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 TP15: A Case for the Chase? A Case Series of Mechanical Thrombectomy of M2 Occlusions

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Hisham Salahuddin ◽  
Julie Shawver ◽  
Gretchen Tietjen ◽  
Syed Zaidi ◽  
Mouhammad Jumaa
Keyword(s):  
Endovascular Treatment ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Randomized Clinical Trials ◽  
Mechanical Thrombectomy ◽  
Tertiary Care ◽  
Case Series ◽  
Anterior Circulation ◽  
Institutional Review ◽  
Tertiary Care Centers

Introduction: Randomized clinical trials have demonstrated an improvement in outcomes with endovascular treatment of large vessel occlusions, however studies evaluating the effectiveness of endovascular treatment of smaller vessels of the anterior circulation are lacking. We present initial data from two tertiary care centers with a focus on outcomes of patients with isolated middle cerebral artery (MCA) M2 occlusions. Methods: With institutional review board approval, we retrospectively reviewed medical records of patients who underwent mechanical thrombectomy (MT) between September 2013 and June 2016. The following data was collected: demographics, stroke risk factors, intravenous tPA use, MT treatment times, grade of recanalization, complications, and 3 month modified Rankin Scores. A favorable clinical outcome was defined as a modified Rankin Scale (mRS) 0-2 at 90 days. Results: A total of 50 patients were included in this analysis with 19 (38%) women and 31 (62%) men, with a mean age of 70 (63-80) years. One patient had an occlusion of both superior and inferior divisions of the middle cerebral artery (MCA) artery, 20 had occlusion of the inferior M2 artery, and the remaining 29 had occlusion of the superior division of the MCA. Baseline characteristics are summarized below. Average door to groin time was 75 (46-112) minutes, mean procedure time was 30 (25-47) minutes, and mean onset of symptoms to recanalization time was 220 (156-305) minutes. Of the cohort, 22 patients had a change of mRS of 3 or more at the time of discharge, 25 (50%) patients had a favorable outcome at 3 months, and 4 (8%) patients were lost to follow up. Ten (20%) patients developed hemorrhagic infarction and five (10%) developed parenchymal hematoma. Conclusions: Our data on MT targeting M2 occlusions demonstrates reasonable safety, recanalization rates, complications, and functional outcomes. Randomized studies are needed to confirm the benefit of pursuing MCA M2 occlusions with MT.

Mechanical thrombectomy versus intravenous alteplase alone in acute isolated posterior cerebral artery occlusion: a systematic review

2021 ◽  
pp. neurintsurg-2021-018017
Author(s):  
Andre Monteiro ◽  
Slah Khan ◽  
Muhammad Waqas ◽  
Rimal H Dossani ◽  
Nicco Ruggiero ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Posterior Cerebral Artery ◽  
Artery Occlusion ◽  
Favorable Outcome ◽  
Intravenous Tissue Plasminogen Activator ◽  
Significant Difference ◽  
Symptomatic Intracranial Hemorrhage ◽  
Cerebral Artery Occlusion ◽  
Iv Tpa

BackgroundAcute isolated posterior cerebral artery occlusions (aPCAOs) were excluded or under-represented in major randomized trials of mechanical thrombectomy (MT). The benefit of MT in comparison to intravenous tissue plasminogen activator (alteplase; IV-tPA) alone in these patients remains controversial and uncertain.MethodsWe performed a systematic search of PubMed, MEDLINE, and EMBASE databases for articles comparing MT with or without bridging IV-tPA and IV-tPA alone for aPCAO using keywords (‘posterior cerebral artery’, ‘thrombolysis’ and ‘thrombectomy’) with Boolean operators. Extracted data from patients reported in the studies were pooled into groups (MT vs IV-tPA alone) for comparison. Estimated rates for favorable outcome (modified Rankin scale score 0–2), symptomatic intracranial hemorrhage (sICH), and mortality were extracted.ResultsSeven articles (201 MT patients, 64 IV-tPA) were included, all retrospective. There was no statistically significant difference between pooled groups in median age, median presentation National Institutes of Health Stroke Scale (NIHSS) score, PCAO segment, and median time from symptom onset to puncture or needle. The recanalization rate was significantly higher in the MT group than the IV-tPA group (85.6% vs 53.1%, p<0.00001). Odds ratios for favorable outcome (OR 1.5, 95% CI 0.8 to 2.5), sICH (OR 1.1, 95% CI 0.2 to 5.5), and mortality (OR 1.4, 95% CI 0.5 to 3.6) did not significantly favor any modality.ConclusionsWe found no significant differences in odds of favorable outcome, sICH, and mortality in MT and IV-tPA in comparable aPCAO patients, despite superior MT recanalization rates. Equipoise remains regarding the optimal treatment modality for these patients.

