Mechanical thrombectomy of M2 occlusions with distal access catheters using ADAPT

Background and purposeThe direct aspiration first pass technique (ADAPT) using distal access catheters (DAC) has proven to be an effective and safe endovascular treatment strategy of acute ischemic stroke with large vessel occlusions (LVO). However, data about direct aspiration using DAC in M2 segment occlusions is limited.We assess the safety and efficacy of DACs in acute M2 occlusions using ADAPT with large bore (5 French /6 French) aspiration catheters as the primary method for endovascular recanalization.Materials and methodsFrom January 2017 to July 2018, 52 patients with an acute ischemic stroke due to M2 occlusions underwent mechanical thrombectomy using ADAPT with DACs (SOFIA 5 French/Catalyst 6) as frontline therapy. Patient demographics, technical parameters and outcome data were recorded.ResultsMedian National Institutes of Health Strokes Scale (NIHSS) Score was 12 at admission. Successful revascularization to mTICI 2b-3 with ADAPT alone was achieved in 45 of 52 patients (86.5%) with mTICI 3 achieved in 32 patients (61.5%). Additional stent retrievers were used in 6 patients and led to an overall successful revascularisation of 92.3% (48/52). Median NIHSS at discharge was 4. 29 of 52 (55.8%) patients had a modified Rankin Scale (mRS) Score 0–2 at three months. Symptomatic intracranial hemorrhage did not occur.ConclusionDACs can safely be used for mechanical thrombectomy of acute M2 occlusions by the ADAPT approach. Their use alone can be a high efficacious treatment of distal intracranial thromboembolic occlusions.     

Critical Use of Balloon Angioplasty after Recanalization Failure with Retrievable Stent in Acute Cerebral Artery Occlusion

Objective

Sudden major cerebral artery occlusion often resists recanalization with currently available techniques or can results in massive symptomatic intracranial hemorrhage (sICH) after thrombolytic therapy. The purpose of this study was to examine mechanical recanalization with a retrievable self-expanding stent and balloon in acute intracranial artery occlusions.

Methods

Twenty-eight consecutive patients with acute intracranial artery occlusions were treated with a Solitaire retrievable stent. Balloon angioplasty was added if successful recanalization was not achieved after stent retrieval. The angiographic outcome was assessed by Thrombolysis in Cerebral Infarction (TICI) and the clinical outcomes were assessed by the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS).

Results

At baseline, mean age was 69.4 years and mean initial NIHSS score was 12.5. A recanalization to TICI 2 or 3 was achieved in 24 patients (85%) after stent retrieval. Successful recanalization was achieved after additional balloon angioplasty in 4 patients. At 90-day follow-up, 24 patients (85%) had a NIHSS improvement of ≥4 and 17 patients (60%) had a good outcome (mRS ≤2). Although there was sICH, there was one death associated with the procedure.

Conclusion

Mechanical thromboembolectomy with a retrievable stent followed by additional balloon angioplasty is a safe and effective first-line therapy for acute intracranial artery occlusions especially in case of unsuccessful recanalization after stent thrombectomy.     

Distribution and outcome of symptomatic stenoses and occlusions in patients with acute cerebral ischemia

OBJECTIVE: To describe the distribution of steno-occlusive disease and the associated rate of recurrence in patients with acute cerebral ischemia. DESIGN: An inception cohort was prospectively recruited after an index event and followed up to assess recurrent stroke and death up to 1 year after the event. SETTING: Eleven German departments of neurology with acute stroke units. PATIENTS: A total of 4157 patients who experienced an acute ischemic stroke or a transient ischemic attack and had complete cerebrovascular examination results. Follow-up information could be obtained in 85.3% of these patients. RESULTS: Symptomatic vessel occlusions were associated with a high mortality rate and were found most often in the proximal internal carotid artery (6.5% of patients), the M1 segment of the middle cerebral artery (3.7%), and the vertebral artery (3.0%). Symptomatic stenosis of 50% to 99% of the internal carotid artery was found in 308 patients (7.4%), and 272 patients (6.5%) had symptomatic intracranial stenosis. The highest rates of recurrent stroke during the first 3 days occurred in patients with symptomatic carotid and intracranial occlusions. Overall, 82 (8.0%) of 1027 patients with symptomatic cerebrovascular disease experienced a recurrent stroke between day 4 and 1 year, but no significant differences in recurrent stroke rates could be found when comparing different locations of steno-occlusive disease. CONCLUSIONS: Our study provides representative data on the distribution and outcome of steno-occlusive disease in patients with acute cerebral ischemia. In contrast to prior studies in more selected populations, the rate of recurrent stroke in patients with symptomatic intracranial stenosis was not elevated compared with that of patients without steno-occlusive disease.     

