scholarly journals Mechanical Thrombectomy for Sequential Bilateral Middle Cerebral Artery Occlusions in a Patient With Recurrent Cryptogenic Strokes: A Case Report

2020 ◽  
Vol 11 (1) ◽  
pp. 54-58
Author(s):  
Matthew J. Kercher ◽  
Dinesh Ramanathan ◽  
Brian C. Dahlin ◽  
Alan H. Yee ◽  
Jared W. Clouse ◽  
...  
Keyword(s):  
Cerebral Ischemia ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Dual Antiplatelet Therapy ◽  
Recurrent Stroke ◽  
Reperfusion Therapy ◽  
Vessel Occlusion ◽  
Normal Functional ◽  
Ischemic Syndrome

Recurrent sequential mechanical thrombectomy for cryptogenic large vessel occlusion (LVO) can lead to excellent clinical outcome. A 68-year-old right-handed male presented with an acute proximal right middle cerebral artery (MCA) ischemic syndrome and underwent successful revascularization by mechanical thrombectomy with normal functional recovery. He was treated with dual antiplatelet therapy for 2 months following discharge, however later discontinued clopidogrel due to side effects. He then developed a recurrent, contralateral MCA occlusion 16 months later and once again received emergent endovascular reperfusion therapy with excellent neurological outcome. He has remained on off-label empiric oral anticoagulation since and has not had recurrent stroke nor evidence of cerebral ischemia. Favorable clinical outcomes can be achieved in patients despite recurrent LVO who underwent emergent mechanical thrombectomy. Optimal antithrombotic secondary stroke prevention strategies following embolic stroke of unknown source remains uncertain as recent evidence does not support rivaroxaban or dabigatran over aspirin. The benefit of apixaban over aspirin for the prevention of recurrent cerebral ischemia is under current investigation.

Abstract P539: Comparison of Transradial Artery versus Transfemoral Artery Access for Solumbra Technique in Mechanical Thrombectomy

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Taha Nisar ◽  
Jimmy Patel ◽  
Muhammad Z Memon ◽  
Amit Singla ◽  
Priyank Khandelwal
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Arrival Time ◽  
Mechanical Thrombectomy ◽  
Retrospective Chart Review ◽  
Functional Independence ◽  
Binary Logistic Regression Analysis ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Number Of Patients

Introduction: Solumbra technique involves the simultaneous use of stent-retriever and large-bore aspiration for clot retrieval in mechanical thrombectomy (MT). We aim to compare various time parameters in patients who undergo MT via solumbra technique via transradial artery (TRA) approach vs. transfemoral artery (TRF) approach. Methods: We performed a retrospective chart review of patients who underwent MT via solumbra technique for anterior circulation large vessel occlusion at a comprehensive stroke center from 7/2014 to 5/2020. We compared time to recanalization parameters, score of TICI≥2b, and functional independence (3-month mRS≤2) in patients who underwent MT via TRA vs.TRF approach via the solumbra technique. A binary logistic regression analysis was performed, controlling for age, sex, pre-treatment-NIHSS, type of anesthesia (general vs.moderate), laterality, and clot location [proximal (internal carotid or M1 segment of the middle cerebral artery) vs.distal (M2 or M3 segment of the middle cerebral artery)]. Results: A total of 98 patients met our inclusion criteria. The mean age was 63.59±14.40 years. 18 (18.37%) patients underwent MT through transradial approach. In our cohort, there was a significant association of TRA with shorter angio suite arrival-time to puncture-time (22.12±9.92mins vs.28.83±12.26mins; OR, 0.94; 95% CI, 0.88-1; P 0.026), but not with puncture-time to recanalization-time (84.34±61.34mins vs.63.73±35.29mins; OR, 1.01; 95% CI, 1-1.03; P 0.085), angio suite arrival-time to recanalization-time (103.12±51.29mins vs.93.42±39.08mins; OR, 1.01; 95% CI, 1-1.02; P 0.524), number of passes to recanalization (1.78±1.36 vs.1.68±1.05; OR, 1.03; 95% CI, 0.66-1.63 ; P 0.899), number of patients with TICI≥2b (83.34% vs.91.25%; OR, 0.68; 95% CI, 0.14-3.4; P 0.633), and functional independence (66.67% vs.78.75%; OR, 0.49; 95% CI, 0.13-1.86; P 0.292), when compared to TRF approach for MT using solumbra technique. Conclusion: Our study demonstrates a significant association between TRA approach with shorter angio suite arrival-time to puncture-time but not with overall time to recanalization, number of patients with TICI≥2b, and functional independence, when compared to TRF approach for MT using solumbra technique.

scholarly journals Impact of early division of the middle cerebral artery on outcome following mechanical thrombectomy

2020 ◽  
Vol 26 (4) ◽  
pp. 389-395
Author(s):  
Hanna Styczen ◽  
Volker Maus ◽  
Amélie C Hesse ◽  
Lukas Goertz ◽  
Sebastian Fischer ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Intracranial Hemorrhage ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Tertiary Care ◽  
Time Interval ◽  
Large Artery ◽  
Vessel Occlusion ◽  
Symptomatic Intracranial Hemorrhage ◽  
Tertiary Care Centers

