Mechanical Thrombectomy in Acute Stroke Due to Carotid Occlusion: A Series of 153 Consecutive Patients

2018 ◽  
Vol 46 (3-4) ◽  
pp. 130-139 ◽  
Author(s):  
Jose Díaz-Pérez ◽  
Guillermo Parrilla ◽  
Mariano Espinosa de Rueda ◽  
Jose María Cabrera-Maqueda ◽  
Blanca García-Villalba ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Functional Outcome ◽  
Intracranial Hemorrhage ◽  
Internal Carotid ◽  
Mechanical Thrombectomy ◽  
Perfusion Ct ◽  
Clinical Prognosis ◽  
Symptomatic Intracranial Hemorrhage ◽  
Baseline Characteristics

Background: Strokes due to carotid artery occlusion (CAO) are associated with bad clinical prognosis and poor response to intravenous thrombolysis. Several studies in the past have shown the benefits of mechanical thrombectomy (MT) and compared bridging therapy (BT) and primary MT (PMT) in large vessel occlusions, but only a few studies have focused on the specific population of CAO and their response to endovascular treatment. Methods: Retrospective review of patients treated at our center between January 2010 and June 2017 that (1) presented with acute ischemic stroke caused by CAO in the first 4.5 h since symptom onset, and (2) were treated with MT (BT or PMT). Baseline characteristics of the population, comparison between BT and PMT, intrahospital mortality, symptomatic intracranial hemorrhage, and functional outcome were investigated. Results: A total of 153 patients were included. Baseline characteristics: 51.6% were male, and the median age was 71 years. The most frequent risk factor was hypertension (71.9%). The main stroke etiology was atherothrombotic (40.5%). The mean admission National Institute of Health Severity Score (NIHSS) was 19, mean discharge NIHSS was 7. Isolated occlusion of the Extracranial or Intracranial Internal Carotid Artery was the most frequent occlusion location (52.3%). TICI 2b-3 was achieved in 87.6%, intrahospital mortality was 26.8%, symptomatic hemorrhage was 8.5%, and 3 months-modified Rankin Score (mRS) 0–2 was 26.8%. Definitive carotid stenting was needed in 33.3% of the cases. BT versus PMT: Patients treated with PMT presented a higher incidence of atrial fibrillation, anticoagulation, and cardioembolic stroke compared to those treated with BT. No differences in TICI 2b-3, 3 months-mRS or symptomatic hemorrhage were found between both groups. Intrahospital mortality: Poor perfusion-CT mismatch (p = 0.005), isolated Internal carotid artery location (p = 0.024), and symptomatic hemorrhage (p < 0.001) were independent predictors. Symptomatic intracranial hemorrhage: Patients with post-treatment symptomatic hemorrhage had higher intrahospital mortality (p < 0.001) and worse 3 months-mRS (p = 0.033). Functional outcome: Admission NIHSS (p = 0.012) independently predicted 3 months-mRS. Conclusions: In our population, patients with CAO clinically present with severe strokes. Isolated occlusions of the extra- or intracranial segments of the carotid are more frequent than tandem occlusions. Successful recanalization after thrombectomy is achieved in most of the patients, but association with favorable functional outcome is poor. Clinical evolution is similar in patients treated with PMT and BT. Intracranial symptomatic hemorrhage after treatment is associated with higher intrahospital mortality and worse 3 months-mRS. Poor perfusion-CT mismatch, symptomatic hemorrhage, and isolated CAO are independent predictors of intrahospital mortality. Admission NIHSS is an independent predictor of 3 months-mRS.

scholarly journals Thrombectomy by primary aspiration technique in a patient with critical internal carotid artery stenosis

2021 ◽  
Author(s):  
Yasmim Nadime José Frigo ◽  
Hendrick Henrique Fernandes Gramasco ◽  
Igor Oliveira Fonseca ◽  
Mateus Felipe dos Santos ◽  
Rodrigo Bazan ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Neurological Deficits ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Clinical Prognosis ◽  
Aspiration Technique

