Christoph Kabbasch

Mechanical Thrombectomy of M2-Occlusion

BACKGROUND There is growing evidence for the efficacy of mechanical thrombectomy in acute stroke patients with large-vessel occlusions in the anterior circulation. Although distal occlusions of the middle cerebral artery (MCA) can cause severe clinical symptoms, endovascular therapy is not considered here as the first choice. The aim of our study was to prove the efficacy and safety of mechanical thrombectomy for distal occlusion types in the anterior circulation (M2-segment). METHODS Stentretriever-based thrombectomy was performed in 119 patients with acute MCA occlusions between October 2011 and April 2013: 104 (87.4%) were M1- and 15 (12.6%) M2-occlusions. These groups were compared with regard to recanalization success, periprocedural complications, hemorrhage, and modified Rankin Scale (mRS) at 90 days. RESULTS Thrombolysis in cerebral infarction 2b/3 reperfusion was more frequent in M2- than in M1-occlusions (93.3% versus 76.0%; P = .186). There was no significant difference in the mean National Institutes of Health Stroke Scale between the M1- and the M2-group both at admission and at discharge (16.18 ± 7.30 versus 13.73 ± 8.30, P = .235; 9.36 ± 8.60 versus 7.43 ± 9.84, P = .446). A good clinical outcome (mRS 0-2) at 3 months was more frequent in the M2-group (60% versus 43.3%; P = .273) and mortality was higher in the M1-group (21.2% versus 6.7%; P = .297). There were 3 periprocedural complications in the M1- and none in the M2-group. CONCLUSIONS Endovascular treatment of M2-occlusions in severely affected patients is not associated with a higher procedural risk or postprocedural hemorrhage. Compared with M1-occlusions, there was a greater chance for a good angiographic and clinical result in our case series. Therefore, stentretriever-based thrombectomy should also be considered for patients with severe symptoms because of an acute M2-occlusion.

Emergency Stenting of the Extracranial Internal Carotid Artery in Combination with Anterior Circulation Thrombectomy in Acute Ischemic Stroke: A Retrospective Multicenter Study

BACKGROUND AND PURPOSE: Several small case series reported a favorable clinical outcome for emergency stent placement in the extracranial internal carotid artery combined with mechanical thrombectomy in acute stroke. The rate of postinterventional symptomatic intracranial hemorrhages was reported to be as high as 20%. Therefore, we investigated the safety and efficacy of this technique in a large multicentric cohort. MATERIALS AND METHODS: The data bases of 4 German stroke centers were screened for all patients who received emergency stent placement of the extracranial internal carotid artery in combination with mechanical thrombectomy of the anterior circulation between 2007 and 2014. The primary outcome measure was the rate of symptomatic intracranial hemorrhage according to the European Cooperative Acute Stroke Study III criteria; secondary outcome measures included the angiographic revascularization results and clinical outcome. RESULTS: One hundred seventy patients with a median age of 64 years (range, 25–88 years) were treated. They presented after a median of 98 minutes (range, 52–160 minutes) with a median NIHSS score of 15 (range, 12–19). Symptomatic intracranial hemorrhages occurred in 15/170 (9%) patients; there was no statistically significant difference among groups pertaining to age, sex, intravenous rtPA, procedural timings, and the rate of successful recanalization. In 130/170 (77%) patients, a TICI score of ≥2b could be achieved. The in-hospital mortality rate was 19%, and 36% of patients had a favorable outcome at follow-up. CONCLUSIONS: Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is effective and safe. It is not associated with a significantly higher risk of symptomatic intracranial hemorrhage compared with published series for mechanical thrombectomy alone.

