Intracranial balloon angioplasty of acute terminal internal carotid artery occlusions

Acute embolic occlusion of the intracranial internal carotid bifurcation is associated with a poor prognosis. Recanalization rates of this lesion with intravenous or intraarterial thrombolysis are exceedingly low. We describe the use of balloon angioplasty after failed thrombolysis to achieve immediate recanalization of acute carotid T occlusions in two patients. At 1-month follow-up, both patients were alive with neurologic deficits. For acute carotid T occlusion, balloon angioplasty should be considered a first-line endovascular therapy.     

颅内动脉溶栓联合机械碎栓治疗急性脑梗死

目的探讨动脉溶栓联合机械碎栓治疗急性脑梗死的可行性和安全性。方法通过对9例急性脑梗死患者实施动脉内尿激酶溶栓联合机械性碎栓介入治疗(其中大脑前动脉A1段栓塞1例、大脑中动脉M1段栓塞6例、颈内动脉C1段狭窄1例、颈内动脉主干栓塞1例;起病距介入治疗时间3 h内2例,3～6 h 5例,>24 h 2例。结果7例6 h以内急性脑梗死患者主要栓塞血管得到100%开通,2例大于24 h患者症状得到改善(颈内动脉C1段狭窄1例、颈内动脉主干栓塞1例)。结论超选择局域性动脉内尿激酶溶栓联合机械碎栓治疗6 h以内急性脑梗死,能使闭塞的血管尽快开通,是一种安全有效的介入治疗术式。     

Angioplasty of the occluded internal carotid artery.

PURPOSETo review patients who have presented with acute strokes from a middle cerebral artery occlusion in whom in addition to the middle cerebral artery thromboembolus, an internal carotid artery occlusion has been present, and in whom angioplasty of these totally occluded internal carotid arteries has bee n successful.METHODSWe reviewed retrospectively our experience in treating a cute stroke patients with intracranial, intraarterial urokinase. Six of 27 patients had internal carotid artery occlusions in addition to middle cerebral artery occlusions. Two patients presented with spontaneous carotid dissections for wh ich no further intervention from the ipsilateral internal carotid artery was attempted. In the remaining four internal carotid artery occlusions secondary to atherosclerotic disease, standard guide wires and catheters were negotiated across the level of the internal carotid artery occlusion, which expedited intracranial catheterization for thrombolysis. Subsequently, angioplasty of the internal carotid artery was performed.RESULTSAll four occluded internal carotid arteries could be traversed. No new neurologic deficits occurred. No vascular injuries occurred. No deaths occurred. Four- to 6-month follow-up showed all four internal carotid arteries remained patent.CONCLUSIONIn acute occlusions of the internal carotid artery from atherosclerosis, the occluded vessel can sometimes be recanalized with low morbidity. In addition, endovascular access to the intracranial circulation can be expedited by using the recanalized internal carotid artery.     

Combined intraarterial/intravenous thrombolysis for acute ischemic stroke

BACKGROUND AND PURPOSE: The intravenous use of recombinant tissue-type plasminogen activator (rTPA) in acute ischemic stroke has been investigated in three large trials. Limited series have reflected outcome after local intraarterial thrombolysis (LIT) in the cerebral territory. The purpose of this study was to evaluate the safety and efficacy of combined intraarterial/intravenous thrombolysis using rTPA (actilyse) for acute ischemic stroke. METHODS: Forty-five patients with acute onset of severe hemispheric stroke and without signs of major cerebral infarction on early CT scans were randomized by order of admission. Twelve patients were treated with 50 mg actilyse (maximal dose, 0.7 mg/kg); three had occlusion of the internal carotid artery and nine had occlusion of the middle cerebral artery. Thrombolysis was started by LIT and continued intravenously within 6 hours of stroke onset. Outcome, assessed after 1 and 12 months according to the modified Rankin scale (MRS), was considered good (MRS score, 0-3) for patients who were functionally independent and poor (MRS score, 4-5) for those who were dependent or had died. RESULTS: In the thrombolysis group, outcome was good in eight patients at 1 month and in 10 patients at 12 months; in the control group, outcome was good in seven (21%) and 11 (33%) patients, respectively. Of the eight patients with a good outcome after thrombolysis, four had complete and one had partial recanalization. In the control group, the rate of intracerebral hemorrhage was 6%. Mortality at 1 month in the thrombolysis and control groups was 17% and 48%, respectively. CONCLUSIONS: Combined intraarterial/intravenous thrombolysis with low-dose rTPA may be a safe and effective treatment for acute ischemic stroke within 6 hours in carefully selected patients.     

