Abstract 114: Diverse Patients Show Physiologic Benefit From Refined Sphenopalatine Ganglion Electrode Placement and Stimulation Level Selection to Augment Blood Flow and Neurologic Function in Acute Ischemic Stroke (The IMPACT-24M Trial)

Background: Two large RCTs have indicated sphenopalatine ganglion (SPG) stimulation reduces 3m disability in acute ischemic stroke patients with confirmed cortical involvement. The current trial evaluated two refinements in SPG stimulation technique: 1) SPG electrode placement with real-time optical tracking guidance; and 2) stimulation intensity comfortable tolerance level (CTL) selection using non-noxious facial physiologic markers. Methods: Single, active arm trial at 4 centers, enrolling patients with anterior circulation ischemic stroke <24h, NIHSS 1-6, not receiving recanalization therapies. Stimulation level was based on ipsilateral facial tingling sensation or lacrimation. SPG stimulation effects were assessed by volumetric blood flow in the ipsilateral common carotid artery (ultrasound) and affected hand grasp and pinch strength before and during stimulation, and by NIHSS change by day 7. Results: Among 50 enrolled patients, age was median 66y (IQR 60-74), 44% female, NIHSS median 5 (IQR 4-5), and median onset-to-screening time 18h (IQR 9-20). Median implantation skin-to-skin time was 4 minutes (IQR 3-7) and all 50 implants were placed correctly. CTL was found based on physiological biomarkers in 96% of patients, including 86% in the optimal, low-medium intensity range. SPG stimulation significantly increased common carotid artery peak systolic and end diastolic blood flow (up 44%, p<0.0001; and up 52%, p<0.0001) and improved pinch strength (up 42%, p<0.0001) and grasp strength (up 26%, p<0.0001). Degree of NIHSS recovery by day 7 was greater than in matched historic controls, median 75% vs 50%, p=0.0003. Forest plot analysis showed benefits were homogenous across the subgroups of: sex, age, time from onset, stroke side, NIHSS, and ASPECTS score. Conclusion: SPG stimulator placement with real-time optical tracking guidance was fast and accurate, and selection of optimal stimulation intensity levels based on non-noxious facial tingling and lacrimation was feasible in nearly all patients. SPG activation led to cranial blood flow augmentation and improved hand motor function during stimulation, and neurologic deficit reduction at 1 week, consistently across broad patient subsets of age, sex, side, severity, and time to treatment.

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Successful carotid artery stenting in patients with aortic dissection

10.22514/sv.2020.16.0089 ◽

2020 ◽

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Aortic Dissection ◽

Cerebral Infarction ◽

Acute Ischemic Stroke ◽

Aortic Arch ◽

Common Carotid Artery ◽

Carotid Artery Stenting ◽

Acute Aortic Dissection ◽

Optimal Timing

Background: There are no guidelines for the optimal timing of surgery (emergency vs. delayed) for ascending aortic dissection with acute ischemic stroke. We retrospectively compared the prognoses and radiological and clinical findings for concomitant aortic dissection and ischemic stroke in a series of case reports. Case presentation: Three patients presented with left hemiparesis. Patient 1 underwent surgery for acute aortic dissection without treatment for acute ischemic stroke. In Patient 2, emergency stenting could not be performed due to cardiac tamponade and hypotension. Therefore, emergency acute aortic dissection surgery was performed. Patient 3 underwent emergency right common carotid artery stenting followed by surgery for acute aortic dissection. Brain perfusion computed tomography angiography (CTA) was performed to diagnose severe stenosis of the right common carotid artery or occlusion concomitant with acute aortic dissection involving the aortic arch with a cerebral perfusion mismatch in all the patients. Patient 3 had postoperative local cerebral infarction, whereas patients 1 and 2 (without stent insertion) had extensive postoperative cerebral infarction. Conclusion: Patient 3 showed a better prognosis than patients without stent treatment. We suggest that perfusion CTA of the aortic arch in suspected acute ischemic stroke can facilitate early diagnosis and prompt treatment in similar patients.

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Endovascular Treatment of Tandem Common Carotid Artery Origin and Distal Intracranial Occlusion in Acute Ischemic Stroke

World Neurosurgery ◽

10.1016/j.wneu.2016.10.039 ◽

2017 ◽

Vol 97 ◽

pp. 360-365 ◽

Cited By ~ 2

Author(s):

Gregory M. Weiner ◽

Rafey Feroze ◽

David M. Panczykowski ◽

Amin Aghaebrahim ◽

William Ares ◽

...

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Common Carotid Artery

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Analysis of Thrombi Retrieved from Cerebral Arteries of Patients with Acute Ischemic Stroke.

Blood ◽

10.1182/blood.v106.11.263.263 ◽

2005 ◽

Vol 106 (11) ◽

pp. 263-263

Author(s):

Victor J. Marder ◽

Dennis J. Chute ◽

Sidney Starkman ◽

Anna M. Abolian ◽

Chelsea Kidwell ◽

...

