Major vessel occlusion may predict subtherapeutic anticoagulation intensity and feasibility of administration of intravenous thrombolytics

Objective: Although Diffusion-weighted imaging (DWI) lesions are commonly irreversible, DWI lesion volume reduction (DVR) is occasionally observed. We investigated clinical significance and predictors of DVR in acute stroke patients with major vessel occlusion receiving recanalization therapy (RT). Methods: The Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism (RESCUE)-Japan registry prospectively registered 1,442 stroke patients with major vessel occlusion who were admitted to 84 Japanese stroke centers within 24 hours after onset from July 2010 to June 2011. We retrospectively analyzed all patients with the internal carotid artery or middle cerebral artery (M1 or M2 segments occlusions receiving RT and undergoing MRI both on admission and at 24 hours after onset from the registry. We defined DVR as a 1 or more-point reduction of the DWI-Alberta Stroke Program Early CT Score (ASPECTS), and CT-DWI mismatch (CTDM) as a 2 or more-point lower DWI-ASPECTS than CT-ASPECTS on admission. Reperfusion was defined as TICI grade 2b-3 on catheter angiography or modified Mori grade 3 on MRA immediately after RT. Dramatic recovery (DR) was defined as a 10 or more-point reduction or a total NIHSS score of 0-1 at 24 hours, and favorable outcome (FO) defined as a mRS score 0-2 at 3 months. Results: A total of 390 patients (215 men, 72 years old,) was included. Median baseline NIHSS score was 16 (IQR 10-19) and median baseline DWI-ASPECTS was 8 (6-9). CTDM was seen in 92 patients (28%) on admission. Intravenous thrombolysis and endovascular therapy were performed in 246 patients (63%) and 223 patients (57%), respectively. Reperfusion was obtained in 170 patients (51%). DVR was seen in 51 patients (13%). Eighty-eight patients (23%) obtained DR and 158 patients (41%) achieved FO. On multivariate analyses, DVR was significantly related to DR (OR 3.8, 95%CI 1.5-10) and FO (4.6, 1.8-12). CTDM was an independent predictor of DVR (OR 2.5, 95% CI 1.1-5.8). Conclusions: DVR was significantly related to DR and FO. CTDM is a rough predictor of DVR of which area is considered as a “DWI-bright” ischemic penumbra, and might be a useful marker to identify the adequate candidates for RT in spite of relatively large DWI lesions.

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Patterns in neurosurgical adverse events: open cerebrovascular neurosurgery

Neurosurgical FOCUS ◽

10.3171/2012.7.focus12181 ◽

2012 ◽

Vol 33 (5) ◽

pp. E15 ◽

Cited By ~ 33

Author(s):

Judith M. Wong ◽

John E. Ziewacz ◽

Allen L. Ho ◽

Jaykar R. Panchmatia ◽

Albert H. Kim ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Adverse Events ◽