球囊碎栓辅助动脉溶栓治疗急性大脑中动脉闭塞

目的 评价利用抽瘪的球囊碎栓辅助动脉溶栓治疗急性大脑中动脉闭塞的可行性、安全性及疗效.方法 5例急性大脑中动脉闭塞患者接受球囊碎栓辅助动脉溶栓治疗.于颈内动脉远端充盈微球囊,抽瘪球囊沿微导丝通过血栓再退至血栓近端注入尿激酶,尿激酶最大剂量为50万u.结果 5例患者中3例获得完全再通,2例部分再通,均获得良好疗效.未见颅内出血并发症.结论 采用抽瘪的球囊碎栓辅助动脉溶栓足治疗急性大脑中动脉闭塞安全、可行、有效的方法.     

Anterior cerebral artery emboli in combined intravenous and intra-arterial rtPA treatment of acute ischemic stroke in the IMS I and II trials

BACKGROUND AND PURPOSE: Anterior cerebral artery (ACA) emboli may occur before or during fibrinolytic revascularization of middle cerebral artery (MCA) and internal carotid artery (ICA) T occlusions. We sought to determine the incidence and effect of baseline and new embolic ACA occlusions in the Interventional Management of Stroke (IMS) studies. MATERIALS AND METHODS: Case report forms, pretreatment and posttreatment arteriograms, and CTs from 142 subjects entered into IMS I & II were reviewed to identify subjects with baseline ACA occlusion, new ACA emboli occurring during fibrinolysis, subsequent CT-demonstrated infarction in the ACA distribution, and to evaluate global and lower extremity motor clinical outcome. RESULTS: During M1/M2 thrombolysis procedures, new ACA embolus occurred in 1 of 60 (1.7%) subjects. Baseline distal emboli were identified in 3 of 20 (15%) T occlusions before intra-arterial (IA) treatment, and new posttreatment distal ACA emboli were identified in 3 subjects. At 24 hours, 8 (32%) T occlusions demonstrated CT-ACA infarct, typically of small volume. Infarcts were less common following sonography microcatheter-assisted thrombolysis compared with standard microcatheter thrombolysis (P = .05). Lower extremity weakness was present in 9 of 10 subjects with ACA embolus/infarct at 24 hours. The modified Rankin 0 to 2 outcomes were achieved in 4 of 25 (16%) subjects with T occlusion overall, but in 0 of 10 subjects with distal ACA emboli or ACA CT infarcts (P = .07). CONCLUSIONS: With IV/IA recombinant tissue plasminogen activator treatment for MCA emboli, new ACA emboli are uncommon events. Distal ACA emboli during T-occlusion thrombolysis are not uncommon, typically lead to small ACA-distribution infarcts, and may limit neurologic recovery.     

Relationship between clot location and outcome after basilar artery thrombolysis.

