ADAPT First-Line Strategy for MCA Mainstem Occlusion; Analysis for Optimal Salvage Therapy and its Related Factor

ObjectivesA direct first-pass aspiration technique (ADAPT) is an attractive interventional technique for mechanical thrombectomy (MT), which could achieve recanalization quickly and safely at a small amount of material resources. To clarify its usefulness, our ADAPT first-line strategy for middle cerebral artery (MCA)-mainstem occlusion was retrospectively analyzed.Materials and MethodsWe reviewed 54 consecutive patients who underwent MT for MCA-mainstem occlusion using ADAPT first-line strategy. A salvage procedure was concurrently conducted in cases that failed to achieve successful recanalization by ADAPT attempt alone. Procedural and clinical outcome were assessed in both ADAPT alone and Salvage groups. Further investigation was performed in cases that required salvage procedure to determine the reason, risk factors, and optimal procedure.ResultsForty-one patients (75.9%) were able to achieve successful recanalization with ADAPT technique alone. In salvage group, the procedural time was longer, and rates of successful recanalization were lower than in ADAPT-alone group. No significant difference in the rates of favorable outcomes was observed. Among 13 patients who required salvage therapy, the major reason (eight cases) was intra-procedural “thrombus distal migration”. Failure of recanalization was seen in two cases due to “inaccessibility”. In patients who had “thrombus distal migration”, occlusion in the proximal portion was more frequently observed than in patients who did not (p = 0.032, 63.6% vs. 23.3%).ConclusionsOur ADAPT first-line strategy for MCA-mainstem occlusion demonstrated favorable procedural and clinical outcomes, even in cases that required additional procedures. Further investigation and better understanding are required to refine this promising procedure.     

急性大脑中动脉闭塞机械取栓治疗的观察性研究

目的探讨大脑中动脉急性闭塞后行血管内机械取栓的优化治疗方式及疗效。方法以行血管内机械取栓的大脑中动脉闭塞的急性缺血性卒中患者为研究对象,回顾性分析其责任病灶特点、血管内治疗方式、血管开通状况及术后神经功能改善状况。结果连续纳入2014年1月-2016年8月期间于中山市人民医院脑血管介入科行急性大脑中动脉闭塞机械取栓的患者77例,其中M1段闭塞52例(右侧27例,左侧25例),上干闭塞15例,下干闭塞10例。取栓后Solitaire支架释放在狭窄部位17例,合并大脑中动脉严重狭窄应用Gateway球囊扩张6例,局部动脉给予溶栓药物3例。经血管内治疗后,77例大脑中动脉闭塞全部成功开通。术后再灌注出血6例(7.79%),取栓术后因急性脑肿胀行去骨瓣减压术5例(6.49%),术后90 d患者预后良好[改良Rankin量表(modified Rankin Scale,m RS)评分2分]48例(62.34%)。结论大脑中动脉急性闭塞行Solitaire支架急诊取栓可获得满意的再通率及3个月良好预后。     

Morphological consequences of early reperfusion following thrombotic or mechanical occlusion of the rat middle cerebral artery

Summary The early morphological consequences of recirculation following middle cerebral artery (MCA) occlusion were studied in two rat models. The proximal MCA was occluded for 1 h by either a surgical clip or platelet thrombus; subsequently, 1 h of recirculation was facilitated. Following clip occlusion and recirculation, mild astrocytic swelling, especially around blood vessels, was detected in reperfused cortical and striatal areas. Neuronal changes included slight chromatin clumping and dilation of the rough endoplasmic reticulum. In contrast, severe structural abnormalities were detected following recanalization of the thrombosed MCA segment. Marked astrocytic swelling of cell bodies and perivascular processes with neuropil vacuolation were commonly seen. A heterogeneous pattern of neuronal alterations, including a high frequency of dense shrunken neurons surrounded by swollen astrocytic processes was documented in cortical and striatal regions. Severe neuronal changes were documented in brain regions exhibiting a wellperfused microcirculation. Vascular endothelial cells contained large numbers of pinocytotic vesicles associated with luminal and abluminal surfaces. Pronounced and rapid morphological changes evolve with reperfusion when thrombotic and ischemic events occur simultaneously. The basis for these rapid parenchymal changes following vascular thrombosis may involve acute alterations in cerebral microvascular permeability which exacerbate ischemic consequences.Supported by USPHS grants NS-05820 and NS-23244, National Parkinson Foundation Grant YR 660068, and by the American Heart Association Grant-in-Aid 87-1012, with funds contributed by the Florida Affiliate. W. Dalton Dietrich is an Established Investigator of the American Heart Association.     

