scholarly journals Mechanical Thrombectomy of the Fetal Posterior Cerebral Artery

2021 ◽  
Author(s):  
Mohamad Abdalkader ◽  
Anurag Sahoo ◽  
Adam A. Dmytriw ◽  
Waleed Brinjikji ◽  
Guilherme Dabus ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Endovascular Treatment ◽  
Cerebral Artery ◽  
Computed Tomography Angiography ◽  
Mechanical Thrombectomy ◽  
Posterior Cerebral Artery ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion

Abstract BACKGROUND Fetal posterior cerebral artery (FPCA) occlusion is a rare but potentially disabling cause of stroke. While endovascular treatment is established for acute large vessel occlusion stroke, FPCA occlusions were excluded from acute ischemic stroke trials. We aim to report the feasibility, safety, and outcome of mechanical thrombectomy in acute FPCA occlusions. METHODS We performed a multicenter retrospective review of consecutive patients who underwent mechanical thrombectomy of acute FPCA occlusion. Primary FPCA occlusion was defined as an occlusion that was identified on the pre‐procedure computed tomography angiography or baseline angiogram whereas a secondary FPCA occlusion was defined as an occlusion that occurred secondary to embolization to a new territory after recanalization of a different large vessel occlusion. Demographics, clinical presentation, imaging findings, endovascular treatment, and outcome were reviewed. RESULTS There were 25 patients with acute FPCA occlusion who underwent mechanical thrombectomy, distributed across 14 centers. Median National Institutes of Health Stroke Scale on presentation was 16. There were 76% (19/25) of patients who presented with primary FPCA occlusion and 24% (6/25) of patients who had a secondary FPCA occlusion. The configuration of the FPCA was full in 64% patients and partial or “fetal‐type” in 36% of patients. FPCA occlusion was missed on initial computed tomography angiography in 21% of patients with primary FPCA occlusion (4/19). The site of occlusion was posterior communicating artery in 52%, P2 segment in 40% and P3 in 8% of patients. Thrombolysis in cerebral infarction 2b/3 reperfusion was achieved in 96% of FPCA patients. There were no intraprocedural complications. At 90 days, 48% (12/25) were functionally independent as defined by modified Rankin scale≤2. CONCLUSIONS Endovascular treatment of acute FPCA occlusion is safe and technically feasible. A high index of suspicion is important to detect occlusion of the FPCA in patients presenting with anterior circulation stroke syndrome and patent anterior circulation. Novelty and significance This is the first multicenter study showing that thrombectomy of FPCA occlusion is feasible and safe.

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 3MAX catheter for thromboaspiration of downstream and new territory emboli after mechanical thrombectomy of large vessel occlusions: initial experience

2018 ◽  
Vol 25 (3) ◽  
pp. 277-284 ◽  
Author(s):  
Fabio Settecase
Keyword(s):  
Cerebral Artery ◽  
Prospective Studies ◽  
Cerebral Ischaemia ◽  
Mechanical Thrombectomy ◽  
Posterior Cerebral Artery ◽  
Large Vessel ◽  
Initial Experience ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Procedural Complications

Distal emboli and emboli to new territories occur in up to 14% and 11% of large vessel occlusion mechanical thrombectomies, respectively. A retrospective review was conducted of 18 consecutive patients with large vessel occlusion acute stroke undergoing mechanical thrombecomy, subsequently developing distal emboli and/or emboli to new territory for which thromboaspiration using the 3MAX catheter was performed. Eighteen distal emboli and two emboli to new territory in 18 patients were treated in the distal M2 and M3 middle cerebral artery, pericallosal and callosomarginal arteries, and P2 posterior cerebral artery (all arteries ≥1.5 mm in diameter). 3MAX thromboaspiration was successful in 13/18 distal emboli and 2/2 emboli to new territory (total 15/20, 75%). 3MAX thromboaspiration resulted in improvement in the final modified treatment in cerebral ischaemia (mTICI) score in 14/18 patients (78%) compared with the initial mTICI score after large vessel occlusion thrombectomy. A shift towards higher final mTICI scores was seen with 3MAX catheter aspiration of distal emboli in this series. The initial mTICI score after large vessel occlusion thrombectomy was 2A in 4/18 (22%) patients and 2B in 14/18 (78%) patients. The final mTICI score after distal emboli/emboli to new territory aspiration improved to 2B in 7/18 (39%) patients, 2C in 3/18 (17%) patients and 3 in 8/18 (44%) patients. No procedural complications were noted. In 13 patients with successful distal emboli/emboli to new territory thromboaspiration, a 90-day modified Rankin score of 0–2 was seen in 10 patients (77%). In five patients with unsuccessful distal emboli/emboli to new territory aspiration, a 90-day modified Rankin score of 0–2 was seen in three patients (60%). 3MAX thromboaspiration of select distal emboli and emboli to new territories is feasible. Larger prospective studies are needed to establish the clinical benefit and safety of this approach.

