Didier Milhaud

Rescue, Combined, and Stand-Alone Thrombectomy in the Management of Large Vessel Occlusion Stroke Using the Solitaire Device: A Prospective 50-Patient Single-Center Study Timing, Safety, and Efficacy

Background and Purpose— Large vessel occlusion in ischemic stroke is associated with a high degree of morbidity. When intravenous thrombolysis fails, mechanical thrombectomy can provide an alternative and synergistic method for flow restoration. In this study we evaluate the safety and efficacy of our stroke management protocol (RECOST study). Methods— Fifty consecutive ischemic stroke patients with large vessel occlusion were included. After clinical and MRI imaging assessment, 3 treatment strategies were selected according to time of symptom onset and location of vessel occlusion: rescue therapy; combined therapy; and stand-alone thrombectomy (RECOST study). MRI ASPECT score <5 was the main exclusion criterion. Mechanical thrombectomy was performed exclusively with the Solitaire flow restoration device. Clinical outcome was assessed after treatment, on day 1, and at discharge. Results— Mean patient age was 67.6 years, mean NIHSS score was 14.7, and mean ASPECT score was 6 on presentation. Vessel occlusions were in the middle cerebral artery (40%), the internal carotid artery (28%), and the basilar artery (32%). Rescue treatment represented 24%, combined therapy represented 56%, and stand-alone thrombectomy represented 20%. Mean recanalization time from symptoms onset was 377 minutes, with overall recanalization rate TICI 3 of 84%. NIHSS score at discharge was 6.5, with 60% of patients demonstrating NIHSS score 0 to 1 or an improvement of >9 points. Symptomatic complication rate was 10%. At 3 months, 54% of patients had a modififed Rankin scale score of 0 to 2, with an overall mortality rate of 12%. Conclusions— The present integrated stroke management protocol (RECOST study) demonstrated rapid, safe, and effective recanalization. We postulate that the Solitaire device contributed to high recanalization and patient selection using MRI ASPECT score to low and complication rates, therefore avoiding futile and dangerous interventions.

Mechanical thrombectomy with the Solitaire device in acute basilar artery occlusion

Aims To evaluate the efficacy and safety of mechanical thrombectomy with the Solitaire FR device in revascularization of patients with acute basilar artery occlusion (ABAO) and to identify the predictive factors for clinical outcome. Methods This prospective single-center study included 31 patients with acute ischemic stroke attributable to ABAO treated within the first 24 h after onset of symptoms with the Solitaire device. Nineteen patients simultaneously received intravenous thrombolysis. Recanalization rates after stent retrieval were determined and the clinical outcome and mortality rate were assessed 180 days after treatment. Results The mean ±SD age of the patients was 61±17 years, the median prethrombectomy NIH Stroke Scale score was 38 (IQR 9–38) and the median Glasgow Coma Scale (GCS) score was 7 (IQR 4–14). Successful recanalization (TICI 3 or 2b) was achieved in 23 patients (74%). Five symptomatic intracranial hemorrhages were related to the procedure. Ten symptomatic distal migrations of thrombotic material occurred. A favorable outcome, defined as a modified Rankin Score (mRS) of 0–2, was observed in 35% of patients (11/31). Overall mortality rate was 32% (10/31). In the univariate analysis, elevated baseline glucose (p=0.008) was significantly associated with a poor outcome (mRS >2), whereas a tendency towards significance was observed with age (p=0.06), GCS on admission (p=0.07) and symptom-related lesions on T2 sequences (p=0.10). Patients with successful recanalization tended to have a better outcome (p=0.20). Conclusion Mechanical thrombectomy with the Solitaire FR device can rapidly and effectively contribute to a high rate of recanalization and improve functional outcome in patients with ABAO and has an acceptable complication rate.

Prognostic factors related to clinical outcome following thrombectomy in ischemic stroke (RECOST Study). 50 patients prospective study