Context: Stroke is one of the main leaders of death and disability in the world. Currently, mechanical thrombectomy with stent retrievers is the technique of choice for large vessel occlusion, however, the primary aspiration technique has been proposed as a fast and safe alternative. Case report: J.E.M, male, 57 years old, hypertensive, atrial fibrillation. Started claudication of neurological deficits, with intermittent paresthesia in left upper limb for 2 days. Admitted with NIHSS 2 (nasolabial sulcus erasure and hypoesthesia in LUL), in thrombolysis window, has seen in cerebral and neck angiotomography critical stenosis of the internal carotid artery and in CT scan with perfusion Mismatch volume 72 ml and infinite ratio. Since the patient did not have sufficient criteria for thrombolysis and since the clinical prognosis was unfavorable, a diagnostic arteriography was indicated, which showed ICAR stenosis 90%. The patient proceeded with angioplasty and stenting using the ADPAT technique and mechanical thrombectomy due to occlusion in segment M1 with total recanalization (TICI 3) and NIHSS after and at discharge of 0. Conclusion: The advent of thrombectomy impacts the improvement of functional dependence and the reduction of mortality, especially in stroke with large vessel occlusion, whose treatment with thrombolytic therapy only has a low chance of recanalization.

Abstract P519: Higher Number of Thrombectomy Passes Significantly Increases Risk of Mass Effect, Poor Functional Outcome, and Mortality

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Victor M Ringheanu ◽  
Laurie Preston ◽  
WONDWOSSEN G TEKLE ◽  
Amrou Sarraj ◽  
Ameer E Hassan
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Functional Outcome ◽  
Internal Carotid ◽  
Mass Effect ◽  
Artery Occlusion ◽  
Delayed Presentation ◽  
Vessel Occlusion ◽  
Presentation Time ◽  
Poor Outcomes

Background: Endovascular treatment (EVT) is a widely proven method to treat patients diagnosed with intracranial large vessel occlusion (LVO). Through this method of treatment, it has been hypothesized that a lower number of thrombectomy passes is an indicator of higher rates of modified Thrombolysis in Cerebral Infarction 2b-3 (mTICI) and favorable outcomes defined as modified Rankin Scale 0-2 (mRS). Methods: Through the utilization of a prospectively collected endovascular database between 2012-2020, variables such as demographics, co-morbid conditions, intracerebral hemorrhage, mass effect, mortality rate, and good/poor outcomes in regard to mTICI score and mRS assessment at discharge were examined. The outcomes between patients receiving EVT who were treated with < 3 thrombectomy passes or ≥ 3 passes were compared. Results: Out of 454 patients treated with mechanical thrombectomy of qualifying intracranial internal carotid artery or middle cerebral artery occlusion, site of occlusion (internal carotid artery, M1 and M2), a total of 372 (81.9%) were treated with < 3 thrombectomy passes (average age 70.34 ± 13.75 years, 46.0% women), and 82 (18.1%) were treated with ≥ 3 thrombectomy passes (average age 70.30 ± 13.72 years, 48.8% women). Significantly higher rates of mass effect (p=0.043), mRS score 3-6 (p=0.029), and mortality (p=0.025) were noted in patients treated with ≥ 3 thrombectomy passes. Further analysis revealed that patients presenting 6-24 hours from symptom onset had significantly lessened chance of effective recanalization (TICI 2B-3; p=0.021). Conclusion: A higher number of thrombectomy passes, characterized as ≥ 3 passes in this study, was associated with significantly worsened patient outcome in regard to functional outcome, and mortality. Further research is required to determine whether the number of thrombectomy passes is an accurate indicator of treatment outcome and whether delayed presentation time increases risk of poor outcome.