scholarly journals Mechanical Thrombectomy for Middle Cerebral Artery Division Occlusions: A Systematic Review and Meta-Analysis

2017 ◽  
Vol 6 (3-4) ◽  
pp. 242-253 ◽  
Author(s):  
Hisham Salahuddin ◽  
Aixa Espinosa ◽  
Mark Buehler ◽  
Sadik A. Khuder ◽  
Abdur R. Khan ◽  
...  
Keyword(s):  
Systematic Review ◽  
Clinical Outcome ◽  
Middle Cerebral Artery ◽  
Clinical Outcomes ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Total N ◽  
Clinical Databases ◽  
The Impact

Background: Middle cerebral artery division (M2) occlusion was significantly underrepresented in recent mechanical thrombectomy (MT) randomized controlled trials, and the approach to this disease remains heterogeneous. Objective: To conduct a systematic review and meta-analysis of outcomes at 90 days among patients undergoing MT for M2 middle cerebral artery (MCA) occlusions. Methods: Five clinical databases were searched from inception through September 2016. Observational studies reporting 90-day modified Rankin Scale scores for patients undergoing MT for M2 MCA occlusions with an M1 MCA control group were selected. The primary outcome of interest was good clinical outcome 90 days after MT of an M1 or M2 MCA occlusion. Secondary outcomes of interest included mortality and excellent clinical outcome, recanalization rates, significant intracerebral hemorrhage, and procedural complications. Results: A total of 323 publications were identified, and 237 potentially relevant articles were screened. Six studies were included in the analysis (M1 = 1,203, M2 = 258; total n = 1,461). We found no significant differences in good clinical outcomes (1.10 [95% CI, 0.83-1.44]), excellent clinical outcomes (1.07 [0.65-1.79]), mortality at 3 months (0.85 [0.58-1.24]), recanalization rates (1.06 [0.32-3.48]), and significant intracranial hemorrhage (1.19 [0.61-2.30]). Conclusions: MT of M2 MCA occlusions is as safe as that of main trunk MCA occlusions, and comparable in terms of clinical outcomes and hemorrhagic complications. Randomized clinical trials are needed to assess the impact of MT in patients with M2 occlusions, given that M1 MCA occlusions have different natural histories than M2 occlusions.

Absent hyperdense middle cerebral artery sign is associated with poor functional outcome after mechanical thrombectomy

2021 ◽  
pp. 174749302199197
Author(s):  
Kiddy L Ume ◽  
Sudeepta Dandapat ◽  
Matthew W Weber ◽  
Cynthia B Zevallos ◽  
Amber Fifer ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Middle Cerebral Artery ◽  
Functional Outcome ◽  
Cerebral Artery ◽  
Functional Disability ◽  
Mechanical Thrombectomy ◽  
Artery Occlusion ◽  
Serum Glucose ◽  
Significant Difference ◽  
Hyperdense Middle Cerebral Artery

