Daniel Behme

Direct aspiration first pass technique for the treatment of acute ischemic stroke: initial experience at a European stroke center

Introduction Over the past decade, endovascular techniques for the treatment of acute ischemic stroke have emerged significantly. However, revascularization rates are limited at approximately 80%, and mechanical thrombectomy procedures still last about 1 h. Therefore, we investigated the novel direct aspiration first pass technique for its efficacy and safety. Methods Our neurointerventional database was screened for patients who received mechanical thrombectomy for acute ischemic stroke using the Penumbra 5MAX ACE aspiration catheter on an intention to treat basis between November 2013 and June 2014. Procedural data, including modified Thrombolysis in Cerebral Infarction (mTICI) score, procedural timings, and complications, as well as clinical data at admission and discharge, were analyzed. Results 54 patients received mechanical thrombectomy using the 5MAX ACE. Median age was 69 (39–94) years (54% were men). Baseline National Institutes of Health Stroke Scale (NIHSS) score was 15 (2–27) and 44/54 (81%) patients received intravenous thrombolysis. Vessel occlusion sites were 91% anterior circulation and 9% posterior circulation. A successful revascularization result (mTICI ≥2b) was achieved in 93% of cases whereas direct aspiration alone was successful in 30/54 (56%) cases; among these, median time from groin puncture to revascularization was 30 min (9–113). Symptomatic intracranial hemorrhage occurred in 2/54 (4%) patients, and embolization to new territories in 3/54 (6%). Median NIHSS at discharge was 6 (0–24); 46% of patients were independent at discharge. Conclusions The direct aspiration first pass technique proofed to be fast, effective, and safe. Promising revascularization results can be achieved quickly in more than 50% of patients using this technique as the firstline option. Nevertheless, stent retrievers are still warranted in approximately 40% of cases to achieve a favorable revascularization result.

Low-profile Visualized Intraluminal Support device (LVIS Jr) as a novel tool in the treatment of wide-necked intracranial aneurysms: initial experience in 32 cases

Background and purpose The focus of this study was to determine ease of deployment, safety and effectiveness of the LVIS Jr device. Methods A retrospective analysis was performed of 32 cases comprising 34 aneurysms in which the LVIS Jr device was used for stent-assisted coil embolization of intracranial aneurysms from February to October 2012, including all clinical and angiographic data as well as mid-term follow-up (1–12 months of treatment). Results The median age of the patients was 54 years (range 21–76) and 19 (59%) were women. The aneurysms were ruptured in 12/34 cases (35.3%); 26 (76.4%) were located within the anterior circulation and the remaining 8 (23.5%) were located in the posterior circulation. Eleven of the 34 aneurysms (32.3%) were treated with a Y-stent configuration. Immediate total occlusion was observed in 16/34 (47%), near total occlusion (90–95%) in 5/34 (14.7%) and a ‘dog ear’ or subtotal occlusion in 12/34 (35.2%). A single aneurysm was treated without coil embolization. Complications occurred in 5/34 cases (15%), including two cases of in-stent thrombosis. Conclusions Implantation of the LVIS Jr device as a support device for stent-assisted coil embolization seems to be safe and effective. The LVIS Jr device can also be implanted in a Y-stent configuration, offering a novel technique with a potentially lower risk of thromboembolic complications compared with other devices.

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.

Multicenter clinical experience in over 125 patients with the Penumbra Separator 3D for mechanical thrombectomy in acute ischemic stroke