PURPOSETo identify factors that predict survival and good neurologic outcome in patients undergoing basilar artery thrombolysis.METHODSOver a 42-month period, 20 of 22 consecutive patients with angiographic proof of basilar artery thrombosis were treated with local intraarterial urokinase. Brain CT scans, neurologic examinations, symptom duration, clot location, and degree of recanalization were analyzed retrospectively.RESULTSOverall survival was 35% at 3 months. Survival in patients with only distal basilar clot was 71%, while survival in patients with proximal or midbasilar clot was only 15%. At 3 months, 29% of patients with distal basilar clot and 15% of patients with proximal or midbasilar clot had good neurologic outcomes (modified Rankin score of 0 to 2 and Barthel index of 95 to 100). Complete recanalization was achieved in 50% of patients; 60% of those survived and 30% had good neurologic outcomes. Of patients with less than complete recanalization, only 10% survived. Neither duration of symptoms before treatment (range, 1 to 79 hours), age (range, 12 to 83 years), nor neurologic status at the initiation of treatment (Glasgow Coma Scale score range, 3 to 15) predicted outcome. Pretreatment CT findings (positive or negative for related ischemic changes) did not predict outcome or hemorrhagic transformation.CONCLUSIONThe single best predictor of survival after basilar thrombosis and intraarterial thrombolysis was distal clot location. Complete recanalization favored survival. Radiologically evident related infarctions, advanced age, delayed diagnosis, and poor pretreatment neurologic status did not predict poor outcome and therefore should not be considered absolute contraindications for intraarterial thrombolysis in patients with basilar artery thrombosis.     

CT angiography in the rapid triage of patients with hyperacute stroke to intraarterial thrombolysis: accuracy in the detection of large vessel thrombus

PURPOSE: The purpose of this work was to evaluate the accuracy of CT angiography (CTA) for the detection of large vessel intracranial thrombus in clinically suspected hyperacute (<6 h) stroke patients. METHOD: Forty-four consecutive intraarterial thrombolysis candidates underwent noncontrast CT followed immediately by CTA. Axial source and two-dimensional collapsed maximum intensity projection reformatted CTA images were rated for the presence or absence of large vessel occlusion. Five hundred seventy-two circle-of-Willis vessels were reviewed; arteriographic correlation was available for 224 of these. RESULTS: Sensitivity and specificity for the detection of large vessel occlusion were 98.4 and 98.1%; accuracy, calculated using receiver operating characteristic analysis, was 99%. Mean time for acquisition, reconstruction, and analysis of CTA images was approximately 15 min. CONCLUSION: CTA is highly accurate for the detection and exclusion of large vessel intracranial occlusion and may therefore be valuable in the rapid triage of hyperacute stroke patients to intraarterial thrombolytic treatment.     

急性缺血性脑中风早期局部动脉内溶栓

目的　评价局部动脉内溶栓在急性缺血性脑中风治疗中的作用。方法　 11例急性缺血性脑中风患者 ,采用局部动脉内灌注尿激酶 (UK)溶栓 ,所有病例均在发病 10h内接受治疗。入院时平均脑中风评分 (NIHS)为 18分。均为大脑中动脉 (MCA)闭塞。术后 3 0d用RankinScale(RS)标准评估疗效。结果　 7例 (63 .6% )闭塞获得完全再通 ,1例 (9% )部分再通后并发颅内出血。 3例(2 7.3 % )无效。术后 3 0d ,2例 (18.2 % )完全恢复 (RS 0～ 1分 ) ,5例 (4 5 .5 % )轻度神经功能障碍 (RS 2～ 3分 ) ,4例 (3 6.3 % )重度神经功能障碍 (RS 4～ 5分 ) ,无死亡。结论　早期 (6h内 )局部动脉内溶栓是治疗急性缺血性脑中风的有效方法     

Endovascular treatment in proximal and intracranial carotid occlusion 9 hours after symptom onset

INTRODUCTION: A debate is emerging over whether the treatment time window in acute stroke can be extended beyond 6 h if penumbral tissue can be identified. Treatment decisions are very difficult in cases of tandem proximal carotid occlusion with arterioarterial intracranial embolism. We enter this debate with the present report on a case of atherosclerotic proximal carotid occlusion and resulting periocclusional carotid T embolism that was successfully treated 9 h after symptom onset. METHODS: The case of a 68-year-old man with fluctuating symptoms of right-hemispheric stroke is presented (NIHSS score 12-20 on admission). CT angiography demonstrated proximal carotid occlusion and periocclusional embolism of the entire internal carotid artery (ICA) including the carotid T segment. Penumbral tissue was diagnosed by nonenhanced and perfusion CT imaging 7.5 h after symptom onset. Treatment was initiated 9 h after symptom onset by passing the proximal occlusion with a microcatheter and local administration of recombinant tissue plasminogen activator (rt-PA) into the carotid T segment at the level of posterior communicating artery (PCoA) origin. RESULTS: Recanalization of the ICA and middle cerebral artery was accomplished within 1 h by flow establishment via the PCoA. The atherosclerotic proximal ICA occlusion was not stented due to the risk of embolism from remnant thrombi in the petrous and cavernous ICA segments. Follow-up MRI showed only mild haemorrhagic infarct transformation of the initial infarct core. The patient was discharged from hospital 18 days after treatment with NIHSS score 5. CONCLUSION: If penumbral tissue can be conclusively identified, endovascular treatment in proximal and intracranial tandem occlusion can be successful, even in treatments initiated 6-9 h after stroke onset. If the intracranial flow after recanalization can be established via the circle of Willis, the underlying proximal ICA occlusion may not require treatment.     

