Endovascular Management of Acute Ischemic Strokes with Tandem Occlusions

Background: Ischemic strokes with tandem occlusions are associated with a poor prognosis. Recent studies demonstrating the effectiveness of endovascular treatment for large vessel occlusions have shown less impressive results in patients with tandem occlusions than in those with isolated intracranial occlusions. Also, the indications and effects of carotid stenting remain unclear. Methods: From a prospectively gathered registry, we analyzed data of 70 consecutive patients who underwent mechanical endovascular treatment for acute stroke with tandem occlusions from November 2011 to August 2014. Clinical (including demographics, National Institutes of Health Stroke Scale (NIHSS), and stroke etiology), imaging (including diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score), and endovascular treatment data were assessed and reviewed in consensus by 2 observers. Good clinical outcome was defined as a modified Rankin Scale of ≤2 at 3-month follow-up. Results: At 3-month follow-up, 50.8% had a poor clinical outcome, including death in 13.4%. Lower NIHSS (initial, at day 1, and at discharge) and successful recanalization (thrombolysis in cerebral infarction 2b-3) were associated with a good clinical outcome (p < 0.05). There were no statistically significant differences between patients with a good or poor clinical outcome in terms of intravenous (IV) tissue plasminogen activator use, delay between symptom onset and recanalization, and endovascular technique including the carotid stenting. Conclusions: Despite the recent randomized control trials demonstrating the effectiveness of thrombectomy, there is still a research gap about tandem occlusions. This subtype of stroke, which usually responds poorly to IV thrombolysis, is also difficult to treat by endovascular means. Guidelines for the endovascular management of tandem occlusions are needed.

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Abstract TP26: The Outcome of Patients With Tandem Occlusion Remains Poor Despite Mechanical Thrombectomy

Stroke ◽

10.1161/str.47.suppl_1.tp26 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Robert Fahed ◽

Hocine Redjem ◽

Raphaël Blanc ◽

Julien Labreuche ◽

Stanislas Smajda ◽

...

Keyword(s):

Clinical Outcome ◽

Endovascular Treatment ◽

Intravenous Thrombolysis ◽

Poor Clinical Outcome ◽

Good Clinical Outcome ◽

Intravenous Tissue Plasminogen Activator ◽

Tandem Occlusion ◽

Treatment Data ◽

Research Gap

Introduction: Ischemic strokes with tandem occlusions are associated with a poor prognosis. Recent studies demonstrating the effectiveness of endovascular treatment for large vessel occlusions have shown less impressive results in patients with tandem occlusions than in those with isolated intracranial occlusions. Besides, the indications and effects of ICA stenting remain unclear. Hypothesis: To determine the factors associated with favorable outcome at 3-month in this subtype of AIS. Methods: From a prospectively gathered registry, we analyzed the data of 70 consecutive patients who underwent mechanical endovascular treatment for acute stroke with tandem occlusions from November 2011 to August 2014. Clinical (including demographics, NIHSS, and stroke etiology), imaging (including DWI-ASPECTS), and endovascular treatment data were assessed and reviewed in consensus by two observers. Good clinical outcome was defined as a modified Rankin Scale (mRS) of ≤2 at 3-month follow-up. The mRS at 3 months follow-up was available in 67 patients. Results: At 3-month follow-up, 33 of 67 (49.3%) patients had a good clinical outcome and 34 (50.8%) had a poor clinical outcome, including 9 deaths (13.4%). Lower NIHSS (initial, at day 1, and at discharge) and successful recanalization (TICI 2b-3) were associated with a good clinical outcome (P<0.05). There were no statistically significant differences between patients with a good or poor clinical outcome in terms of intravenous tissue plasminogen activator use, delay between symptom onset and recanalization, and endovascular technique, including the ICA stenting. Conclusions: Despite the recent randomized control trials demonstrating the effectiveness of thrombectomy, there is still a research gap about tandem occlusions. This subtype of stroke, which usually responds poorly to intravenous thrombolysis, is also difficult to treat by endovascular means.

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Flow diversion treatment for acutely ruptured aneurysms

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015077 ◽

2019 ◽

Vol 12 (3) ◽

pp. 283-288 ◽

Cited By ~ 4

Author(s):

Michelle F M ten Brinck ◽

Maike Jäger ◽

Joost de Vries ◽

J André Grotenhuis ◽

René Aquarius ◽

...

