scholarly journals Anterior cerebral artery embolism during thrombectomy increases disability and mortality

2018 ◽  
Vol 10 (11) ◽  
pp. 1057-1062 ◽  
Author(s):  
Vanessa Chalumeau ◽  
Raphaël Blanc ◽  
Hocine Redjem ◽  
Gabriele Ciccio ◽  
Stanislas Smajda ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Anterior Cerebral Artery ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Stent Retriever ◽  
Favorable Outcome ◽  
Anterior Circulation ◽  
Artery Embolism ◽  
Uncommon Condition ◽  
Number Of Passes

ObjectiveDuring thrombectomy, thromboembolic migration in previously unaffected territory may occur and is not systematically notified. We report our data on the incidence, predictors, and clinical outcome of anterior cerebral artery emboli (ACAE).MethodsFrom a prospectively collected thrombectomy database of consecutive patients with anterior circulation stroke between January 2012 and December 2016, 690 angiographic images were analyzed to assess ACAE. The primary outcome was a favorable outcome, defined as a 3 month modified Rankin Scale score of 0–2 or equal to the pre-stroke score.ResultsACAE occurred in 65 patients (9.4%; 95% CI 7.2% to 11.6%). Internal carotid artery occlusion (tandem or terminal), Alberta Stroke Program Early CT Score <7, increasing number of passes, and use of stent retriever alone (compared with distal aspiration alone or combined with stent retriever) were found to be independent predictors of ACAE. Compared with patients without ACAE, patients with ACAE had lower rates, with an adjusted OR (95% CI) of 0.48 (0.25 to 0.92; P=0.027) for favorable outcome and 0.49 (0.25 to 0.96; P=0.038) for early neurologic improvement. ACAE was significantly associated with a higher mortality (adjusted OR 1.93; 95% CI 1.03 to 3.61; P=0.039) and intracranial hemorrhagic complications (adjusted OR 2.45; 95% CI 1.33 to 4.47; P=0.004). Despite a successful reperfusion modified Thrombolysis in Cerebral Infarction score of 2b–3 at the end of the procedure, a favorable outcome was reached in 30% of patients with ACAE compared with 52.4% in the other patients (OR 0.39; 95% CI 0.19 to 0.78; P=0.008).ConclusionsProcedural ACAE was not an uncommon condition, and was associated with increased mortality and disability rates, regardless of the success of reperfusion.

What constitutes the M1 segment of the middle cerebral artery?

2016 ◽  
Vol 8 (12) ◽  
pp. 1273-1277 ◽  
Author(s):  
Mayank Goyal ◽  
Bijoy K Menon ◽  
Timo Krings ◽  
Shivanand Patil ◽  
Emmad Qazi ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Overwhelming Evidence ◽  
Segment Versus ◽  
Proximal Occlusion

Intravenous tissue plasminogen activator has limited efficacy in fibrinolysis of large proximal intracranial thrombi. Thus, recent endovascular acute stroke trials restricted their selection criteria to patients with proximal occlusions in the anterior circulation. Although the terminal internal carotid artery occlusion is relatively easy to identify, there is often a debate as to what constitutes a proximal (involving the M1 segment) versus a distal (involving the M2 segment and beyond) middle cerebral artery occlusion. In light of overwhelming evidence demonstrating superiority of endovascular treatment in patients with proximal occlusion, this distinction has significant practical implications in patient selection. Here we present a brief review of the proximal (M1) segment of the middle cerebral artery anatomy and provide practical methods to recognize and separate the M1 and M2 segments. In keeping with the belief that CT angiography (CTA) (preferably multiphase CTA) is the ideal screening test for patients with emergent large vessel occlusion, we have provided tips for expeditious and accurate vascular imaging interpretation.