Safety and efficacy of delayed intraarterial urokinase therapy with mechanical clot disruption for thromboembolic stroke.

PURPOSETo evaluate safety and efficacy of delayed intraarterial urokinase therapy with mechanical disruption of clot to treat thromboembolic stroke.METHODSThirteen patients with cerebral thrombolic disease (10 carotid territory, 3 basilar territory) were treated with catheter-directed intraarterial urokinase therapy with mechanical disruption of the clots. All patients were excluded from a 6-hour multicenter thrombolytic trial by either time, recent surgery, age, seizure, or myocardial infarction. Time elapsed before treatment ranged from 3.5 to 48 hours (12 +/- 13 hours), with 200,000 to 900,000 U of urokinase used.RESULTSTen patients had successful vessel recanalization, confirmed by repeat angiography. Cases with distal branch vessel occlusions were less likely to recanalize. Asymptomatic hemorrhagic conversion occurred in 2 patients on repeat scans. Both acute neurologic and functional outcomes were assessed with significant improvement occurring in 9 (69%) of 13 patients at 48 hours (greater than four-point change on the National Institutes of Health scale) and in 100% of 3-month survivors. All patients who improved had normal initial CT scans.CONCLUSIONSIntraarterial cerebral thrombolysis with mechanical disruption of clot seems to be a useful therapy in selected stroke cases even after 6 hours.     

Endovascular stent-assisted thrombolysis in acute occlusive carotid artery dissection

Introduction  

Internal carotid artery dissection with tandem internal carotid and middle cerebral artery occlusion may be responsible for large cerebral infarction that carries a general poor prognosis. Recanalization of internal carotid artery (ICA) dissection by stent-assisted thrombolysis has been recently proposed. We report two cases of acute symptomatic ICA dissection with tandem occlusion successfully treated with emergent endovascular stent-assisted thrombolysis using new self-expandable intracranial stents.     

静脉溶栓桥接Solitaire支架取栓治疗急性缺血性脑卒中的效果分析

目的探讨静脉溶栓桥接Solitaire支架取栓开通颅内闭塞大血管的疗效。 方法回顾我院2014年6月—2015年10月采用桥接模式接受血管内治疗的15例急性缺血性脑卒中患者资料。分析大血管开通情况,术中、术后并发症发生情况,早期神经功能改善情况以及随访90 d时mRS情况。 结果15例患者中,大脑中动脉闭塞9例,颈内动脉颅内段合并大脑中动脉闭塞2例,椎基底动脉系统闭塞4例。所有患者大血管均获得开通。2例患者出现颅内出血,1例为颞叶出血、1例为丘脑出血。死亡2例。入院NIHSS评分(14.83±5.65)与3天后NIHSS评分(6.82±5.53)比较,差异有统计学意义。90 d随访临床结果优良患者9例(mRS<2)。 结论静脉溶栓桥接Solitaire支架动脉取栓能使大血管获得较好的再通率,显著改善急性缺血性脑卒中患者的预后。     

