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

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.

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

The Neuroradiology Journal ◽

10.1177/19714009211019383 ◽

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.

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Mechanical Thrombectomy of the Fetal Posterior Cerebral Artery

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.121.000115 ◽

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.

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Utility of a Y-configured stentriever technique as a rescue method of thrombectomy for an intractable rooted thrombus located on the middle cerebral artery bifurcation: technical note

Neurosurgical FOCUS ◽

10.3171/2017.1.focus16511 ◽

2017 ◽

Vol 42 (4) ◽

pp. E17 ◽

Cited By ~ 4

Author(s):

Hideo Okada ◽

Yoshikazu Matsuda ◽

Joonho Chung ◽

R. Webster Crowley ◽

Demetrius K. Lopes

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Gold Standard ◽

Mechanical Thrombectomy ◽

Technical Note ◽

Large Vessel ◽

Alternative Technique ◽

Large Vessel Occlusion ◽

Vessel Occlusion

Mechanical thrombectomy with stentriever and/or aspiration is the new gold standard for the treatment of acute strokes with large-vessel occlusion. As many as 20% of cases remain refractory to current stentriever and/or aspiration devices. “Saddle clots” obstructing a bifurcation may be a particular challenge for recanalization with conventional techniques and devices. The authors describe an alternative technique to bifurcation occlusions resistant to the conventional mechanical thrombectomy approach in which they simultaneously deployed 2 stentrievers into both branches of an occluded bifurcation. This stentriever Y-configuration was very effective in managing a challenging intracranial bifurcation occlusion.

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P-042 Initial experience with tenecteplase as the intravenous thrombolytic of choice before mechanical thrombectomy for large vessel occlusion acute ischemic stroke

10.1136/neurintsurg-2021-snis.78 ◽

2021 ◽

Author(s):

U Ugur ◽

S Platko ◽

D Peters ◽

F Bensabeur ◽

J Terry ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Large Vessel ◽

Initial Experience ◽

Large Vessel Occlusion ◽

Vessel Occlusion

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Mechanical thrombectomy versus intravenous thrombolysis for distal large-vessel occlusion: a systematic review and meta-analysis of observational studies

Neurosurgical FOCUS ◽

10.3171/2021.4.focus21139 ◽

2021 ◽

Vol 51 (1) ◽

pp. E5

Author(s):

Muhammad Waqas ◽

Cathleen C. Kuo ◽

Rimal H. Dossani ◽

Andre Monteiro ◽

Ammad A. Baig ◽

...

Keyword(s):

Systematic Review ◽

Cerebral Artery ◽

Medical Management ◽

Mechanical Thrombectomy ◽

Meta Analysis ◽

Intravenous Thrombolysis ◽

Large Vessel ◽

Cochrane Library ◽

Large Vessel Occlusion ◽

Vessel Occlusion

OBJECTIVE While several studies have compared the feasibility and safety of mechanical thrombectomy (MT) for distal large-vessel occlusion (LVO) strokes in patients, few studies have compared MT with intravenous thrombolysis (IVT) alone. The purpose of this systematic review was to compare the effectiveness and safety between MT and standard medical management with IVT alone for patients with distal LVOs. METHODS PubMed, Google Scholar, Embase, Scopus, Web of Science, Ovid Medline, and Cochrane Library were searched in order to identify studies that directly compared MT with IVT for distal LVOs (anterior cerebral artery A2, middle cerebral artery M3–4, and posterior cerebral artery P2–4). Primary outcomes of interest included a modified Rankin Scale (mRS) score of 0 to 2 at 90 days posttreatment, occurrence of symptomatic intracerebral hemorrhage (sICH), and all-cause mortality at 90 days posttreatment. RESULTS Four studies representing a total of 381 patients were included in this meta-analysis. The pooled results indicated that the proportion of patients with an mRS score of 0 to 2 at 90 days (OR 1.16, 95% CI 0.23–5.93; p = 0.861), the occurrence of sICH (OR 2.45, 95% CI 0.75–8.03; p = 0.140), and the mortality rate at 90 days (OR 1.73, 95% CI 0.66–4.55; p = 0.263) did not differ between patients who underwent MT and those who received IVT alone. CONCLUSIONS The meta-analysis did not demonstrate a significant difference between MT and standard medical management with regard to favorable outcome, occurrence of sICH, or 90-day mortality. Prospective clinical trials are needed to further compare the efficacy of MT with IVT alone for distal vessel occlusion.

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Endovascular intervention of acute ischemic stroke due to occlusion of fetal posterior cerebral artery

Interventional Neuroradiology ◽

10.1177/1591019918801285 ◽

2018 ◽

Vol 25 (2) ◽

pp. 202-207 ◽

Cited By ~ 1

Author(s):

Krishna Amuluru ◽

James P Ho ◽

Fawaz Al-Mufti ◽

Sten Solander ◽

Charles E Romero

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Cerebral Artery ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Posterior Cerebral Artery ◽

Endovascular Intervention ◽

Large Vessel Occlusion ◽

Cerebral Infarcts ◽

Vessel Occlusion

A fetal posterior cerebral artery (FPCA) is an anatomic variant in which the posterior cerebral artery is an embryological derivative of the internal carotid artery. Although most cases of ischemic strokes in patients with FPCAs involve embolic infarcts, emergent large vessel occlusion of a FPCA is extremely rare. We present two cases of successful endovascular intervention for emergent occlusion of a FPCA, one of which is only the second reported case of a mechanical thrombectomy of a FPCA. We review the embryology of FPCA, the controversy regarding its association with cerebral infarcts, and various approaches used in the treatment of such occlusive lesions.

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

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000207 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

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.

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