Safety of intravenous thrombolysis and mechanical thrombectomy in bilateral posterior cerebral artery territory infarction.

2021 ◽  
Vol 16 ◽  
Author(s):  
Maurizio Acampa ◽  
Francesca Guideri ◽  
Sandra Bracco ◽  
Rossana Tassi ◽  
Carlo Domenichelli ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Controlled Trial ◽  
Cerebral Arteries ◽  
Intravenous Thrombolysis ◽  
Cortical Blindness ◽  
Posterior Circulation ◽  
Neurological Deficits ◽  
Complete Revascularization ◽  
Mechanical Thrombolysis ◽  
Acute Hemorrhage

Background: Acute bilateral blindness is an uncommon phenomenon, that requires immediate diagnosis and action. The emergent evaluation should concentrate on an early distinction between ocular, cortical, and psychogenic etiologies. Objective: To present a case of cortical blindness without anosognosia due to the embolic occlusion of both posterior cerebral arteries (PCAs) and treated by intravenous and mechanical thrombolysis. Case Report: A 67-year-old woman was admitted to the Stroke Unit due to cortical blindness without anosognosia. At the admission to the Hospital an emergent computed tomography scan of the brain ruled out intracranial acute hemorrhage and showed subtle changes consistent with hyperacute ischemia of the left occipital cortex, while a CT angiography demonstrated the occlusion of the P3 segment of both right and left posterior cerebral arteries. The patient was treated with combined thrombolysis (intravenous and mechanical thrombolysis), obtaining the complete revascularization and a significant clinical improvement. Conclusion: Even if there is no randomized controlled trial to compare the effectiveness and safety of mechanical thrombectomy (MT) to intravenous thrombolysis in patients with posterior circulation occlusion, the good outcome of this case encourages combined stroke treatments in posterior circulation stroke, even in case of mild but disabling neurological deficits.

Intravenous thrombolysis pretreatment and other predictors of infarct in a new previously unaffected territory (INT) in ELVO strokes treated with mechanical thrombectomy

2019 ◽  
Vol 12 (2) ◽  
pp. 142-147 ◽  
Author(s):  
Nitin Goyal ◽  
Georgios Tsivgoulis ◽  
Jason J Chang ◽  
Konark Malhotra ◽  
Juan Goyanes ◽  
...  
Keyword(s):  
Regression Models ◽  
Mechanical Thrombectomy ◽  
Independent Predictor ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Posterior Circulation ◽  
National Institutes Of Health ◽  
Special Focus ◽  
Vessel Occlusion ◽  
Logistic Regression Models

IntroductionOne uncommon complication of mechanical thrombectomy (MT) is an infarct in a new previously unaffected territory (infarct in new territory (INT)).ObjectiveTo evaluate the predictors of INT with special focus on intravenous thrombolysis(IVT)pretreatmentbefore MT.MethodsConsecutive patients with emergent large vessel occlusion (ELVO) treated with MT during a 5-year period were evaluated. INT was defined using standardized methodology proposed by ESCAPE investigators. The predictors of INT and its impact on outcomes were investigated.ResultsA total of 419 consecutive patients with ELVO received MT (mean age 64±15 years, 50% men, median baseline National Institutes of Health Stroke Scale score 16 points (IQR 11–20), 69% pretreated with IVT). The incidence of INT was lower in patients treated with combination therapy (IVTandMT) than in patients treated with MT alone, respectively (10% vs 20%; p=0.011). The INT group had more patients with posterior circulation occlusions than the group without INT (28% vs 10%, respectively; p<0.001). The rates of 3-month functional independence were lower in patients with INT (30% vs 50%; p=0.007). IVT pretreatment was not independently related to INT (OR=0.75; 95% CI 0.32 to 1.76), and INT did not emerge as an independent predictor of 3-month functional independence (OR=0.69; 95% CI 0.29 to 1.62) on multivariable logistic regression models. Location of posterior circulation occlusion was independently associated with a higher odds of INT (OR=3.33; 95% CI 1.43 to 7.69; p=0.005).ConclusionsIVT pretreatment is not independently associated with a lower likelihood of INT in patients with ELVO treated with MT. Patients with ELVO with posterior circulation occlusion are more likely to have INT after MT.

scholarly journals Modelling Combined Intravenous Thrombolysis and Mechanical Thrombectomy in Acute Ischaemic Stroke: Understanding the Relationship between Stent Retriever Configuration and Clot Lysis Mechanisms

Life ◽  
2021 ◽  
Vol 11 (11) ◽  
pp. 1271
Author(s):  
Emily Louise Manchester ◽  
Dylan Roi ◽  
Boram Gu ◽  
Xiao Yun Xu ◽  
Kyriakos Lobotesis
Keyword(s):  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Drug Transport ◽  
Mechanical Thrombectomy ◽  
Numerical Models ◽  
Cerebral Arteries ◽  
Intravenous Thrombolysis ◽  
Stent Retriever ◽  
Patient Specific ◽  
Clot Lysis