Management of Mobile Thrombus With Distal Protection Devices During Carotid Artery Angioplasty: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Salomon Cohen-Cohen ◽  
Giuseppe Lanzino ◽  
Waleed Brinjikji ◽  
Adam Arthur ◽  
Mark Bain ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Video Production ◽  
Left Internal Carotid Artery ◽  
Left Middle Cerebral Artery ◽  
Cerebral Angiogram ◽  
Protection Devices

Abstract Embolic protection devices (EPDs) have become a standard of care during internal carotid artery revascularization.1,2 This video is about a 57-yr-old-male who presented with a wake-up stroke with a left hemispheric syndrome. Head computed tomography angiography (CTA) revealed tandem occlusions of the proximal left internal carotid artery (ICA) and of the distal left middle cerebral artery (MCA) with an ASPECT (Alberta Stroke Program Early CT Score) score of 6. The patient underwent a cerebral angiogram and was treated with balloon angioplasty with a distal EPD and mechanical thrombectomy. The EPD became occluded with thrombus from the ICA and was retrieved through a 6-Fr Sofia (MicroVention) under continuous aspiration. Successful revascularization of the proximal ICA and distal MCA was achieved. No procedure-related complications occurred, and the patient's neurological exam improved. Tandem occlusions can occur in up to 15% of strokes. The optimal treatment can be controversial, but mechanical thrombectomy and ICA revascularization with a distal EPD appear to be safe and effective in selected patients.3 Consent was obtained for the procedure and for the video production.

Abstract WP20: Efficacy and Safety of Mechanical Thrombectomy in Emergent Large Vessel Occlusions with Concomitant Cervical Internal Carotid Artery Occlusion

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Nitin Goyal ◽  
Georgios Tsivgoulis ◽  
Abhi Pandhi ◽  
Yasser M Khorchid ◽  
Abhishek Ojha ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Efficacy And Safety ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Aspiration Thrombectomy ◽  
Cervical Internal Carotid Artery

Introduction: Recently, five published major randomized controlled clinical trials have demonstrated that timely mechanical thrombectomy (MT) of acute ischemic strokes (AIS) with emergent large vessel occlusion (ELVO) is safe and improves functional outcomes. However, data evaluating the efficacy and safety of MT in ELVO patients with concomitant cervical internal carotid artery (cICA) occlusion is limited. The purpose of this study is to evaluate efficacy and safety of MT in ELVO patients with concomitant cICA occlusion Methods: We prospectively analyzed consecutive AIS patients with anterior circulation ELVO who underwent stent-retriever or primary aspiration thrombectomy at two tertiary stroke centers. Outcome measures in our study were 3-month mortality and modified ranking scale (mRS), as well as symptomatic intracranial hemorrhage (sICH). Safety and efficacy outcomes were compared between ELVO patients with and without concomitant cICA occlusion. Results: A total of 137 AIS patients had anterior circulation ELVO and underwent MT (age 63 ± 14, 49% male, median NIHSS 17, IQR [13-20]). ELVO patients with concomitant cICA occlusion (n=19) did not differ in terms of rates of sICH (0% versus 11%, p=0.21), complete recanalization (68 % versus 68%, p=1.00), onset to groin puncture time (minutes [IQR] 268 [211-379] versus 225 [165-312], p=0.47), 3-month mortality (35% versus 26 %, p=0.55), and mRS of 0-2 at 3 months (41% versus 45%, p=0.80) when compared with ELVO patients without concomitant cICA occlusion (n=118). Admission NIHSS was higher among ELVO patients with concomitant cICA occlusion (median [IQR], 18 [15-22] versus 16 [12-19], p=0.01), and they tended to have higher groin puncture to recanalization time (minutes [IQR] 74 [42-97] versus 49 [38-78], p=0.09). The ordinal shift analysis did not show any difference in favorable outcomes in two groups in unadjusted analyses or after adjustment for admission NIHSS and groin to recanalization time (common OR=0.78 [95% CI: 0.27-2.29, p=0.66]). Angioplasty was performed in 11 of 19 ELVO patients with concomitant cICA occlusion. Three patients required stent placement. Discussion: Our study indicates that MT can be performed safely and effectively in ELVO patients with concomitant cICA occlusion.