重组葡激酶动静脉途径溶栓治疗犬急性脑梗死对照研究

目的 研究重组葡激酶(r-Sak)经不同途径溶栓治疗犬急性脑栓塞的疗效、并发症及对凝血纤溶系统的影响.方法 成年毕格犬24条,随机分为对照组、r-Sak动脉组、r-Sak静脉组.用介入技术建立犬急性脑栓塞模型,栓塞后5 h(静脉3 h)行脑血管造影观察被栓塞的左颈内动脉通畅情况,继而经成功栓塞的左颈内动脉或股静脉于30 min内注入r-Sak行溶栓治疗(r-Sak组:r-Sak 10 000 u/kg;对照组:生理盐水10 ml).治疗后30、60和120 min分别测定凝血指标并再行脑血管造影观察栓塞血管的再通情况,24 h内对犬作行为学观察,24 h后处死动物行病理检查.结果 溶栓后2 h对照组、r-Sak动脉组和r-Sak静脉组的血管再通率分别为0.0%、93.3%和37.5%,两治疗组与对照组比较差异有统计学意义(P＜0.05);3组完全再通的比率分别为0%、60%和6.7%;血管再通率和完全再通率于动脉组明显高出静脉组(P＜0.05).r-Sak两组对凝血纤溶系统影响的比较无明显差异.24 h内无严重并发症.结论 重组葡激酶具有较强的血栓溶解作用,动脉途径给药比静脉法更能有效溶解脑内血栓.     

Fluid-attenuated inversion recovery intraarterial signal: an early sign of hyperacute cerebral ischemia.

BACKGROUND AND PURPOSE: Early detection of arterial occlusion and perfusion abnormality is necessary for effective therapy of hyperacute cerebral ischemia. We attempted to assess the utility of the fast fluid-attenuated inversion recovery (fast-FLAIR) sequence in detecting occluded arteries as high signal (referred to as intraarterial signal) and to establish the role of fast-FLAIR in detecting ischemic penumbra of hyperacute stroke within 24 hours after ictus. METHODS: We studied 60 patients with hyperacute cerebral ischemia caused by occlusion of intracranial major arteries. We compared intraarterial signal on FLAIR images with time of flight (TOF) on MR angiograms, flow voids on T2-weighted images, hyperintense lesions on diffusion-weighted images, and results of follow-up CT or MR scans. RESULTS: In 58 (96.7%) patients, FLAIR detected intraarterial signals as early as 35 minutes after stroke onset. In 48 (80.0%) patients, intraarterial signal on FLAIR images coincided with lack of TOF on MR angiograms. In 41 (74.5%) of 55 patients, the intraarterial signals of fast T2-weighted imaging depicted occlusion better than did deficient flow void on T2-weighted images. In 25 (41.7%) of 60 patients, the area of intraarterial signal distribution was larger than the hyperintense lesion measured on diffusion-weighted images. Areas of final infarction had sizes between those of intraarterial signal distribution on FLAIR images and lesions measured on diffusion-weighted images. In 35 (87.5%) of 40 patients, areas of intraarterial signal distribution were equal to regions of abnormal perfusion. CONCLUSION: Intraarterial signal on FLAIR images is an early sign of occlusion of major arteries. FLAIR combined with diffusion-weighted imaging can be helpful to predict an area at risk for infarction (ischemic penumbra). FLAIR plays an important role for determining whether a patient should undergo perfusion study.     

Low-Dose Eptifibatide for Tandem Occlusion in Stroke: Safety and Carotid Artery Patency

BACKGROUND AND PURPOSE:Maintaining carotid patency and avoiding symptomatic intracranial hemorrhage are competing concerns in tandem occlusions. This study provides data regarding the safety and efficacy of eptifibatide in stroke from tandem occlusion of the extracranial carotid artery and the intracranial carotid or middle cerebral artery.MATERIALS AND METHODS:This is a retrospective analysis of 58 consecutive patients who received low-dose eptifibatide (135-mcg/kg bolus, 1-mcg/kg/min infusion) during treatment of tandem occlusions. Brain imaging and carotid sonography were performed at 24–36 hours. mRS was documented at 90 days, and carotid sonography, at 30–60 days.RESULTS:The median age and NIHSS score were 64 years and 15, respectively. Twenty-five patients (43%) received tPA. ASPECTSs were 8–10 in 47 (81%) and 5–7 in 11 (19%) patients. Thirty-eight patients had angioplasty/stent placement acutely; 20 had angioplasty alone. Symptomatic intracranial hemorrhage occurred in 1 patient (2%). TICI 2b or higher was achieved in 56 patients (96%). Fifty-seven of 58 patients had clinical follow-up at 90 days (1 lost to follow up). The 90-day mRS was 0–2 in 42 patients (72%). There were 4/58 (7%) re-occlusions within 24–36 hours, all originally treated with stent placement. Forty-nine of 53 surviving patients had carotid sonography at 30–60 days, with 3 delayed re-occlusions, 2 with stents and 1 with angioplasty alone. The overall carotid patency at 30–60 days was 42/49 (86%). Carotid re-occlusion was not associated with clinical decline.CONCLUSIONS:Low-dose eptifibatide seemed to be safe in tandem occlusions (symptomatic intracranial hemorrhage, 2%), although asymptomatic cervical carotid artery re-occlusions still occurred in 14% of patients.