Background The hyperdense middle cerebral artery sign on computed tomography indicates proximal middle cerebral artery occlusion. Recent reports suggest an association between the hyperdense sign and successful reperfusion. The prognostic value of the hyperdense middle cerebral artery sign in patients receiving mechanical thrombectomy has not been extensively studied. Aims Our study aims to evaluate the association between the hyperdense middle cerebral artery sign and functional outcome in patients with M1 occlusions that had undergone mechanical thrombectomy. Methods We conducted a single-center retrospective observational cohort study of 102 consecutive patients presenting with acute M1 occlusions that had undergone mechanical thrombectomy. Patients were stratified into cohorts based on the presence of hyperdense middle cerebral artery sign visually assessed on computed tomography by two readers. The outcomes of interests were functional disability measured by the ordinal Modified Rankin Scale (mRS) at 90 days, mortality, reperfusion status and hemorrhagic conversion. Results Out of the 102 patients with M1 occlusions, 71 had hyperdense middle cerebral artery sign. There was no significant difference between the cohorts in age, baseline mRS, NIHSS, ASPECTS, and time to reperfusion. The absence of hyperdense middle cerebral artery sign was associated with increased odds of being dependent or dying (higher mRS) (OR: 3.24, 95% CI: 1.30–8.06, p = 0.011) after adjusting for other significant predictors, including age, female sex, hypertension, presenting serum glucose, ASPECTS, CTA collateral score, and successful reperfusion. Conclusion The absence of hyperdense middle cerebral artery sign is associated with worse functional outcome in patients presenting with M1 occlusions undergoing thrombectomy.

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.

Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: a meta-analysis

2017 ◽  
Vol 10 (7) ◽  
pp. 620-624 ◽  
Author(s):  
Hamidreza Saber ◽  
Sandra Narayanan ◽  
Mohan Palla ◽  
Jeffrey L Saver ◽  
Raul G Nogueira ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Functional Independence ◽  
Vessel Occlusion ◽  
Increased Risk ◽  
Significant Difference

BackgroundEndovascular thrombectomy has demonstrated benefit for patients with acute ischemic stroke from proximal large vessel occlusion. However, limited evidence is available from recent randomized trials on the role of thrombectomy for M2 segment occlusions of the middle cerebral artery (MCA).MethodsWe conducted a systematic review and meta-analysis to investigate clinical and radiographic outcomes, rates of hemorrhagic complications, and mortality after M2 occlusion thrombectomy using modern devices, and compared these outcomes against patients with M1 occlusions. Recanalization was defined as Thrombolysis in Cerebral Infarction (TICI) 2b/3 or modified TICI 2b/3.ResultsA total of 12 studies with 1080 patients with M2 thrombectomy were included in our analysis. Functional independence (modified Rankin Scale 0–2) rate was 59% (95% CI 54% to 64%). Mortality and symptomatic intracranial hemorrhage rates were 16% (95% CI 11% to 23%) and 10% (95% CI 6% to 16%), respectively. Recanalization rates were 81% (95% CI 79% to 84%), and were equally comparable for stent-retriever versus aspiration (OR 1.05; 95% CI 0.91 to 1.21). Successful M2 recanalization was associated with greater rates of favorable outcome (OR 4.22; 95% CI 1.96 to 9.1) compared with poor M2 recanalization (TICI 0–2a). There was no significant difference in recanalization rates for M2 versus M1 thrombectomy (OR 1.05; 95% CI 0.77 to 1.42).ConclusionsThis meta-analysis suggests that mechanical thrombectomy for M2 occlusions that can be safely accessed is associated with high functional independence and recanalization rates, but may be associated with an increased risk of hemorrhage.

scholarly journals A Comparison of Mechanical Thrombectomy in the M1 and M2 Segments of the Middle Cerebral Artery: A Review of 585 Consecutive Patients

2017 ◽  
Vol 6 (3-4) ◽  
pp. 191-198 ◽  
Author(s):  
Pervinder Bhogal ◽  
Philipp Bücke ◽  
Muhammad AlMatter ◽  
Oliver Ganslandt ◽  
Hansjörg Bäzner ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Intracranial Haemorrhage ◽  
Mechanical Thrombectomy ◽  
Outcome Data ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Computed Tomographic ◽  
Significant Difference