Background: Combined intravenous thrombolysis and mechanical thrombectomy (IVT-MT) is a common treatment in acute ischaemic stroke, however the interaction between IVT and MT from a physiological standpoint is poorly understood. In this pilot study, we conduct numerical simulations of combined IVT-MT with various idealised stent retriever configurations to evaluate performance in terms of complete recanalisation times and lysis patterns. Methods: A 3D patient-specific geometry of a terminal internal carotid artery with anterior and middle cerebral arteries is reconstructed, and a thrombus is artificially implanted in the MCA branch. Various idealised stent retriever configurations are implemented by varying stent diameter and stent placement, and a configuration without a stent retriever provides a baseline for comparison. A previously validated multi-level model of thrombolysis is used, which incorporates blood flow, drug transport, and fibrinolytic reactions within a fibrin thrombus. Results: Fastest total recanalisation was achieved in the thrombus without a stent retriever, with lysis times increasing with stent retriever diameter. Two mechanisms of clot lysis were established: axial and radial permeation. Axial permeation from the clot front was the primary mechanism of lysis in all configurations, as it facilitated increased protein binding with fibrin fibres. Introducing a stent retriever channel allowed for radial permeation, which occurred at the fluid-thrombus interface, although lysis was much slower in the radial direction because of weaker secondary velocities. Conclusions: Numerical models can be used to better understand the complex physiological relationship between IVT and MT. Two different mechanisms of lysis were established, providing a basis towards improving the efficacy of combined treatments.

Thrombectomy of symptomatic isolated occlusions of posterior cerebral arteries in segment P1 and P2 in acute stroke treatment

2021 ◽  
pp. 028418512110141
Author(s):  
Jens Altenbernd ◽  
Michael Forsting ◽  
Werner Weber ◽  
Sebastian Fischer
Keyword(s):  
Clinical Outcome ◽  
Mechanical Thrombectomy ◽  
Cerebral Arteries ◽  
Posterior Circulation ◽  
Limited Data ◽  
First Line ◽  
Good Clinical Outcome ◽  
Stroke Treatment ◽  
Stent Retrievers ◽  
Favorable Clinical Outcome

Background Interventional stroke treatments for occlusions of the posterior circulation are established procedures. However, there are limited data on the treatment of isolated symptomatic P1 and P2 occlusions, which we have examined in this study. Purpose To investigate the mechanical thrombectomy of distal posterior occlusions Material and Methods Retrospectively, data from patients with isolated P1 and P2 occlusions treated with MT were evaluated. Successful reperfusions have been defined as modified thrombolysis in cerebral infarct (mTICI) Grade 2b–3. A good clinical outcome was defined as a 90-day modified Rankin score 0–2. Results All 79 treated patients were primarily aspirated. Stent retrievers were used secondarily in nine patients. Successful reperfusion was achieved in 95% of patients. Of the patients, 57% had a favorable clinical outcome after 90 days. Conclusion Mechanical thrombectomy with first line aspiration of symptomatic P1 and P2 occlusions is a safe and effective procedure.

Mechanical thrombectomy for acute ischemic stroke in the posterior circulation: assessment of efficacy and outcome and identification of prognostic factors

2020 ◽  
pp. 028418512096273
Author(s):  
Maciej Szmygin ◽  
Michał Sojka ◽  
Krzysztof Pyra ◽  
Piotr Tarkowski ◽  
Piotr Luchowski ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Clinical Outcome ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Posterior Circulation ◽  
Stroke Severity ◽  
Anterior Circulation ◽  
Tissue Plasminogen ◽  
Meta Analyses

Background Mechanical thrombectomy (MT) is well-established in the treatment of acute ischemic anterior circulation stroke. However, there is no evidence from randomized trials or meta-analyses that MT is safe and effective in the treatment of patients with acute ischemic posterior circulation stroke (PCS). Purpose To evaluate the clinical and procedural factors associated with recanalization and outcome of patients with PCS treated with MT. Material and Methods Forty-three patients with PCS (median age 73 years) who underwent treatment with MT were included. Data including demographics, baseline stroke severity, radiological imaging, procedure and post-procedure complications were documented. Clinical outcome was evaluated using the modified Rankin Scale (mRS). The patients were classified into two groups based on clinical outcome (favorable vs. unfavorable mRS after 90 days). Results Median baseline National Institute of Health Stroke Scale (NIHSS) was 17. Twenty patients were eligible for intravenous thrombolysis and received recombinant tissue plasminogen activator before MT. Successful recanalization was observed in 88.4% of patients. After 90 days, favorable outcome (defined as mRS 0–2) was achieved in 26 patients; six patients had an unfavorable outcome (mRs >2). Final mortality rate was 25.5%. Baseline NIHSS, onset to reperfusion time, procedure duration, and successful recanalization had a statistically significant association with outcome. Failed recanalization and occurrence of intracranial hemorrhage were found to be associated with a higher mortality rate. Conclusion MT is feasible and effective method in treatment of PCS. Baseline NIHSS and onset to reperfusion time were found to be independent predictive factors of clinical outcome.