A comparative analysis of 3MAX aspiration versus 3 mm Trevo Retriever for distal occlusion thrombectomy in acute stroke

2019 ◽  
Vol 12 (3) ◽  
pp. 279-282 ◽  
Author(s):  
Diogo C Haussen ◽  
Brendan Eby ◽  
Alhamza R Al-Bayati ◽  
Jonathan A Grossberg ◽  
Gabriel Martins Rodrigues ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Primary Outcome ◽  
Anterior Cerebral Artery ◽  
Median Number ◽  
Stent Retriever ◽  
First Pass ◽  
Multivariable Regression ◽  
Baseline Characteristics ◽  
Distal Occlusion ◽  
Number Of Passes

BackgroundAlthough aspiration and stent retriever thrombectomy perform similarly in proximal occlusions, no comparative series are available in distal occlusions. We aimed to compare the 3 mm Trevo Retriever against the 3MAX thromboaspiration catheter in distal arterial occlusions.MethodsA single-center retrospective review of a prospectively maintained databank for patients treated with the 3 mm Trevo stent retriever or 3MAX thromboaspiration as the upfront approach for distal occlusions (middle cerebral artery mid/distal M2/M3, anterior cerebral artery A1/A2/A3 or posterior cerebral artery P1/P2) from January 2014 to July 2018 was performed. The primary outcome was the rate of distal occlusion first-pass reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b–3).ResultsOf 1100 patients treated within the study period, 137 patients/144 different arteries were treated with the 3 mm Trevo (n=92) or 3MAX device (n=52). The groups had comparable demographics and baseline characteristics. There was a higher rate of first-pass mTICI 2b–3 reperfusion (62% vs 44%; p=0.03), a trend towards a higher rate of final mTICI 2b–3 reperfusion (84% vs 69%; p=0.05), and lower use of adjuvant therapy (15% vs 31%; p=0.03) with the 3 mm Trevo compared with the 3MAX. The median number of passes (p=0.46), frequency of arterial spasm (p=1.00), rates of parenchymal hematomas (p=0.22)/subarachnoid hemorrhage (p=0.37) in the territory of the approached vessel were similar across the two groups. The 90-day rate of good outcomes (45% vs 46% in the 3 mm Trevo and 3MAX groups, respectively; p=0.84) was comparable. Multivariable regression identified baseline NIH Stroke Scale (NIHSS) score (OR 0.9; 95% CI 0.8 to 0.97; p<0.01) and use of 3 mm Trevo (OR 2.2; 95% CI 1.1 to 4.6; p=0.02) independently associated with first-pass mTICI 2b–3 reperfusion.ConclusionsIn the setting of distal arterial occlusions, the 3 mm Trevo may lead to higher rates of first-pass reperfusion than direct 3MAX thromboaspiration. Lower NIHSS was found to be associated with improved reperfusion rates as observed in more proximal lesions. Further studies are warranted.

Abstract WP21: Primary Thrombectomy Within 3 Hours of Onset in Acute Ischemic Stroke From Large Artery Occlusion (PAST3-LAO)- A Pilot Study

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Yahia M Lodi ◽  
Varun Reddy ◽  
George Petro ◽  
Anas Hourani ◽  
Chun-An Chou
Keyword(s):  
Pilot Study ◽  
Artery Occlusion ◽  
Primary Objective ◽  
Stent Retriever ◽  
Large Artery ◽  
Good Outcome ◽  
Randomized Controlled ◽  
Randomized Controlled Studies ◽  
New Generation ◽  
Number Of Passes

