data, we found that the need for more than one pass to achieve recanalization led to a trend toward a longer GP-to-recanalization time and a worse outcome. When the stent was placed in the dominant division, the chances of recanalization were significantly higher. Conclusions: Division MCA occlusions have higher recanalization rates with fewer stent retriever passes and better clinical outcomes than main trunk MCA occlusions, likely due to a more favorable anatomy. Measures like placing the stent retriever in the dominant division may decrease recanalization times and improve clinical outcomes in main trunk MCA occlusions.

scholarly journals Short-Vessel Occlusion Might Indicate Higher Possibility of Success in Reperfusion following Mechanical Thrombectomy in Acute Middle Cerebral Artery Occlusion

2021 ◽  
pp. 131-136
Author(s):  
Tomoyuki Yoshihara ◽  
Ryuzaburo Kanazawa ◽  
Takanori Uchida ◽  
Tetsuhiro Higashida ◽  
Hidenori Ohbuchi ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Active Zone ◽  
Mechanical Thrombectomy ◽  
Area Under The Curve ◽  
Maximum Intensity Projection ◽  
Stent Retriever ◽  
Vessel Occlusion ◽  
Mca Occlusion ◽  
The Impact

<b><i>Background:</i></b> The impact of the length of the occluded vessel in acute large-vessel occlusion on successful reperfusion by mechanical thrombectomy remains unclear. This study evaluated whether diameter and length of the occluded vessel in acute middle cerebral artery (MCA) occlusion might relate to successful reperfusion following mechanical thrombectomy. <b><i>Methods:</i></b> This retrospective study included patients with acute MCA occlusion who underwent intra-aortic injection of contrast medium to obtain maximum intensity projection (MIP) images acquired by flat-panel detector computed tomography (FD-CT) equipped with an angiographic system. All patients received mechanical thrombectomy and were divided into two groups: those with successful reperfusion (Thrombolysis in Cerebral Infarction [TICI] 2b/3) and those without. We compared the diameter and length of the occluded vessel between the groups. In the sub-analysis of patients with stent retriever use, ratio of length of occluded vessel to length of the active zone was compared. <b><i>Results:</i></b> We enrolled 29 patients (median age: 73, M1 occlusion: 51%, stent retriever use: 72%). Eighteen patients achieved TICI 2b/3 with significantly larger distal end diameter (1.7 [interquartile range: 1.5–1.9] vs. 1.2 [1.2–1.5] mm, <i>p</i> = 0.007) and shorter length (7.1 [4.9–9.7] vs. 12.3 [7.2–15.8] mm, <i>p</i> = 0.043) of the occluded vessel. Sub-analysis of 21 patients showed that the cut-off value for TICI 2b/3 reperfusion was 0.32 as the ratio between the occluded vessel and stent retriever active zone (receiver operating characteristic area under the curve: 0.90). <b><i>Conclusion:</i></b> In acute MCA occlusion, larger diameter of the distal end and shorter length of the occluded vessel on FD-CT MIP images might indicate a higher possibility of achieving TICI 2b/3 following mechanical thrombectomy.

Mechanical thrombectomy of M1 and M2 middle cerebral artery occlusions

2017 ◽  
Vol 10 (4) ◽  
pp. 330-334 ◽  
Author(s):  
Hisham Salahuddin ◽  
Guru Ramaiah ◽  
Diana E Slawski ◽  
Julie Shawver ◽  
Mark Buehler ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Clinical Outcomes ◽  
Cerebral Artery ◽  
Randomized Clinical Trials ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Current Standard ◽  
Institutional Review ◽  
Intravenous Tissue Plasminogen Activator ◽  
Significant Difference

