Abstract TP11: Beyond Large Vessel Occlusion Strokes: Distal Occlusion Thrombectomy

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jonathan A Grossberg ◽  
Leticia C Rebello ◽  
Diogo C Haussen ◽  
Mehdi Bouslama ◽  
Meredith Bowen ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Endovascular Therapy ◽  
Standard Of Care ◽  
Primary Treatment ◽  
Large Vessel ◽  
Treatment Modalities ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Distal Occlusion ◽  
Iv Tpa

Introduction: Endovascular therapy is the standard of care for the treatment of proximal large vessel occlusion strokes (LVOS). Its safety and efficacy in the treatment of distal intracranial occlusions has not been well studied. Methods: We retrospectively reviewed a prospectively collected endovascular database (September 2010-December 2015, n=898) for all patients with distal intracranial occlusions treated with endovascular therapy. Distal occlusions were defined as any occlusion of the anterior cerebral artery (ACA), any occlusion of the posterior cerebral artery (PCA), or any occlusion at or distal to the middle cerebral artery (MCA)-M3 opercular segment. Results: Distal occlusions were treated in 70 patients. The mean age was 66+/-14 and 57% of the patients were male. Thirty-one (44%) of the patients received IV-tPA. The median pre-procedure NIHSS was 19 (IQR, 13-23). The distal occlusion was the primary treatment location in 54 patients and in 16 patients the distal occlusion was treated as a rescue strategy after successful treatment of a proximal LVOS. The locations of the primary cases were MCA-M3 (n=21), ACA with a concomitant MCA-M1 or MCA-M2 (n=16), ACA alone (n=9), PCA (n=6), and ACA with a concomitant MCA-M3 (n=2). The locations of the rescue cases were MCA-M3 (n=8), ACA (n=7), and both MCA-M3 and ACA (n=1). The most common treatment modalities employed were intra-arterial tPA (n=37, 52%), small (3mm) stent-retrievers (n=24, 33%), and thromboaspiration (n=30, 42%). Near or complete reperfusion (mTICI 2b-3) was achieved in 56 cases (80%). Overall, there were 5 (7%) cases of any parenchymal hematoma (PH). However, two of the PHs were in patients with both a MCA-M1 and an ACA occlusion, and both of these hemorrhages were in the MCA territory. Thus only 3 PHs (4.3%) occurred in the territory of the treated distal occlusion with two of these patients also receiving IV tPA. At 90 days, 24 patients (40%) had a mRS of 0-2 and 13 (21%) had died. Conclusions: Distal intracranial occlusions can be treated safely and successfully with endovascular therapy. Although promising our results need to be corroborated by larger prospective controlled studies.

365 Beyond Large Vessel Occlusion Strokes: Distal Occlusion Thrombectomy

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 285-285
Author(s):  
Jonathan Andrew Grossberg ◽  
Leticia C Rebello ◽  
Diogo C Haussen ◽  
Mehdi Bouslama ◽  
Michael R Frankel ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Endovascular Therapy ◽  
Standard Of Care ◽  
Primary Treatment ◽  
Large Vessel ◽  
Treatment Modalities ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Distal Occlusion ◽  
Iv Tpa

Abstract INTRODUCTION Endovascular therapy is the standard of care for the treatment of proximal large vessel occlusion strokes (LVOS). Its safety and efficacy in the treatment of distal intracranial occlusions has not been well studied. METHODS We reviewed a prospectively collected database (2010-2015, n = 898) for all patients with distal intracranial occlusions treated with endovascular therapy. Distal occlusions were defined as any occlusion of the anterior cerebral artery(ACA), any occlusion of the posterior cerebral artery(PCA), or any occlusion at or distal to the middle cerebral artery (MCA)-M3 opercular segment. RESULTS >Distal occlusions were treated in 70 patients. The mean age was 66 +/−14 and 57% of the patients were male. Thirty-one (44%) of the patients received IV-tPA. The median pre-procedure NIHSS was 19 (IQR,13-23). The distal occlusion was the primary treatment location in 54 patients and in 16 patients the distal occlusion was treated as a rescue strategy after successful treatment of a proximal LVOS. The locations of the primary cases were MCA-M3 (n = 21), ACA with concomitant MCA-M1 or MCA-M2 (n = 16), ACA alone(n = 9), PCA (n = 6), and ACA with a concomitant MCA-M3 (n = 2). The locations of the rescue cases were MCA-M3 (n = 8), ACA (n = 7), and both MCA-M3 and ACA (n = 1). The most common treatment modalities employed were intra-arterial tPA (n = 37,52%), small (3 mm) stent-retrievers (n = 24,33%), and thromboaspiration (n = 30,42%). Near or complete reperfusion (mTICI 2b-3) was achieved in 56 cases (80%). There were 3 (4.3%) parenchymal hematoma in the territory of the treated distal occlusion with two of these patients also receiving IV tPA. At 90 days, 24 patients (40%) had a mRS of 0–2 and 13 (21%) had died. CONCLUSION Distal intracranial occlusions can be treated safely and successfully with endovascular therapy. Although promising our results need to be corroborated by larger prospective controlled studies.