BACKGROUND AND AIMS New thrombectomy devices allow successful and rapid recanalization in acute ischemic stroke. Nevertheless prognostics factors need to be systematically analyzed in the context of these new therapeutic strategies. The aim of this study was to analyze prognostic factors related to clinical outcome following Solitaire FR thrombectomy in ischemic stroke. METHODS Fifty consecutive ischemic stroke patients with large vessel occlusion were included. Three treatment strategies were applied; rescue therapy, combined therapy, and standalone thrombectomy. DWI ASPECT score<5 was the main exclusion criterion after initial MRI (T2, T2, TOF, FLAIR, DWI). Sexes, age, time to recanalization were prospectively collected. Clinical outcome was assessed post treatment, day one and discharge by means of a NIHSS. Three months mRS evaluation was performed by an independent neurologist. The probability of good outcome at 3 months was assessed by forward stepwise logistic regression using baseline NIHSS score, Glasgow score at entrance, hyperglycemia, dyslipidemia, blood-brain barrier disruption on post-operative CT, embolic and hemorrhagic post procedural complication, ischemic brain lesion extension on 24h imaging, NIHSS at discharge, ASPECT score, and time to recanalization. All variables significantly associated with the outcome in the univariate analysis were entered in the model. The significance of adding or removing a variable from the logistic model was determined by the maximum likelihood ratio test. Odds-ratio (OR) and their 95% confidence intervals were calculated. RESULTS At 3 months 54% of patients had a mRS 0-2, 70% in MCA, 44% in ICA, and 43% in BA with an overall mortality rate of 12%. Baseline NIHSS score (p=0.001), abnormal Glasgow score at entrance (p=0.053) hyperglycemia (p=0.023), dyslipidemia (p=0.031), blood-brain barrier disruption (p=0.022), embolic and hemorrhagic post procedural complication, ischemic brain lesion extension on 24h imaging (p=0.008), NIHSS at discharge (0.001) were all factors significantly associated with 3 month clinical outcome. ASPECT subgroup (5-7 and 8-10), and time to recanalization were not correlated to 3 months outcome. Baseline NIHSS score (OR, 1.228; 95% CI, 1.075-1.402; p=0.002), hyperglycemia (OR, 10.013; 95% CI, 1.068-93.915; p=0.04), emerged as independent predictors of outcome at 3 months. Overall embolic complication rate was 10%, and symptomatic intracranial hemorrhage was 2%. CONCLUSION The MCA location was associated with the best clinical outcome. A DWI ASPECT cutoff score of 5 was reliable and safe. No correlation with time to recanalization was observed in this study. NIHSS and hyperglycemia at admission were the two factors independently associated with a bad outcome at 90 days.

Diffusion-weighted imaging score of the brain stem: A predictor of outcome in acute basilar artery occlusion treated with the Solitaire FR device.

BACKGROUND AND PURPOSE: The prognosis for ischemic stroke due to acute basilar artery occlusion is very poor: Early recanalization remains the main factor that can improve outcomes. The baseline extent of brain stem ischemic damage can also influence outcomes. We evaluated the validity of an easy-to-use DWI score to predict clinical outcome in patients with acute basilar artery occlusion treated by mechanical thrombectomy. MATERIALS AND METHODS: We analyzed the baseline clinical and DWI parameters of 31 patients with acute basilar artery occlusion, treated within 24 hours of symptom onset by using a Solitaire FR device. The DWI score of the brain stem was assessed with a 12-point semiquantitative score that separately considered each side of the medulla, pons, and midbrain. Clinical outcome was assessed at 180 days by using the mRS. According to receiver operating characteristic analyses, the cutoff score determined the optimal positive predictive value for outcome. The Spearman rank correlation coefficient assessed the correlation between the DWI brain stem score and baseline characteristics. RESULTS: Successful recanalization (Thrombolysis in Cerebral Infarction 3–2b) was achieved in 23 patients (74%). A favorable outcome (mRS ≤ 2) was observed in 11 patients (35%). An optimal DWI brain stem score of <3 predicted a favorable outcome. The probability of a very poor outcome (mRS ≥ 5) if the DWI brain stem score was ≥5 reached 80% (positive predictive value) and 100% if this score was ≥6. Interobserver reliability of the DWI brain stem score was excellent, with an intraclass correlation coefficient of 0.97 (95% CI, 0.96–0.99). The DWI brain stem score was significantly associated with baseline tetraplegia (P = .001) and coma (P = .005). CONCLUSIONS: In patients with acute basilar artery occlusion treated by mechanical thrombectomy, the baseline DWI brain lesion score seems to predict clinical outcome.

Mechanical Thrombectomy in Acute Ischemic Stroke: Catch Device

BACKGROUND AND PURPOSE: Mechanical thrombectomy presents today a promising alternative to traditional stroke therapies. Our aim with this study was to evaluate the safety and efficacy of the Catch mechanical thrombectomy device in the treatment of acute stroke and report the angiographic results and clinical outcomes. MATERIALS AND METHODS: We performed an analysis of 40 consecutive patients with ischemic stroke treated with the Catch device at our academic center. Forty patients were treated with the device: 25 with anterior circulation stroke and 15 with posterior circulation stroke. Thirty seven (92.5%) patients received an additional treatment to aid revascularization, including 36 patients treated with rtPA (mean dose of 35 mg). RESULTS: The mean age was 63.5 years (range, 31–82 years; 55% men). The median NIHSS score at presentation was 18 (range, 3–38). The mean symptom-to-procedure start time was 440 minutes (range, 150–2637 minutes). Recanalization (TIMI 2–3) was achieved in 26/40 (65%). Symptomatic hemorrhage occurred in 18%. Procedural complications occurred in 6 patients without clinical consequences: 4 clot fragmentations and 2 vasospasms. Data were missing for 4 patients at 90 days. Ninety-day mortality was 41%; good 90-day functional outcome (mRS, ≤ 2) was achieved by 39% (14/36). Good neurologic outcomes at 90 days were more frequent (56.5% versus 7.7%), and mortality rates were lower (30% versus 61.5%) with successful compared with unsuccessful recanalization. CONCLUSIONS: In our retrospective case series, the Catch device appears effective in achieving recanalization and improving 90-day outcome in patients with acute ischemic stroke.

