Optical coherence tomography imaging after endovascular thrombectomy for basilar artery occlusion: report of 3 cases

2020 ◽  
Vol 133 (4) ◽  
pp. 1141-1146 ◽  
Author(s):  
Christopher R. Pasarikovski ◽  
Joel Ramjist ◽  
Leodante da Costa ◽  
Sandra E. Black ◽  
Victor Yang
Keyword(s):  
Optical Coherence Tomography ◽  
Real Time ◽  
Basilar Artery ◽  
Vessel Wall ◽  
Artery Occlusion ◽  
Endothelial Injury ◽  
Basilar Artery Occlusion ◽  
Optical Coherence ◽  
Endovascular Thrombectomy ◽  
Residual Thrombus

Studies evaluating individuals for endothelial injury after endovascular thrombectomy (EVT) have been done by means of retrieved human thrombus, MR vessel-wall imaging, and animal histopathological studies. These techniques have limitations, because MR imaging has insufficient spatial resolution to directly visualize endothelium, and histopathological examinations are performed ex vivo and are unable to provide real-time patterns of injury. The purpose of the current study was to obtain in vivo intraluminal imaging after EVT by using optical coherence tomography (OCT), examining for evidence of endothelial injury in real time.Three consecutive patients with acute basilar artery occlusion underwent OCT imaging immediately after EVT. There were no complications and adequate images were obtained for all patients. Anatomical features of the vessel wall were discernible, including intima, media, adventitia, and internal/external elastic lamina. Basilar artery thick concentric plaque fibrosis was present, causing outward remodeling and loss of the internal/external lamina in certain regions. Evidence of significant residual thrombus was also visible, with mostly red thrombus present despite complete angiographic revascularization. The residual thrombus was not visible on CT, MR, or cerebral angiography and could certainly cause ongoing function-limiting strokes with occlusion of adjacent vital basilar perforators after EVT.

scholarly journals Optical Coherence Tomography Imaging in Acute Ischemic Stroke: Preliminary Animal and Human Results

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Christopher R Pasarikovski ◽  
Leo da Costa ◽  
Joel Ramjist ◽  
Yuta Dobashi ◽  
Victor Xiao Dong Yang
Keyword(s):  
Animal Model ◽  
Optical Coherence Tomography ◽  
Real Time ◽  
Endothelial Injury ◽  
Basilar Artery Occlusion ◽  
Complete Revascularization ◽  
Optical Coherence ◽  
Stroke Patients ◽  
Oct Imaging ◽  
Residual Thrombus

Abstract INTRODUCTION Studies evaluating endothelial injury after endovascular thrombectomy (EVT) have been done by means of retrieved human thrombus, magnetic resonance (MR) vessel-wall imaging, and animal histopathologic studies. These techniques have limitations, as MR imaging has insufficient spatial resolution to directly visualize endothelium, and histopathologic examinations are ex vivo and unable to provide real-time patterns of injury. The aim of the current study is intraluminal imaging after EVT using optical coherence tomography (OCT). We describe our animal model for thrombus preparation, vessel occlusion, mechanical thrombectomy, and subsequent endovascular OCT imaging. Furthermore, we describe the first human endovascular OCT imaging after EVT in 2 stroke patients. METHODS A total of 3 swine weighing 35 to 40 kg were selected for the animal model. Autologous venous whole blood drawn 48 h before the procedure was used to create thrombus. The bilateral superficial cervical arteries and right internal thoracic artery were used for occlusion given their diameters of 2 to 3 mm and 3 to 4 mm, respectively. A second-generation stent retriever was used for EVT. Thrombi were retrieved after 1, 3, and 6 h with subsequent intraluminal OCT imaging. Next, 2 consecutive patients with basilar artery occlusion underwent EVT and endovascular OCT imaging. RESULTS In the animal model, revascularization and OCT imaging was successful for all 9 vessels. Endothelial injury was observed in 4/9 (44%) of vessels, and residual thrombus was observed in 4/9 (44%) of vessels despite complete revascularization. All vessels undergoing EVT after 6 h had evidence of endothelial injury, and 2/3 (66%) had residual thrombus. Both basilar stroke patients had significant residual thrombus despite complete angiographic revascularization. CONCLUSION Endothelial injury and residual thrombus despite complete revascularization is present after EVT and can be observed in real time using intravascular OCT. It is possible that the longer occlusive thrombus is present, the more endothelial injury will occur during EVT.