scholarly journals Neurointerventional therapy for large vessel occlusion stroke: the new standard of care

2016 ◽  
Vol 4 (16) ◽  
pp. 26
Author(s):  
Pavis Laengvejkal ◽  
Doungporn Ruthirago ◽  
Parunyou Julayanont ◽  
Yazan Alderazi
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Standard Of Care ◽  
Stent Retriever ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
The Past ◽  
Iv Tpa

For the past two decades, intravenous tissue plasminogenactivator (IV tPA) has been the gold standardtreatment of acute ischemic stroke (AIS) for patientspresenting to the hospital in the first 4.5 hours aftersymptom onset. However, in patients with AIS due tointracranial large vessel occlusion (LVO), IV tPA hasvery poor recanalization rates. This group of patientshas significantly worse outcomes than those withoutLVO. Endovascular therapy has evolved significantlysince the first trial in 1998. With the publication of recenttrials using modern stent-retriever devices andselection of patients with LVO, endovascular therapyhas become the standard of care for patients with themost severe ischemic strokes. In this article we outlinethe two decade evolution of this therapy.

Abstract 202: Endovascular Therapy for Acute Ischemic Stroke With Distal Large Vessel Occlusion in the Anterior Circulation

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Amrou Sarraj ◽  
Navdeep Sangha ◽  
Muhammad Shazam Hussain ◽  
Dolora Wisco ◽  
Nirav Vora ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Primary Outcome ◽  
Large Vessel ◽  
Secondary Outcome ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
Baseline Characteristics ◽  
Iv Tpa

Introduction: Five RCTs demonstrated the superiority of endovascular therapy (EVT) over best medical management (MM) for acute ischemic strokes (AIS) with large vessel occlusion (LVO) in the anterior circulation. Patients with M2 occlusions, however, were underrepresented (95 randomized; 51 EVT treated). Evidence from RCTs of the benefit of EVT for M2 occlusions is lacking, as reflected in the recent AHA guidelines. Methods: A retrospective cohort was pooled from 10 academic centers from 1/12 to 4/15 of AIS patients with LVO isolated to M2 presenting within 8 hours from last known normal (LKN). Patients were divided into EVT and MM groups. Primary outcome was 90 day mRS (good outcome 0-2); secondary outcome was sICH. Logistic regression compared the 2 groups. Univariate and multivariate analyses evaluated predictors of good outcome in the EVT group. Results: Figure 1 shows participating centers, 522 patients (288 EVT and 234 MM) were identified. Table (1) shows baseline characteristics. MM treated patients were older and had higher IV tPA treatment rates, otherwise the 2 groups were balanced. 62.7 % EVT patients had mRS 0-2 at 90 days compared to 35.4 % MM (figure 2). EVT patients had 3 times the odds of good outcome as compared to MM patients (OR: 3.1, 95% CI:2.1-4.4, P <0.001) even after adjustment for age, NIHSS, ASPECTS, IV tPA and LKN to door time (OR: 3.2, 95%CI: 2-5.2, P<0.001). sICH rate was 5.6 %, which was not statistically different than the MM group (table 1, P=0.1). Age, NIHSS, good ASPECTS, LKN to reperfusion time and successful reperfusion mTICI ≥ 2b were independent predictors of good outcome in EVT patients. There was a linear relationship between good outcome and time LKN to reperfusion (Figure 3). Conclusion: Despite inherent limitations of its retrospective design, our study suggests that EVT may be effective and safe for distal LVO (M2) relative to best MM. A trial randomizing M2 occlusions to EVT vs. MM is warranted to confirm these findings.