Background The aim of this study was to assess reperfusion and clinical outcome of treatment with the self-expanding retrievable Separator 3D in revascularization of acute ischemic stroke. The three-dimensional (3D) device secures thrombus with direct aspiration and supports debulking of the clot. Methods At two centers, 129 consecutive stroke patients with National Institutes of Health Stroke Scale (NIHSS) scores ≥5 were treated with mechanical thrombectomy using the Separator 3D as a component of the Penumbra System within 8 h of symptom onset; modified Treatment in Cerebral Infarction (mTICI) revascularization scores, NIHSS score on admission and discharge, mortality rates, and modified Rankin Scale (mRS) outcomes at 90 days were evaluated. Results A total of 129 vessels in 129 patients were treated. Occlusions were located in the middle cerebral artery (MCA, 48%), internal carotid artery (ICA, 33%), cervical ICA–MCA (3%), and vertebrobasilar arteries (16%). Intravenous thrombolytic therapy with recombinant tissue plasminogen activator was given to 78% of patients. Median NIHSS was 15 prior to treatment. Reperfusion to mTICI 2b or 3 was successful in 96/129 (74%) target arterial lesions, with more than half of cases (51%) achieving mTICI 3. The mean time from arterial puncture to revascularization was 65 min. At 90 days, the symptomatic intracranial hemorrhage rate was 4%, all cause mortality was 32%, and 43/99 patients (43%) achieved functional independence with an mRS score of ≤2. Conclusions The results suggest that the Separator 3D enables safe and effective revascularization of occluded large arteries in acute stroke intervention, leading to a high rate of functional independence at 90 days.

Woven EndoBridge Intrasaccular Flow Disrupter for the Treatment of Ruptured and Unruptured Wide-Neck Cerebral Aneurysms: Report of 55 Cases.

This is a retrospective study of all ruptured and unruptured aneurysms that were treated with a WEB device (WEB Dual-Layer, Single-Layer, and Single-Layer Sphere) between April 2012 and August 2014 at 2 centers. Fifty-five aneurysms in 52 patients, including 14 ruptured aneurysms, underwent treatment with the WEB device. A favorable angiographic result at 3 months was achieved in 66% of cases, whereas the percentage of good anatomic results increased from 40% in 2012 to 75% in 2014. BACKGROUND AND PURPOSE: The safety and efficacy of the Woven EndoBridge (WEB) device for the treatment of cerebral aneurysms have been investigated in several studies. Most of these studies focused on specific aneurysms or a certain WEB device. Our objective was to report the experience of 2 German centers with the WEB device, including technical feasibility, safety, and short-term angiographic outcome. MATERIALS AND METHODS: We performed a retrospective study of all ruptured and unruptured aneurysms that were treated with a WEB device (WEB Double-Layer, Single-Layer, and Single-Layer Sphere) between April 2012 and August 2014. Primary outcome measures included the feasibility of the implantation and the angiographic outcome at 3-month follow-up. Secondary outcome measures included the clinical outcome at discharge and procedural complications. RESULTS: Fifty-five aneurysms in 52 patients, including 14 ruptured aneurysms, underwent treatment with the WEB device. The median age of patients was 55 years (range, 30–75 years); 19/55 (37%) were men. The device could be deployed in all patients and was implanted in 51/55 (93%) cases. Procedural complications occurred in 6/51 (12%), comprising 2 thromboembolic events, 2 thrombus formations, 1 high-grade posterior cerebral artery stenosis, and 1 aneurysm rupture. None of these had clinical sequelae. Angiographic follow-up at 3 months was available for 44/51 (86%) aneurysms. A favorable angiographic result at 3 months was achieved in 29/44 (66%) cases, whereas the percentage of good anatomic results increased from 40% in 2012 to 75% in 2014. CONCLUSIONS: The WEB device proved to be safe. Acceptable occlusion rates can be achieved but seem to require wide experience with the device.

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.

M1 is not M1 in ischemic stroke: the disability-free survival after mechanical thrombectomy differs significantly between proximal and distal occlusions of the middle cerebral artery M1 segment

Aims Recent recommendations on the designation of target artery lesions in acute ischemic stroke include the anatomical differentiation between a proximal and a distal occlusion site of the M1 segment of the middle cerebral artery (MCA). The aim of this study was to evaluate whether these occlusion types differ in terms of a disability-free (modified Rankin Scale (mRS) 0 or 1) clinical outcome at 90 days. Methods A retrospective analysis was performed of all patients with MCA M1 occlusions who had a successful revascularization result after mechanical thrombectomy between October 2009 and September 2013 and for whom follow-up at 90 days was available. Imaging data were regraded and re-evaluated according to the modified Thrombolysis In Cerebral Infarction (mTICI) scale and the respective vessel occlusion site definitions. Outcome measures included National Institutes of Health Stroke Scale (NIHSS), mRS, Alberta Stroke Program Early CT Score (ASPECTS) scoring and procedural timings. Results 62 patients were successfully recanalized; follow-up at 90 days was available for 42/62 patients (68%). There were proximal MCA occlusions in 24/42 patients (57%) and distal occlusions in 18/42 (43%). Baseline NIHSS, ASPECTS, procedural timings and final mTICI scores did not differ significantly between proximal and distal M1 occlusions. There was a statistically significant difference between proximal and distal M1 occlusions regarding a disability-free early outcome (mRS 0 or 1) at discharge (p=0.03) and at 90 days (p=0.04). Conclusions Proximal occlusions of the M1 segment of the MCA incorporating the lenticulostriate perforators are associated with a poorer clinical outcome than distal M1 occlusions that spare these perforators. Involvement of these perforators might become an additional predictor of clinical outcome after mechanical thrombectomy in ischemic stroke.

