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.

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 Effects of Collateral Status on Infarct Distribution Following Endovascular Therapy in Large Vessel Occlusion Stroke

Stroke ◽  
2020 ◽  
Vol 51 (9) ◽  
Author(s):  
Khalid Al-Dasuqi ◽  
Seyedmehdi Payabvash ◽  
Gerardo A. Torres-Flores ◽  
Sumita M. Strander ◽  
Cindy Khanh Nguyen ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Internal Capsule ◽  
Large Vessel ◽  
Favorable Outcome ◽  
Middle Cerebral Artery Territory ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Deep White Matter ◽  
Border Zones

Background and Purpose: We aim to examine effects of collateral status and post-thrombectomy reperfusion on final infarct distribution and early functional outcome in patients with anterior circulation large vessel occlusion ischemic stroke. Methods: Patients with large vessel occlusion who underwent endovascular intervention were included in this study. All patients had baseline computed tomography angiography and follow-up magnetic resonance imaging. Collateral status was graded according to the criteria proposed by Miteff et al and reperfusion was assessed using the modified Thrombolysis in Cerebral Infarction (mTICI) system. We applied a multivariate voxel-wise general linear model to correlate the distribution of final infarction with collateral status and degree of reperfusion. Early favorable outcome was defined as a discharge modified Rankin Scale score ≤2. Results: Of the 283 patients included, 129 (46%) had good, 97 (34%) had moderate, and 57 (20%) had poor collateral status. Successful reperfusion (mTICI 2b/3) was achieved in 206 (73%) patients. Poor collateral status was associated with infarction of middle cerebral artery border zones, whereas worse reperfusion (mTICI scores 0–2a) was associated with infarction of middle cerebral artery territory deep white matter tracts and the posterior limb of the internal capsule. In multivariate regression models, both mTICI ( P <0.001) and collateral status ( P <0.001) were among independent predictors of final infarct volumes. However, mTICI ( P <0.001), but not collateral status ( P =0.058), predicted favorable outcome at discharge. Conclusions: In this cohort of patients with large vessel occlusion stroke, both the collateral status and endovascular reperfusion were strongly associated with middle cerebral artery territory final infarct volumes. Our findings suggesting that baseline collateral status predominantly affected middle cerebral artery border zones infarction, whereas higher mTICI preserved deep white matter and internal capsule from infarction; may explain why reperfusion success—but not collateral status—was among the independent predictors of favorable outcome at discharge. Infarction of the lentiform nuclei was observed regardless of collateral status or reperfusion success.

scholarly journals Validation of a Deep Learning Tool in the Detection of Intracranial Hemorrhage and Large Vessel Occlusion

2021 ◽  
Vol 12 ◽  
Author(s):  
Joel McLouth ◽  
Sebastian Elstrott ◽  
Yasmina Chaibi ◽  
Sarah Quenet ◽  
Peter D. Chang ◽  
...  
Keyword(s):  
Deep Learning ◽  
Middle Cerebral Artery ◽  
Intracranial Hemorrhage ◽  
Cerebral Artery ◽  
The United States ◽  
Large Vessel ◽  
True Positive ◽  
Large Vessel Occlusion ◽  
Learning Tool ◽  
Vessel Occlusion

Purpose: Recently developed machine-learning algorithms have demonstrated strong performance in the detection of intracranial hemorrhage (ICH) and large vessel occlusion (LVO). However, their generalizability is often limited by geographic bias of studies. The aim of this study was to validate a commercially available deep learning-based tool in the detection of both ICH and LVO across multiple hospital sites and vendors throughout the U.S.Materials and Methods: This was a retrospective and multicenter study using anonymized data from two institutions. Eight hundred fourteen non-contrast CT cases and 378 CT angiography cases were analyzed to evaluate ICH and LVO, respectively. The tool's ability to detect and quantify ICH, LVO, and their various subtypes was assessed among multiple CT vendors and hospitals across the United States. Ground truth was based off imaging interpretations from two board-certified neuroradiologists.Results: There were 255 positive and 559 negative ICH cases. Accuracy was 95.6%, sensitivity was 91.4%, and specificity was 97.5% for the ICH tool. ICH was further stratified into the following subtypes: intraparenchymal, intraventricular, epidural/subdural, and subarachnoid with true positive rates of 92.9, 100, 94.3, and 89.9%, respectively. ICH true positive rates by volume [small (&lt;5 mL), medium (5–25 mL), and large (&gt;25 mL)] were 71.8, 100, and 100%, respectively. There were 156 positive and 222 negative LVO cases. The LVO tool demonstrated an accuracy of 98.1%, sensitivity of 98.1%, and specificity of 98.2%. A subset of 55 randomly selected cases were also assessed for LVO detection at various sites, including the distal internal carotid artery, middle cerebral artery M1 segment, proximal middle cerebral artery M2 segment, and distal middle cerebral artery M2 segment with an accuracy of 97.0%, sensitivity of 94.3%, and specificity of 97.4%.Conclusion: Deep learning tools can be effective in the detection of both ICH and LVO across a wide variety of hospital systems. While some limitations were identified, specifically in the detection of small ICH and distal M2 occlusion, this study highlights a deep learning tool that can assist radiologists in the detection of emergent findings in a variety of practice settings.

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 Middle Cerebral Artery Occlusion

2019 ◽  
pp. 155-164
Author(s):  
Phillip A. Bonney ◽  
Parampreet Singh ◽  
Benjamin Yim ◽  
William J. Mack
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Middle Cerebral Artery Occlusion ◽  
Cerebral Artery ◽  
Artery Occlusion ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Cerebral Artery Occlusion

Abstract: This chapter addresses the neurosurgical management of stroke due to acute middle cerebral artery occlusion. Large vessel occlusion is a common mechanism of acute ischemic stroke. Mechanical thrombectomy has emerged as an important procedure that drastically improves outcomes in this disease. This chapter discusses the diagnosis and treatment of acute ischemic stroke from large vessel occlusion, including the rapid radiographic evaluation with CT, CTA, MRI, and perfusion imaging. The scoring of the stroke using scales such as the ASPECTS score and their use in decision-making is reviewed. The chapter then discusses treatment with both chemical thrombolysis and mechanical thrombectomy, including the technical aspects of the procedure.

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

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.

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.

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