BackgroundOver half of patients who receive intravenous tissue plasminogen activator for middle cerebral artery division (MCA-M2) occlusion do not recanalize, leaving a large percentage of patients who may need mechanical thrombectomy (MT). However, the outcomes of MT for M2 occlusion have not been well characterized.ObjectiveTo determine if MT of M2 occlusion is as safe and efficacious as current standard-of-care MT for M1 occlusions.MethodsWith institutional review board approval, we retrospectively reviewed records of 212 patients undergoing MT for isolated MCA M1 or M2 occlusions during a 36-month period (Sept 2013 to Sept 2016) at two centres. Treatment variables, clinical outcomes, and complications in each group were recorded.ResultsThere were 153 M1 MCA occlusions and 59 M2 MCA occlusions. No statistically significant difference was found in the rate of mortality (20% in M1 vs 13.6% in M2, p=0.32), excellent (34.5% vs 37.3%, p=0.75) or good (51% vs 55.9%, p=0.54) clinical outcomes between the two groups. Infarct volumes (48.4 mL vs 46.2 mL, p=0.62) were comparable between the two groups, as were the rates of hemorrhagic (3.3% vs 3.4%, p=1.0) and procedural complications (3.3% vs 5.1%, p=0.69).ConclusionOur data on MT targeting M2 occlusions demonstrates reasonable safety and functional outcomes. Further randomized clinical trials are needed to clarify which patients may benefit from MT for M2 occlusions.

Abstract P361: Visualization of the Anterior Temporal Artery as a Predictor of Outcome in Middle Cerebral Artery Occlusion Patients Achieving Successful Recanalization After Interfacility Transfer

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Jonathan M Parish ◽  
William R Stetler ◽  
Dale Strong ◽  
Tanushree Prasad ◽  
Jeremy B Rhoten ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Functional Outcome ◽  
Computerized Tomography ◽  
Patient Outcomes ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Temporal Artery ◽  
Artery Occlusion ◽  
Mca Occlusion ◽  
Proximal Site

Introduction: Many non-thrombectomy centers lack Computerized Tomography Perfusion (CTP) capability. Anterior temporal artery (ATA) visualization on Computerized Tomography Angiography (CTA) has been previously associated with good outcomes in middle cerebral artery (MCA) occlusions, but not in the context of recanalization after interfacility transfer for thrombectomy. We hypothesized that independent functional outcome at 90 days would be greater for MCA occlusion patients initially presenting to non-thrombectomy centers with a visualized ATA on CTA who achieved TICI 2b or greater recanalization after transfer. Methods: We conducted a retrospective cohort study of patients transferred for mechanical thrombectomy. A neuroradiologist blinded to patient outcomes confirmed the MCA as the most proximal site of occlusion on CTA, and assessed for visualization of the ATA. TICI 2b or greater revascularization scores were confirmed by neurointerventionalists blinded to patient outcomes. Ninety-day mRS scores were obtained via telephone utilizing a structured questionnaire. Results: We identified a total of 107 MCA occlusion patients over a 3 ½ year period meeting our inclusion criteria. There were no significant differences in age, gender, race, comorbidities, median NIHSS, or time-to-revascularization variables between the ATA visualized (n=50) versus non-visualized (n=57) group, with the exception of significantly more wake-up strokes in the ATA visualized group (34.7% vs 16.1%, p=0.03). There was a non-significant trend for independent outcome (mRS ≤2) at 90 days for patients with ATA visualization compared to those for whom the ATA was not visualized on the CTA (63.8% vs 45.5%, p=0.06). Conclusion: For MCA occlusion patients initially presenting to non-thrombectomy centers achieving successful recanalization via mechanical thrombectomy, there is a strong trend for visualization of the anterior temporal artery on the CTA performed at the non-thrombectomy center as being a predictor of independent functional outcome. Especially for institutions without CTP capability, this association with ATA visualization should be further investigated as a predictor for good outcome after transfer for successful mechanical thrombectomy.

Lenticulostriate infarctions after successful mechanical thrombectomy in middle cerebral artery occlusion

2016 ◽  
Vol 9 (3) ◽  
pp. 234-239 ◽  
Author(s):  
Justus F Kleine ◽  
Ebba Beller ◽  
Claus Zimmer ◽  
Johannes Kaesmacher
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Symptom Onset ◽  
Predictive Value ◽  
False Positive ◽  
Mechanical Thrombectomy ◽  
Time Window ◽  
Vascular Anatomy ◽  
Statistical Measures ◽  
Mca Occlusion

