Abstract WP1: Thrombectomy Outcomes in Acute Ischemic Stroke due to Middle Cerebral Artery M2 Occlusion with Stent-Retriever, Aspiration, MERCI: Multi-Center Experience

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Kunakorn Atchaneeyasakul ◽  
Amer M Malik ◽  
Dileep R Yavagal ◽  
Mehdi Bouslama ◽  
Diogo C Haussen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Tertiary Care ◽  
Stent Retriever ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Significant Difference

Introduction: Recent trials demonstrated that mechanical thrombectomy improve functional outcome in anterior circulation acute ischemic stroke (AIS) due to emergent large vessel occlusion (ELVO) of the middle cerebral artery (MCA) M1 segment. However, such data regarding AIS due to MCA M2 segment ELVO is limited. Analysis of the STAR, SWIFT, and SWIFT-PRIME trials found thrombectomy in MCA M2 occlusion to be feasible in achieving successful reperfusion. The most optimal technique and/or device used for such reperfusion is not clearly defined. We aim to compare the outcome for the contemporary techniques and devices used for thrombectomy of AIS patients due to MCA M2 ELVO. Methods: A retrospective review of AIS patients with MCA M2 ELVO receiving thrombectomy from three tertiary care academic medical centers was conducted. Thrombectomy technique and thrombectomy device utilized were recorded. Outcomes were successful angiographic reperfusion (TICI ≥2b), favorable modified Rankin Scale (mRS≤2) at discharge and at 90 days, and rate of symptomatic intracerebral hemorrhage (sICH). Results: From October 1999 through June 2016, 253 AIS patients underwent thrombectomy for MCA M2 ELVO. Thrombectomy methods utilized were Stent-retriever (n=118), Aspiration only [manual or Penumbra device] (n=83), and MERCI retriever (n=52). Table 1 shows rate of outcomes measured. There was no difference in baseline NIHSS or in stroke onset to groin puncture time. Stent-retriever group showed a significantly higher recanalization rate, lower sICH rate, and favorable 90-day mRS versus Aspiration group or MERCI group, respectively. No significant difference was seen in discharge mRS between the groups. Conclusions: Thrombectomy for AIS patients with MCA M2 ELVO with Stent-retriever appears to be feasible with a significantly higher rate of recanalization, lower sICH rate, and favorable 90-day mRS when compared to Aspiration and MERCI.

scholarly journals Thrombectomy Outcomes in Acute Ischemic Stroke due to Middle Cerebral Artery M2 Occlusion with Stent Retriever versus Aspiration: A Multicenter Experience

2019 ◽  
Vol 8 (2-6) ◽  
pp. 180-186 ◽  
Author(s):  
Kunakorn Atchaneeyasakul ◽  
Amer M. Malik ◽  
Dileep R. Yavagal ◽  
Diogo C. Haussen ◽  
Ashutosh P. Jadhav ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Stent Retriever ◽  
Secondary Outcome ◽  
Vessel Occlusion ◽  
Aspiration System ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Aspiration Technique

Objective: To examine outcomes for thrombectomy devices used for treatment of acute ischemic stroke (AIS) with middle cerebral artery (MCA) M2 segment emergent large vessel occlusion (ELVO) as the optimal device for such reperfusion is not clearly defined. Methods: A retrospective cohort study of consecutive AIS patients with MCA M2 ELVO undergoing thrombectomy from 3 academic medical centers was conducted from October 1999 through June 2016. The patients were divided based on the device utilized. Multivariate analysis of associations between devices (stent retriever or aspiration only [manual or pump aspiration system]) was performed. Primary outcomes were good recanalization (i.e., modified thrombolysis in cerebral infarction score ≥2b) and a favorable modified Rankin scale (mRS) score (i.e. ≤2). The secondary outcome was symptomatic intracerebral hemorrhage (sICH). Results: A total of 197 AIS patients underwent MCA M2 ELVO thrombectomy with either a stent retriever (n = 120) or aspiration only (n = 77). The aspiration-only group utilized either manual (n = 38) or pump aspiration (n = 39). Utilization of a stent retriever over manual aspiration is independently associated with higher odds of a favorable mRS score (OR = 3.2; 95% CI 1.02–9.7) and lower odds of sICH (OR = 0.09; 95% CI 0.03–0.31). Utilization of a stent retriever over a pump aspiration system is independently associated with higher odds of good recanalization (OR = 3.8; 95% CI 1.5–9.6). Utilization of a newer-generation pump aspiration catheter compared to a stent retriever resulted in similar rates of favorable mRS scores, sICH, successful recanalization, and mortality. Conclusion: Utilization of a newer-generation pump aspiration catheter compared to a stent retriever resulted in similar outcomes, but worse outcomes were seen with the manual aspiration technique. These findings need to be confirmed with a large randomized trial utilizing stent retrievers and newer-generation pump aspiration systems.

Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: a meta-analysis

2017 ◽  
Vol 10 (7) ◽  
pp. 620-624 ◽  
Author(s):  
Hamidreza Saber ◽  
Sandra Narayanan ◽  
Mohan Palla ◽  
Jeffrey L Saver ◽  
Raul G Nogueira ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Functional Independence ◽  
Vessel Occlusion ◽  
Increased Risk ◽  
Significant Difference

BackgroundEndovascular thrombectomy has demonstrated benefit for patients with acute ischemic stroke from proximal large vessel occlusion. However, limited evidence is available from recent randomized trials on the role of thrombectomy for M2 segment occlusions of the middle cerebral artery (MCA).MethodsWe conducted a systematic review and meta-analysis to investigate clinical and radiographic outcomes, rates of hemorrhagic complications, and mortality after M2 occlusion thrombectomy using modern devices, and compared these outcomes against patients with M1 occlusions. Recanalization was defined as Thrombolysis in Cerebral Infarction (TICI) 2b/3 or modified TICI 2b/3.ResultsA total of 12 studies with 1080 patients with M2 thrombectomy were included in our analysis. Functional independence (modified Rankin Scale 0–2) rate was 59% (95% CI 54% to 64%). Mortality and symptomatic intracranial hemorrhage rates were 16% (95% CI 11% to 23%) and 10% (95% CI 6% to 16%), respectively. Recanalization rates were 81% (95% CI 79% to 84%), and were equally comparable for stent-retriever versus aspiration (OR 1.05; 95% CI 0.91 to 1.21). Successful M2 recanalization was associated with greater rates of favorable outcome (OR 4.22; 95% CI 1.96 to 9.1) compared with poor M2 recanalization (TICI 0–2a). There was no significant difference in recanalization rates for M2 versus M1 thrombectomy (OR 1.05; 95% CI 0.77 to 1.42).ConclusionsThis meta-analysis suggests that mechanical thrombectomy for M2 occlusions that can be safely accessed is associated with high functional independence and recanalization rates, but may be associated with an increased risk of hemorrhage.

scholarly journals Blind Exchange With Mini-Pinning Technique Using the Tron Stent Retriever for Middle Cerebral Artery M2 Occlusion Thrombectomy in Acute Ischemic Stroke

2021 ◽  
Vol 12 ◽  
Author(s):  
Takeshi Yoshimoto ◽  
Kanta Tanaka ◽  
Junpei Koge ◽  
Masayuki Shiozawa ◽  
Hiroshi Yamagami ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Scale Score ◽  
Cerebral Artery ◽  
Stent Retriever ◽  
Vessel Occlusion ◽  
First Pass ◽  
Stent Retrievers ◽  
Procedural Outcomes

Introduction: The usefulness of the blind exchange with mini-pinning (BEMP) technique has recently been reported for mechanical thrombectomy in patients with stroke owing to medium vessel occlusion (MeVO). The Tron stent retriever can be delivered and deployed through a 0.0165-inch microcatheter. This retriever has potential as an effective and safe treatment for acute ischemic stroke (AIS) due to occlusion of the M2 segment of the middle cerebral artery (MCA). Here, we report the outcomes of the BEMP technique using Tron stent retrievers for M2 occlusion thrombectomy.Methods: Consecutive patients with AIS owing to M2 occlusion who underwent the BEMP technique using 2 × 15-mm or 4 × 20-mm Tron stent retrievers were included. The technique involves deploying a Tron stent retriever through a 0.0165-inch microcatheter, followed by microcatheter removal and blind navigation of a 3MAX or 4MAX aspiration catheter over the bare Tron delivery wire until the aspiration catheter reaches the clot. A Tron stent retriever is inserted into the aspiration catheter like a cork and subsequently pulled as a unit. We assessed procedural outcomes [first-pass expanded thrombolysis in cerebral infarction (eTICI) score 2c/3 and 2b/2c/3], safety outcomes [symptomatic intracranial hemorrhage (sICH)], and clinical outcomes (good outcome rate defined as modified Rankin Scale score 0–2 at 90 days and mortality at 90 days).Results: Eighteen M2 vessels were treated in 15 patients (six female, median age: 80 years, and median National Institutes of Health Stroke Scale score: 18). The BEMP technique was performed successfully in all cases. Whether to use a 3MAX or 4MAX catheter was determined by considering one of the following target vessels: dominant, non-dominant, or co-dominant M2 (3MAX, n = 9; 4MAX, n = 9). The first-pass eTICI 2c/3 and 2b/2c/3 rates were 47 (7/15) and 60% (9/15), respectively; sICH was not observed. Seven patients (47%) achieved good outcomes, and one patient (7%) died within 90 days.Conclusions: The Tron stent retriever was safely and effectively used in the BEMP technique for acute MCA M2 occlusion and can be combined with a 0.0165-inch microcatheter, which may be useful for treating MeVO, in general.