Large Vessel Occlusion

2016 ◽  
Author(s):  
Ji Y. Chong ◽  
Michael P. Lerario
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Stent Retrievers ◽  
Iv Tpa

Select patients who are not eligible for IV tPA, or who do not recanalize with IV thrombolysis alone, may be treated with acute endovascular therapies within a 6-hour window. Mechanical thrombectomy, with or without intra-arterial tPA, has recently been shown to be effective in treating acute ischemic stroke caused by large vessel occlusion. Intra-arterial therapy using approved stent retrievers has become the standard of care for acute large vessel occlusion.

scholarly journals Endovascular therapy in patients with large vessel occlusion due to cardioembolism versus large-artery atherosclerosis

2021 ◽  
Vol 14 ◽  
pp. 175628642199901
Author(s):  
Meredeth Zotter ◽  
Eike I. Piechowiak ◽  
Rupashani Balasubramaniam ◽  
Rascha Von Martial ◽  
Kotryna Genceviciute ◽  
...  
Keyword(s):  
Heart Failure ◽  
Endovascular Therapy ◽  
Independent Predictor ◽  
Intravenous Thrombolysis ◽  
Stent Retriever ◽  
Large Vessel ◽  
Large Artery ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Significant Difference

Background and aims: To investigate whether stroke aetiology affects outcome in patients with acute ischaemic stroke who undergo endovascular therapy. Methods: We retrospectively analysed patients from the Bernese Stroke Centre Registry (January 2010–September 2018), with acute large vessel occlusion in the anterior circulation due to cardioembolism or large-artery atherosclerosis, treated with endovascular therapy (±intravenous thrombolysis). Results: The study included 850 patients (median age 77.4 years, 49.3% female, 80.1% with cardioembolism). Compared with those with large-artery atherosclerosis, patients with cardioembolism were older, more often female, and more likely to have a history of hypercholesterolaemia, atrial fibrillation, current smoking (each p < 0.0001) and higher median National Institutes of Health Stroke Scale (NIHSS) scores on admission ( p = 0.030). They were more frequently treated with stent retrievers ( p = 0.007), but the median number of stent retriever attempts was lower ( p = 0.016) and fewer had permanent stent placements ( p ⩽ 0.004). Univariable analysis showed that patients with cardioembolism had worse 3-month survival [72.7% versus 84%, odds ratio (OR) = 0.51; p = 0.004] and modified Rankin scale (mRS) score shift ( p = 0.043) and higher rates of post-interventional heart failure (33.5% versus 18.5%, OR = 2.22; p < 0.0001), but better modified thrombolysis in cerebral infarction (mTICI) score shift ( p = 0.025). Excellent (mRS = 0–1) 3-month outcome, successful reperfusion (mTICI = 2b–3), symptomatic intracranial haemorrhage and Updated Charlson Comorbidity Index were similar between groups. Propensity-matched analysis found no statistically significant difference in outcome between stroke aetiology groups. Stroke aetiology was not an independent predictor of favourable mRS score shift, but lower admission NIHSS score, younger age and independence pre-stroke were (each p < 0.0001). Stroke aetiology was not an independent predictor of heart failure, but older age, admission antithrombotics and dependence pre-stroke were (each ⩽0.027). Stroke aetiology was not an independent predictor of favourable mTICI score shift, but application of stent retriever and no permanent intracranial stent placement were (each ⩽0.044). Conclusion: We suggest prospective studies to further elucidate differences in reperfusion and outcome between patients with cardioembolism and large-artery atherosclerosis.