Microsurgical glue embolectomy of the middle cerebral artery following embolization of a maxillofacial arteriovenous malformation

With increasing application of endovascular therapies worldwide, the management of procedure-related complications has become increasingly important. Of particular interest is the surgical management of complications refractory to endovascular recanalization. Here, we present the unique surgical management of an inadvertent intracranial glue embolus following urgent glue embolization of a maxillofacial arteriovenous malformation. This is the first report to document management of this complication. An arteriotomy was performed and the glue, despite being adhered to the vessel intima, was retrieved in its entirety from the middle cerebral artery (MCA). Following the procedure, the patient developed a new thrombus at the previous glue site, likely related to endothelial injury. With post-operative heparin therapy, the patient recovered to baseline neurological state. This report demonstrates that microsurgical arteriotomy and glue embolectomy of the MCA is feasible, safe and may be useful in the management of complications of inadvertent intracranial glue embolization.     

Local intra-arterial fibrinolysis in acute hemispheric stroke: effect of occlusion type and fibrinolytic agent on recanalization success and neurological outcome

BACKGROUND: To evaluate the effect of occlusion type and fibrinolytic agent on recanalization success and clinical outcome in patients undergoing local intra-arterial fibrinolysis (LIF) in acute hemispheric stroke. METHODS: LIF was performed in 137 patients with angiographically established occlusion in the carotid circulation within 6 h of stroke onset. Retrospective analysis included recanalization success, recanalization time, type of occlusion and fibrinolytic treatment mode. Five types of occlusion were categorized: intracranial bifurcation (carotid 'T') of the internal carotid artery (ICA; n = 35); proximal segment of the middle cerebral artery (MCA; n = 66); distal segment of the MCA (n = 20); extracranial ICA with MCA embolism (n = 8); multiple peripheral branches of the anterior cerebral artery and the MCA (n = 8). Neurologic outcome was evaluated after 3 months by Barthel Index (BI) as good (BI >90), moderate (BI 50-90), poor (BI <50) or death. RESULTS: Recanalization was achieved in 74 patients (54%). Mean recanalization time in recanalized patients was 91 min. Neurologic outcome was good in 48 patients (35%), moderate in 34 (25%), poor in 30 (22%) and 25 died (18%). Outcome was significantly better in recanalized than in nonrecanalized patients (p < 0.001). Treatment results were significantly better in proximal and distal MCA occlusion than in carotid 'T' occlusions (p < 0.001). Recanalization success hardly differed between urokinase and rt-PA. Combined treatment with rt-PA and lys-plasminogen tended toward a faster recanalization. Parenchymal hemorrhage occurred in 13 patients (9%). CONCLUSION: The type of occlusion is of high prognostic value for successful fibrinolysis in the anterior circulation. However, recanalization is a time-consuming process even with an intra-arterial approach. Recanalization did not differ between type or dosage of plasminogen activators. Further innovative attempts are warranted towards hastening recanalization time in endovascular acute stroke treatment.     

Outcome predictors of open embolectomy in middle cerebral artery occlusion

Abstract

Objective: The purpose of this paper was to analyse the outcome of the patients with acute middle cerebral artery (MCA) occlusion treated by open embolectomy.

Methods: A clinical chart review was retrospectively conducted for 30 patients who had MCA occlusion and were treated with open embolectomy. According to the Glasgow Outcome Scale, the patients' outcome at discharge is divided in two groups: favorable outcome (good recovery and moderate disability) or unfavorable outcome (severe disability, vegetative state and death). The following variables between the favorable and unfavorable outcomes were analysed: age, sex, Glasgow Coma Scale score on admission, affected side, occlusion site, occlusion time, atrial fibrillation on electrocardiogram, fibrinolysis, aphasia, hemiparesis and hemorrhagic infarction after surgery.