First-line lesional aspiration in acute stroke thrombectomy using a novel intermediate catheter: Initial experiences with the SOFIA

Introduction Five randomized controlled trials (RCTs) on endovascular therapy (EVT) of stroke have proven a clinical benefit over conservative treatment or IV-thrombolysis alone. Lesional clot aspiration with a dedicated system can achieve revascularization without an additional retriever (a direct-aspiration first-pass technique, ADAPT), and the SOFIA has been shown to be both safe and efficacious in a multicentric retrospective study. We have evaluated a subset of these data acquired in two major stroke centers with regard to using the SOFIA for first-line lesional aspiration. Methods Thirty patients with large-vessel occlusions treated with first-line lesional aspiration were identified. Procedural data, clot length, reperfusion success (mTICI), procedural timings, complications, and clinical status at admission, discharge and at 90 days were analyzed. Results The median baseline NIHSS was 16. IV thrombolysis was administered in 15/30 patients. Ninety-three percent of occlusions were in the anterior circulation. TICI ≥ 2b was achieved in 90% of multimodality treatments; lesional aspiration was successful in 67% within a median time of 20 minutes. The highest first-attempt success rate was in MCA occlusions (median time to recanalization 10 minutes). There were no device-related events. Symptomatic intracerebral hemorrhage (sICH) occurred in 10%, but never with sole lesional aspiration. Embolization to new territories was recorded in 1/30 (3%). Median discharge NIHSS was 7; 30% were mRS ≤ 2 at discharge and 43% at 90-day follow-up. Conclusions Lesional aspiration with SOFIA is in line with published data. The SOFIA may be used as a first-line device, aiming at fast recanalization by sole aspiration with good safety and efficacy. If unsuccessful, it converts into part of a stent retriever-based multimodality treatment.

Initial experience with a new distal intermediate and aspiration catheter in the treatment of acute ischemic stroke: clinical safety and efficacy

Purpose To describe our initial experience with the novel 5 F SOFIA (Soft Torqueable catheter Optimized For Intracranial Access) intermediate and aspiration catheter for endovascular treatment of patients with acute ischemic stroke. Methods A retrospective review was performed in three centers of prospectively collected data of all stroke patients who underwent endovascular therapy using the SOFIA catheter. Patients were enrolled between November 2013 and December 2014. The primary endpoint of the study was accessibility of the thrombus with the SOFIA catheter. As a secondary endpoint, the study assessed recanalization success (Thrombolysis In Cerebral Infarction (TICI) ≥2b). Clinical presentation on admission and discharge was also documented. In addition, catheter- and procedure-related complications (particularly thromboembolic complications) were recorded. Results The SOFIA catheter was used in 115 acute stroke procedures. In 110 cases (96%) the catheter could be advanced to the occlusion site. After mechanical thrombectomy, successful recanalization (TICI ≥2b) was documented in 86.9%. There were no complications related to positioning of the catheter. Distal thrombus migration into a new vascular territory occurred in three patients following thrombectomy with a stent retriever (2.6%). The mean NIH Stroke Scale (NIHSS) score on admission was 16.8±6 and at discharge the mean NIHSS score was 8.2±7.7. Sixteen patients died. Conclusions The SOFIA catheter is a safe and efficient catheter for endovascular stroke therapy.

Intravenous Thrombolysis Facilitates Successful Recanalization with Stent-Retriever Mechanical Thrombectomy in Middle Cerebral Artery Occlusions

AIM Several factors influence the outcome after acute ischemic stroke secondary to proximal occlusions of cerebral vessels. Among others, noneligibility for intravenous thrombolysis (IVT) and incomplete revascularization have been identified as predictors of unfavorable outcome. The aim of this study was to investigate whether concomitant IVT influences the revascularization efficacy in mechanical thrombectomy (MT). METHODS This study conducted a retrospective analysis of all consecutive patients presenting with an anterior circulation stroke due to large-artery occlusion with imaging evidence who were treated with MT between July 2012 and December 2013 at 2 high-volume stroke centers. Imaging data were regraded and re-evaluated according to the modified Treatment in Cerebral Ischemia scale and its respective vessel occlusion site definitions. Clinical end points included National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale; imaging and procedural measures were technical end points. RESULTS We identified 93 patients who presented with an occlusion of the middle cerebral artery (MCA): of these patients, 66 (71%) received IVT. We did not find statistically significant differences in the baseline NIHSS score, time from symptom onset to groin puncture, and age when comparing the IVT group with the non-IVT group. The rate of successful recanalizations (modified Treatment in Cerebral Ischemia score ≥ 2b) was significantly higher in patients with MCA occlusion and concomitant IVT (P = .01). Stepwise logistic regression identified IVT and thrombus length as predictive factors for successful mechanical recanalization (P = .004, P = .002). CONCLUSION IVT and thrombus length are predictive factors for a successful recanalization in MT for acute ischemic stroke with underlying MCA occlusion.