Abstract WP430: Endothelial Cell Collection from Ipsilateral Middle Cerebral Artery in Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Sunil A Sheth ◽  
Abhishek Verma ◽  
David S Liebeskind ◽  
Jeffrey L Saver ◽  
Gary Duckwiler ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endothelial Cell ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Critical Role ◽  
Early Time ◽  
Stent Retriever ◽  
Positive Controls

Introduction: The cerebrovascular endothelium plays a critical role in the pathogenesis of and response to acute ischemic stroke (AIS). To date, techniques to study its function have relied on animal and in vitro models. A robust method of endothelial cell (EC) capture in patients with AIS at early time points, from within the ischemic region, could greatly advance our understanding of cerebrovascular injury. Method: Patients undergoing thrombectomy for middle cerebral artery occlusion (MCA) within 8 hours of onset were offered enrollment if the pass of their stent-retriever device occurred directly into a distal access catheter in the proximal M1 segment, limiting exposure of the device to only the MCA. After retrieval, ECs adherent to the devices were retrieved and stained for EC (CD31) and leukocyte (CD45) markers. EC identity and yield were confirmed by flow cytometry with simultaneous immuno-fluorescence microscopy. Cultured human ECs were used as positive controls. The EC fraction was defined as CD31 + CD45 - with size and morphological features consistent with the positive controls. Results: ECs from stent-retriever devices (n=3) were collected and pooled. Approximately 8% of the collected cells represented ECs. EC collected from the stent-retrievers demonstrated highly similar shape, morphology and antibody staining patterns compared to the positive controls (Figure). Conclusions: Here we provide the first demonstration of a rapid post-thrombectomy method for reliable harvesting of cerebral ECs in humans. The ability to capture these cells in patients with AIS within hours of symptom onset opens many avenues of exploration for determining the role of ECs in AIS.

scholarly journals Workflow Intervals of Endovascular Acute Stroke Therapy During On- Versus Off-Hours

Stroke ◽  
2019 ◽  
Vol 50 (10) ◽  
pp. 2842-2850 ◽  
Author(s):  
Wouter H. Hinsenveld ◽  
Inger R. de Ridder ◽  
Robert J. van Oostenbrugge ◽  
Jan A. Vos ◽  
Adrien E. Groot ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Large Vessel ◽  
Complication Rates ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Significant Difference

Background and Purpose— Endovascular treatment (EVT) of patients with acute ischemic stroke because of large vessel occlusion involves complicated logistics, which may cause a delay in treatment initiation during off-hours. This might lead to a worse functional outcome. We compared workflow intervals between endovascular treatment–treated patients presenting during off- and on-hours. Methods— We retrospectively analyzed data from the MR CLEAN Registry, a prospective, multicenter, observational study in the Netherlands and included patients with an anterior circulation large vessel occlusion who presented between March 2014 and June 2016. Off-hours were defined as presentation on Monday to Friday between 17:00 and 08:00 hours, weekends (Friday 17:00 to Monday 8:00) and national holidays. Primary end point was first door to groin time. Secondary end points were functional outcome at 90 days (modified Rankin Scale) and workflow time intervals. We stratified for transfer status, adjusted for prognostic factors, and used linear and ordinal regression models. Results— We included 1488 patients of which 936 (62.9%) presented during off-hours. Median first door to groin time was 140 minutes (95% CI, 110–182) during off-hours and 121 minutes (95% CI, 85–157) during on-hours. Adjusted first door to groin time was 14.6 minutes (95% CI, 9.3–20.0) longer during off-hours. Door to needle times for intravenous therapy were slightly longer (3.5 minutes, 95% CI, 0.7–6.3) during off-hours. Groin puncture to reperfusion times did not differ between groups. For transferred patients, the delay within the intervention center was 5.0 minutes (95% CI, 0.5–9.6) longer. There was no significant difference in functional outcome between patients presenting during off- and on-hours (adjusted odds ratio, 0.92; 95% CI, 0.74–1.14). Reperfusion rates and complication rates were similar. Conclusions— Presentation during off-hours is associated with a slight delay in start of endovascular treatment in patients with acute ischemic stroke. This treatment delay did not translate into worse functional outcome or increased complication rates.