Abstract 1122‐000207: Mechanical Thrombectomy of the Fetal Posterior Cerebral Artery

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Mohamad Abdalkader ◽  
Mohamad Abdalkader ◽  
Anurag Sahoo ◽  
Adam A Dmytriw ◽  
Waleed Brinjikji ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Clinical Presentation ◽  
Posterior Cerebral Artery ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Ct Angiogram ◽  
Procedural Complications ◽  
High Index Of Suspicion

Introduction : Fetal posterior cerebral artery (FPCA) occlusion is a rare but potentially disabling cause of stroke. While endovascular treatment is established for acute large vessel occlusion (LVO) stroke, FPCA occlusions were excluded from acute ischemic stroke trials. We aim to report the feasibility, safety and outcome of mechanical thrombectomy (MT) in acute FPCA occlusions. Methods : We performed a multi‐center retrospective review of consecutive patients who underwent MT of acute FPCA occlusion. Primary FPCA occlusion was defined as an occlusion that was identified on the pre‐procedure CT angiogram or baseline angiogram whereas a secondary FPCA occlusion was defined as an occlusion that occurred secondary to embolization to a new territory after recanalization of a different LVO. Demographics, clinical presentation, imaging findings, endovascular treatment and outcome were reviewed. Results : There were twenty‐five patients with acute FPCA occlusion who underwent MT, distributed across 14 centers. Median NIHSS on presentation was 16. There were 76% (19/25) of patients who presented with primary FPCA occlusion and 24% (6/25) of patients who had a secondary FPCA occlusion. The configuration of the FPCA was full in 64% patients and partial or “fetal‐type” in 36% of patients. FPCA occlusion was missed on initial CTA in 21% of patients with primary FPCA occlusion (4/19). The site of occlusion was posterior communicating artery in 52%, P2 segment in 40% and P3 in 8% of patients. TICI 2b/3 reperfusion was achieved in 96% of FPCA patients. There were no intra‐procedural complications. At 90 days, 48% (12/25) were functionally independent as defined by mRS≤2. Conclusions : Endovascular treatment of acute FPCA occlusion is safe and technically feasible. A high index of suspicion is important to detect occlusion of the fetal posterior cerebral artery in patients presenting with anterior circulation stroke syndrome and patent anterior circulation.

Abstract WP290: Endovascular Treatment Of In-hospital Strokes: An Open Book

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Dolora Wisco ◽  
KEN UCHINO ◽  
ESTEBAN CHENG CHING ◽  
Shazia Alam ◽  
SHUMEI MAN ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Patient Characteristics ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Valve Repair ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Ct Brain ◽  
Contrast Ct ◽  
Iv Tpa

INTRODUCTION: In-hospital stroke (IHS) presents a different treatment challenge than out of hospital stroke. IHS often has contraindication to IV tPA, such as such as recent surgery, MI, and use of anticoagulation. Intra-arterial therapy (IAT) with tPA and/or mechanical thrombectomy is an option for large vessel acute IHS with contraindications to or fail to recanalize with IV tPA, to restore cerebral perfusion. Objective: To assess the characteristics and outcomes of patients with in-hospital strokes large vessel occlusion who receive IAT. Methods: From our database of patients from 1/1/2008 to 12/31/2011 who had IAT for an acute stroke due to large vessel occlusion, in hospital strokes and out of hospital strokes were identified. Patient characteristics, imaging, and outcomes were retrospectively collected. Statistical analysis was performed on JMP 9.0. Result: 151 patients were included, 23 (15%) were in-hospital strokes (IHS) and 128 (85%) were out of hospital strokes (OHS). Initial median NIHSS of 17 and 16 respectively (p=0.3). IHS were frequently in the cardiology/CTS service (14, 60%) for CHF and cardiac valve repair (12, 52%). Other comorbidities present were atrial fibrillation (68%), hypertension (68%), and hyperlipidemia (56%). Seven (30%) were on warfarin prior to admission, but all had subtherapeutic INR. Three (13%) IHS received IV tPA. The time from last known well (LKW) to non-contrast CT brain was 80 min, and to CTA was 113 min in IHS, and 147 min and 229 min respectively in OHS (p = 0.0003). 20 (87%) had lesion in the anterior circulation. LKW to IAT recanalization was 248 min in IHS, compared to 375 min in OHS. Recanalization rate was 68% for IHS and 81% for OHS (p=0.2). Nine (39%) IHS had favorable mRS of 1 to 3 at 90 days, compared to 44 (34%) OHS, (p = 0.6). Despite faster recanalization time, there was no difference in the 90 day mortality of IHS v OHS (48% vs 30%, p = 0.1), and IHS had greater 1 year mortality (65% vs 30%, p = 0.005). Discussion: In-hospital strokes have higher mortality than out of hospital strokes. There is a role for IAT In carefully selected IHS with large vessel occlusion. A multicenter study is needed to reveal the characteristics of IHS patients who may benefit from IAT.