Treatment with anticoagulants in cerebral events (TRACE)

90 patients with acute stroke and a concomitant cardiac embolism source or a symptomatic high-grade stenosis of an extra-or intracranial vessel received in a mulitcenter, randomized, controlled study either Enoxaparin 1 mg/kg BW s.c. b.i.d. or i.v. heparin aPTT-adjusted daily for 8 +/- 2 days as secondary prophylaxis. There were no significant differences between the two groups regarding cerebral and systemic embolic events, bleeding complications, length of hospital stay, number of diagnostic and therapeutic measures and outcome after three months. This suggests that Enoxaparin, which is easier to administer and monitor, is a safe drug in patients with acute cerebral events.     

Safety and efficacy of mechanical thrombectomy with the Solitaire device in large artery occlusion

Background and Purpose: Intravenous tissue plasminogen activator (TPA) has limited efficacy in proximal large vessel occlusions. This study was to assess the safety and efficacy of mechanical thrombectomy with a retrievable Solitaire stent in acute large artery occlusions . Materials and Methods: This is a single center study enrolling patients treated with Solitaire-assisted thrombectomy between November 2010 and March 2011. Inclusion criteria were severe stroke of National Institutes of Health Stroke Scale (NIHSS) score ≥10, treatment initiation within 6 hours from onset, and an angiographically verified occlusion of proximal middle cerebral artery (MCA) or internal carotid artery (ICA). The primary outcome was recanalization defined as Thrombolysis in Cerebral Infarct (TICI) reperfusion grade 2b/3. Secondary outcomes were good functional outcome at 3 months (modified Rankin Scale [mRS] ≤2), early substantial neurological improvement (NIHSS score improvement ≥8 at 24 hours), and symptomatic hemorrhagic transformation (SHT). Results: Ten patients were consecutively enrolled: Age: 72.4 ? 5.7 years; female: 70%; baseline median NIHSS score: 19.5; and ICA occlusion in 50% and M1 portion of MCA occlusion in 50%. Six patients received intravenous TPA before intra-arterial treatment, and five patients were treated with adjuvant intra-arterial urokinase. Successful recanalization was achieved in 7 (70%) patients. Four (40%) patients had a good functional outcome at 3 months, and three (30%) patients had an early substantial neurological improvement. SHT occurred in two patients (20%), and 3-month mortality rate was 30%. There was no procedure-related complication. Conclusions: Mechanical thrombectomy with the Solitaire device can effectively recanalize proximal large vessel occlusions, and potentially improves clinical outcome.     

Internal borderzone infarction following acute middle cerebral artery occlusion

In 36 patients suffering acute middle cerebral artery (MCA) occlusion, we studied the angiographic findings within 6 hours of the ictus and the chronic CT results at 3 months. Seven patients suffering distal pial MCA branch occlusion developed a pattern of internal borderzone infarction on follow-up CT. Carotid artery or carotid siphon stenosis or occlusion was absent in all seven. Proximal MCA branch occlusions, prior to the origin of the lenticulostriate arteries, were associated with extensive cortical and deep infarction in the entire MCA territory in 14 patients. There was proximal carotid artery or siphon stenosis or occlusion in 12 of these 14 patients. The remaining 15 patients showed a mixture of proximal and distal MCA occlusions and patchy ischemic damage in the MCA territory. There were no cases of superficial cortical watershed infarction. These data show that internal borderzone infarctions may result from intracranial MCA branch occlusions alone and need not be associated with hemodynamic alterations due to large vessel extracranial disease.     