Background: Mechanical thrombectomy for anterior-circulation large-vessel occlusion has shown benefit; however, the question of whether this technique is safe and effective in the distal vasculature remains unanswered. We sought to compare the outcome data from mechanical thrombectomy of the M2 branches of the middle cerebral artery (MCA) with those of the M1 segment. Methods: We performed a retrospective analysis of prospectively collected data of patients with acute ischaemic stroke undergoing mechanical thrombectomy of isolated M1 or M2 branches of the MCA between August 2008 and August 2016. Results: We identified 585 patients, 479 with M1 occlusions and 106 with M2 occlusions. The average age was 72 ± 12.8 and 68 ± 13.8 years, respectively (p = 0.007). The baseline Alberta Stroke Program Early Computed Tomographic (ASPECT) score was similar in both cohorts, but patients with M1 occlusions presented with higher mean National Institutes of Health Stroke Scale (NIHSS) scores of 15.7 compared to 11.8 (p < 0.001). There was no significant difference in the average procedure time for each cohort; fewer thrombectomy attempts were required in the M2 cohort (2.3 vs. 1.8, p = 0.0004), but the overall time to recanalization was longer in the M2 cohort (353 vs. 399 min, p < 0.001). Similar rates of successful reperfusion (Thrombolysis in Ischaemic Stroke score [TICI] ≥2b 88.5 vs. 90.5%, p = 0.612) were seen, but food outcome (modified Rankin Scale ≤2) was lower in M1 occlusions (37.2 vs. 54.3%, p < 0.001). Rates of symptomatic intracranial haemorrhage were similar. Conclusion: Good clinical outcomes can be achieved for both groups with no significant differences in procedure length, final TICI recanalization rates or intracranial haemorrhage between the M1 and M2 cohorts.

Abstract P517: The Effect of Unfavorable Vascular Anatomy on Mechanical Thrombectomy for Middle Cerebral Artery Occlusion Strokes Preliminary Evaluation of the AIM2 Score System

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Okkes Kuybu ◽  
Mahmoud Mohammaden ◽  
Diogo C Haussen ◽  
Alhamza R Al-bayati ◽  
Samir R Belagaje ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Vascular Anatomy ◽  
Preliminary Evaluation ◽  
Vessel Occlusion ◽  
Simple Method ◽  
Score System ◽  
Significant Difference ◽  
The Impact

Background: Time to reperfusion remains one of the strongest predictors of outcome in large vessel occlusion strokes (LVOS). Herein, we aim to assess the impact of unfavorable vascular anatomy on mechanical thrombectomy (MT) number of passes and procedural times. Methods: Retrospectively review of a prospective MT database spanning January-July 2018 including acute LVOS involving the middle cerebral artery-M1 segment and available baseline CT angiography. The AIM2 score (Table 1) was applied with patients categorized as favorable (AIM2: 0-2) versus unfavorable (AIM2: >=3) anatomy. The primary outcome was the rate of <3 device passes. Secondary outcomes included procedural times and the rates of successful reperfusion (mTICI2b-3) and 90-day mRS 0-2. Safety measures included rates of sICH and 90-day mortality. Results: Patients with unfavorable anatomy (n=15) were significantly younger (52±19, p=0.02) and had lower rates of hypertension (46% vs 80%, p=0.01) and smoking (0% vs 39%, p<0.001) versus those with favorable anatomy (n=50). Successful reperfusion with <3 passes was more often achieved with AIM2 scores 0-2 vs. ≥3 (84% vs 60%, p=0.04). There were no significant difference in other outcome measures (Table 2). Conclusions: The AIM2 score system represents a simple method for the systematically evaluation of vascular anatomy in MT and correlates significantly with increased number of MT passes.

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