Comparative analysis of sialendoscopy, sonography, and CBCT in the detection of sialolithiasis

The diagnosis of sialolithiasis is, along with clinical presentation, based on different imaging techniques and more invasive procedures such as sialendoscopy. The aim of the study was to analyze the potential of cone beam computed tomography (CBCT) for the diagnosis of sialolithiasis and to compare the results with those of sonography and sialendoscopy.

Multicenter experience with the new SOFIA Plus catheter as a primary local aspiration catheter for acute stroke thrombectomy

Introduction The direct aspiration first pass technique (ADAPT) has been introduced as a rapid and safe endovascular treatment strategy in patients with ischemic stroke. Objective To determine the technical feasibility, safety, and functional outcome with ADAPT using the new large-bore 6F SOFIA Plus catheter. Methods A retrospective analysis of prospectively collected data from six university hospitals was performed. The following parameters of all acute stroke procedures (June 2015– January 2016) using the SOFIA Plus catheter were analyzed: accessibility of the thrombus with the catheter, recanalization success (Thrombolysis in Cerebral Infarction ≥2b), time to recanalization, procedure-related complications. Furthermore, National Institutes of Health Stroke Scale (NIHSS) scores at presentation and discharge and the modified Rankin scale (mRS) score at 90 days were recorded. Results 85 patients were treated using the SOFIA Plus catheter. The occlusion site was the anterior circulation in 94.1%. Median baseline NIHSS score was 18. In 64.7%, ADAPT alone was successful after a median procedure time of 21 min. With additional use of stent retrievers in the remaining cases, the recanalization rate was 96.5%. No catheter-related complications such as dissections were observed. Thrombus migration to a new vascular territory occurred in 4.7% and symptomatic hemorrhage in 4.7%. After 3 months, mRS 0–2 was achieved in 49.4%. Mortality rate was 20%. Conclusions In the majority of cases, thrombus aspiration using the SOFIA Plus catheter results in successful recanalization after a short procedure time. With additional use of stent retrievers, a high recanalization rate can be achieved (96.5%). The complication rate was in line with those of previous publications.

Stent Retriever Thrombectomy in Patients Who Are Ineligible for Intravenous Thrombolysis: A Multicenter Retrospective Observational Study

BACKGROUND AND PURPOSE: Intravenous thrombolysis with rtPA is the standard of care for patients with acute ischemic stroke within 4.5 hours after symptom onset. However, a considerable number of patients are ineligible for IV thrombolysis due to various contraindications. Recent studies have proved the superiority of mechanical thrombectomy for patients with large-vessel occlusions in combination with IV rtPA compared with IV rtPA alone. We aimed to demonstrate the efficacy of mechanical thrombectomy for patients who are ineligible for IV rtPA. MATERIALS AND METHODS: Patients from the stroke registries of 4 dedicated centers who were treated with mechanical thrombectomy from January 2010 to October 2014 were retrospectively evaluated. Inclusion criteria were the following: acute stroke due to proved large-artery occlusion, ineligibility for IV thrombolysis, and a timeframe of ≤4.5 hours between stroke and the start of mechanical thrombectomy. Recanalization success, periprocedural complications, clinical outcome, and hemorrhages were evaluated. RESULTS: One hundred thirty endovascular recanalization procedures were identified. The locations were the following: proximal ICA in 17 (13.1%), terminus ICA in 25 (19.2%), M1 segment in 77 (59.2%), and M2 segment in 11 (8.5%). TICI 2b/3 results were achieved in 101 (77.7%), and an mRS score of 0–2 in 47 patients (37.9%). There was a significant correlation between TICI 2b/3 results and good clinical outcomes (87.2% versus 6.8%; P = .048). A good clinical result was most frequent when recanalization was achieved within 4.5 hours (37/74 = 50% versus 10/50 = 20.0%; P = .001). Symptomatic hemorrhage occurred in 13.1% of patients; mortality was 24.2%. Periprocedural complications were recorded in 10 patients (7.7%). CONCLUSIONS: Mechanical thrombectomy can achieve good clinical outcomes in patients with acute large-artery occlusion ineligible for IV thrombolysis, in particular when recanalization is reached early.