Abstract 1: Optical Coherence Tomography Imaging in Acute Ischemic Stroke: Preliminary Animal and Human Results

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Christopher Pasarikovski ◽  
Julia Keith ◽  
Leodante daCosta ◽  
Joel Ramjist ◽  
Yuta Dobashi ◽  
...  
Keyword(s):  
Animal Model ◽  
Optical Coherence Tomography ◽  
Mr Imaging ◽  
Real Time ◽  
Endothelial Injury ◽  
Basilar Artery Occlusion ◽  
Complete Revascularization ◽  
Optical Coherence ◽  
Oct Imaging ◽  
Residual Thrombus

Background: Studies evaluating endothelial injury after EVT have been done by means of retrieved human thrombus, MR vessel-wall imaging, and animal histopathologic studies. These techniques have limitations, as MR imaging has insufficient spatial resolution to directly visualize endothelium, and histopathologic examinations are ex-vivo and unable to provide real-time patterns of injury. Objective: Endovascular imaging after EVT using optical coherence tomography (OCT) to examine for vessel injury in real-time. Methodology: Three swine weighing 35-40kg were selected for the animal model. Autologous venous whole-blood was used to create thrombus. A second-generation stent retriever was used for EVT. Next, three consecutive patients with basilar artery occlusion underwent EVT and endovascular OCT imaging. Results: In the animal model, revascularization and OCT imaging was successful for all 9 vessels. Endothelial injury was observed in 4/9 (44%) of vessels, and residual thrombus was observed in 4/9 (44%) of vessels despite complete angiographic revascularization. All vessels undergoing EVT after 6 hours had evidence of endothelial injury, and 2/3 (66%) had residual thrombus. Two basilar stroke patients (2/3) 66% had significant residual thrombus despite complete angiographic revascularization. The residual thrombus was also not visible on CT angiography or MR imaging done within 24 hours of EVT. Conclusions: Endothelial injury and residual thrombus despite complete revascularization is present after EVT and can be observed in real-time using OCT. It is possible that the longer occlusive thrombus is present, the more endothelial injury will occur during EVT.

Abstract TMP13: Tenecteplase versus Alteplase Before Endovascular Therapy in Basilar Artery Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Fana Alemseged ◽  
Volker Puetz ◽  
Gregoire Boulouis ◽  
Alessandro Rocco ◽  
Timothy Kleinig ◽  
...  
Keyword(s):  
Basilar Artery ◽  
Endovascular Therapy ◽  
Primary Outcome ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Randomized Controlled ◽  
Repeat Imaging

Background: Tenecteplase (TNK) is a genetically modified variant of alteplase with greater fibrin specificity and longer half-life than alteplase. The recent Tenecteplase versus Alteplase before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK) trial demonstrated that increased reperfusion with TNK compared to alteplase prior to endovascular thrombectomy (EVT) in large vessel occlusion ischaemic strokes. However, only 6 patients with basilar artery occlusion (BAO) were included. We aimed to investigate the efficacy of TNK versus alteplase before EVT in patients with basilar artery occlusion (BAO). Methods: Clinical and procedural data of consecutive BAO diagnosed on CT Angiography or MR Angiography from the multisite international Basilar Artery Treatment and MANagement (BATMAN) collaboration were retrospectively analysed. The primary outcome was reperfusion of greater than 50% of the involved ischemic territory or absence of retrievable thrombus at the time of the initial angiographic assessment. Results: We included 119 BAO patients treated with intravenous thrombolysis prior to EVT; mean age 68 (SD 14), median NIHSS 16 (IQR 7-32). Eleven patients were treated with TNK (0.25mg/kg or 0.4mg/kg) and 108 with alteplase (0.9mg/kg). Overall, 113 patients had catheter angiography or early repeat imaging after thrombolysis. Reperfusion of greater than 50% of the ischemic territory or absence of retrievable thrombus occurred in 4/11 (36%) of patients treated with TNK vs 8/102 (8%) treated with alteplase (p=0.02). Onset-to-needle time did not differ between the two groups (p=0.4). Needle-to-groin-puncture time was 61 (IQR 33-100) mins in patients reperfused with TNK vs 111 (IQR 86-198) mins in patients reperfused with alteplase (p=0.048). Overall, the rate of symptomatic haemorrhage was 3/119 (2.5%). No differences were found in the rate of symptomatic intracranial haemorrhage (p=0.3) between the two thrombolytic agents. Conclusions: Despite shorter needle-to-groin-puncture times, tenecteplase was associated with an increased rate of reperfusion in comparison with alteplase before EVT in BAO. Randomized controlled trials to compare tenecteplase with alteplase in BAO patients before endovascular thrombectomy are warranted.

scholarly journals Outcomes of Endovascular Thrombectomy for Basilar Artery Occlusion