Doppler ophthalmic blood pressure measurement in the hemodynamic evaluation of occlusive carotid artery disease

In 102 patients with angiographically proven occlusive carotid artery disease of 60-100% diameter reduction, Doppler ophthalmic artery pressure and blood flow direction were recorded by the recently developed ophthalmomanometry-Doppler technique. Among these 102 patients, 50 presented with complete carotid artery occlusions and 52 with carotid artery diameter stenoses of greater than or equal to 60%. Mean +/- SD Doppler ophthalmic artery pressure was 69 +/- 15 mm Hg ipsilateral to the occlusion and 86 +/- 18 mm Hg ipsilateral to a stenosis of the carotid artery (p less than 0.001). The mean +/- SD Doppler ophthalmic pressure index (ratio of the ophthalmic artery to systemic blood pressure) was lower ipsilateral to the occlusion (0.46 +/- 0.08) than ipsilateral to a carotid artery stenosis (0.54 +/- 0.08; p less than 0.001); in both, the index was clearly diminished compared with normal values (0.68 +/- 0.04; p less than 0.001). It is concluded that the intracranial hemodynamic consequences in the patients with occlusion are on average more profound than in the patients with stenosis. In carotid artery occlusions, the mean +/- SD ipsilateral ophthalmic pressure index was 0.46 +/- 0.06 for antegrade and 0.46 +/- 0.09 for retrograde ophthalmic artery blood flow. In carotid artery stenoses, the mean +/- SD ipsilateral ophthalmic pressure index was 0.55 +/- 0.07 for antegrade and 0.48 +/- 0.06 for retrograde ophthalmic artery blood flow (p less than 0.01). These results indicate that in carotid stenoses the collateral capacity of the ophthalmic artery is insufficient compared with intracranial collaterals, while in carotid occlusions the blood flow direction in the ophthalmic artery does not predict intracranial hemodynamic compensation.     

Morphological changes of platelets in disturbed cerebral microcirculation--a clinical study using a scanning electron microscope (author's transl)

Many factors are known that contribute to the pathogenesis of the cerebral microcirculatory disturbances, but, there are few reports investigating the roles of the intravascular components directly. The present study was undertaken to evaluate morphological changes of platelets in patients with cerebral damage, in relation to neurological signs, especially consciousness levels. Morphological changes of platelets were observed in 72 patients with intracranial organic lesions. These lesions included subarachnoid hemorrhages, hypertensive cerebral hemorrhages, cerebral infarctions, brain tumors, chronic subdural hematomas, and acute epidural hematomas. Two blood samples were taken, one from the internal jugular vein (the blood after cerebral perfusion), the other from the cubital vein (systemic blood). After fixative procedures with 1% glutaraldehyde, the differences in the three-dimensional structures of platelets were compared, using a scanning electron microscope. In general, remarkably activated forms of platelets were found in the blood after cerebral perfusion in cases with severely impaired consciousness in the acute stage. But, in cases without severe neurological deficits, such changes of platelet forms were rarely seen. A close relationship was suggested between the degree of neurological damage (especially consciousness levels) and that of platelet activation in the acute stage. In the chronic stage, these changes of platelets in the cerebral blood disappeared. Changes of platelet forms were not found in the systemic blood from the cubital vein, even in the acute stage. It is clinically suggested that morphological changes of platelets play an important role in the pathogenesis of the disturbed cerebral microcirculation. Obstruction of cerebral microvasculature may be caused, mechanically by the activated platelets themselves, and/or chemically by vasoconstrictive substances released from these platelets. Therefore, in the treatment of these intracranial organic lesions, it is concluded that the possible roles of activated platelets should be taken into consideration.     

Proton magnetic resonance spectroscopy (1H MRS) in patients with sporadic cerebellar degeneration.