Results: The outcomes of 30 patients were favorable in 16 patients (good recovery in nine and moderate disability in seven) and unfavorable in 14 patients (severe disability in 12, vegetative state in one and death in one). The M1 occlusion and fibrinolysis performance were more frequent in the unfavorable outcome group than in the favorable one. Logistic regression analysis with a stepwise method indicated that the only occlusion site was independently associated with the unfavorable outcome. The occlusion time >360 minutes was not the predictor of the unfavorable outcome.

Discussion: The outcome of patients with MCA occlusion treated by the open embolectomy depends on the occlusion site and the fibrinolysis performance in the present study. The M1 occlusion is also the independent risk factor of the unfavorable outcome. However, the occlusion time itself has no relation to the unfavorable outcome. These results indicate that therapeutic time windows vary in individuals probably due to the collateral blood flow.     

Blunt traumatic dissection in common carotid artery with serial morphological changes detected by carotid ultrasonography in the acute phase]

A 68-year-old man was admitted to our hospital with left hemiparesis, unilateral spatial neglect, and anosognosia at nine hours after blunt neck trauma. Carotid ultrasonography and angiography revealed occlusion of the right common carotid artery. A second ultrasonographic examination detected a double lumen, intimal flap, and a movable thrombus at the occlusion site, with reversed flow in the external cerebral artery and antegrade flow in the internal cerebral artery. Magnetic resonance angiography showed occlusion of the M1 distal section of the right middle cerebral artery. We diagnosed dissection of the right common carotid artery and artery-to-artery embolism from the thrombus in the dissecting common carotid artery. We started anticoagulation on the second hospital day. The patient was able to walk independently at discharge. The finding of carotid dissection on ultrasonography varied during the acute phase. We observed a mural thrombus in the true lumen and vessel recanalization. Treated only by anticoagulants without surgical therapy, the patient had a good outcome without reattack or hyperperfusion syndrome.     

Does thrombus imaging characteristics predict the degree of recanalisation after endovascular thrombectomy in acute ischaemic stroke?

BackgroundIdentification of computed tomography (CT) thrombus imaging characteristics can predict the degree of recanalization and outcome after endovascular thrombectomy (EVT) in patients with acute ischaemic stroke and large vessel occlusion.AimWe analyzed the thrombus imaging characteristics and procedural factors and correlated with the degree of recanalization and functional outcome after EVT.MethodsWe evaluated the thrombus imaging characteristics (hyperdense MCA sign, thrombus location, length and thrombus permeability) from thin slice CT and CT angiogram. In addition, groin to recanalization time, number of passes, and EVT technique were documented. The primary outcome was degree of recanalization (mTICI score) and secondary outcome was modified Rankin scale (mRS) at 3 months.ResultsThe mean age of 102 patients was 60.5±11.8 years. Patients with hyperdense MCA sign (90 % vs 75%, p=0.07) and permeable thrombus (86 % vs 70 %, p=0.09) had good recanalization (mTICI grade 2b,2c or 3). The requirement of <3 passes (90 % vs 62 %, p= 0.001) was associated with good recanalization. Multiple logistic regression analysis showed thrombus permeability (OR 5.9; 95% CI 1.3-26.6, p=0.02), use of stent retreiver alone (without aspiration) (OR 5.4; 95% CI 1.3-22.5, p=0.02) and a puncture to recanalization ≤60 minutes (OR 7.9; 95% CI 1.7-36.8; p=0.008) were associated with good recanalization. The requirement of ≥3 passes was associated with poor functional outcome (OR 3.4;95% CI 1.2-9.8; p=0.02).ConclusionsThrombus permeability was a predictor of successful recanalization after EVT. The requirement of three or more passes during EVT was associated with poor recanalization and poor functional outcome.     