Keyword(s):

Blood Flow ◽

Ischemic Stroke ◽

Carotid Artery ◽

Middle Cerebral Artery ◽

Acute Ischemic Stroke ◽

Cerebral Artery ◽

Cerebral Arteries ◽

Clinical Consequence ◽

Initiation Of Therapy ◽

Stroke Center

Abstract To obtain insights into the pathogenesis of ischemic stroke, we analyzed thromboemboli and other occlusive material retrieved acutely from the cerebral arteries of patients. The experimental design was an observational study in 25 consecutive patients with acute ischemic stroke treated by endovascular mechanical thromboembolectomy. Patients with acute occlusion of a proximal cerebral artery, a disabling neurologic deficit, and either initiation of therapy within 8 hours of onset or initiation of therapy beyond 8 hours if imaging demonstrated substantial residual penumbral tissue at risk were treated at a tertiary Comprehensive Stroke Center (the UCLA Stroke Center). Thrombus was removed by an endovascular mechanical embolectomy device (Merci® Retriever System, Concentric Medical, Mountain View, CA) after placement by angiographic catheter into the occluded intracranial carotid artery, middle cerebral artery or vertebral-basilar artery under fluoroscopic guidance. Our results show that the large majority (20 of 25) of extracted thrombi have similar histologic architecture, a complex of layered, sometimes serpentine, lengths of fibrin:platelet deposits interspersed with linear streaks of nucleated cells. This histology was prevalent with both cardioembolic and atherosclerotic etiologies, indicating the same pathogenetic influences of blood flow and shear in thrombus formation. This histologic pattern among thrombi was present in both the internal carotid artery (ICA) and the middle cerebral artery (MCA). Clots composed uniformly of erythrocytes were uncommon (3 of 25) and were observed only with incomplete extractions, suggesting that sampling was of the proximal thrombus tail where post-occlusion thrombosis had occurred under conditions of stagnant flow. Calcifications or cholesterol were not present. Thrombus size, not histology, predicted the site of arterial occlusion, with no thrombus larger than 3 mm width causing stroke limited to the MCA and no thrombus larger than 5 mm width removed from the ICA. Fungus-containing thrombus was extracted from one patient who had mycotic valvular disease, and an unusual complication occurred in another case, namely, scraping of a small atheroma and attached intima from the MCA, albeit without clinical consequence. We conclude that thromboemboli that cause acute ischemic stroke are of similar, complex structure, regardless of macroscopic dimensions, and are similarly influenced by blood flow, whether the primary etiology is cardioembolic or atherosclerotic. Embolus size is the critical aspect that determines its ultimate destination, those of more than 5 mm width appearing to bypass the cerebral vessels entirely. The mixed fibrin:platelet pattern present in the preponderance of thromboemboli provides foundation for the success of both antiplatelet and anticoagulant treatment strategies in stroke prevention.

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Acute ischemic stroke complicating common carotid artery thrombosis during a severe COVID-19 infection

Journal of Neuroradiology ◽

10.1016/j.neurad.2020.04.003 ◽

2020 ◽

Vol 47 (5) ◽

pp. 393-394 ◽

Cited By ~ 29

Author(s):

Alain Viguier ◽

Louis Delamarre ◽

Julien Duplantier ◽

Jean-Marc Olivot ◽

Fabrice Bonneville

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Acute Ischemic Stroke ◽

Common Carotid Artery ◽

Carotid Artery Thrombosis ◽

Artery Thrombosis

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Influence of carotid tortuosity on internal carotid artery access time in the treatment of acute ischemic stroke

Interventional Neuroradiology ◽

10.1177/1591019917729364 ◽

2017 ◽

Vol 23 (6) ◽

pp. 583-588 ◽

Cited By ~ 24

Author(s):

ZO Kaymaz ◽

O Nikoubashman ◽

MA Brockmann ◽

M Wiesmann ◽

C Brockmann

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Acute Ischemic Stroke ◽

Common Carotid Artery ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Left Common Carotid Artery ◽

Access Time ◽

Vessel Tortuosity

Purpose Carotid artery anatomy is thought to influence internal carotid artery access time (ICA-AT) in patients requiring mechanical thrombectomy for acute ischemic stroke. This study investigates the association between ICA-AT and carotid anatomy. Material and methods Computed tomography angiography (CTA) data of 76 consecutive patients presenting with acute ischemic stroke requiring mechanical thrombectomy for middle cerebral artery or carotid T occlusion were evaluated. The supraaortic extracranial vasculature was analyzed regarding take-off angles and curvature of the affected side. Digital subtraction angiography data were primarily analyzed regarding ICA-AT and secondarily regarding recanalization time and radiographic result. Results ICA-AT was significantly influenced by vessel tortuosity. Take-off angle of the left common carotid artery ( p = 0.001) and the brachiocephalic trunk ( p = 0.002) as well as the tortuosity of the common carotid artery ( p = 0.002) had highest impact on ICA-AT. For recanalization time, however, we found only the take-off angle of the left common carotid artery to be of significance ( p = 0.020). There was a tendency for ICA-AT to correlate with successful (mTICI ≥ 2 b) revascularization (average time of successful results was 24.3 minutes, of unsuccessful was 35.6 minutes; p = 0.065). Every evaluated segment with less carotid tortuosity showed a carotid AT below 25 minutes. Conclusion Supraaortic vessel tortuosity significantly influences ICA-AT in mechanical thrombectomy for an acute large vessel. There furthermore was a trend for lower successful recanalization rates with increasing ICA-AT.

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