Effect of Occlusion Site on the Safety and Efficacy of Intravenous Alteplase Before Endovascular Thrombectomy: A Prespecified Subgroup Analysis of DIRECT-MT

Stroke ◽  
2021 ◽  
Author(s):  
Yu Zhou ◽  
Pengfei Xing ◽  
Zifu Li ◽  
Xiaoxi Zhang ◽  
Lei Zhang ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Odds Ratio ◽  
Internal Carotid ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Bridging Therapy ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Intravenous Alteplase

Background and Purpose: Recent trials showed thrombectomy alone was comparable to bridging therapy in patients with anterior circulation large vessel occlusion eligible for both intravenous alteplase and endovascular thrombectomy. We performed this study to examine whether occlusion site modifies the effect of intravenous alteplase before thrombectomy. Methods: This is a prespecified subgroup analysis of a randomized trial evaluating risk and benefit of intravenous alteplase before thrombectomy (DIRECT-MT [Direct Intra-Arterial Thrombectomy in Order to Revascularize AIS Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals]). Among 658 randomized patients, 640 with baseline occlusion site information were included. The primary outcome was the score on the modified Rankin Scale at 90 days. Multivariable ordinal logistic regression analysis with an interaction term was used to estimate treatment effect modification by occlusion location (internal carotid artery versus M1 versus M2). We report the adjusted common odds ratio for a shift toward better outcome on the modified Rankin Scale after thrombectomy alone compared with combination treatment adjusted for age, the National Institutes of Health Stroke Scale score at baseline, the time from stroke onset to randomization, the modified Rankin Scale score before stroke onset, and collateral score per the DIRECT-MT statistical analysis plan. Results: The overall adjusted common odds ratio was 1.08 (95% CI, 0.82–1.43) with thrombectomy alone compared with combination treatment, and there was no significant treatment-by-occlusion site interaction ( P =0.47). In subgroups based on occlusion location, we found the following adjusted common odds ratios: 0.99 (95% CI, 0.62–1.59) for internal carotid artery occlusions, 1.12 (95% CI, 0.77–1.64) for M1 occlusions, and 1.22 (95% CI, 0.53–2.79) for M2 occlusions. No treatment-by-occlusion site interactions were observed for dichotomized modified Rankin Scale distributions and successful reperfusion (extended thrombolysis in Cerebral Infarction score ≥2b) before thrombectomy. Differences in symptomatic hemorrhage rate were not significant between occlusion locations (internal carotid artery occlusion: 7.02% in bridging therapy versus 7.14% for thrombectomy alone, P =0.97; M1 occlusion: 5.06% versus 2.48%, P =0.22; M2 occlusion: 9.09% versus 4.76%; P =0.78). Conclusions: In this prespecified subgroup of a randomized trial, we found no evidence that occlusion location can inform intravenous alteplase decisions in endovascular treatment eligible patients directly presenting at endovascular treatment capable centers. Future studies are needed to confirm our findings. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03469206.

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.

Impact of Strategy on Clinical Outcome in Large Vessel Occlusion Stroke Successfully Reperfused: ETIS Registry Results

Stroke ◽  
2021 ◽  
Author(s):  
Marian Douarinou ◽  
Benjamin Gory ◽  
Arturo Consoli ◽  
Bertrand Lapergue ◽  
Maeva Kyheng ◽  
...  
Keyword(s):  
Odds Ratio ◽  
Therapy Group ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Favorable Outcome ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Bridging Therapy ◽  
Anterior Circulation ◽  
Vessel Occlusion

Background and Purpose: Approximately half of the patients with acute ischemic stroke due to anterior circulation large vessel occlusion do not achieve functional independence despite successful reperfusion. We aimed to determine influence of reperfusion strategy (bridging therapy, intravenous thrombolysis alone, or mechanical thrombectomy alone) on clinical outcomes in this population. Methods: From ongoing, prospective, multicenter, observational Endovascular Treatment in Ischemic Stroke registry in France, all patients with anterior circulation large vessel occlusion who achieved successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b-3) following reperfusion therapy were included. Primary end point was favorable outcome, defined as 90-day modified Rankin Scale score ≤2. Patient groups were compared using those treated with bridging therapy as reference. Differences in baseline characteristics were reduced after propensity score-matching, with a maximum absolute standardized difference of 14% for occlusion site. Results: Among 1872 patients included, 970 (51.8%) received bridging therapy, 128 (6.8%) received intravenous thrombolysis alone, and the remaining 774 (41.4%) received MT alone. The rate of favorable outcome was comparable between groups. Excellent outcome (90-day modified Rankin Scale score 0–1) was achieved more frequently in the bridging therapy group compared with the MT alone (odds ratio after propensity score-matching, 0.70 [95% CI, 0.50–0.96]). Regarding safety outcomes, hemorrhagic complications were similar between the groups, but 90-day mortality was significantly higher in the MT alone group compared with the bridging therapy group (odds ratio, 1.60 [95% CI, 1.09–2.37]). Conclusions: This real-world observational study of patients with anterior circulation large vessel occlusion demonstrated a similar rate of favorable outcome following successful reperfusion with different therapeutic strategies. However, our results suggest that bridging therapy compared with MT alone is significantly associated with excellent clinical outcome and lower mortality. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03776877.

