Mechanical thrombectomy and rescue therapy for intracranial large artery occlusion with underlying atherosclerosis

ObjectiveTo investigate the safety and efficacy of mechanical thrombectomy plus rescue therapy for intracranial large artery occlusion (ILAO) with underlying intracranial atherosclerosis (ICAS).MethodsPatients enrolled in the intervention group of EAST (Endovascular Therapy for Acute ischemic Stroke Trial) were analyzed. For underlying ICAS identified during the stent retrieval procedure, rescue treatment was required for those with (1) a degree of arterial stenosis >70% or (2) any degree of arterial with blood flow impairment or (3) evidence of re-occlusion. Outcomes were compared between the ICAS group and the embolic group. Multivariate logistic regression was performed to determine independent predictors of functional independence at 90 days.ResultsAmong the 140 patients included in the analysis, underlying ICAS was identified in 47 (34%), and 30 patients (21.4%) were considered to be eligible to receive rescue treatment. Of the 30 patients, 27 (90%) actually received rescue therapy. Recanalization rate (95.7% vs 96.8%, P=0.757) and functional independence at 90 days (63.8% vs 51.6%, P=0.169) were comparable between the ICAS group and the embolic group. No significant difference in symptomatic hemorrhage (4.3% vs 4.3%, P=1.000) or death (12.8% vs 12.9%, P=0.982) was found between the two groups. National Institutes of Health Stroke Scale score at presentation (OR=0.865, 95% CI 0.795 to 0.941; P=0.001) and modified Thrombolysis in Cerebral Infarction after the procedure (OR=2.864, 95% CI 1.018 to 8.061; P=0.046) were independently associated with functional independence at 90 days.ConclusionsMechanical thrombectomy is safe in patients with ILAO with underlying ICAS. By employing a standard rescue therapy, favorable outcomes could be achieved in such patients.Clinical trial registrationNCT02350283 (Post-results).

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Endovascular treatment for acute basilar artery occlusion: descriptive analysis of the experience in a comprehensive stroke centre

10.22514/sv.2021.038 ◽

2021 ◽

Keyword(s):

General Anaesthesia ◽

Basilar Artery ◽

Endovascular Therapy ◽

Mechanical Thrombectomy ◽

Functional Independence ◽

Artery Occlusion ◽

Basilar Artery Occlusion ◽

Anterior Circulation ◽

Significant Difference ◽

Epidemiological Characteristics

Objectives: To describe the clinical and epidemiological characteristics of patients with basilar artery occlusion (BAO) treated with mechanical thrombectomy (MT) in Aragón, and to compare its anaesthetic management, technical effectivity, security, and prognosis with those of anterior circulation. Methods: 322 patients from the prospective registry of mechanical thrombectomies from Aragon were assessed: 29 with BAO and 293 with an anterior circulation large vessel occlusion. Baseline characteristics, procedural, clinical and safety outcomes variables were compared. Results: Out of 29 patients with BAO that underwent endovascular therapy (62.1% men; average age 69.8 ± 14.05 years) 18 (62.1%) received endovascular therapy (EVT) alone and 11 (37.9%) EVT plus intravenous thrombolysis. Atherothrombotic stroke was the most common etiology (41%). The BAO group had longer Door-to-groin (160 vs 141 min; P = 0.043) and Onset-to-reperfusion times (340 vs 297 min; P = 0.005), and higher use of general anaesthesia (60.7% vs 14.7%; P < 0.01). No statistically significant difference was found for Procedure time (60 vs 50 min; P = 0.231) nor the rate of successful recanalization (72.4% vs 82.7%; P = 0.171). Functional independence at 90 days was significantly worse in the BAO group (17.9% vs 38.2%; P < 0.01). Conclusions: Patients with basilar artery occlusion had higher morbimortality despite similar angiographic results. Mechanical thrombectomy for BAOs is a safe and effective procedure in selected patients. A consensus about the effect of anaesthesia has yet to be reached, for BAO general anaesthesia remains the most frequently used technique.