Hemorrhagic Risk of Recent Silent Cerebral Infarct on Prethrombolysis MR Imaging in Acute Stroke

BACKGROUND AND PURPOSE: EIH is a rare complication after thrombolysis in patients with acute stroke, occurring in brain regions without visible ischemic change on pretreatment imaging. RSCIs can be detected by multimodal MR imaging and might be associated with an increased risk of HT postthrombolysis, related to BBBD. We aimed to assess the incidence of RSCI on pretreatment MR imaging and the subsequent risk of HT within RSCI areas on follow-up CT performed <36 hours after rtPA administration and on additional cerebral imaging before patient discharge. MATERIALS AND METHODS: Pretreatment MR imaging was retrospectively analyzed from consecutive patients with stroke who received intravenous or intra-arterial rtPA for 2 years. RSCI was defined on MR imaging as a parenchymal area markedly hyperintense on FLAIR, different from the hyperacute infarct, and mildly-to-markedly hyperintense on DWI or enhanced on postgadolinium T1WI imaging. RESULTS: Eighty-six patients with a median age of 66 years and a median NIHSS score on admission of 15 were studied; 66.3% received rtPA intravenously. The presence of RSCI was identified in 10 patients (11.6%) and was associated with large-vessel-disease etiology (40% versus 5.3%, P < .001) on univariate analysis. No HT was identified within the RSCI areas on any follow-up cerebral imaging. CONCLUSIONS: These preliminary results require validation but suggest that small RSCIs are rather frequent and might not pose a higher risk of postthrombolysis HT.

Evaluation of an Intravenous-Endovascular Strategy in Patients with Acute Proximal Middle Cerebral Artery Occlusion

Here, the safety and efficacy of mechanical thrombectomy after intravenous therapy failure were assessed in 123 patients with acute MCA occlusions. All patients imaged were within 4.5 hours of onset, had DWI ASPECTS greater than 5, and variable NIHSS scores (8–25). The authors found that mechanical thrombectomy after failure of intravenous thrombolysis improves clinical outcomes at 3 months and could represent an alternative in the management of patients with acute MCA occlusion. Additionally, no symptomatic intracranial hemorrhages were detected in patients treated this way, suggesting this protocol is safe. BACKGROUND AND PURPOSE: IVT administered in acute ischemic stroke provides low recanalization rates in proximal intracranial occlusions, with consequently poor clinical outcome. The safety and efficacy of an IES by using mechanical thrombectomy after IVT failure were assessed in acute MCA occlusions. MATERIALS AND METHODS: Patients presenting with acute MCA occlusion within 4.5 hours with an NIHSS score between 8 and 25 and a DWI ASPECTS of >5 were eligible. From September 2009 to September 2010, mechanical thrombectomy by using the Solitaire FR device was systematically performed if no clinical improvement was observed 1 hour after the initiation of IVT (IES group). Results in terms of clinical outcome were compared with those from an IVT series from January 2007 to August 2009 (IVT group). RESULTS: Alteplase was administered in 123 patients with proximal intracranial occlusion. Fifty-six had a confirmed MCA occlusion: 32 were included in the IVT group; and 24, in the IES group. At 24 hours, the median NIHSS improvement was 8.5 points in the IES group (25%–75% CI, 1.5–13) and 3 points in the IVT group (25%–75% CI, 1–5) (P = .001). At 3 months, 17/22 (77%) patients from the IES group and 15/30 (50%) from the IVT group had an mRS score of ≤2. After adjustment for confounding variables, IES was strongly associated with favorable clinical outcome (77% versus 50%; adjusted odds ratio = 11.9; 95% CI, 1.6–89.1; P < .02). No symptomatic intracranial hemorrhage was observed. CONCLUSIONS: IES by using systematic mechanical thrombectomy after IVT failure safely improves the clinical outcome at 3 months and could represent an interesting alternative in the management of patients with acute MCA occlusion.

Feasibility of hypothermia beyond 3 weeks in severe ischemic stroke: an open pilot study using γ-hydroxybutyrate.