369 The TREVO Registry-Subgroup Analysis, Treatment Beyond 6 Hours

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 286-286
Author(s):  
Mandy Jo Binning ◽  
Erol Veznedaroglu ◽  
Ronald Budzik ◽  
Joey English ◽  
Blaise Baxter ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Real World ◽  
Symptom Onset ◽  
Subgroup Analysis ◽  
Mechanical Thrombectomy ◽  
Stent Retriever ◽  
Real World Data ◽  
Vessel Occlusion ◽  
Significant Difference

Abstract INTRODUCTION Current randomized trials demonstrating superiority of mechanical thrombectomy for the treatment of acute ischemic stroke for anterior circulation large vessel occlusion, have enrolled patients with symptom onset up to 6 hours. Outcomes of thrombectomy beyond 6 hours have not been well studied. The Trevo Registry is designed to assess real world outcomes of the Trevo Retriever in patients experiencing acute ischemic stroke. Trevo registry has currently enrolled 1431 patients with 90-day outcome data. Outcomes of patients treated beyond 6 hours of symptom onset were studied. METHODS The study design is a prospective, open-label, consecutive enrollment, multi-center, global registry of all patients who undergo mechanical thrombectomy for acute stroke using the Trevo stent retriever as the initial device. Enrollment is expected to reach 2000 subjects at up to 100 sites. Subgroup analysis of enrolled patients treated beyond 6 hours of symptom onset and with 90-day follow-up was performed. RESULTS >As of March 24, 2017, a total of 1846 total patients were enrolled. Median NIHSS at admission was 15.5 (IQR 11–20). The majority of patients (67.4%) were treated at 6 hours or less from last known normal with a median procedure time of 50 minutes (8-286 minutes). In patients treated after 6 hours from time last known well, the revascularization rate was 93.7% with symptomatic ICH of 1.8% and 90-day mRS = 2 was 51.8%. Subgroup analysis of patients presenting within 6 hours and those presenting beyond 6 hours showed no significant difference in patient demographics or medical comorbidities. There was no difference in complication rate or 90-day outcome between the two groups. CONCLUSION The Trevo Retriever Registry represents the first look at real world data with stent retriever use in the era of clinical trials showing the overwhelming benefit of stent retrievers to treat acute ischemic stroke. This data represents real world use of the Trevo Retriever including those treated beyond 6 hours after stroke symptoms (33.8%), and this data adds to the results from recent trials with restricted eligibility criteria.

MIDDLE CEREBRAL ARTERY STENTING FOR ACUTE ISCHEMIC STROKE AFTER UNSUCCESSFUL MERCI RETRIEVAL

Neurosurgery ◽  
2007 ◽  
Vol 60 (4) ◽  
pp. 701-706 ◽  
Author(s):  
Eric Sauvageau ◽  
Rodney M. Samuelson ◽  
Elad I. Levy ◽  
Alison M. Jeziorski ◽  
Ricky A. Mehta ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Scale Score ◽  
Cerebral Artery ◽  
National Institutes Of Health ◽  
High Rate ◽  
Vessel Occlusion ◽  
Intracranial Stenting ◽  
Acute Cerebral Ischemia