Significant Proportion ◽

Current Evidence ◽

Neurophysiological Monitoring ◽

Complication Rates ◽

Vessel Occlusion ◽

Surgeon Experience ◽

Major Vessel ◽

Monitoring Technologies

Object As part of a project to devise evidence-based safety interventions for specialty surgery, we sought to review current evidence concerning the frequency of adverse events in open cerebrovascular neurosurgery and the state of knowledge regarding methods for their reduction. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice. Methods The authors performed a PubMed search using search terms “cerebral aneurysm”, “cerebral arteriovenous malformation”, “intracerebral hemorrhage”, “intracranial hemorrhage”, “subarachnoid hemorrhage”, and “complications” or “adverse events.” Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the reported adverse events. Results The review revealed hemorrhage-related hyperglycemia (incidence rates ranging from 27% to 71%) and cerebral salt-wasting syndromes (34%–57%) to be the most common perioperative adverse events related to subarachnoid hemorrhage (SAH). Next in terms of frequency was new cerebral infarction associated with SAH, with a rate estimated at 40%. Many techniques are advocated for use during surgery to minimize risk of this development, including intraoperative neurophysiological monitoring, but are not universally used due to surgeon preference and variable availability of appropriate staffing and equipment. The comparative effectiveness of using or omitting monitoring technologies has not been evaluated. The incidence of perioperative seizure related to vascular neurosurgery is unknown, but reported seizure rates from observational studies range from 4% to 42%. There are no standard guidelines for the use of seizure prophylaxis in these patients, and there remains a need for prospective studies to support such guidelines. Intraoperative rupture occurs at a rate of 7% to 35% and depends on aneurysm location and morphology, history of rupture, surgical technique, and surgeon experience. Preventive strategies include temporary vascular clipping. Technical adverse events directly involving application of the aneurysm clip include incomplete aneurysm obliteration and parent vessel occlusion. The rates of these events range from 5% to 18% for incomplete obliteration and 3% to 12% for major vessel occlusion. Intraoperative angiography is widely used to confirm clip placement; adjuncts include indocyanine green video angiography and microvascular Doppler ultrasonography. Use of these technologies varies by institution. Discussion A significant proportion of these complications may be avoidable through development and testing of standardized protocols to incorporate monitoring technologies and specific technical practices, teamwork and communication, and concentrated volume and specialization. Collaborative monitoring and evaluation of such protocols are likely necessary for the advancement of open cerebrovascular neurosurgical quality.

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Abstract WP43: Diffusion and T2 Star Weighted MR Angiography Mismatch Predicts Ischemic Penumbra in the Acute Stage

Stroke ◽

10.1161/str.48.suppl_1.wp43 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Susumu Yamaguchi ◽

Nobutaka Horie ◽

Yohei Tateishi ◽

MInoru Morikawa ◽

Kazuhiko Suyama ◽

...

Keyword(s):

Ischemic Stroke ◽

Contrast Media ◽

Mr Angiography ◽

Acute Stage ◽

The Other ◽

Unknown Etiology ◽

Ischemic Penumbra ◽

Vessel Occlusion ◽

Major Vessel

Background and purpose: T2 star weighted MR angiography (SWAN) can detect hemodynamic insufficiency as hypointensity areas in the medullary or cortical veins. In this study, we investigate whether SWAN in 1.5T MRI can help to detect ischemic penumbra-like lesions in acute ischemic stroke (AIS) patients. Materials and methods: Patients showing acute major vessel occlusion (ICA and MCA) within 4.5 hours from onset were consecutively analyzed with MRI including SWAN, DWI, and MRA. To evaluate ischemic area in SWAN and DWI, modified ASPECT (mASPECTS) were used. SWAN- and DWI- based mASPECTS was calculated, and correlation between DWI-SWAN mismatch and final infarct lesion or outcome was evaluated. Results: Thirty-five patients were included in this study. Of the 35 patients (mean age: 73.5 ± 13.5 years), cardioembolic stroke was confirmed in 26 patients, atherothrombotic stroke was in 4 patients, and the others had unknown etiology. Overall, recanalization was achieved in 23 patients (65%), showing higher mASPECTS in follow up DWI and lower mRS at 90 days than patients with no recanalization ( P =0.037 and P <0.001). Initial SWAN-based mASPECTS and follow-up DWI-based mASPECTS were both significantly higher in atherothrombotic stroke than in cardiogenic stroke ( P =0.016 and P =0.042). Of 12 patients showing no recanalization, DWI-SWAN mismatch was significantly correlated with infarct growth (R 2 =0.6160, P =0.0025). On the other hand, there was no such correlation for patients showing recanalization. Interestingly, initial SWAN-based mASPECTS was significantly correlated with mRS at 90 days (R=-0.38, P =0.037) regardless of recanalization. Conclusions: DWI-SWAN mismatch in 1.5T MRI could show penumbra-like lesions in AIS patients with major vessel occlusion. Low mASPECTS in initial SWAN might predict unfavorable outcome. Assessment of ischemic penumbra from venous side using SWAN can visualize a lesion’s viable tissue and is quite useful without contrast media.