PURPOSE Hypothermia is a promising neuroprotective therapy. We studied the feasibility and safety of very prolonged moderate hypothermia for severe acute ischemic stroke. METHODS Moderate hypothermia was induced within 24h after a severe ischemic stroke involving the middle cerebral artery. Hypothermia, with cooling blankets, reduced body-core temperature to 32-33°C, and was prolonged for up to 22 days until cerebral edema had significantly decreased (assessed by serial cerebral computed tomography) before slow rewarming (<1.5°C/day). Patients were mechanically ventilated and sedated with gamma-hydroxybutyrate (GHB), a naturally occurring metabolite of gamma-aminobutyric acid (GABA), which acts on the GABA(B) receptors. Outcomes and side effects at 12 months were recorded. RESULTS Nineteen patients (mean age: 52.6 years, mean National Institute of Health Stroke Scale (NIHSS) score 21) were enrolled. Cooling was achieved in all patients. The mean time to reach target temperature was 11.4 ± 8.6h and the mean duration of rewarming was 4.0 ± 1.1 days. For the 10 survivors (53%), the mean duration of hypothermia and rewarming was 22.6 ± 4.9 days. Five patients underwent a hemicraniectomy. All patients presented with hypotension, bradycardia, and hematological side effects. Eight patients had pneumonia (42%). At 12 months, the mean NIHSS score was 8.3 ± 2.7, the Barthel Index was 67 ± 18, and the modified Rankin scale was 3.2 ± 0.9. CONCLUSIONS This study shows the feasibility of very prolonged hypothermia beyond 3 weeks using GHB sedation in severe hemispheric infarcts.

Favorable Bridging Therapy Based on DWI-FLAIR Mismatch in Patients with Unclear-Onset Stroke

BACKGROUND AND PURPOSE: Standard selection criteria for revascularization therapy usually exclude patients with unclear-onset stroke. Our aim was to evaluate the efficacy and safety of revascularization therapy in patients with unclear-onset stroke in the anterior circulation and to identify the predictive factors for favorable clinical outcome. MATERIALS AND METHODS: We retrospectively analyzed 41 consecutive patients presenting with acute stroke with unknown time of onset treated by intravenous thrombolysis and/or mechanical thrombectomy. Only patients without well-developed fluid-attenuated inversion recovery changes of acute diffusion lesions on MR imaging were enrolled. Twenty-one patients were treated by intravenous thrombolysis; 19 received, simultaneously, intravenous thrombolysis and mechanical thrombectomy (as a bridging therapy); and 1 patient, endovascular therapy alone. Clinical outcome was evaluated at 90 days by using the mRS. Mortality and symptomatic intracranial hemorrhage were also reported. RESULTS: Median patient age was 72 years (range, 17–89 years). Mean initial NIHSS score was 14.5 ± 5.7. Successful recanalization (TICI 2b–3) was assessed in 61% of patients presenting with an arterial occlusion, symptomatic intracranial hemorrhage occurred in 2 patients (4.9%), and 3 (7.3%) patients died. After 90 days, favorable outcome (mRS 0–2) was observed in 25 (61%) patients. Following multivariate analysis, initial NIHSS score (OR, 1.43; 95% CI, 1.13–1.82; P = .003) and bridging therapy (OR, 37.92; 95% CI, 2.43–591.35; P = .009) were independently associated with a favorable outcome at 3 months. CONCLUSIONS: The study demonstrates the safety and good clinical outcome of acute recanalization therapy in patients with acute stroke in the anterior circulation and an unknown time of onset and a DWI/FLAIR mismatch on imaging. Moreover, bridging therapy versus intravenous thrombolysis alone was independently associated with favorable outcome at 3 months.

Infarctus latéro-bulbaire sur dissection intracrânienne suivi d’une hémorragie sous-arachnoïdienne

Resume Introduction Les anevrysmes dissequants de l’artere vertebrale intracrânienne sont une cause reconnue d’hemorragie sous-arachnoidienne et le risque de recidive hemorragique apres une premiere rupture de l’anevrysme dissequant est eleve et de mauvais pronostic. Cependant, lorsque la dissection est revelee par un infarctus dans le territoire vertebro-basilaire, le risque de rupture hemorragique est peu connu et la conduite a tenir mal codifiee. Observation Nous rapportons le cas d’un homme âge de 49 ans qui a presente une hemorragie sous-arachnoidienne apres un syndrome latero-bulbaire en rapport avec une dissection spontanee avec occlusion de l’artere vertebrale droite. L’arteriographie de controle mit en evidence un anevrysme dissequant du segment V4 de l’artere vertebrale droite qui fut traite par stent et coiling sans complications. Conclusion Ce cas souligne le risque hemorragique d’une dissection de l’artere vertebrale intracrânienne et son evolution possible en un anevrysme qui doit etre recherche par une imagerie angiographique de controle et qui peut necessiter un traitement specifique chirurgical ou endovasculaire precoce en raison d’un risque hemorragique ulterieur eleve.