Background Mechanical thrombectomy has become the standard care for acute ischemic stroke caused by large vessel occlusion. However, complete reperfusion cannot be achieved in all cases, and several factors influencing the results of mechanical thrombectomy have been investigated. Among others, a tortuous anatomy is associated with lower rates of complete reperfusion. We aimed to investigate whether an early division of the middle cerebral artery has an impact on reperfusion results in mechanical thrombectomy. Methods Retrospective review of consecutive patients with M1 occlusion treated endovascularly between January 2016 and December 2019 at three tertiary care centers. The study group was dichotomized based on the length of the M1 segment. Early division of the middle cerebral artery was defined as a maximum length of 10 mm of the M1 segment. Primary endpoints were first-pass mTICI scores of 3, ≥2c, and ≥2b. Secondary endpoints contained final reperfusion, number of device-passes, time interval from groin puncture to reperfusion, rate of postinterventional symptomatic intracranial hemorrhage, and frequency of emboli of new territory. Results Among 284 included patients, 70 presented with an early division of the M1 segment (25%). Reperfusion results did not differ significantly between early and late division of M1. A higher rate of symptomatic intracranial hemorrhage was found in the group with an early M1 division treated with aspiration only (14.3% vs. 0%; p = 0.013). Patients with late M1 division had a significantly higher rate of large artery sclerosis (19.2% vs. 8.6%, p = 0.039). Conclusion The anatomic variant of an early division of the middle cerebral artery was not a predictor for incomplete reperfusion.

scholarly journals 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

2017 ◽  
Vol 42 (4) ◽  
pp. E17 ◽  
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.

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 Direct thrombectomy versus bridging thrombolysis with mechanical thrombectomy in middle cerebral artery stroke: a real-world analysis through National Inpatient Sample data

2021 ◽  
Vol 51 (1) ◽  
pp. E4
Author(s):  
Sandeep Kandregula ◽  
Amey R. Savardekar ◽  
Pankaj Sharma ◽  
Jerry McLarty ◽  
Jennifer Kosty ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Real World ◽  
Mechanical Thrombectomy ◽  
Smoking Status ◽  
Combined Treatment ◽  
Intravenous Thrombolysis ◽  
National Inpatient Sample ◽  
Real World Data ◽  
Vessel Occlusion

OBJECTIVE A paradigm shift in the management of acute ischemic stroke (AIS) due to large-vessel occlusion (LVO) occurred after 2015 when 7 randomized controlled trials demonstrated better outcomes using second-generation thrombectomy devices combined with best medical management than did stand-alone intravenous thrombolysis (IVT) with tissue plasminogen activator (tPA). All recently published landmark trials were designed to study the outcome of mechanical thrombectomy (MT); therefore, the majority of the patients enrolled in these trials received intravenous tPA. Currently, initiating IVT before MT is a matter of debate. Recent trials (DIRECT-MT, DEVT) exploring this clinical question showed noninferiority of MT alone compared with the combined treatment. With this uncertainty, the authors aimed to explore real-world data through the latest National Inpatient Sample (NIS) to compare the safety and outcomes of MT alone with bridging IVT and MT in AIS due to LVO in the middle cerebral artery (MCA). METHODS NIS data from 2017 to 2018 were analyzed to compare the outcomes and safety profiles of patients who underwent MT+IVT with those who underwent MT alone. RESULTS A total of 2895 patients were included in the final analysis (MT, n = 1669; MT+IVT, n = 1226). The mean National Institutes of Health Stroke Scale score was 16.2 (SD 6.1) in the MT group and 16.6 (SD 5.97) in the MT+IVT group (p = 0.04). With respect to comorbidities, the two groups did not differ in rates of hypertension (p = 0.730), atrial fibrillation/flutter (p = 0.828), and smoking status (p = 0.914). The rate of diabetes mellitus was significantly higher in the MT group (28%) than in the MT+IVT group (22.1%) (p < 0.001). The frequency of intracerebral hemorrhage (ICH) in the MT group was 17.7% (n = 296) and 21.5% (n = 263) in the MT+IVT group (p = 0.012). Intraventricular hemorrhage (p = 0.875), subarachnoid hemorrhage (p = 0.99), and vasospasm (p = 0.976) did not differ significantly between the groups. The primary outcome considered was disability status between the groups; 23.8% of patients in the MT+IVT group had minimal disability versus 18.2% in the MT group (p = 0.001). The risk of progressing to severe disability from minimal disability decreased with the addition of IVT to MT (OR 0.762, 95% CI 0.637–0.912). The adjusted odds ratio for ICH in the MT+IVT group was 1.28 (95% CI 1.043–1.571, p = 0.018) and 2.676 (95% CI 1.259–5.686, p = 0.01) for access-site hemorrhages. CONCLUSIONS In the analysis of the NIS database, the MT+IVT group had significantly higher rates of minimal disability at the time of hospital discharge versus the MT-alone group, despite a higher rate of ICH. The question of whether to treat patients with MT+IVT rather than MT alone is currently being addressed in ongoing prospective clinical trials (SWIFT-DIRECT [NCT03494920], MR CLEAN–NO IV [ISRCTN80619088], and DIRECT-SAFE [NCT03494920]). The results of these studies will contribute to greater understanding and progressive improvement in outcomes for AIS patients.