The authors studied 23 patients with cerebellar degeneration including multiple systemic atrophy (MSA) and cerebellar cortical atrophy (CCA) by proton magnetic resonance spectroscopy (1H-MRS). 1H-MRS allowed noninvasive measurement of the signal intensities derived from N-acetylaspartate (NAA), creatine + phosphocreatine (CRE), and choline-containing compounds (CHO). There was significant reduction of the NAA/CRE level in the frontal cortex, putamen, cerebellar hemisphere and cerebellar vermis of patients with MSA, and in the frontal cortex, cerebellar hemisphere and cerebellar vermis of patients with CCA as compared with those of normal controls. There was significant reduction of the NAA/CRE level also in the putamen of patients with MSA as compared with that of patients with CCA. These results indicated the presence of a degenerative process and/or functional impairment in the frontal cortex and putamen of patients with MSA and in the frontal cortex of patients with CCA, in addition to a degenerative process in the cerebellum. There was a significant correlation between the NAA/CRE level and the severity of clinical signs. 1H-MRS is valuable in providing information regarding the pathophysiology and the progress of cerebellar degenerative diseases.     

Safety and Feasibility of Argatroban,Recombinant Tissue Plasminogen Activator,and Intra-Arterial Therapy in Stroke (ARTSS-IA Study)

Background

A randomized trial of concurrent recombinant tissue-type plasminogen activator (r-tPA)?+?thrombin-inhibition with Argatroban in stroke patients recently demonstrated safety and signal of efficacy compared to r-tPA alone, but patients having endovascular therapy (EVT) were excluded. The current study intended to study feasibility and safety of concurrent r-tPA and Argatroban in patients undergoing EVT.

European Cooperative Acute Stroke Study (ECASS): (rt-PA—Thrombolysis in acute stroke) study design and progress report

At present, no therapy for acute ischemic stroke has been established. Vascular occlusions are demonstrated in up to 75–90% of ischemic stroke patients, and it is assumed that rapid lysis of the causal vascular occlusion will improve outcome of ischemic stroke. The purpose of the ECASS study is to evaluate whether thrombolytic therapy with recombinant tissue plasminogen activator, alteplase, improves outcome compared to a placebo-treated control group. Patients with acute ischemic hemispheric stroke in whom intravenous rt-PA (alteplase) could be initiated within 6 h from the onset of symptoms were evaluated by neurological examination and cerebral computed tomographic scans (CT scans) of the brain. Patients fulfilling inclusion criteria and not meeting any exclusion criteria were, after informed consent, treated by 1.1 mg rt-PA per kg body weight (max 100 mg) intravenously or placebo. No angiographic evaluation was included in the trial. In total, 623 patients were randomized in 14 European countries. In addition, 81 patients were treated in an open pilot phase with the active drug. Treatment effect was evaluated using the Barthel Index and the Modified Rankin Scale at 90 ± 7 days in both an intention-to-treat analysis and an explanatory analysis. The clinical course was evaluated by repeated neurological ratings on the Scandinavian Stroke Scale. Adverse events (intracranial hemorrhage or cerebral edema) were evaluated by repeating CT scans at 24 h and at 7 days. Recruitment was terminated in March 1994. Follow-up evaluations were terminated in late June 1994. The first unblinded results are expected in February 1995. Overall mortality was 18.5% in the pilot study and 18.9% in the randomized trial. The incidence of cerebral bleeding complications associated with clinical deterioration was 11.1% (pilot) and 6.5% (randomized trial).     

Carotid ultrasound criteria for detecting intracranial carotid stenosis

BACKGROUND/AIMS: This study attempted to establish carotid ultrasound criteria for identifying stenosis of the intracranial internal carotid artery (ICA) and middle cerebral artery (MCA). METHODS: Two hundred and fifty-five patients were enrolled. Ultrasound measurements for common carotid artery (CCA) and ICA were as follows: flow volume (FV), peak systolic velocity (PSV), end-diastolic velocity (EDV), pulsatility index (PI) and resistance index (RI). The sensitivity and specificity of the ultrasound criteria for determining intracranial ICA or MCA>or=50% stenosis were calculated. RESULTS: The criteria identified for detecting intracranial ICA>or=50% stenosis were ICA FV<159 ml/min, ICA PSV<33 cm/s and CCA PSV<42 cm/s. When ICA PSV<33 cm/s was combined with CCA PSV<42 cm/s, sensitivity increased to 82%, with 91% specificity. The criteria identified for detecting MCA>or=50% stenosis were CCA FV<285 ml/min, ICA FV<179 ml/min, ICA PSV<33 cm/s, >35% reduction in FV in the CCA, >40% reduction in FV in ICA, and >35% reduction in PSV in ICA. When these criteria were combined, sensitivity increased to 69%, with 85% specificity. CONCLUSION: This study demonstrated that ultrasound criteria are sensitive and specific for detecting intracranial ICA and MCA significant obstruction.     