scholarly journals Cervical internal carotid artery tortuosity: A morphologic analysis of patients with acute ischemic stroke

2019 ◽  
Vol 26 (2) ◽  
pp. 216-221
Author(s):  
John C Benson ◽  
Waleed Brinjikji ◽  
Steven A Messina ◽  
Giuseppe Lanzino ◽  
David F Kallmes
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Acute Ischemic Stroke ◽  
Internal Carotid ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Procedure Time ◽  
Vessel Occlusion ◽  
Cervical Internal Carotid Artery

Background and purpose Cervical internal carotid artery (ICA) tortuosity is thought to impede distal catheterization during attempted mechanical thrombectomy in patients with acute ischemic stroke. This study sought to assess the morphologic characteristics of ICAs and the effects of tortuosity on thrombectomy attempts. Methods A retrospective review was completed of neck CTAs of patients with acute ischemic stroke due to a large vessel occlusion that underwent attempted endovascular recanalization. Significant tortuosity of ICAs was defined as the presence of kink(s) (acute (<90°) angulation), loop(s) (C- or S-shaped curvature with 2+ areas of acute (<90°) angulation), or coil(s) (full 360° turn arterial bend). Findings were statistically compared to procedure time, successful recanalization rate, patient demographics, and co-morbidities. Results Of 120 included patients, 47 (39.2%) had some form of tortuosity of one or both ICAs. Twenty-eight patients (23.3%) had a kink of one or both ICAs; this was followed in frequency by loops (n = 20; 16.7%) and coils (n = 8; 6.7%). Kinks were associated with lower rates of successful recanalization (p = 0.02). The presence of any tortuosity (kinks, loops, or coils) was not associated with number of passes during thrombectomy (p = 0.88), successful recanalization (p = 0.11), or total procedure time (p = 0.22). No association was noted between the presence of tortuosity and age (p = 0.96) or prior or current tobacco use (p = 0.75 and p = 0.69, respectively). Conclusion Among patients referred for urgent revascularization for large vessel occlusion, approximately 40% exhibit some tortuosity. Kinks may portend lower likelihood of recanalization success, although tortuosity as a whole seems to have little effect on endovascular thrombectomy.

scholarly journals Management of Tandem Cervical Internal Carotid Artery Stenosis and Large Vessel Occlusion During Acute Stroke: A Single Institution's Initial Experience

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Nicolas W Villelli ◽  
Andrew DeNardo ◽  
John Scott ◽  
Daniel Sahlein ◽  
Troy D Payner ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Acute Stroke ◽  
Carotid Stenosis ◽  
Internal Carotid ◽  
Treatment Algorithm ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Ica Stenosis

Abstract INTRODUCTION Thrombectomy for large vessel occlusion (LVO) has become a well-established treatment for acute stroke. Management of tandem internal carotid artery (ICA) stenosis in thrombectomy patients can be challenging, as no formal treatment algorithm exists for this unique pathology. We present a single institution's experience with the acute treatment of ICA stenosis during or after thrombectomy with either carotid artery stent (CAS) or carotid endarterectomy (CEA). METHODS A retrospective analysis was performed on all patients who underwent thrombectomy with tandem ICA stenosis at our institution. All demographic, stroke presentation, stroke treatment, cervical carotid stenosis treatment, and follow-up data were analyzed for these patients. RESULTS From 2015 to 2018, 31 patients with tandem ICA stenosis underwent thrombectomy for LVO. Of these patients, 26 had a CAS placed, 25 of which were done at time of thrombectomy, and 1 placed 5 d after thrombectomy. CAS patients were placed on antiplatelet therapy after stent placement. Of the 25 patients who had CAS placed at time of thrombectomy, 5 patients had a symptomatic ICH, 4 of which did not survive the hospitalization. Two additional CAS patients did not survive hospitalization. There were 5 patients who had a CEA performed during the same hospital stay, ranging from 1 to 10 d post-thrombectomy. Patients who underwent CEA had a smaller area of infarct and a shorter thrombectomy procedure time when compared to the CAS patients, and all CEA patients survived hospitalization, with good outcomes. CONCLUSION CAS placement for tandem ICA stenosis at time of thrombectomy may be less safe than previously published. Early, but not simultaneous, intervention on cervical ICA stenosis after thrombectomy allows for the assessment of infarct volume, patient recovery, and the presence of intracerebral hemorrhage, and thus provides the opportunity to appropriately select patients who would benefit from treatment of the carotid stenosis with either CAS or CEA.