Keyword(s):

Clinical Outcome ◽

Flow Diverter ◽

Poor Clinical Outcome ◽

Good Clinical Outcome ◽

Ruptured Aneurysms ◽

Secondary Endpoints ◽

Aneurysm Occlusion ◽

Occlusion Rate ◽

Ruptured Intracranial Aneurysms

Background and purposeFlow diverters are sometimes used in the setting of acutely ruptured aneurysms. However, thromboembolic and hemorrhagic complications are feared and evidence regarding safety is limited. Therefore, in this multicenter study we evaluated complications, clinical, and angiographic outcomes of patients treated with a flow diverter for acutely ruptured aneurysms.MethodsWe conducted a retrospective observational study of 44 consecutive patients who underwent flow diverter treatment within 15 days after rupture of an intracranial aneurysm at six centers. The primary end point was good clinical outcome, defined as modified Rankin Scale score (mRS) 0–2. Secondary endpoints were procedure-related complications and complete aneurysm occlusion at follow-up.ResultsAt follow-up (median 3.4 months) 20 patients (45%) had a good clinical outcome. In 20 patients (45%), 25 procedure-related complications occurred. These resulted in permanent neurologic deficits in 12 patients (27%). In 5 patients (11%) aneurysm re-rupture occurred. Eight patients died resulting in an all-cause mortality rate of 18%. Procedure-related complications were associated with a poor clinical outcome (mRS 3–6; OR 5.1(95% CI 1.0 to 24.9), p=0.04). Large aneurysms were prone to re-rupture with rebleed rates of 60% (3/5) vs 5% (2/39) (p=0.01) for aneurysms with a size ≥20 mm and <20 mm, respectively. Follow-up angiography in 29 patients (median 9.7 months) showed complete aneurysm occlusion in 27 (93%).ConclusionFlow diverter treatment of ruptured intracranial aneurysms was associated with high rates of procedure-related complications including aneurysm re-ruptures. Complications were associated with poor clinical outcome. In patients with available angiographic follow-up, a high occlusion rate was observed.

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An unusual ischaemic presentation of thrombosed intracranial mycotic aneurysm with subsequent subarachnoid haemorrhage

BMJ Case Reports ◽

10.1136/bcr-2020-237044 ◽

2020 ◽

Vol 13 (10) ◽

pp. e237044

Author(s):

Patrick Brown ◽

Daniel Fulks

Keyword(s):

Clinical Outcome ◽

Subarachnoid Haemorrhage ◽

Mycotic Aneurysm ◽

Unusual Case ◽

Endovascular Management ◽

Coil Embolisation ◽

Vessel Occlusion ◽

Aneurysmal Rupture ◽

Excellent Clinical Outcome

We present an unusual case of acute ischaemic stroke secondary to thrombosed mycotic aneurysm with subsequent early aneurysmal rupture and subarachnoid haemorrhage, successfully treated with endovascular coil embolisation of the thrombosed segment. Imaging correlates are presented demonstrating successful endovascular management despite vessel occlusion precluding angiographic visualisation of the aneurysmal segment. Imaging and clinical follow-up is provided demonstrating durable occlusion and excellent clinical outcome with full functional recovery.

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Abstract P338: Incidence, Predictors and Impact of Infarct in New Territory in Escape Na1 Trial

Stroke ◽

10.1161/str.52.suppl_1.p338 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Nishita Singh ◽

Martha Marko ◽

Petra Cimflova ◽

Johanna Ospel ◽

Nima Kashani ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Endovascular Therapy ◽

Randomized Study ◽

Maximum Diameter ◽

Vascular Territory ◽

Poor Clinical Outcome ◽

Guide Catheter ◽

Ct And Mri

Introduction: Infarct in new territory (INT) is a known complication of endovascular therapy. We assessed the prevalence, predictors and clinical relevance of INT Methods: We included patients from the ESCAPE-NA1: a multicenter, international randomized study that assessed the efficacy of intravenous nerinetide in patients with acute ischemic stroke who underwent EVT within 12 hours from onset. All imaging was re-evaluated, and INT was defined by presence of infarct in new vascular territory, outside the baseline target occlusion(s) on follow up CT and MRI. INT’s were classified by maximum diameter (<2mm, 2-20mm and >20mm) and location. Results: Of 1099 analyzed patients in ESCAPE NA1, 107 had INT (9.7%, mean age 67 years, 51.4% females). There were no differences at baseline in those with vs without INT. Most INTs (75.7%) were angiographically occult and 41(38.3%) were > 20mm. The most common INT territory was the ACA alone or in combination with MCA/PCA (30.3%). The presence of emboli in new territory angiographically was significantly associated with INT (OR 16.39, 95%CI 8.14-33.09). Alteplase use, balloon guide catheter use, nerinetide and initial occlusion site did not predict INT. INT patients had higher final median infarct volumes compared to non-INT (44.5cc vs 23.3cc, P<0.001). Large INT (diameter of >20mm) were associated with poor clinical outcome compared to INT (<2mm) OR (mRS 0-2) 0.17, 95%CI 0.05-0.55). Conclusion: Infarcts in new territory are common and are associated with poor outcome.