Tandem occlusion presents the simultaneous problem of an intracranial embolic large-vessel occlusion and an acute plaque rupture/thrombotic event in the cervical carotid artery. Tandem occlusion is common, representing between 13% and 32% of patients with large-vessel occlusion.^1-3 Outcomes in the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial were similar between patients with and without tandem occlusions.⁴ The goal of tandem occlusion treatment is to remove the intracranial embolus and re-establish normal flow in the cervical carotid artery without causing hemorrhage. Optimal conditions for elective carotid stent placement include therapeutic dual-antiplatelet therapy, statin loading, and intraprocedural anticoagulation. Unfortunately, such a strategy, and particularly the use of heparin, increases the risk of intracranial hemorrhage in the setting of acute stroke and particularly tandem occlusion.⁵ In general, following a successful intracranial embolectomy, extracranial carotid re-occlusion is not always associated with neurologic deterioration and poor neurologic outcome, whereas symptomatic intracranial hemorrhage (SICH) almost always is.^5-7 Avoiding SICH must be the primary consideration. However, re-occlusion of the internal carotid artery may be associated with repeat embolization. Also, direct carotid inflow to support pial collaterals may be beneficial when less-than-perfect results were achieved with intracranial thrombectomy (eg, modified TICI [mTICI] <3). At least 1 retrospective study suggested that re-occlusion is associated with worse clinical outcomes in the tandem occlusion population.⁸ Judicious medical therapy to preserve the patency of the internal carotid artery following angioplasty or stent placement is therefore reasonable, providing this can be accomplished without increasing the risk of SICH. This report aims to provide evidence regarding the safety of a specific low-dose eptifibatide antiplatelet strategy in the tandem occlusion population applied uniformly to both patients who were treated with stents and those treated with angioplasty alone and also to provide data regarding carotid artery patency in both the acute phase and the postoperative period.     

动、静脉结合r-tPA溶栓治疗早期脑梗死

目的 评价动、静脉结合r-tPA溶栓治疗急性脑梗死的方法和临床疗效.方法 共15例急性脑梗死患者,术前均行CT、MR 和DSA检查证实颅内动脉闭塞部位：M1段4例,M2段2例,M3、4段2例,A1、2段1例,颈内动脉2例, P1段1例,豆纹动脉1例,其他穿支2例.其中术前经DSA证实12例.溶栓治疗时间在发病后3～7 h,采用动脉内药物灌注和机械疏通相结合方法溶栓,另外经静脉术前和术后持续滴注r-tPA辅助.术后观察临床症状和影像表现.结果 15例患者溶栓治疗中微导管和溶栓导管均到位满意,DSA所示闭塞段血管均有效再通.术后CT检查发现片状渗血2例,异位脑梗死1例.术后肢体功能即刻明显改善6例.临床观察3个月,症状基本完全恢复6例,较好改善7例,2例无明显改善;生活能力完全自理13例,有效率达87%（13/15）,生活能部分自理者1例,失去生活自理能力 1例,无患者死亡.结论 动、静脉结合溶栓治疗急性颅内动脉栓塞是一种有效、安全的治疗方法;局部动脉内灌注和机械疏通有效结合以及术前各项影像学检查的综合分析,将有利于动脉溶栓治疗的进行.     