Background: Based on recent trials, AIS due to large artery occlusion (LAO) is resistant to IV thrombolysis and adjunctive stent retriever thrombectomy (SRT) is associated with better recanalization rates and outcomes.Despite the benefit with endovascular therapy 39% to 68% of patients were either disabled or dead.Thrombectomy in AIS with LAO within 3 hours (IV t-PA window) is performed as secondary therapy after IV thrombolysis, which may be associated with delay in enrollment and recanalization. Objective: Primary objective is to evaluate the safety, feasibility and recanalization rate of primary SRT (without IV tPA) within 3 hours in AIS with NIHSS >10 from LAO.Secondary objective is to determine the functional outcome in 30-days and 90-days. Methods: Based on institutionally approved protocol patients with LAO with LCB within 3 hours were offered primary SRT alone as an alternative to IV rtPA, after informed consent.Consecutive patients who underwent primary SRT for LAO within 3 hours from 2012 to 2014 were enrolled.Outcomes were measured using modified Rankin Scale. Results: 18 patients with LAO; mean age 62.8±15.3 years and mean NIHSS 16±5; chose primary SRT after informed consent.Thrombectomy was performed using new generation stent-retriever device in addition to small intra-arterial rtPA (2-10 mg).Number of passes was 1.6±0.9.Near complete (TICI2b in 1) and complete (TICI3 in 17) recanalization was observed in all (100%) patients.Mean time to recanalization from symptoms onset was 188.5±82.7 and from groin puncture was 64.61±40.14 minutes.Immediate post-thrombectomy, 24 hour and 30 day NIHSS score was 4.4±3.7, 1.9±3.2 and 0.3±0.9 respectively.There was no procedure related complication.Asymptomatic perfusion related hemorrhage developed in 6 patients (33%).30 days good outcome was observed in all cases (mRS0= 38.9%, mRS1=44.4%, mRS2=16.7%). 90 days good outcome was observed as follows (mRS0= 50.0%, mRS1=44.4%, mRS2=5.6%). Conclusion: Our pilot study demonstrates that primary SRT in AIS due LAO occlusion with LCB is not only safe and feasible, but associated with complete recanalization and good functional outcome.Larger randomized controlled studies are needed.

Azygous Anterior Cerebral Artery Acute Occlusion Managed With Endovascular Mechanical Thrombectomy: 2-Dimensional Operative Video

2018 ◽  
Vol 16 (4) ◽  
pp. 514-515 ◽  
Author(s):  
Leonardo Rangel-Castilla ◽  
Adnan H Siddiqui
Keyword(s):  
Cerebral Artery ◽  
Cerebral Blood Volume ◽  
Mechanical Thrombectomy ◽  
Anterior Cerebral Artery ◽  
Stent Retriever ◽  
Vessel Occlusion ◽  
Nihss Score ◽  
Acute Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Azygous Anterior Cerebral Artery

Abstract Mechanical thrombectomy has become the standard of care for management of most acute large-vessel occlusion (LVO) strokes. Most intracranial occlusions are located in the middle cerebral and internal carotid arteries. We present a unique case of acute occlusion of an azygous anterior cerebral artery (ACA). A 59-yr-old man with known hypertension and alcoholism presented with right hemiparesis, right facial palsy, aphasia, and dysarthria. His initial National Institutes of Health Stroke Scale (NIHSS) score was 20. Computed tomographic angiography and perfusion imaging demonstrated acute bilateral ACA occlusion with viable penumbra and preserved cerebral blood volume. The patient was not a candidate for intravenous tissue plasminogen activator because he presented with a wake-up stroke. After consent was obtained from his family, the patient was taken urgently for endovascular recanalization. Digital subtraction angiography confirmed acute azygous ACA occlusion. Under conscious sedation, the patient underwent mechanical thrombectomy with a stent retriever and a large-bore aspiration catheter. Successful revascularization (thrombolysis in cerebral infarction [TICI] grade 3) of the azygous ACA and both A2 arteries was obtained after 2 attempts and the use of a different stent retriever (first a 3 × 30 mm Trevo [Stryker Neurovascular, Kalamazoo, Michigan] and then a 4 × 40 mm Solitaire Platinum [Medtronic, Dublin, Ireland]). A reperfusion catheter was used during both attempts. No procedure-related complications occurred. The patient was discharged to a rehabilitation facility 3 d after the procedure with an NIHSS score of 2. In this video, we present the operative nuances of an uncommon location of LVO and its endovascular management.

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