Stent for temporary endovascular bypass and thrombectomy in major ischemic stroke

Endovascular techniques for acute stroke have evolved from a pharmacological to a mechanical approach. We report illustrative cases of successful anterior circulation recanalization in patients with large arterial occlusions, using a stent-based technique to perform arterial recanalization and thrombectomy, without permanent stent implantation. Four patients (mean age 59 years), presented with National Institutes of Health Stroke Scale (NIHSS) scores of 18 to 24, from 2 hours to 6 hours after stroke onset, with middle cerebral artery (MCA), MCA branch, internal carotid artery (ICA) terminus, or tandem ICA-MCA occlusions. A closed-cell stent was temporarily inserted to achieve temporary endovascular bypass, and then used as a thrombectomy device during withdrawal. Rapid and complete recanalization with successful thrombectomy was achieved in all patients within 28 minutes to 52 minutes. One week after treatment patients achieved NIHSS scores of 2 to 5, with no hemorrhagic complications. This approach allowed rapid endovascular revascularization and thrombectomy, without permanent stent implant. Stent-based thrombectomy devices may become a valuable tool in the management of acute ischemic stroke.     

Stent-Assisted Coil Embolization for the Proximal Middle Cerebral Artery Fusiform Aneurysm

Middle cerebral artery (MCA) fusiform aneurysms often have an unfavorable geometry that may limit surgical or endovascular treatment. Herein, we present a case of a fusiform aneurysm of the proximal MCA, which was successfully treated using stent-assisted coil embolization. A 42-year-old man presented with repeated headache and syncope. Five years earlier, a right MCA aneurysm had been treated by aneurismal wrapping. Magnetic resonance images (MRI) revealed a partially-thrombosed proximal MCA aneurysm at the right perisylvian region. Digital subtraction angiography (DSA) revealed a multilobulated fusiform-shaped aneurysm. The patient underwent stent-assisted coil embolization under general anesthesia and symptoms resolved postoperatively. A three-month follow-up angiography revealed no recanalization of the aneurysm and indicated tolerable blood flow through the right MCA, as compared to the preoperative angiography. We suggest that in selected patients, stent-assisted coil embolization of proximal MCA fusiform aneurysms can be an effective treatment modality.     

伴大核心梗死的前循环串联闭塞的急性期同期血管内治疗研究

目的 评价伴大核心梗死的前循环串联病变急性期同期血管内治疗的安全性及有效性。方法 回顾性分析2018年3月-2020年5月收治的伴大核心梗死的前循环串联病变患者的临床及影像资料,对患者的术前评估、手术方式、手术要点及术中不同处理方式、围手术期的管理及手术结果和预后进行总结分析。结果 5例患者中男性4例,女性1例;年龄61～71岁,颈内动脉（internal carotid artery,ICA）起始段闭塞合并远端C7段闭塞1例,合并同侧大脑中动脉（middle cerebral artery,MCA）M1段闭塞4例。5例患者均采用取栓支架半释放保护（solitaire stent-retriever half-release protection,Sharp）技术先处理远端病变、后处理近端病变。2例患者MCA再通后即刻行同侧ICA支架置入;2例患者MCA再通后予以较长时间观察,等待颅内灌注得到一定恢复后再予以ICA支架置入;1例患者MCA再通后仅行颈动脉球囊扩张治疗。5例患者的闭塞血管均成功再通,且未出现症状性颅内出血及远端血栓事件。患者从发病到再通时间为637.2±172.2（451～814）min,再通至颈ICA支架置入时间为152.5±92.2（59～270）min。2例患者术后发生高灌注损伤导致死亡,其余3例患者术后90 d预后良好（mRS均为3分）。结论 伴大核心梗死的前循环串联病变进行急性血管内治疗可使部分患者获益,为降低术后的高灌注损伤风险,予以适当的“再灌注预适应”时间再同期处理颅外病变可能降低术后的高灌注损伤风险,但最佳的预适应时间仍需进一步探讨与实践。     

Modified permanent middle cerebral artery occlusion rat model aiming to reduce variability in infarct size