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Non-invasive methods for identifying major vessel occlusion in acute cerebral infarction: correlation between CT findings and Doppler patterns of underlying vascular pathology

Proceedings of the XIV Symposium Neuroradiologicum ◽

10.1007/978-3-642-49329-4_83 ◽

1991 ◽

pp. 258-259

Author(s):

A. R. Naylor ◽

R. J. Sellar ◽

P. A. G. Sandercock ◽

M. V. Merrick ◽

C. P. Warlow

Keyword(s):

Cerebral Infarction ◽

Acute Cerebral Infarction ◽

Vascular Pathology ◽

Vessel Occlusion ◽

Non Invasive ◽

Ct Findings ◽

Major Vessel

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Cellular Components with Adaptive Responses Contributing to Expansion and Repair Process of Ischemic Brain Damages Caused by Major Vessel Occlusion

Maturation Phenomenon in Cerebral Ischemia IV ◽

10.1007/978-3-642-59446-5_22 ◽

2001 ◽

pp. 181-187

Author(s):

M. Matsumoto ◽

K. Kitagawa ◽

T. Mabuchi ◽

M. Hori ◽

T. Yanagihara

Keyword(s):

Repair Process ◽

Adaptive Responses ◽

Vessel Occlusion ◽

Ischemic Brain ◽

Major Vessel ◽

Cellular Components

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Paroxysmal Atrial Fibrillation in Cryptogenic Stroke Patients With Major-Vessel Occlusion

Frontiers in Neurology ◽

10.3389/fneur.2020.580572 ◽

2020 ◽

Vol 11 ◽

Author(s):

Ryosuke Doijiri ◽

Hiroshi Yamagami ◽

Masafumi Morimoto ◽

Tomonori Iwata ◽

Tetsuya Hashimoto ◽

...

Keyword(s):

Atrial Fibrillation ◽

Paroxysmal Atrial Fibrillation ◽

Cryptogenic Stroke ◽

Stroke Patients ◽

Vessel Occlusion ◽

Major Vessel

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Routine Cerebral Angiography after Surgery for Saccular Aneurysms: Is It Worth It?

Neurosurgery ◽

10.1227/01.neu.0000141043.07303.60 ◽

2004 ◽

Vol 55 (5) ◽

pp. 1015-1024 ◽

Cited By ~ 66

Author(s):

Riku P. Kivisaari ◽

Matti Porras ◽

Juha Öhman ◽

Jari Siironen ◽

Keisuke Ishii ◽

...

Keyword(s):

Posterior Circulation ◽

Consecutive Series ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Intraoperative Angiography ◽

Unruptured Aneurysms ◽

Giant Aneurysms ◽

Complex Aneurysms ◽

Major Vessel ◽

Anterior Circulation Aneurysms

Abstract OBJECTIVE: The objective of this study was to determine whether an angiographically proven rate of saccular intracranial aneurysm occlusion after surgical clipping suggests that postoperative angiography should continue to be used routinely or should be supplanted by intraoperative angiography. These data also should establish a basis for comparing surgery with new endovascular methods of treatment. METHODS: During a 3.5-year period, a consecutive series of 622 patients (955 aneurysms, 808 of which were surgically clipped) who underwent postoperative angiography were studied retrospectively. This series comprised 493 ruptured and 315 unruptured aneurysms. RESULTS: Complete aneurysm closure was achieved in 88% of aneurysms, a neck remnant was discovered in 9%, and a fundus remnant was revealed in 3%. Of 493 ruptured aneurysms, 86% were completely occluded. Of 315 unruptured aneurysms, 91% were completely occluded. The results for clipping of complex aneurysms, i.e., posterior circulation or large to giant aneurysms, were significantly inferior to those for small and anterior circulation aneurysms. In one-third of the large and giant aneurysms, a part of the base was left intentionally because of calcifications or strong wall or to prevent occlusion of any branches. In the series, a significant 5% complication rate of major vessel occlusion was detected. CONCLUSION: Our retrospective analysis revealed that ruptured, posterior circulation, and large/giant aneurysms are more prone to incomplete clipping. Therefore, these aneurysms require postoperative if not intraoperative evaluation with angiography. Many clippings of anterior circulation aneurysms experience unexpected failures, which suggests that intraoperative angiography could be beneficial. This series, which has no selection bias, can be used as a basis to compare the results of other series reporting surgical or endovascular treatment.

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