Rheolytic thrombectomy of the occluded internal carotid artery in the setting of acute ischemic stroke

BACKGROUND AND PURPOSE: Acute thromboembolic stroke complicated by ipsilateral carotid occlusion may present both mechanical and inflow-related barriers to effective intracranial thrombolysis. We sought to review our experience with a novel method of mechanical thrombectomy, in such cases, using the Possis AngioJet system, a rheolytic thrombectomy device. METHODS: A review of our interventional neuroradiology database revealed three patients in whom an occluded cervical internal carotid artery was encountered during endovascular treatment for acute stroke and in whom thrombectomy was attempted, using the 5F Possis AngioJet thrombectomy catheter. The medical records and radiographic studies of these patients were reviewed. RESULTS: Three patients were identified (ages, 52--84 years). Two patients had isolated occlusion of the internal carotid artery; in one patient, thrombus extended down into the common carotid artery. Treatment was initiated within 190 to 360 minutes of stroke onset. Thrombectomy of the carotid artery was deemed necessary because of poor collateral flow to the affected hemisphere (chronic contralateral internal carotid artery occlusion [one patient] and thrombus extending to the carotid "T" [one patient]) or inability to pass a microcatheter through the occluded vessel (one patient). Adjunctive therapy included pharmacologic thrombolysis with tissue plasminogen activator (all patients), carotid angioplasty and stenting (two patients), and middle cerebral artery angioplasty (one patient). Patency of the carotid artery was reestablished in two patients, with some residual thrombus burden. In the third patient, the device was able to create a channel through the column of thrombus, allowing intracranial access. CONCLUSION: Rheolytic thrombectomy shows potential for rapid, large-burden thrombus removal in cases of internal carotid artery thrombosis, allowing expedient access to the intracranial circulation for additional thrombolytic therapy.     

Successful Recanalization of Acute Superior Mesenteric Artery Thromboembolic Occlusion by a Combination of Intraarterial Thrombolysis and Mechanical Thrombectomy with a Carotid Filter

Acute superior mesenteric artery (SMA) occlusion is a life-threatening disease, and acute intestinal ischemia develops from the sudden decrease in perfusion to the intestines. The key to saving the patient’s life is early diagnosis, and prompt revascularization of the SMA can prevent intestinal infarction and decrease the risk of bowel segment necrosis. Computed tomographic angiography may be useful for rapid diagnosis. We report recanalization of an SMA occlusion in an 80-year-old man with a combination of intraarterial thrombolysis and mechanical thrombectomy with a carotid filter.     

Initial angiographic appearance of intracranial vascular occlusions in acute stroke as a predictor of outcome of thrombolysis: initial experience

PURPOSE: To determine whether the initial angiographic morphology and location of intracranial arterial occlusions in acute stroke are reliable predictors of success of thrombolysis. MATERIALS AND METHODS: Thirty-three intracranial occlusions were studied in 32 patients who underwent intraarterial thrombolysis with urokinase within 6 hours from clinical onset of stroke symptoms. The initial angiographic appearance of each occlusion was categorized as cutoff, tapered, meniscus, tram-track, or tandem. Following thrombolysis, outcomes were classified as complete, partial, or no recanalization. RESULTS: Complete recanalization was accomplished in 17 of the 33 lesions, partial recanalization in nine, and no effect in seven. Tram-track (n = 3) and tapered (n = 7) lesions demonstrated the highest rates of at least partial recanalization (100% and 86%, respectively), whereas cutoff lesions (n = 13) demonstrated the lowest rate (69%). Intracranial hemorrhage was associated with higher doses of urokinase. Complete recanalization success rates were 60% for M1 lesions (n = 10), 43% for M2 or A2 lesions (n = 14), and 33% for M3 lesions (n = 3). Vertebrobasilar lesion (n = 5) success rates for complete and at least partial recanalization were 80% and 100%, respectively. CONCLUSION: Relationships were found to exist between the success rate of recanalization and initial angiographic lesion location and morphology, which represent important trends; however, further studies with a larger sample size are needed.