Prognosis of Tandem Occlusions versus Isolated Intracranial Occlusions

Background

Both acute single intracranial and tandem occlusions are managed with intravascular thrombectomy with success, but little evidence exists about the differences in their mid-term outcome. We aim to compare the outcome at 3 months after tandem (extracranial internal carotid and/or middle cerebral artery) and single intracranial (M1 division) occlusions, and to identify the factors, which determine such prognosis.

Side effects of thrombolytic treatment with porcine plasmin and low dose streptokinase

In the sequential thrombolytic therapy with porcine plasmin and low dose streptokinase side effects are mainly due to bleeding, intolerance reactions are less important. Treatment had to be prematurely stopped in 42 (37%) of 114 DVT cases because of severe bleeding and in 12 (10%) due to intolerance reactions. The corresponding figures for the 45 cases with arterial occlusions are 15 (33%) and 2 (4%) respectively. The intensity of systemic proteolysis as represented by the thromboplastin time is significantly correlated with haemorrhagic manifestations. Macrohematuria and bleeding from puncture sites are the most frequent haemorrhagic complications followed by spontaneous bleeding into skin and muscles. Non-fatal intracranial bleeding occurred in 1 DVT case (0.9%) and in 2 patients with arterial occlusions (4.4%). The benefit of this potent thrombolytic regimen would greatly improve if a strong reduction of premature treatment stop could be achieved.     

“Adaptative endovascular strategy to the CloT MRI in large intracranial vessel occlusion” (VECTOR): Study protocol of a randomized control trial

A correlation between the susceptibility vessel sign (SVS) and red thrombi has been identified in MRI. We hypothesized that the Embotrap allow better retrieving of SVS+ thrombi. The AdaptatiVe Endovascular strategy to the CloT MRI in large intracranial vessel Occlusion (VECTOR) trial is a multicenter, prospective and randomized study designed to compare a first-line strategy combining Embotrap added to contact aspiration (CA) versus CA alone in patients with SVS+ occlusions.     

Computed tomographic-angiographic findings within the first five hours of cerebral infarction

BACKGROUND AND PURPOSE: Modern management of acute stroke necessitates early diagnosis. To this end, we sought to delineate the radiographic features of focal hemispheric infarction within 5 hours of ictus. METHODS: Fifty patients, ages 54-79, with ischemic strokes productive of at least hemiparesis underwent computed tomographic scanning and cerebral angiography (n = 38) or carotid ultrasound (n = 12). Radiographic lesions were characterized for location, size, and pathophysiology. RESULTS: Acute abnormalities, hypodensity, and mass effect were seen in 56% of scans and confirmed on a second scan 5-7 days later. Intracranial angiographic abnormalities occurred in 61% of patients: arterial occlusions in 45% and delayed arterial filling in 16%. Hemorrhagic infarctions occurred in 26% of second scans and were associated with mass effect (100%) and arterial occlusions (89%). Infarcts with hemorrhagic transformation were larger on both scans than those without (p = 0.001). Of four patients with infarctions in watershed territories on the scans, two had middle cerebral artery occlusions on angiography, thereby questioning the specificity of such scan lesions to low-flow states. CONCLUSIONS: We conclude that cerebral infarctions are often visible on early scans, but their locations may not be etiologically determinative. The infarcts associated with intracranial arterial occlusions (45%) were of thromboembolic origin, but, given current controversies as to the pathophysiology of lacunar and watershed infarctions, we cannot ascertain the etiology in the remainder. These findings are relevant to the new stroke therapies that require administration in the first hours after infarction.     