scholarly journals Transcarotid Mechanical Thrombectomy for Embolic Intracranial Large Vessel Occlusion after Endovascular Deconstructice Embolization for Carotid Blowout Syndrome

2020 ◽  
Vol 15 (1) ◽  
pp. 37-43 ◽  
Author(s):  
Chi-Ju Lu ◽  
Yen-Heng Lin ◽  
Chung-Wei Lee
Keyword(s):  
Head And Neck Cancer ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Head And Neck ◽  
Neck Cancer ◽  
Internal Carotid ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Carotid Blowout Syndrome

Carotid blowout syndrome (CBS) is a fatal complication of head and neck cancer. Endovascular treatment, particularly deconstructive embolization, is effective for CBS, but it might result in thromboembolic events. We report the case of a 57-year-old man with underlying recurrent head and neck cancer who had CBS. The patient received endovascular embolization of the right internal, external, and common carotid arteries. Right internal carotid artery to middle cerebral artery embolic occlusion was noted immediately after the procedure, and left-sided weakness and facial palsy were found. Ipsilateral suprabulbar cervical internal carotid artery puncture was performed under fluoroscopic guidance, and rescue suction thrombectomy was successful. The patient had no significant neurological sequela. Transcarotid intraarterial thrombectomy is a reasonable method for managing postembolization large vessel occlusion, even in the neck, after irradiation.

Simultaneous Bilateral Carotid Thrombectomies: A Technical Note

2019 ◽  
Vol 18 (5) ◽  
pp. E143-E148 ◽  
Author(s):  
Thomas Larrew ◽  
Zachary Hubbard ◽  
Eyad Almallouhi ◽  
Chirantan Banerjee ◽  
Mark Moss ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cerebral Infarction ◽  
Collateral Circulation ◽  
Internal Carotid ◽  
Technical Note ◽  
Large Vessel Occlusion ◽  
Morbid Condition ◽  
Vessel Occlusion ◽  
Bilateral Carotid

Abstract BACKGROUND Although extremely rare, acute bilateral large vessel occlusion (LVO) is a morbid condition that requires prompt intervention. OBJECTIVE To report the technique used to achieve recanalization of bilateral internal carotid artery (ICA) terminus occlusions. METHODS This is a case of bilateral ICA terminus occlusions managed with simultaneous bilateral thrombectomies with poor collateral circulation. RESULTS Recanalization of bilateral ICA with thrombolysis in cerebral infarction (TICI) grade 0 to left TICI 2b flow with distal left A1 occlusion and right TICI 3 flow was achieved in 32 min with the use of simultaneous catheterization and aspiration thrombectomies. CONCLUSION The described technique offers an efficient and feasible means to reduce time to recanalization and radiation in cases of bilateral LVO.

scholarly journals Successful Bridging Therapy in a 103-Year-Old Woman with Acute Terminal Internal Carotid Artery Occlusion

2020 ◽  
Vol 12 (Suppl. 1) ◽  
pp. 9-14
Author(s):  
Trung Quoc Nguyen ◽  
Hoang Thi Phan ◽  
Tinh Quang Dang ◽  
Vu Thanh Tran ◽  
Thang Huy Nguyen
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Left Internal Carotid Artery ◽  
Bridging Therapy ◽  
Nihss Score ◽  
Current Guidelines

The efficacy of intravenous thrombolysis and endovascular therapy and their favorable treatment outcomes have been established in clinical trials irrespective of age. Current guidelines do not recommend an age limit in selecting eligible patients for reperfusion treatment as long as other criteria are satisfied. A 103-year-old woman was admitted at our hospital within 1 h of stroke onset secondary to a left internal carotid artery terminus occlusion. On admission, her National Institutes of Health Stroke Scale (NIHSS) score was 30, with a small left thalamic diffusion restriction lesion on MRI. Her medical history included paroxysmal atrial fibrillation, prior myocardial infarction, hypertension, chronic kidney disease, and diabetes mellitus. Her pre-stroke modified Rankin Scale score was 0, and she was fully independent before stroke. Once intravenous thrombolysis was started, the patient successfully underwent mechanical thrombectomy, and thrombolysis in cerebral infarction-3 recanalization was achieved 225 min after symptom onset. She showed dramatic recovery (NIHSS score of 5 after 48 h) and was discharged on day 7 with a modified Rankin Score of 1. To our knowledge, our patient is the second oldest documented patient who successfully underwent bridging therapy for stroke.

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