In animal cerebral infarct experiments, the most important aspect is to produce consistent infarct size and localization. In an attempt to improve the conventional middle cerebral artery (MCA) coagulation technique, we developed a new animal model using a microclip to reduce variability in infarct size. Male Sprague-Dawley rats were subjected to right MCA occlusion. The animals were divided into two groups; conventional MCA occlusion group (Group 1; n = 9) and modified clip occlusion group (Group 2; n = 9). In Group 2, the proximal portion of MCA was occluded by applying a small clip just proximal to the olfactory nerve, and the MCA from the clipped position to the position just proximal to the level of the inferior cerebral vein was electrocoagulated using a bipolar diathermy in the same manner as in Group 1. In other words, the only difference between these two groups was the manner of occlusion of the most proximal portion of the MCA. Rats were killed 24 hours after the stroke-inducing surgery, and infarct volume was determined by an image analysis program following staining with 2,3,5-triphenyltetrazolium chloride. The cortical infarct volumes were 51.0 +/- 13.8% in Group 1 and 46.3 +/- 6.2% in Group 2. The scattering of cortical infarct volume was significantly small in Group 2 (p=0.0176). The differences in scattering of striatal and total infarct volumes did not reach statistical significance. The present results demonstrated that the new MCA occlusion model using a clip significantly reduces the variability in cortical infarct volume, solving the problems of the model using coagulation alone. That permanent MCA occlusion model using a clip is an excellent method that produces more consistent and reproducible infarction.     

Failure of a clot retrieval device in an adolescent stroke patient

A previously healthy 14-year-old boy collapsed after a football game, with aphasia and right hemiparesis. Cranial magnetic resonance imaging and magnetic resonance angiography revealed left middle cerebral artery distribution ischemic infarct with thrombus and possible dissection at the horizontal segment of the middle cerebral artery. The patient was treated 9 hours after collapse with intra-arterial tissue plasminogen activator, but without success. The Merci clot retrieval device was then used, but the device broke in the middle cerebral artery and led to complete occlusion. At follow-up 3 months later, the boy had persistent aphasia, but notable improvement in his right hemiparesis. This is a novel report of a complication of mechanical clot retrieval treatment in a child. Further research is needed to determine the safety and effectiveness of intracranial endovascular clot retrieval devices in children.     

颅内中等血管急性闭塞的血管内治疗分析

目的 探讨血管内介入治疗颅内中等血管急性闭塞的安全性及有效性。方法 回顾性分析2017年1月至2021年9月采用血管内介入治疗的16例颅内中等血管急性闭塞的临床资料。颅内中等血管包括大脑中动脉M2/3段、大脑前动脉A2/3段和大脑后动脉P2/3段。结果 16例中,大脑中动脉M2段闭塞9例、M3段闭塞2例,大脑前动脉A2段闭塞2例,大脑后动脉P2段闭塞3例;8例符合静脉溶栓标准,行静脉溶栓后桥接血管内治疗。13例使用Solitaire AB支架取栓,2例动脉溶栓,1例直接球囊扩张成形。术后即刻TICI分级3级13例,2b级2例,血管再通率为93.7%（15/16）;另1例出现无症状性出血转化。术后90 d随访,预后良好率（mRS评分0~2分）为87.5%（14/16）。结论 对于颅内中等管径动脉急性闭塞,严格把握手术指征,采用可回收支架进行机械取栓治疗,血管开通率高,疗效好且安全。     

Modification by an aspiration catheter for vessel stretching in thrombectomy using a stent retriever in vitro

ObjectivesPost-thrombectomy subarachnoid hemorrhage, which is caused by vessel stretching when retrieving a stent retriever (SR), is a complication of endovascular mechanical thrombectomy (EVT) using an SR. This in vitro study examined the association between EVT for middle cerebral artery (MCA) occlusion and M2 vessel stretching depending on the positioning of the SR or combined use of SR and aspiration catheter (AC) technique (CBT).Materials and methodsA silicone vascular model was used. The maximum migration distance (MMD) in the anteroposterior view of an X-ray impermeable metal marker located at an M2 trunk 20 mm distal to the M1-2 bifurcation in angiographic images during an SR retrieval was calculated. According to the positioning of SR deployment (distal or proximal) and use of an AC [SR alone without an AC (SR alone) group, stent retrieval into an AC (SA) group, and stent-AC retrieval as a unit into a guiding catheter (SA unit) group], 60 attempts were conducted with each group of 10 attempts.ResultsIn distal SR deployment, the MMD in the CBT group, consisting of SA and SA unit groups, was significantly smaller than the SR alone group (1.36 ± 0.32 mm VS 2.39 ± 1.10 mm; p = 0.001). In proximal SR deployment, the CBT group showed a tendency to decrease MMD (1.38 ± 0.33 mm VS 1.63 ± 0.28 mm; p = 0.077).ConclusionsThis in vitro study showed that CBT might help modify the stretching of M2 when an SR is distally deployed in MCA occlusion.     