Systemische Thrombolysetherapie mit rt-PA beim akuten Mediaterritorialinfarkt Erfahrungen aus der klinischen Routine

BACKGROUND AND PURPOSE: Only a few clinical reports about the routine use of intravenous rt-PA for the treatment of acute ischemic stroke have been published. Wether the perfusion of the extracranial parts of the internal carotid artery influences the outcome of the patients is still unknown, because the two major studies about systemic thrombolytic therapy with rt-PA in stroke (ECASS and NINDS) did not formally assess the status of the extracranial vessels. METHODS: 56 Patients were treated with intravenous rt-PA within 6 h of acute ischemic stroke between January 1995 and May 1998. Before and within 24 h after the thrombolytic therapy usually a neurovascular diagnostic with extra- und transcranial Doppler-ultrasound or CT-angiography was performed. Occlusions of the intracranial parts of the internal carotid artery (Carotid-T) were excluded from thrombolytic therapy. The outcome was assessed using the Rankin-scale at least 3 month after the therapy. RESULTS: The average time from stroke onset to administration of treatment was 3.7 h.A parenchymal hemorrhage with clinical deterioration was found in four patients (7.1%). Eight patients died until the follow-up (14.3%), four within 14 days. 39 patients showed a clinical improvement. Outcome and recanalization rate of the medial cerebral artery was not influenced by stenoses or occlusions of the extracranial internal carotid artery. CONCLUSIONS: Routine intravenous use of rt-PA for acute ischemic stroke shows safety comparable to the results of the NINDS study even in 6 h time window. The outcome and recanalization rate depends not on the perfusion of the extracranial parts of the internal carotid artery.     

伴活动性恶性肿瘤的急性缺血性卒中患者静脉溶栓的临床分析及文献回顾

目的 探讨伴有活动性恶性肿瘤的急性缺血性卒中应用rt-PA进行静脉溶栓的有效性及安全性.方法 回顾性连续收集2017年4月-2020年4月在北京市石景山医院卒中单元进行静脉溶栓的伴有活动性恶性肿瘤的急性缺血性卒中患者的临床资料,统计溶栓后7 d神经功能好转率(NIHSS评分下降≥2分)、90 d良好预后率(mRS评分≤...     

Use of High Frequency Oscillatory Ventilation (HFOV) in Neurocritical Care Patients

Introduction  

Adult respiratory distress syndrome (ARDS) can be a common problem associated with the treatment of acute brain injury. High frequency oscillatory ventilation (HFOV) is a developing therapy for the treatment of ARDS in adult patients that can be life saving. However, often patients with acute, severe brain injury demonstrate intracranial hypertension (hICP) due to a variety of injuries (e.g., traumatic brain injury, mass lesion, acute hydrocephalus). There is concern over the use of HFOV due to its effects on intracranial pressure in patients with hICP.     

Mechanical Thrombectomy of the Middle Cerebral Artery – Neither Segment nor Diameter Matter

ObjectivesThe aim of this study was to explore the role of the vessel diameter at the site of middle cerebral artery (MCA) occlusion in acute ischemic stroke patients who underwent mechanical thrombectomy (MT) regarding technical aspects, safety, and clinical outcomes.MethodsIn a retrospective analysis, cerebral artery diameters were measured using digital subtraction angiography in patients with isolated M1 or M2 occlusions undergoing MT. Associations between occluded vessel, occlusion diameter and outcomes were analyzed using logistic regression models adjusting for prespecified prognostic factors.Results168 patients with M1 occlusions and 98 patients with M2 occlusions who underwent MT were included. Mean vessel diameters at M1 and M2 occlusion sites differed significantly (2.15 +/− .36 1.55 +/− .38, P < .001). Vessel diameters at the occlusion site and occluded vessel segment did not predict good functional outcome (aOR 1.2 CI .28-5.26, P = .659; aOR .84 CI .35-2.03, P = .841) or mortality (aOR .21 CI .04-1.01, P = .215; aOR 1.36 CI .55-3.37, P = .676). No significant differences in successful recanalization, good functional outcome, mortality, procedural complications, and intracranial hemorrhages between M1 and M2 occlusions was observed.ConclusionsIn this study no significant effect of the MCA vessel diameter on successful recanalization, good functional outcome, or mortality of acute ischemic stroke patients treated with MT could be detected. However, these findings need to be confirmed in further studies.