Mechanical thrombectomy with the Trevo ProVue device in ischemic stroke patients: does improved visibility translate into a clinical benefit?

Purpose To investigate the efficacy and safety of the Trevo ProVue (TPV) stent retriever in stroke patients with large artery occlusions, with particular attention to the full structural radiopacity of the TPV. Materials and methods Case files and images of TPV treatments were reviewed for clinical and technical outcome data, including revascularization rates, device and procedure related complications, and outcome at discharge and after 90 days. Results 76 patients were treated with TPV. Mean National Institutes of Health Stroke Scale (NIHSS) score was 18 and 68% had additional intravenous thrombolysis. 63 occlusions were in the anterior circulation: 44 M1 (58%), 8 M2 (11%), 8 internal carotid artery-terminus (11%), 2 internal carotid artery- left (3%), 1 A2 (1%), and 13 vertebrobasilar (17%). 58 of 76 (76%) were solely treated with TPV; the remainder were treated with additional stent retrievers. Mean number of passes in TPV only cases was 2.2 (SD 1.2). In rescue cases, 3.2 (SD 2.2) passes were attempted with the TPV followed by 2.6 rescue device passes (SD 2). TPV related adverse events occurred in 4/76 cases (5%) and procedural events in 6/76 cases (8%). Mean procedural duration was 64 min (SD 42). Thrombolysis in Cerebral Infarction (TICI) 2b/3 recanalization was achieved in 69/76 patients (91%), including 50% TICI 3. Of 56 survivors (74%), 37 (49%) showed a favorable outcome at 90 days (Solitaire With the Intention for Thrombectomy trial criteria), statistically associated with age, baseline NIHSS, onset to revascularization time, and TICI 2b–3 reperfusion. TPV radiopacity allowed for visual feedback, changing the methodology of stent retriever use in 44/76 cases (58%). Conclusions Neurothrombectomy with TPV is feasible, effective, and safe. The recanalization rate compares favorably with reported data in the literature. Improved structural radiopacity may facilitate neurothrombectomy or influence the course of action during retrieval.

Stenting of the cervical internal carotid artery in acute stroke management: The Karolinska experience

Background Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is a routine procedure. Yet, precise indications and clinical safety in this setting remains controversial. Present data for mechanical thrombectomy include few studies with acute stenting of tandem occlusions. We evaluated the feasibility, safety and clinical outcome of this endovascular treatment in a retrospective analysis of all consecutive cases at a comprehensive stroke centre. Methods This was a retrospective analysis of all consecutive patients with acute extracranial carotid artery occlusion including acute dissection or high-grade stenosis and concomitant intracranial large-vessel occlusion treated with emergency carotid stenting and intracranial mechanical thrombectomy between November 2007 and May 2015. Results A total of 63 patients with a median age of 67 years (range 33–84 years) were treated. Of these, 33 (52%) patients had concomitant intravenous thrombolysis with recombinant tissue-type plasminogen activator initially. Median admission National Institutes of Health Stroke Scale was 14 (range 1–29). Median time from stroke onset to recanalization was 408 minutes (range 165–1846 minutes). Procedure time was significantly shorter after intravenous thrombolysis (110 minutes [range 15–202 minutes] vs. 130 minutes [range 60–280 minutes]; p = 0.02). Three (5%) patients experienced post-procedural symptomatic intracerebral haemorrhage. In 55/63 (87%) patients, a score of ≥2b on the Thrombolysis in Cerebral Infarction scale could be achieved. Eight (13%) patients died, five (8%) during the acute phase. A total of 29/63 (46%) patients showed a favourable outcome (modified Rankin Scale score of 0–2) after three months. Conclusions Our single-centre retrospective analysis of emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy demonstrated high technical success, reasonable clinical outcomes and acceptable rates of symptomatic intracranial haemorrhage in carefully chosen patients which are triaged interdisciplinary based on clinical and computed tomography imaging criteria. This warrants further study in a randomised prospective trial.