Massive haemorrhagic transformation in cardioembolic stroke: the role of arterial wall trauma and dissection

The pathogenesis of massive haemorrhagic transformation is not well established. Fatal haemorrhagic transformation associated with in situ dissection after acute middle cerebral artery (MCA) occlusion in a patient with atrial fibrillation is reported. An 80 year old woman with atrial fibrillation developed mild hemiparesis and aphasia. Brain CT and MRI at 4 and 5 hours, respectively, of symptom onset showed proximal MCA trunk occlusion with developing striatocapsular infarct and hypoperfusion in the superficial MCA territory. A few hours later, she developed massive bleeding into the ischaemic area and died. Pathological examination showed MCA trunk dissection, surrounded by a subarachnoid clot which communicated with the cerebral haematoma. It is suggested that direct arterial wall trauma as a result of cardioembolic MCA occlusion caused bleeding into the infarct. Secondary in situ dissection may be an overlooked mechanism of haemorrhagic transformation.     

Recurrent Cardioembolic Stroke Treated Successfully with Repeated Mechanical Thrombectomy within the Acute Index Stroke Period

Background

The safety of repeated mechanical thrombectomy within the acute stroke period has not yet been clearly demonstrated. We describe herein a patient who was successfully treated with repeated mechanical thrombectomy within the acute index stroke period.

Case Report

A 50-year-old woman with atrial fibrillation presented with left-sided weakness caused by occlusion of the right middle cerebral artery (MCA). Emergent mechanical thrombectomy with the Solitaire device achieved complete recanalization. The left MCA occlusion redeveloped at 6 days after the first treatment, at which time her international normalized ratio (INR) was 2.3. Endovascular thrombectomy was reattempted rapidly and complete recanalization was achieved again. Her neurologic symptoms resolved after the thrombectomy.

Conclusions

This case demonstrates that repeated mechanical thrombectomy can be safely and successfully performed even in a patient with a high INR and a recurrent stroke during the acute period after the index stroke.     

Transcranial Doppler 6 h after Successful Reperfusion as a Predictor of Infarct Volume

ObjectivesThe aim of the study is to analyze the hemodynamic changes in the middle cerebral artery (MCA) after endovascular revascularization in acute ischemic stroke (AIS) due to large vessel occlusion and its association with the infarct volume size in the control head CT.Materials and MethodsProspective study of patients with AIS due to internal carotid artery terminus or M1 segment of the MCA occlusion, who underwent endovascular treatment with a final TICI 2b-3 score, without concomitant stenosis ≥50% in both cervical carotid arteries. Transcranial Doppler ultrasound (TCD) of both MCAs was carried out at 6 h after the endovascular procedure. Mean flow velocities (MFV) after arterial reperfusion and its association with the infarct volume size in 24?36 h control head CT were determined.Results91 patients (51 women) were included with a median age of 78 years and National institute of Health Stroke Scale of 18. The MCA was occluded in 76.92%, and intravenous thrombolysis was administered in 40.7%. The incidence of symptomatic intracranial hemorrhage was 5.5%. At three months, mortality was 19.8% and a 52.7% of patients achieved functional independence (modified Rankin Scale 0-2). After a multivariable logistic regression analysis, an increase in the MFV greater than 50% at 6 h in the treated MCA compared to contralateral MCA, was an independent predictor of large infarct volume in the control head CT with an OR 9.615 (95%CI: 1.908?47.620), p=0.006ConclusionsIncreased MFV assessed by TCD examination following endovascular recanalization is independently associated with larger infarct volume