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The endovascular management of splenic artery aneurysms and pseudoaneurysms

Vascular ◽

10.1258/vasc.2011.oa0289 ◽

2011 ◽

Vol 19 (5) ◽

pp. 257-261 ◽

Cited By ~ 18

Author(s):

Jia Xin ◽

Liu Xiao-ping ◽

Guo Wei ◽

Xiong Jiang ◽

Zhang Hong-peng ◽

...

Keyword(s):

Endovascular Treatment ◽

Splenic Artery ◽

Endovascular Procedures ◽

Endovascular Management ◽

Total Procedure Time ◽

The Mean ◽

Postembolization Syndrome ◽

Mid Term Results ◽

Total Procedure

The purpose of this study was to evaluate outcomes of the endovascular treatment of splenic artery aneurysms (SAAs) and pseudoaneurysms (SAPAs). From April 2003 to December 2009, 12 patients (mean age 46.8 years, range 29–58) with SAAs ( n = 9) or SAPAs ( n = 3) underwent endovascular treatment. Four patients were asymptomatic and three had ruptured aneurysms. Lesions were in the proximal splenic artery ( n = 3), intermediate splenic artery ( n = 3) and distal splenic artery ( n = 6). Endovascular procedures included embolization by sac packing ( n = 5), sandwich occlusion of the splenic artery ( n = 4) or stent graft deployment ( n = 3). Computed tomography (CT) was done before the operation, 3 and 12 months after the operation, then yearly. Endovascular treatment was successful at the first attempt in all 12 (100%) patients, with complete angiographic exclusion of the aneurysm at the end of the operation. The mean amount of contrast medium used was 165 mL (range 100–230), and the mean total procedure time was 92 minutes (range 55–160). No major complications occurred. Postoperational CT scans showed splenic multisegmental infarcts in eight patients (66.7%, 8/12) and among them postembolization syndrome developed in six patients, manifesting as abdominal pain and fever. The mean follow-up was 32 months (range 9–51). No patient demonstrated gross evidence of aneurysm sac growth, and no significant decrease in aneurysm sac size postintervention was noted on follow-up. The endovascular management of SAAs and SAPAs is safe and effective and may induce less mortality than open surgery. Regardless of the etiology, endovascular treatment can provide excellent mid-term results.

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Posterior Cerebral Artery Aneurysm: Endovascular Treatment of a Fusiform, Partially Thrombosed P2-Aneurysm with a Dual-Layer Flow-Diverting Stent (FRED) in a Young Patient with Good Clinical Outcome

The Aneurysm Casebook ◽

10.1007/978-3-319-70267-4_32-1 ◽

2019 ◽

pp. 1-8

Author(s):

Dominik F. Vollherbst ◽

Markus A. Möhlenbruch

Keyword(s):

Clinical Outcome ◽

Endovascular Treatment ◽

Young Patient ◽

Cerebral Artery ◽

Posterior Cerebral Artery ◽

Artery Aneurysm ◽

Good Clinical Outcome ◽

Layer Flow ◽

Cerebral Artery Aneurysm ◽

Flow Diverting Stent

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Pseudoarthrosis of second metatarsal fracture

La Pediatria Medica e Chirurgica ◽

10.4081/pmc.2018.205 ◽

2018 ◽

Vol 40 (2) ◽

Author(s):

Jessica Zanovello ◽

Barbara Bertani ◽

Redento Mora ◽

Gabriella Tuvo ◽

Mario Mosconi ◽

...

Keyword(s):

Clinical Outcome ◽

Good Clinical Outcome ◽

Non Union ◽

Fractures In Children ◽

Second Metatarsal ◽

Traumatic Fracture ◽

Metatarsal Fracture ◽

Metatarsal Fractures ◽

Foot Fractures

Metatarsal fractures make up the greatest portion of foot fractures in children. Most of them are treated with closed reduction and non-weightbearing cast immobilization.Usually, these fractures heal uneventfully and delay union and pseudoarthrosis are rare. We report a case of a 10-year-old child with non-union of the second metatarsal following a traumatic fracture, caused by an accident 10 months before, and treated successfully by osteosynthesis with plate and screws. Good clinical outcome was achieved at 2 years follow-up.