BackgroundIn stroke due to middle cerebral artery (MCA) occlusion, collaterals may sustain tissue in the peripheral MCA territory, extending the time window for recanalizing therapies. However, MCA occlusions often block some or all of the ‘lenticulostriate’ (LS) arteries originating from the M1 segment, eliminating blood flow to dependent territories in the striatum, which have no collateral supply. This study examines whether mechanical thrombectomy (MTE) can avert imminent striatal infarction in patients with acute MCA occlusion.Methods279 patients with isolated MCA occlusion subjected to MTE were included. Actual LS occlusions and infarctions were assigned to predefined ‘LS occlusion’ and ‘LS infarct’ patterns derived from known LS vascular anatomy. The predictive performance of LS occlusion patterns regarding ensuing infarction in striatal subterritories was assessed by standard statistical measures.ResultsLS occlusion patterns predicted infarction in associated striatal subterritories with a positive predictive value (PPV) of 91% and a negative predictive value of 81%. In 15 of the 22 patients who did not develop the predicted striatal infarctions, reassessment of angiographies revealed LS vascular supply variants that explained these ‘false positive’ LS occlusion patterns, raising the PPV to 96%. Symptom onset to recanalization times were relatively short, but this alone could not account for the false positive LS occlusion patterns in the remaining seven of these patients.ConclusionsWith currently achievable symptom onset to recanalization times, striatal infarctions are determined by MCA occlusion sites and individual vascular anatomy, and cannot normally be averted by MTE, but there are exceptions. Further study of such exceptional cases may yield important insights into the determinants of infarct growth in the hyperacute phase of infarct evolution.

scholarly journals Collateral status evaluation coupled with time window by dynamic axial computed tomographic angiography with a focus on the middle cerebral artery for mechanical thrombectomy

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Takahisa Mori ◽  
Kazuhiro Yoshioka ◽  
Wataru Mori ◽  
Yuhei Tanno
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Time Window ◽  
Computed Tomographic Angiography ◽  
Ct Scanner ◽  
Computed Tomographic ◽  
Upper Limit ◽  
Mca Occlusion ◽  
Tomographic Angiography

Abstract Background Dynamic axial computed tomographic angiography (dynax–CTA), covering a thin width, with a focus on the bilateral middle cerebral artery (MCA), can quickly visualize the internal carotid artery (ICA) or MCA occlusion. We aimed to investigate whether dynax–CTA appropriately evaluated the collateral status coupled with the upper limit of the onset-to-reperfusion (OtR) time to achieve a major neurological improvement (MNI) at a 24-h follow-up examination after mechanical thrombectomy (MT). Methods We included acute ischemic stroke patients admitted from 2018 to 2020 who underwent dynax–CTA on admission and emergent MT for ICA or MCA occlusion. We performed dynax–CTA using an 80-row CT scanner and acquired 25 volume scans, consisting of 40 images of 1-mm thickness and 4-cm width. We classified the collateral status as good, intermediate, and poor based on MCA branch opacification. We evaluated the collateral status and the upper OtR time limit to achieve MNI. Results Forty-eight patients met our inclusion criteria. Dynax–CTA findings demonstrated MCA and ICA occlusion in 30 and 18 patients, respectively. The collateral status was good, intermediate, and poor in four, 25, and 19 patients, respectively. The upper limits of the OtR time for MNI were 3.63, 8.08, and 8.67 h in patients with poor, intermediate, and intermediate or good collateral status, respectively. Conclusions Dynax–CTA appropriately evaluated the collateral status coupled with the upper limit of the OtR time before performing MT.

scholarly journals Crossed cerebellar diaschisis in patients with acute middle cerebral artery infarction: Occurrence and perfusion characteristics

2015 ◽  
Vol 36 (4) ◽  
pp. 743-754 ◽  
Author(s):  
Wieland H Sommer ◽  
Christine Bollwein ◽  
Kolja M Thierfelder ◽  
Alena Baumann ◽  
Hendrik Janssen ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Symptom Onset ◽  
Ct Perfusion ◽  
Clinical Factors ◽  
Middle Cerebral Artery Infarction ◽  
Whole Brain ◽  
Crossed Cerebellar Diaschisis ◽  
Brain Ct ◽  
Cerebellar Diaschisis