Abstract OBJECTIVE Intracranial stenting has been used in the treatment of ischemic stroke caused by acute intracranial vessel occlusion after unsuccessful recanalization with the Merci retriever. We describe our early experience with this technique. METHODS Patients who had intra-arterial therapy for acute ischemic stroke with concomitant use of the retriever between February 1, 2005 and May 2, 2006 were identified from our endovascular database. Cases in which recanalization was not achieved with the retriever and in which stenting was attempted as a secondary means of mechanical recanalization were retrospectively reviewed. RESULTS Ten patients with unsuccessful Merci retrieval underwent intracranial stenting. The average admission National Institutes of Health Stroke Scale score was 16.4. Occlusions were located in the middle cerebral artery (six extended into M2 branches). Four patients received intra-arterial reteplase (two prestent, one preretriever and poststent, and one poststent). Eptifibatide was administered immediately before stenting in every patient. Successful recanalization (thrombolysis in myocardial infarction 2 or 3) was achieved in nine out of 10 patients. Complications included an extradural perforation with arteriovenous fistula. Six patients had intracranial hematoma and/or subarachnoid hemorrhage; there were four deaths. The six surviving patients experienced at least a 6-point National Institutes of Health Stroke Scale improvement at discharge, although only one had a modified Rankin Scale score of 2 or less. CONCLUSION Angiographic recanalization has been associated with improvement in clinical outcome after acute cerebral ischemia. Recanalization is not always achieved using the Merci retriever. We found that stenting after unsuccessful Merci retrieval resulted in a high rate of angiographic success. Further research into refining indications and optimizing outcome is warranted.

Acute Middle Cerebral Artery Occlusion

2019 ◽  
pp. 155-164
Author(s):  
Phillip A. Bonney ◽  
Parampreet Singh ◽  
Benjamin Yim ◽  
William J. Mack
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Middle Cerebral Artery Occlusion ◽  
Cerebral Artery ◽  
Artery Occlusion ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Cerebral Artery Occlusion

Abstract: This chapter addresses the neurosurgical management of stroke due to acute middle cerebral artery occlusion. Large vessel occlusion is a common mechanism of acute ischemic stroke. Mechanical thrombectomy has emerged as an important procedure that drastically improves outcomes in this disease. This chapter discusses the diagnosis and treatment of acute ischemic stroke from large vessel occlusion, including the rapid radiographic evaluation with CT, CTA, MRI, and perfusion imaging. The scoring of the stroke using scales such as the ASPECTS score and their use in decision-making is reviewed. The chapter then discusses treatment with both chemical thrombolysis and mechanical thrombectomy, including the technical aspects of the procedure.

scholarly journals A Comparison of Mechanical Thrombectomy in the M1 and M2 Segments of the Middle Cerebral Artery: A Review of 585 Consecutive Patients

2017 ◽  
Vol 6 (3-4) ◽  
pp. 191-198 ◽  
Author(s):  
Pervinder Bhogal ◽  
Philipp Bücke ◽  
Muhammad AlMatter ◽  
Oliver Ganslandt ◽  
Hansjörg Bäzner ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Intracranial Haemorrhage ◽  
Mechanical Thrombectomy ◽  
Outcome Data ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Computed Tomographic ◽  
Significant Difference

Background: Mechanical thrombectomy for anterior-circulation large-vessel occlusion has shown benefit; however, the question of whether this technique is safe and effective in the distal vasculature remains unanswered. We sought to compare the outcome data from mechanical thrombectomy of the M2 branches of the middle cerebral artery (MCA) with those of the M1 segment. Methods: We performed a retrospective analysis of prospectively collected data of patients with acute ischaemic stroke undergoing mechanical thrombectomy of isolated M1 or M2 branches of the MCA between August 2008 and August 2016. Results: We identified 585 patients, 479 with M1 occlusions and 106 with M2 occlusions. The average age was 72 ± 12.8 and 68 ± 13.8 years, respectively (p = 0.007). The baseline Alberta Stroke Program Early Computed Tomographic (ASPECT) score was similar in both cohorts, but patients with M1 occlusions presented with higher mean National Institutes of Health Stroke Scale (NIHSS) scores of 15.7 compared to 11.8 (p < 0.001). There was no significant difference in the average procedure time for each cohort; fewer thrombectomy attempts were required in the M2 cohort (2.3 vs. 1.8, p = 0.0004), but the overall time to recanalization was longer in the M2 cohort (353 vs. 399 min, p < 0.001). Similar rates of successful reperfusion (Thrombolysis in Ischaemic Stroke score [TICI] ≥2b 88.5 vs. 90.5%, p = 0.612) were seen, but food outcome (modified Rankin Scale ≤2) was lower in M1 occlusions (37.2 vs. 54.3%, p < 0.001). Rates of symptomatic intracranial haemorrhage were similar. Conclusion: Good clinical outcomes can be achieved for both groups with no significant differences in procedure length, final TICI recanalization rates or intracranial haemorrhage between the M1 and M2 cohorts.

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