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Intracranial Hemorrhage Secondary to a Delayed Cerebral Pseudoaneurysm Rupture 18 Years after Cranial Trauma

Case Reports in Neurology ◽

10.1159/000503812 ◽

2019 ◽

Vol 11 (3) ◽

pp. 325-329

Author(s):

Mikel Terceño ◽

Sebastià Remollo ◽

Yolanda Silva ◽

Saima Bashir ◽

Carlos Castaño ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Clinical Outcome ◽

Previous History ◽

Complete Recovery ◽

Good Clinical Outcome ◽

Intracranial Hematoma ◽

Cranial Trauma ◽

History Of ◽

Etiological Study

We report the case of a 38-year-old male with a previous history of severe cranial trauma and subsequent large subdural and subarachnoid hemorrhage on whom an emergent hematoma evacuation was performed with a good outcome and follow-up. Despite a good clinical evolution, the patient experienced a further intracranial hematoma 18 years after the trauma, with severe aphasia and mild right hemiparesis. After complete etiological study, two cranial pseudoaneurysms were observed in the cerebral angiography. Endovascular treatment was successfully completed, achieving full embolization without complications. No rebleeding was detected during follow-up. The patient had a good clinical outcome at 3 months and achieved complete recovery. Cranial pseudoaneurysm rupture is a rare cause of intracerebral hemorrhage, especially if the trauma occurs years before the bleeding.

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DWI-pc-ASPECT score in basilar artery occlusion: is 6 points or less always indicative of a bad outcome?

Interventional Neuroradiology ◽

10.1177/1591019919827505 ◽

2019 ◽

Vol 25 (4) ◽

pp. 371-379 ◽

Cited By ~ 2

Author(s):

Joong-Goo Kim ◽

Dongwhane Lee ◽

Jay Chol Choi ◽

Yunsun Song ◽

Deok Hee Lee ◽

...

Keyword(s):

Clinical Outcome ◽

Confidence Interval ◽

Odds Ratio ◽

Arterial Occlusion ◽

Reperfusion Therapy ◽

Basilar Artery Occlusion ◽

Poor Clinical Outcome ◽

Good Clinical Outcome ◽

Outcome Group ◽

Initial Symptoms

Background and purpose The prognosis of patients with acute basilar arterial occlusion after endovascular reperfusion therapy with diffusion-weighted imaging – posterior circulation–Alberta Stroke Program Early Computed Tomography Score (DWI-pc-ASPECTS) of 6 or less remains unclear. We aimed to assess the characteristics and prognosis of endovascular reperfusion therapy in patients with acute basilar arterial occlusion and DWI-pc-ASPECTS of 6 or less. Methods We analysed data collected from 1 January 2012 to 31 January 2018 in a prospective neuro-interventional registry of consecutive patients treated with endovascular reperfusion therapy. Clinical and imaging data on patients with DWI-pc-ASPECTS of 6 or less who underwent endovascular reperfusion therapy for acute basilar arterial occlusion were collected for this study. A good clinical outcome was defined as a modified Rankin scale of 2 or less at 90 days. Results Forty-five acute basilar arterial occlusion patients with DWI-pc-ASPECTS of 6 or less were included. Among them, 11 (24.4%) patients had a good clinical outcome at 90 days. Patients with a good clinical outcome had less severe neurological symptoms at presentation (National Institutes of Health Stroke Scale (NIHSS) 19.0 (12.0–25.0) vs. 8.0 (6.0–11.5); P = 0.003) and were younger (72.5 years (57.0–80.0 years) vs. 63.0 years (55.5–69.0 years), P = 0.096) than those with a poor clinical outcome. The symptomatic intracranial haemorrhage rate was significantly higher in the poor clinical outcome group (13 (38.2%)) than in the good clinical outcome group (0 (0.0%)) ( P = 0.045). In particular, in patients aged over 70 years, a favourable outcome was low (18 (52.9%) vs. 1 (9.1%); P = 0.027) even after successful recanalisation. In a multivariate model, a low initial NIHSS score (odds ratio 1.21; 95% confidence interval 1.07–1.44; P = 0.0093) and age over 70 years (odds ratio 15.27; 95% confidence interval 1.85–379.79; P = 0.0321) were independent predictors of poor clinical outcome. Conclusions Even with DWI-pc-ASPECTS of 6 or less, good clinical outcome can be achieved after endovascular reperfusion therapy. Relatively mild initial symptoms and younger age can predict a better outcome in acute basilar arterial occlusion patients with DWI-pc-ASPECTS of 6 or less.

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