2020 ◽  
Vol 47 (4) ◽  
pp. 479-485
Author(s):  
Christopher R. Pasarikovski ◽  
Houman Khosravani ◽  
Leodante da Costa ◽  
Chinthaka Heyn ◽  
Stefano M. Priola ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Functional Outcome ◽  
Basilar Artery ◽  
Treatment Time ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Posterior Circulation ◽  
Basilar Artery Occlusion ◽  
Related Complication ◽  
Endovascular Thrombectomy

ABSTRACT:Background and Purpose:Large prospective observational studies have cast doubt on the common assumption that endovascular thrombectomy (EVT) is superior to intravenous thrombolysis for patients with acute basilar artery occlusion (BAO). The purpose of this study was to retrospectively review our experience for patients with BAO undergoing EVT with modern endovascular devices.Methods:All consecutive patients undergoing EVT with either a second-generation stent retriever or direct aspiration thrombectomy for BAO at our regional stroke center from January 1, 2013 to March 1, 2019 were included. The primary outcome measure was functional outcome at 1 month using the modified Rankin Scale (mRS) score. Multivariable logistic regression was used to assess the association between patient characteristics and dichotomized mRS.Results:A total of 43 consecutive patients underwent EVT for BAO. The average age was 67 years with 61% male patients. Overall, 37% (16/43) of patients achieved good functional outcome. Successful reperfusion was achieved in 72% (31/43) of cases. The median (interquartile range) stroke onset to treatment time was 420 (270–639) minutes (7 hours) for all patients. The procedure-related complication rate was 9% (4/43). On multivariate analysis, posterior circulation Alberta stroke program early computed tomography score and Basilar Artery on Computed Tomography Angiography score were associated with improved functional outcome.Conclusion:EVT appears to be safe and feasible in patients with BAO. Our finding that time to treatment and successful reperfusion were not associated with improved outcome is likely due to including patients with established infarcts. Given the variability of collaterals in the posterior circulation, the paradigm of utilizing a tissue window may assist in patient selection for EVT. Magnetic resonance imaging may be a reasonable option to determine the extent of ischemia in certain situations.

scholarly journals Predictors of Outcome After Endovascular Thrombectomy in Acute Basilar Artery Occlusion and the 6hr Time Window to Recanalization

2019 ◽  
Vol 10 ◽  
Author(s):  
Johannes Ravindren ◽  
Marta Aguilar Pérez ◽  
Victoria Hellstern ◽  
Pervinder Bhogal ◽  
Hansjörg Bäzner ◽  
...  
Keyword(s):  
Basilar Artery ◽  
Time Window ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Predictors Of Outcome ◽  
Endovascular Thrombectomy

Improved Clinical Outcome after Acute Basilar Artery Occlusion since the Introduction of Endovascular Thrombectomy Devices

2013 ◽  
Vol 36 (5-6) ◽  
pp. 394-400 ◽  
Author(s):  
S. Nagel ◽  
L. Kellert ◽  
M. Möhlenbruch ◽  
J. Bösel ◽  
S. Rohde ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Basilar Artery ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Endovascular Thrombectomy

Tenecteplase Versus Alteplase Before Endovascular Therapy in Basilar Artery Occlusion

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000011520
Author(s):  
Fana Alemseged ◽  
Felix C Ng ◽  
Cameron Williams ◽  
Volker Puetz ◽  
Gregoire Boulouis ◽  
...  
Keyword(s):  
Basilar Artery ◽  
Endovascular Therapy ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Class Iii ◽  
Endovascular Thrombectomy ◽  
Randomized Controlled ◽  
Symptomatic Intracranial Hemorrhage

Objective:To investigate the efficacy of tenecteplase (TNK), a genetically modified variant of alteplase with greater fibrin specificity and longer half-life than alteplase, prior to endovascular thrombectomy (EVT) in patients with basilar artery occlusion (BAO).Methods:To determine whether tenecteplase is associated with better reperfusion rates than alteplase prior to EVT in BAO, clinical and procedural data of consecutive BAO patients from the Basilar Artery Treatment and MANagement (BATMAN) registry and the Tenecteplase versus Alteplase before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK) trial were retrospectively analyzed. Reperfusion >50% or absence of retrievable thrombus at the time of the initial angiogram was evaluated.Results:We included 110 BAO patients treated with intravenous thrombolysis prior to EVT [mean age 69(SD 14); median NIHSS 16(IQR 7-32)]. Nineteen patients were thrombolysed with TNK (0.25mg/kg or 0.40mg/kg) and 91 with alteplase (0.9mg/kg). Reperfusion>50% occurred in 26% (n=5/19) of patients thrombolysed with TNK vs 7% (n=6/91) thrombolysed with alteplase (RR 4.0 95%CI 1.3-12; p=0.02), despite shorter thrombolysis-to-arterial-puncture time in the TNK-treated patients (48[IQR 40-71]mins) vs alteplase-treated patients (110[IQR 51-185]mins, p=0.004). No difference in symptomatic intracranial hemorrhage was observed (0/19(0%) TNK, 1/91(1%) alteplase, p=0.9).Conclusions:Tenecteplase may be associated with an increased rate of reperfusion in comparison with alteplase before EVT in BAO. Randomized controlled trials to compare tenecteplase with alteplase in BAO patients are warranted.Classification of evidence:This study provides Class III evidence that tenecteplase leads to higher reperfusion rates in comparison with alteplase prior to EVT in BAO patients.