scholarly journals Short-Vessel Occlusion Might Indicate Higher Possibility of Success in Reperfusion following Mechanical Thrombectomy in Acute Middle Cerebral Artery Occlusion

2021 ◽  
pp. 131-136
Author(s):  
Tomoyuki Yoshihara ◽  
Ryuzaburo Kanazawa ◽  
Takanori Uchida ◽  
Tetsuhiro Higashida ◽  
Hidenori Ohbuchi ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Active Zone ◽  
Mechanical Thrombectomy ◽  
Area Under The Curve ◽  
Maximum Intensity Projection ◽  
Stent Retriever ◽  
Vessel Occlusion ◽  
Mca Occlusion ◽  
The Impact

<b><i>Background:</i></b> The impact of the length of the occluded vessel in acute large-vessel occlusion on successful reperfusion by mechanical thrombectomy remains unclear. This study evaluated whether diameter and length of the occluded vessel in acute middle cerebral artery (MCA) occlusion might relate to successful reperfusion following mechanical thrombectomy. <b><i>Methods:</i></b> This retrospective study included patients with acute MCA occlusion who underwent intra-aortic injection of contrast medium to obtain maximum intensity projection (MIP) images acquired by flat-panel detector computed tomography (FD-CT) equipped with an angiographic system. All patients received mechanical thrombectomy and were divided into two groups: those with successful reperfusion (Thrombolysis in Cerebral Infarction [TICI] 2b/3) and those without. We compared the diameter and length of the occluded vessel between the groups. In the sub-analysis of patients with stent retriever use, ratio of length of occluded vessel to length of the active zone was compared. <b><i>Results:</i></b> We enrolled 29 patients (median age: 73, M1 occlusion: 51%, stent retriever use: 72%). Eighteen patients achieved TICI 2b/3 with significantly larger distal end diameter (1.7 [interquartile range: 1.5–1.9] vs. 1.2 [1.2–1.5] mm, <i>p</i> = 0.007) and shorter length (7.1 [4.9–9.7] vs. 12.3 [7.2–15.8] mm, <i>p</i> = 0.043) of the occluded vessel. Sub-analysis of 21 patients showed that the cut-off value for TICI 2b/3 reperfusion was 0.32 as the ratio between the occluded vessel and stent retriever active zone (receiver operating characteristic area under the curve: 0.90). <b><i>Conclusion:</i></b> In acute MCA occlusion, larger diameter of the distal end and shorter length of the occluded vessel on FD-CT MIP images might indicate a higher possibility of achieving TICI 2b/3 following mechanical thrombectomy.

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.

Abstract P517: The Effect of Unfavorable Vascular Anatomy on Mechanical Thrombectomy for Middle Cerebral Artery Occlusion Strokes Preliminary Evaluation of the AIM2 Score System

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Okkes Kuybu ◽  
Mahmoud Mohammaden ◽  
Diogo C Haussen ◽  
Alhamza R Al-bayati ◽  
Samir R Belagaje ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Vascular Anatomy ◽  
Preliminary Evaluation ◽  
Vessel Occlusion ◽  
Simple Method ◽  
Score System ◽  
Significant Difference ◽  
The Impact

Background: Time to reperfusion remains one of the strongest predictors of outcome in large vessel occlusion strokes (LVOS). Herein, we aim to assess the impact of unfavorable vascular anatomy on mechanical thrombectomy (MT) number of passes and procedural times. Methods: Retrospectively review of a prospective MT database spanning January-July 2018 including acute LVOS involving the middle cerebral artery-M1 segment and available baseline CT angiography. The AIM2 score (Table 1) was applied with patients categorized as favorable (AIM2: 0-2) versus unfavorable (AIM2: >=3) anatomy. The primary outcome was the rate of <3 device passes. Secondary outcomes included procedural times and the rates of successful reperfusion (mTICI2b-3) and 90-day mRS 0-2. Safety measures included rates of sICH and 90-day mortality. Results: Patients with unfavorable anatomy (n=15) were significantly younger (52±19, p=0.02) and had lower rates of hypertension (46% vs 80%, p=0.01) and smoking (0% vs 39%, p<0.001) versus those with favorable anatomy (n=50). Successful reperfusion with <3 passes was more often achieved with AIM2 scores 0-2 vs. ≥3 (84% vs 60%, p=0.04). There were no significant difference in other outcome measures (Table 2). Conclusions: The AIM2 score system represents a simple method for the systematically evaluation of vascular anatomy in MT and correlates significantly with increased number of MT passes.

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