We aimed to investigate the overall prevalence and possible factors influencing the occurrence of crossed cerebellar diaschisis after acute middle cerebral artery infarction using whole-brain CT perfusion. A total of 156 patients with unilateral hypoperfusion of the middle cerebral artery territory formed the study cohort; 352 patients without hypoperfusion served as controls. We performed blinded reading of different perfusion maps for the presence of crossed cerebellar diaschisis and determined the relative supratentorial and cerebellar perfusion reduction. Moreover, imaging patterns (location and volume of hypoperfusion) and clinical factors (age, sex, time from symptom onset) resulting in crossed cerebellar diaschisis were analysed. Crossed cerebellar diaschisis was detected in 35.3% of the patients with middle cerebral artery infarction. Crossed cerebellar diaschisis was significantly associated with hypoperfusion involving the left hemisphere, the frontal lobe and the thalamus. The degree of the relative supratentorial perfusion reduction was significantly more pronounced in crossed cerebellar diaschisis-positive patients but did not correlate with the relative cerebellar perfusion reduction. Our data suggest that (i) crossed cerebellar diaschisis is a common feature after middle cerebral artery infarction which can robustly be detected using whole-brain CT perfusion, (ii) its occurrence is influenced by location and degree of the supratentorial perfusion reduction rather than infarct volume (iii) other clinical factors (age, sex and time from symptom onset) did not affect the occurrence of crossed cerebellar diaschisis.

scholarly journals A Case of Delayed Symptomatic Middle Cerebral Artery Stenosis Following Mechanical Thrombectomy

2016 ◽  
Vol 10 (3) ◽  
pp. 138-143 ◽  
Author(s):  
Sangnyon Kim ◽  
Masafumi Ohtaki ◽  
Hiroshige Tsuda ◽  
Yusuke Kimura ◽  
Ayaka Sasagawa ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Artery Stenosis ◽  
Middle Cerebral Artery Stenosis

Abstract TP34: Is there an Added Value for Vascular Imaging Prior to Administration of Intravenous tPA in Patients with Acute Middle Cerebral Artery Occlusion

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Ronen R Leker ◽  
Roni Eichel ◽  
John M Gomori ◽  
Tamir Ben Hur ◽  
Jose E Cohen
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Acute Stage ◽  
Added Value ◽  
Vascular Pathology ◽  
Stroke Severity ◽  
Imaging Studies ◽  
Stroke Registry ◽  
Intravenous Tissue Plasminogen Activator ◽  
Neurovascular Imaging

Background and objectives: Advanced neurovascular imaging with CT or MR angiography (CTA/MRA) adds information regarding the vascular pathology and prognosis but may delay treatment with intravenous tissue plasminogen activator (tPA) in patients with proximal middle cerebral artery occlusions (pMCAO). Methods: Patients with pMCAO included in our prospective stroke registry were identified. Stroke severity was measured with the National Institutes of Health Stroke Scale (NIHSS) and only patients presenting with NIHSS>10 were included. Patients underwent multi-parametric imaging studies whenever possible. Patients that underwent CTA/MRA were compared to those that only had a non-contrast CT prior to tPA. Disability was measured with the modified Ranking Scale (mRS) and shifts towards favorable outcomes (mRS≤2) were analyzed. Logistic regression was used to determine outcome modifiers. Results: We included 73 patients (median age 73, 52% men) with moderate-severe stroke (median admission NIHSS 14). Forty four patients had a neurovascular imaging study and 29 did not have such a study. There were no differences between the groups in risk factor profile or baseline characteristics including stroke severity and door to needle, door to imaging or imaging to treatment times. At 90 days post stroke there were no statistically significant differences in mortality or favorable outcomes between the groups. On multivariate analysis performance of CTA/MRA had no impact on the chances of obtaining favorable outcome at day 90 after stroke. Conclusions: Advanced neurovascular imaging studies do not delay treatment with tPA but do not impact the outcome of patients with pMCAO treated with tPA and may therefore be unnecessary in the acute stage prior to administration of tPA.

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