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Stenting as a Rescue Treatment After Failure of Mechanical Thrombectomy for Anterior Circulation Large Artery Occlusion

Stroke ◽

10.1161/strokeaha.116.014073 ◽

2016 ◽

Vol 47 (9) ◽

pp. 2360-2363 ◽

Cited By ~ 56

Author(s):

Jang-Hyun Baek ◽

Byung Moon Kim ◽

Dong Joon Kim ◽

Ji Hoe Heo ◽

Hyo Suk Nam ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Artery Occlusion ◽

Large Artery ◽

Anterior Circulation ◽

Rescue Treatment

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Bridging Intravenous Thrombolysis Before Mechanical Thrombectomy for Large Artery Occlusion May be Detrimental with Thrombus Fragmentation

Current Neurovascular Research ◽

10.2174/1567202617666191223143831 ◽

2020 ◽

Vol 17 (1) ◽

pp. 18-26 ◽

Cited By ~ 3

Author(s):

Ho Jun Yi ◽

Jae Hoon Sung ◽

Dong Hoon Lee

Keyword(s):

Clinical Outcome ◽

Subgroup Analysis ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

Artery Occlusion ◽

Stent Retriever ◽

Large Artery ◽

Simultaneous Application

Objective: We investigated whether intravenous thrombolysis (IVT) affected the outcomes and complications of mechanical thrombectomy (MT), specifically focusing on thrombus fragmentation. Methods: The patients who underwent MT for large artery occlusion (LAO) were classified into two groups: MT with prior IVT (MT+IVT) group and MT without prior IVT (MT-IVT) group. The clinical outcome, successful recanalization with other radiological outcomes, and complications were compared, between two groups. Subgroup analysis was also performed for patients with simultaneous application of stent retriever and aspiration. Results: There were no significant differences in clinical outcome and successful recanalization rate, between both groups. However, the ratio of pre- to peri-procedural thrombus fragmentation was significantly higher in the MT+IVT group (14.6% and 16.2%, respectively; P=0.004) compared to the MT-IVT group (5.1% and 6.8%, respectively; P=0.008). The MT+IVT group required more second stent retriever (16.2%), more stent passages (median value = 2), and more occurrence of distal emboli (3.9%) than the MT-IVT group (7.9%, median value = 1, and 8.1%, respectively) (P=0.004, 0.008 and 0.018, respectively). In subgroup analysis, the results were similar to those of the entire patients. Conclusion: Thrombus fragmentation of IVT with t-PA before MT resulted in an increased need for additional rescue therapies, and it could induce more distal emboli. The use of IVT prior to MT does not affect the clinical outcome and successful recanalization, compared with MT without prior IVT. Therefore, we need to reconsider the need for IVT before MT.

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

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-018017 ◽

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.

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Abstract WP25: Concomitant IV tPA Does Not Increase Harm to Patients Who Receive Simultaneous Mechanical Thrombectomy and Emergent Carotid Artery Stent Treatment

Stroke ◽

10.1161/str.44.suppl_1.awp25 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Hormozd Bozorgchami ◽

Jeremy Fields ◽

Gary Walker ◽

Cindy Jahans ◽

Helmi Lutsep ◽

...

Keyword(s):