scholarly journals Day 1 Extracranial Internal Carotid Artery Patency Is Associated With Good Outcome After Mechanical Thrombectomy for Tandem Occlusion

Stroke ◽  
2018 ◽  
Vol 49 (10) ◽  
pp. 2520-2522 ◽  
Author(s):  
Nicolas Bricout ◽  
Thomas Personnic ◽  
Marc Ferrigno ◽  
Julien Labreuche ◽  
Laurent Estrade ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Mechanical Thrombectomy ◽  
Extracranial Internal Carotid Artery ◽  
Good Outcome ◽  
Tandem Occlusion

scholarly journals Thrombus Imaging Characteristics and Outcomes in Acute Ischemic Stroke Patients Undergoing Endovascular Treatment

Stroke ◽  
2019 ◽  
Vol 50 (8) ◽  
pp. 2057-2064 ◽  
Author(s):  
Bruna G. Dutra ◽  
Manon L. Tolhuisen ◽  
Heitor C.B.R. Alves ◽  
Kilian M. Treurniet ◽  
Manon Kappelhof ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Internal Carotid ◽  
Common Odds Ratio ◽  
Imaging Characteristics

Background and Purpose— Thrombus imaging characteristics have been reported to be useful to predict functional outcome and reperfusion in acute ischemic stroke. However, conflicting data about this subject exist in patients undergoing endovascular treatment. Therefore, we aimed to evaluate whether thrombus imaging characteristics assessed on computed tomography are associated with outcomes in patients with acute ischemic stroke treated by endovascular treatment. Methods— The MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry is an ongoing, prospective, and observational study in all centers performing endovascular treatment in the Netherlands. We evaluated associations of thrombus imaging characteristics with the functional outcome (modified Rankin Scale at 90 days), mortality, reperfusion, duration of endovascular treatment, and symptomatic intracranial hemorrhage using univariable and multivariable regression models. Thrombus characteristics included location, clot burden score (CBS), length, relative and absolute attenuation, perviousness, and distance from the internal carotid artery terminus to the thrombus. All characteristics were assessed on thin-slice (≤2.5 mm) noncontrast computed tomography and computed tomography angiography, acquired within 30 minutes from each other. Results— In total, 408 patients were analyzed. Thrombus with distal location, higher CBS, and shorter length were associated with better functional outcome (adjusted common odds ratio, 3.3; 95% CI, 2.0–5.3 for distal M1 occlusion compared with internal carotid artery occlusion; adjusted common odds ratio, 1.15; 95% CI, 1.07–1.24 per CBS point; and adjusted common odds ratio, 0.96; 95% CI, 0.94–0.99 per mm, respectively) and reduced duration of endovascular procedure (adjusted coefficient B, −14.7; 95% CI, −24.2 to −5.1 for distal M1 occlusion compared with internal carotid artery occlusion; adjusted coefficient B, −8.5; 95% CI, −14.5 to −2.4 per CBS point; and adjusted coefficient B, 7.3; 95% CI, 2.9–11.8 per mm, respectively). Thrombus perviousness was associated with better functional outcome (adjusted common odds ratio, 1.01; 95% CI, 1.00–1.02 per Hounsfield units increase). Distal thrombi were associated with successful reperfusion (adjusted odds ratio, 2.6; 95% CI, 1.4–4.9 for proximal M1 occlusion compared with internal carotid artery occlusion). Conclusions— Distal location, higher CBS, and shorter length are associated with better functional outcome and faster endovascular procedure. Distal thrombus is strongly associated with successful reperfusion, and a pervious thrombus is associated with better functional outcome.

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