Abstract WMP10: The Role of Intravenous Thrombolysis Before Mechanical Thrombectomy: A Subgroup Analysis of the RESILIENT Trial

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Gisele Sampaio Silva ◽  
Maramelia Miranda ◽  
Felipe Barros ◽  
Michel Frudit ◽  
Octavio Pontes-Neto ◽  
...  
Keyword(s):  
Effect Size ◽  
Functional Disability ◽  
Mechanical Thrombectomy ◽  
Controlled Trial ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
P Value ◽  
Significant Difference ◽  
Iv Tpa

Background: Mechanical thrombectomy (MT) in addition to intravenous thrombolysis (IVT) is now the recommended treatment for acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). The positive trials also demonstrated that MT alone among patients ineligible for IVT is an effective therapy for AIS. Whether MT alone is as effective, worse, or better than pretreatment with IVT before MT among IVT-eligible AIS patients with LVO is debatable. We aimed to assess the effect of IVT on the clinical outcome of MT in the RESILIENT trial. Methods: RESILIENT was a randomized, prospective, multicenter, controlled trial evaluating the safety, efficacy, and cost-effectiveness of thrombectomy versus medical treatment alone. A total of 221 patient were enrolled. The trial showed a strong benefit to thrombectomy (90-day mRS ordinal shift, OR 95%CI). All eligible patients received intravenous tPA within the 4.5-hour-window. The primary end-point was the common odds ratio (cOR) of mRs at 90 days (shift analysis) and the main secondary endpoint was the rate of functional independence (mRS 0-2) at 90 days. Ordinal logistic and binary regression analyses with the use of intravenous tPA as an interaction term were performed with adjustments for potential confounders including age, baseline NIHSS score, occlusion site, IV tPA use and ASPECTS. A p value < 0.05 was considered statistically significant. Results: Among 221 randomized patients (median NIHSS, 18 IQR [14-21]), 155 (70%) were treated with IV tPA. The frequency of good recanalization (TICI 2b> ) and of hemorrhagic transformation was not affected by IVT. There was no significant difference in the treatment effect size across patients who received intravenous tPA versus those who did not in terms of overall functional disability (ordinal mRS shift: aOR: 2.63, 95%CI [1.48-4.69] vs. 1.54, 95%CI [0.63-3.74]; p=0.42) or functional independence (mRS 0-2: aOR: 3.06, 95%CI [1.37-6.48] vs. 1.71 95%CI [0.55-5.33], p=0.40) at 90 days. Conclusions: The large effect size of MT on LVO outcomes was not significantly affected by IVT. Further studies directly evaluating the role of IVT before MT are of utmost importance.

Treatment of cerebral vasospasm with intra-arterial papaverine

1992 ◽  
Vol 77 (6) ◽  
pp. 848-852 ◽  
Author(s):  
Neal F. Kassell ◽  
Gregory Helm ◽  
Nathan Simmons ◽  
C. Douglas Phillips ◽  
Wayne S. Cail
Keyword(s):  
Cerebral Vasospasm ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Cerebral Arteries ◽  
Posterior Circulation ◽  
Neurological Deficits ◽  
Arterial Infusion ◽  
Content Type ◽  
Repeat Angiography ◽  
Safe Dose ◽  
Fine Print

✓ Cerebral vasospasm continues to be the leading treatable cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage. In this preliminary anecdotal series of 12 patients who were candidates for balloon angioplasty, vasospasm was treated instead with intra-arterial papaverine. Eight patients had marked angiographic reversal of the arterial narrowing following papaverine infusion, four of whom showed dramatic reversal of profound neurological deficits. Two patients deteriorated clinically 5 days after the initially successful papaverine infusions. In both, repeat angiography demonstrated severe recurrent vasospasm, which was partially reversed with a second intra-arterial papaverine treatment. Two patients developed focal neurological deficits during papaverine infusion, which resolved spontaneously over several hours after cessation of the intra-arterial infusion. Arterial narrowing in the posterior circulation and middle cerebral artery distribution appeared to be more responsive to papaverine infusion than was spasm in the anterior cerebral arteries. The infusion of 300 mg of papaverine over 1 hour seemed to be an adequate and safe dose to effect these angiographic and clinical improvements.

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