Carotid Artery ◽

Mechanical Thrombectomy ◽

Functional Independence ◽

Treated Group ◽

Stroke Patients ◽

Time To Treatment ◽

Exact Test ◽

Symptomatic Intracerebral Hemorrhage ◽

Significant Difference ◽

Iv Tpa

Background: Stenting of the cervical internal carotid artery (ICA) may be performed acutely in patients undergoing endovascular intervention for stroke due to occlusion of the intracranial ICA or MCA. It is unclear if pre-intervention IV tPA increases complications of carotid artery stenting (CAS) in this group. Hypothesis: We assessed the hypothesis that pre-intervention IV tPA does not increase the risk of complications in acute ischemic stroke patients (AIS) who require concurrent mechanical thrombectomy and emergent CAS. Methods: Patients undergoing both mechanical thrombectomy and CAS within 24 hours of stroke onset were identified from the Merci Registry, a prospective database of AIS patients treated with the Merci Retriever. Those receiving IV tPA were compared with those that did not for associations with functional independence (mRS 0-2) and risk of symptomatic intracerebral hemorrhage (sICH). The primary endpoint for this study was the percentage of patients with mRS 0-2 at 90 days. Secondary endpoints included 90-day mortality and sICH. Outcomes were compared with Fisher’s exact test. Results: 103 patients were included. Thirty received IV tPA (mean age 59.1, time to treatment 6.3 hrs, median NIHSS 18) and 74 did not (mean age 66.1, time to treatment 9.8 hrs, median NIHSS 16). Although numerically higher, there was no significant difference in sICH at 24 hours, occurring in 18.2% (4/22) of IV tPA patients and 7.3% (4/55) of patients without IV tPA (p=0.22) [sICH data was not available on 28 patients]. At 90 days, 40% of the IV tPA group (12/30) was functionally independent while 30.6% (22/73) was functionally independent in the non-IV tPA group (p=0.36). There was no difference in 90-day mortality between the two groups (26.7% vs. 34.7%, p=0.67). Conclusions: This study demonstrates that concomitant IV tPA use in acute stroke patients who had simultaneous mechanical thrombectomy and CAS did not significantly affect patient outcomes or increase complications. Although neither result was statistically significant, there was a trend toward improved functional outcomes at 90 days in the IV tPA treated group despite a trend toward increased rates of sICH.

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Abstract 107: Rescue Tirofiban in Mechanical Thrombectomy for Acute Cerebral Large Artery Occlusion: A Multicenter Prospective Registry Study

Stroke ◽

10.1161/str.50.suppl_1.107 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Ming Yang ◽

Xiaochuan Huo ◽

Feng Gao ◽

Anxin Wang ◽

Xiaoli Zhang ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Artery Occlusion ◽

Large Artery ◽

Registry Study

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Mechanical thrombectomy for basilar artery occlusion: efficacy, outcomes, and futile recanalization in comparison with the anterior circulation

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014516 ◽

2019 ◽

Vol 11 (12) ◽

pp. 1174-1180 ◽

Cited By ~ 18

Author(s):

Thomas Raphael Meinel ◽

Johannes Kaesmacher ◽

Panagiotis Chaloulos-Iakovidis ◽

Leonidas Panos ◽

Pasquale Mordasini ◽

...

Keyword(s):

Basilar Artery ◽

Mechanical Thrombectomy ◽

Artery Occlusion ◽

Favorable Outcome ◽

Basilar Artery Occlusion ◽

Secondary Outcome ◽

Stroke Severity ◽

Anterior Circulation ◽

Link Type ◽

Significant Difference

BackgroundPerforming mechanical thrombectomy (MT) in patients with basilar artery occlusion (BAO) is currently not evidence-based.ObjectiveTo compare patients’ outcome, relative merits of achieving recanalization, and predictors of futile recanalization (FR) between BAO and anterior circulation large vessel occlusion (ACLVO) MT.MethodsIn the multicenter BEYOND-SWIFT registry (NCT03496064), univariate and multivariate (displayed as adjusted Odds Ratios, aOR and 95% confidence intervals, 95%-CI) outcome comparisons between BAO (N=165) and ACLVO (N=1574) were performed. The primary outcome was favorable outcome at 90 days (modified Rankin Scale, mRS 0-2). Secondary outcome included mortality, symptomatic intracranial hemorrhage (sICH) and FR. The relative merits of achieving successful recanalization between ACLVO and BAO were evaluated with interaction terms.ResultsMT in BAO was more often technically effective and equally safe in regards to mortality and sICH when compared to ACLVO. When adjusting for baseline differences, there was no significant difference between BAO vs ACLVO regarding rates of favorable outcome (aOR 0.986, 95%-CI 0.553 – 1.758). However, BAO were associated with increased rates of FR (aOR 2.146, 95%-CI 1.267 – 3.633). Predictors for FR were age, stroke severity, maneuver count and intracranial stenting. No significant heterogeneity on the relative merits of achieving successful recanalization on several outcome parameters were observed when comparing BAO and ACLVO.ConclusionsIn selected patients, similar outcomes can be achieved in BAO and ACLVO patients treated with MT. Randomized controlled trials comparing patient selection and interventional strategies seem warranted to avoid FR.Trial registration numberNCT03496064