Long-term occlusion results with SILK flow diversion in 28 aneurysms: Do recanalizations occur during follow-up?

Background and purpose The purpose of this article is to report on the long-term success rates of Silk flow-diverter (FD) treatment in a multicenter prospective study for the treatment of complex aneurysms. Methods Between May 2008 and January 2011, all consecutive patients featuring complex intracranial aneurysms eligible for FD treatment with the Silk in three neurovascular centers were included. Clinical and imaging data were assessed during hospitalization and follow-up. Results Five patients were initially asymptomatic, 20 patients showed various neurological symptoms. Twenty-eight FDs were implanted in 25 patients treating 28 aneurysms. The immediate procedure-related morbidity was 8% (two of 25), mortality 0%. One procedure-related death was observed during follow-up (in-stent thrombosis). Compared to the immediate result nearly two of three aneurysms improved during follow-up; all angiographically confirmed inflow changes took place within six months after treatment. Final anatomic outcome in 24 aneurysms of 22 patients comprised 14 (59%) with complete occlusion, seven (29%) with a neck remnant, two (8%) with residual filling <50%, none with residual filling >50% and one (4%) unchanged in comparison to its pretreatment status. Postinterventional recanalizations were seen in three of 13 (23%) aneurysms treated with FD alone; none were observed in 15 aneurysms treated with adjunctive coiling. Conclusion Anatomic presentation and location are key for successful FD treatment. The rate of successful occlusion increases during follow-up. Postinterventional monitoring for at least six months is paramount, as anatomic outcome is not reliably predictable and recanalizations may occur in initially completely occluded aneurysms.

Emergent Carotid Stenting After Thrombectomy in Patients With Tandem Lesions

A 68-year-old diabetic woman presents to the emergency department 1 hour after right-sided hemiplegia and global aphasia. National Institutes of Health Stroke Scale score is 21; Alberta Stroke Program Early CT score (ASEPCTS) on computed tomographic scan is 8; and computed tomographic angiography shows severe left internal carotid artery stenosis and proximal left M1 middle cerebral artery occlusion (tandem lesion). She is treated with intravenous tPA (tissue-type plasminogen activator) and is being considered for endovascular intervention. Would you consider a left internal carotid artery stenting immediately after successful thrombectomy (thrombolysis in cerebral infarction [TICI]-3)? If so, when do you start dual-antiplatelet therapy? Emergent carotid stenting after thrombectomy in patients with tandem lesions. ### Daniel Behme I would always go for stenting of the internal carotid artery (ICA) stenosis because the clot in the middle cerebral artery was likely caused by the stenosis. Therefore, acute stenting in combination with thrombectomy allows for treatment of the symptomatic middle cerebral artery occlusion and the suspected cause of the stroke, the severe ICA stenosis, simultaneously. More importantly, I would never refuse to provide endovascular therapy (EVT) because of an underlying tandem lesion. The data of the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) have shown that patients having tandem occlusions benefit from EVT.1 This was also true for the other randomized trials, which are summarized in the HERMES meta-analysis (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials).2 Immediate stenting is thereby justified for 2 reasons. First, the ICA stenosis is obviously symptomatic and therefore should be considered for stenting or surgical treatment according to the current recommendations anyway.3 Second, it is much easier to perform intracranial thrombectomy if one can place a large guiding catheter or a femoral long sheath distally in the ICA …