A human brain test bed for research in large vessel occlusion stroke

2021 ◽  
pp. 1-9
Author(s):  
Daniel Gebrezgiabhier ◽  
Yang Liu ◽  
Adithya S. Reddy ◽  
Evan Davis ◽  
Yihao Zheng ◽  
...  
Keyword(s):  
Human Brain ◽  
Mechanical Thrombectomy ◽  
Posterior Circulation ◽  
Large Vessel ◽  
Suction Catheter ◽  
Large Vessel Occlusion ◽  
Test Bed ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Human Brains

OBJECTIVEEndovascular removal of emboli causing large vessel occlusion (LVO)–related stroke utilizing suction catheter and/or stent retriever technologies or thrombectomy is a new standard of care. Despite high recanalization rates, 40% of stroke patients still experience poor neurological outcomes as many cases cannot be fully reopened after the first attempt. The development of new endovascular technologies and techniques for mechanical thrombectomy requires more sophisticated testing platforms that overcome the limitations of phantom-based simulators. The authors investigated the use of a hybrid platform for LVO stroke constructed with cadaveric human brains.METHODSA test bed for embolic occlusion of cerebrovascular arteries and mechanical thrombectomy was developed with cadaveric human brains, a customized hydraulic system to generate physiological flow rate and pressure, and three types of embolus analogs (elastic, stiff, and fragment-prone) engineered to match mechanically and phenotypically the emboli causing LVO strokes. LVO cases were replicated in the anterior and posterior circulation, and thrombectomy was attempted using suction catheters and/or stent retrievers.RESULTSThe test bed allowed radiation-free visualization of thrombectomy for LVO stroke in real cerebrovascular anatomy and flow conditions by transmural visualization of the intraluminal elements and procedures. The authors were able to successfully replicate 105 LVO cases with 184 passes in 12 brains (51 LVO cases and 82 passes in the anterior circulation, and 54 LVO cases and 102 passes in the posterior circulation). Observed recanalization rates in this model were graded using a Recanalization in LVO (RELVO) scale analogous to other measures of recanalization outcomes in clinical use.CONCLUSIONSThe human brain platform introduced and validated here enables the analysis of artery-embolus-device interaction under physiological hemodynamic conditions within the unmodified complexity of the cerebral vasculature inside the human brain.

Abstract WP502: Predictors Of First Pass Reperfusion In Anterior Circulation Large Vessel Occlusion Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Mahmoud Mohammaden ◽  
Leonardo Pisani ◽  
Catarina Perry da Camara ◽  
Mehdi Bousalma ◽  
Alhamza Al bayati ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Univariate Analysis ◽  
Multivariate Regression Analysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Performance Metric ◽  
First Pass ◽  
Thrombectomy Device