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Safety and Feasibility of Using Argatroban Immediately After Mechanical Thrombectomy for Large Artery Occlusion

World Neurosurgery ◽

10.1016/j.wneu.2019.08.151 ◽

2019 ◽

Vol 132 ◽

pp. e341-e349 ◽

Cited By ~ 2

Author(s):

Jeeyong Kim ◽

Ho Jun Yi ◽

Dong Hoon Lee ◽

Jae Hoon Sung

Keyword(s):

Mechanical Thrombectomy ◽

Artery Occlusion ◽

Large Artery

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Safety and efficacy of mechanical thrombectomy with the Solitaire device in large artery occlusion

Neurology India ◽

10.4103/0028-3886.100701 ◽

2012 ◽

Vol 60 (4) ◽

pp. 400 ◽

Cited By ~ 5

Author(s):

Keun-Sik Hong ◽

Ah-Ro Kim ◽

Yong-Jin Cho ◽

JiEun Kim ◽

YoungMin Paek ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Artery Occlusion ◽

Large Artery ◽

Safety And Efficacy

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Early Thrombectomy Protects the Internal Capsule in Patients With Proximal Middle Cerebral Artery Occlusion

Stroke ◽

10.1161/strokeaha.120.031977 ◽

2021 ◽

Author(s):

Johannes Kaesmacher ◽

Mirjam Kaesmacher ◽

Maria Berndt ◽

Christian Maegerlein ◽

Sebastian Mönch ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Mechanical Thrombectomy ◽

Internal Capsule ◽

Functional Independence ◽

Artery Occlusion ◽

Proximal Middle Cerebral Artery ◽

Lenticulostriate Artery

Background and Purpose: Proximal middle cerebral artery (MCA) occlusions impede blood flow to the noncollateralized lenticulostriate artery territory. Previous work has shown that this almost inevitably leads to infarction of the dependent gray matter territories in the striate even if perfusion is restored by mechanical thrombectomy. Purpose of this analysis was to evaluate potential sparing of neighboring fiber tracts, ie, the internal capsule. Methods: An observational single-center study of patients with proximal MCA occlusions treated with mechanical thrombectomy and receiving postinterventional high-resolution diffusion-weighted imaging was conducted. Patients were classified according to internal capsule ischemia (IC+ versus IC−) at the postero-superior level of the MCA lenticulostriate artery territory (corticospinal tract correlate). Associations of IC+ versus IC− with baseline variables as well as its clinical impact were evaluated using multivariable logistic or linear regression analyses adjusting for potential confounders. Results: Of 92 included patients with proximal MCA territory infarctions, 45 (48.9%) had an IC+ pattern. Longer time from symptom-onset to groin-puncture (adjusted odds ratio, 2.12 [95% CI, 1.19–3.76] per hour), female sex and more severe strokes were associated with IC+. Patients with IC+ had lower rates of substantial neurological improvement and functional independence (adjusted odds ratio, 0.26 [95% CI, 0.09–0.81] and adjusted odds ratio, 0.25 [95% CI, 0.07–0.86]) after adjustment for confounders. These associations remained unchanged when confining analyses to patients without ischemia in the corona radiata or the motor cortex and here, IC+ was associated with higher National Institutes of Health Stroke Scale motor item scores (β, +2.8 [95% CI, 1.5 to 4.1]) without a significant increase in nonmotor items (β, +0.8 [95% CI, −0.2 to 1.9). Conclusions: Rapid mechanical thrombectomy with successful reperfusion of the lenticulostriate arteries often protects the internal capsule from subsequent ischemia despite early basal ganglia damage. Salvage of this eloquent white matter tract within the MCA lenticulostriate artery territory seems strongly time-dependent, which has clinical and pathophysiological implications.

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