IV tPA given in the golden hour for emergent large vessel occlusion stroke improves recanalization rates and clinical outcomes

2021 ◽  
pp. 117580
Author(s):  
Rodica Di Lorenzo ◽  
Maher Saqqur ◽  
Andrew Blake Buletko ◽  
Lacy Sam Handshoe ◽  
Bhageeradh Mulpur ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Golden Hour ◽  
Iv Tpa

Acute occlusion of the fetal posterior cerebral artery: diagnosis and management paradigms

2021 ◽  
pp. 197140092110193
Author(s):  
Mohamad Abdalkader ◽  
Anurag Sahoo ◽  
Julie G Shulman ◽  
Elie Sader ◽  
Courtney Takahashi ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Posterior Cerebral Artery ◽  
Management Strategies ◽  
Artery Occlusion ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Cerebral Artery Occlusion

Background and purpose The diagnosis and management of acute fetal posterior cerebral artery occlusion are challenging. While endovascular treatment is established for anterior circulation large vessel occlusion stroke, little is known about the course of acute fetal posterior cerebral artery occlusions. We report the clinical course, radiological findings and management considerations of acute fetal posterior cerebral artery occlusion stroke. Methods We performed a retrospective review of consecutive patients presenting with acute large vessel occlusion who underwent cerebral angiogram and/or mechanical thrombectomy between January 2015 and January 2021. Patients diagnosed with fetal posterior cerebral artery occlusion were included. Demographic data, clinical presentation, imaging findings and management strategies were reviewed. Results Between January 2015 and January 2021, three patients with fetal posterior cerebral artery occlusion were identified from 400 patients who underwent angiogram and/or mechanical thrombectomy for acute stroke (0.75%). The first patient presented with concomitant fetal posterior cerebral artery and middle cerebral artery occlusions. Thrombectomy was performed with recanalisation of the fetal posterior cerebral artery but the patient died from malignant oedema. The second patient presented with isolated fetal posterior cerebral artery occlusion. No endovascular intervention was performed and the patient was disabled from malignant posterior cerebral artery infarct. The third patient presented with carotid occlusion and was found to have fetal posterior cerebral artery occlusion after internal carotid artery recanalisation. No further intervention was performed. The patient was left with residual contralateral homonymous hemianopia and mild left sided weakness. Conclusion Fetal posterior cerebral artery occlusion is a rare, but potentially disabling, cause of ischaemic stroke. Endovascular treatment is feasible. Further investigation is needed to compare the efficacy of medical versus endovascular management strategies.

scholarly journals Repeated Mechanical Endovascular Thrombectomy for Recurrent Large Vessel Occlusion

Stroke ◽  
2021 ◽  
Author(s):  
Ghada A. Mohamed ◽  
Hassan Aboul Nour ◽  
Raul G. Nogueira ◽  
Mahmoud H. Mohammaden ◽  
Diogo C. Haussen ◽  
...  
Keyword(s):  
Scale Score ◽  
Standard Of Care ◽  
The United States ◽  
Outcome Data ◽  
Large Vessel ◽  
Time Interval ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Previously Treated

Background and Purpose: Mechanical thrombectomy (MT) is now the standard of care for large vessel occlusion (LVO) stroke. However, little is known about the frequency and outcomes of repeat MT (rMT) for patients with recurrent LVO. Methods: This is a retrospective multicenter cohort of patients who underwent rMT at 6 tertiary institutions in the United States between March 2016 and March 2020. Procedural, imaging, and outcome data were evaluated. Outcome at discharge was evaluated using the modified Rankin Scale. Results: Of 3059 patients treated with MT during the study period, 56 (1.8%) underwent at least 1 rMT. Fifty-four (96%) patients were analyzed; median age was 64 years. The median time interval between index MT and rMT was 2 days; 35 of 54 patients (65%) experienced recurrent LVO during the index hospitalization. The mechanism of stroke was cardioembolism in 30 patients (56%), intracranial atherosclerosis in 4 patients (7%), extracranial atherosclerosis in 2 patients (4%), and other causes in 18 patients (33%). A final TICI recanalization score of 2b or 3 was achieved in all 54 patients during index MT (100%) and in 51 of 54 patients (94%) during rMT. Thirty-two of 54 patients (59%) experienced recurrent LVO of a previously treated artery, mostly the pretreated left MCA (23 patients, 73%). Fifty of the 54 patients (93%) had a documented discharge modified Rankin Scale after rMT: 15 (30%) had minimal or no disability (modified Rankin Scale score ≤2), 25 (50%) had moderate to severe disability (modified Rankin Scale score 3–5), and 10 (20%) died. Conclusions: Almost 2% of patients treated with MT experience recurrent LVO, usually of a previously treated artery during the same hospitalization. Repeat MT seems to be safe and effective for attaining vessel recanalization, and good outcome can be expected in 30% of patients.

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