Introduction: The speed and completeness of endovascular reperfusion strongly correlate with functional outcomes. First-Pass Reperfusion (FPR) has been recently established as a critical procedural performance metric for mechanical thrombectomy (MT). We aimed to study the predictors of FPR and its effect on the outcome Methods: Review of a prospectively collected database of MT patients with large vessel occlusion strokes (LVOS) from 05/2012-11/2018. Patients were included in the analysis if they had an anterior circulation LVOS that was successfully reperfused (mTICI 2b-3). FPR was defined as the achievement of mTICI 2c-3 after a single pass with any thrombectomy device. Uni- and multivariate analyses were performed to identify the independent predictors of FPR. Results: A total of 563 patients qualified for the analysis (mean age, 64.4±12.3 years, baseline NIHSS 16.2). FPR was achieved in 202 (35.9%) patients. On univariate analysis, FPR was significantly associated with higher ASPECTS (8.1 vs. 7.8, p=0.008), higher usage of balloon guide catheters (BGC) (88.1% vs. 75.3%, p<0.001), lower use of general anesthesia (9.5% vs. 18.2%, p= 0.006), and shorter procedure duration (mean, 45.5 vs. 79.9 min, p <0.001 and 90.5%). Both BGC (OR, 2.26; 95%CI [1.32-3.87], p=0.003) and ASPECTS (OR, 1.15; 95% CI [1.03-1.28], p= 0.01) were independent predictors of FPE on multivariate regression analysis. Conclusion: Higher baseline ASPECTS score and the use of BGC are strong predictors of First-Pass Reperfusion in mechanical thrombectomy.

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.

scholarly journals Endovascular Treatment of Stroke Caused by Carotid Artery Dissection

2020 ◽  
Vol 10 (11) ◽  
pp. 800
Author(s):  
Grzegorz Meder ◽  
Milena Świtońska ◽  
Piotr Płeszka ◽  
Violetta Palacz-Duda ◽  
Dorota Dzianott-Pabijan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Endovascular Treatment ◽  
Small Proportion ◽  
Mechanical Thrombectomy ◽  
Carotid Artery Dissection ◽  
Large Vessel ◽  
Artery Dissection ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Ischemic stroke due to large vessel occlusion (LVO) is a devastating condition. Most LVOs are embolic in nature. Arterial dissection is responsible for only a small proportion of LVOs, is specific in nature and poses some challenges in treatment. We describe 3 cases where patients with stroke caused by carotid artery dissection were treated with mechanical thrombectomy and extensive stenting with good outcome. We believe that mechanical thrombectomy and stenting is a treatment of choice in these cases.

Transradial versus transfemoral access for anterior circulation mechanical thrombectomy: comparison of technical and clinical outcomes

2019 ◽  
Vol 11 (9) ◽  
pp. 874-878 ◽  
Author(s):  
Stephanie H Chen ◽  
Brian M Snelling ◽  
Samir Sur ◽  
Sumedh Subodh Shah ◽  
David J McCarthy ◽  
...  
Keyword(s):  
Aortic Arch ◽  
Mechanical Thrombectomy ◽  
Vascular Anatomy ◽  
Patient Characteristics ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Cohort Differences ◽  
Number Of Passes

BackgroundA transradial approach (TRA) is associated with fewer access site complications than a transfemoral technique (TFA).However, there is concern that performing mechanical thrombectomy (MT) via TRA may lead to longer revascularization times and thus worse outcomes. Nonetheless, TRA may confer added benefits in MT since navigation of challenging aortic arch and carotid anatomy is often facilitated by a right radial artery trajectory.ObjectiveTo compare outcomes in patients who underwent MT via TRA versus TFA.MethodsWe performed a retrospective review of our institutional database to identify 51 patients with challenging vascular anatomy who underwent MT for anterior circulation large vessel occlusion between February 2015 and February 2018. Patient characteristics, procedural techniques, and outcomes were recorded. TFA and TRA cohorts were compared.ResultsOf the 51 patients, 18 (35%) underwent MT via TRA. There were no significant cohort differences in patient characteristics, clot location, or aortic arch type and presence of carotid tortuosity. There were no significant differences in outcomes between the two cohorts, including single-pass recanalization rate (54.5% vs 55.6%, p=0.949) and average number of passes (1.9 vs 1.7, p=0.453). Mean access-to-reperfusion time (61.9 vs 61.1 min, p=0.920), successful revascularization rates (Thrombolysis in Cerebral Infarction score ≥2b 87.9% vs 88.9%, p=1.0) and functional outcomes (modified Rankin Scale score≤2, 39.4% vs 33.3%, p=0.669) were similar between TFA and TRA cohorts, respectively.ConclusionsOur results demonstrate equivalence in efficacy and efficiency between TRA and TFA for MT of anterior circulation large vessel occlusion in patients with challenging vascular anatomy. TRA may be better than TFA in well-selected patients undergoing MT.

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