Association of pretreatment pontine infarction with extremely poor outcome after endovascular thrombectomy in acute basilar artery occlusion

2020 ◽  
pp. neurintsurg-2020-015930
Author(s):  
Woong Yoon ◽  
Byung Hyun Baek ◽  
Yun Young Lee ◽  
Seul Kee Kim ◽  
Joon-Tae Kim ◽  
...  
Keyword(s):  
Brain Stem ◽  
Basilar Artery ◽  
Multivariate Logistic Regression Analysis ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Infarct Core ◽  
Endovascular Thrombectomy ◽  
Poor Outcome ◽  
Pontine Infarction ◽  
Pontine Infarct

BackgroundThe association between pretreatment brain stem infarction and thrombectomy outcomes remains to be elucidated in patients with acute basilar artery occlusion (BAO). We aimed to assess the association between pretreatment pontine infarction and extremely poor outcome in patients who underwent endovascular thrombectomy due to acute BAO.MethodsWe retrospectively reviewed data from a stroke database to identify patients with acute BAO who underwent thrombectomy between January 2011 and August 2019. Patient characteristics, pretreatment diffusion-weighted imaging (DWI) data, and outcomes were evaluated. The largest infarct core was expressed as the percentage of infarct core area in each brain stem region on the DWI slice displaying the largest lesion. Extremely poor outcome was defined as a 90-day modified Rankin Scale score of 5 or 6.ResultsA total of 113 patients were included, 37 of whom had extremely poor outcome. Among the 15 patients with extensive pontine infarction (largest pontine infarct core of ≥70%), 93.3% had extremely poor outcome. Multivariate logistic regression analysis revealed that the following variables were independent predictors of extremely poor outcome: extensive pontine infarction (adjusted OR 22.494; 95% CI 2.335 to 216.689; p=0.007), posterior circulation ASPECTS on DWI (adjusted OR per 1-point decrease 1.744; 95% CI 1.197 to 2.541; p=0.004), age (adjusted OR per 1-year increase 1.067; 95% CI 1.009 to 1.128; p=0.023), and baseline NIHSS (adjusted OR per 1-point increase 1.105; 95% CI 1.004 to 1.216; p=0.040).ConclusionOur results showed that a large pontine infarct core of ≥70% on pretreatment DWI was strongly associated with extremely poor outcome among patients treated with endovascular thrombectomy for acute BAO.

scholarly journals Direct Brachial Approach for Acute Basilar Artery Occlusion: Technical Note and Preliminary Clinical Experience

2020 ◽  
Vol 15 (1) ◽  
pp. 31-36 ◽  
Author(s):  
Teishiki Shibata ◽  
Masahiro Oomura ◽  
Yusuke Nishikawa ◽  
Mitsuhito Mase
Keyword(s):  
Clinical Experience ◽  
Basilar Artery ◽  
Femoral Artery ◽  
The Elderly ◽  
Artery Occlusion ◽  
Technical Note ◽  
Basilar Artery Occlusion ◽  
Modified Rankin Scale ◽  
Endovascular Thrombectomy ◽  
Guide Catheter

In mechanical endovascular thrombectomy (MET) for acute basilar artery occlusion (ABAO) in the elderly, navigating a guide catheter via the femoral artery may be difficult due to the approach route’s significant tortuosity. To resolve this problem, we have been performing a technique that uses a direct brachial approach (DiBA) with a large-bore aspiration catheter. We reported our preliminary clinical experience with this technique. MET for ABAO using the DiBA technique was performed on 4 consecutive patients between August 2017 and December 2018. In all patients, thrombolysis in cerebral infarction 2B or 3 recanalization was achieved, but the modified Rankin Scale at 90 days was ≥4. There were no technical difficulties or complications with this technique. The DiBA technique is an effective and feasible approach in MET for ABAO. Although excellent clinical outcomes could not be achieved, the angiographic outcomes were excellent with no technical complications. This approach can be an alternative to the femoral artery approach, particularly for tortuous arteries in the elderly.

Sign in / Sign up

Export Citation Format

Share Document