M Taqi

Balloon Guide Catheter Improves Revascularization and Clinical Outcomes With the Solitaire Device Analysis of the North American Solitaire Acute Stroke Registry

Background and Purpose— Efficient and timely recanalization is an important goal in acute stroke endovascular therapy. Several studies demonstrated improved recanalization and clinical outcomes with the stent retriever devices compared with the Merci device. The goal of this study was to evaluate the role of the balloon guide catheter (BGC) and recanalization success in a substudy of the North American Solitaire Acute Stroke (NASA) registry. Methods— The investigator-initiated NASA registry recruited 24 clinical sites within North America to submit demographic, clinical, site-adjudicated angiographic, and clinical outcome data on consecutive patients treated with the Solitaire Flow Restoration device. BGC use was at the discretion of the treating physicians. Results— There were 354 patients included in the NASA registry. BGC data were reported in 338 of 354 patients in this subanalysis, of which 149 (44%) had placement of a BGC. Mean age was 67.3±15.2 years, and median National Institutes of Health Stroke Scale score was 18. Patients with BGC had more hypertension (82.4% versus 72.5%; P=0.05), atrial fibrillation (50.3% versus 32.8%; P=0.001), and were more commonly administered tissue plasminogen activator (51.6% versus 38.8%; P=0.02) compared with patients without BGC. Time from symptom onset to groin puncture and number of passes were similar between the 2 groups. Procedure time was shorter in patients with BGC (120±28.5 versus 161±35.6 minutes; P=0.02), and less adjunctive therapy was used in patients with BGC (20% versus 28.6%; P=0.05). Thrombolysis in cerebral infarction 3 reperfusion scores were higher in patients with BGC (53.7% versus 32.5%; P<0.001). Distal emboli and emboli in new territory were similar between the 2 groups. Discharge National Institutes of Health Stroke Scale score (mean, 12±14.5 versus 17.5±16; P=0.002) and good clinical outcome at 3 months were superior in patients with BGC compared with patients without (51.6% versus 35.8%; P=0.02). Multivariate analysis demonstrated that the use of BGC was an independent predictor of good clinical outcome (odds ratio, 2.5; 95% confidence interval, 1.2–4.9). Conclusions— Use of a BGC with the Solitaire Flow Restoration device resulted in superior revascularization results, faster procedure times, decreased need for adjunctive therapy, and improved clinical outcome.

North American SOLITAIRE Stent-Retriever Acute Stroke Registry: choice of anesthesia and outcomes.

Background and Purpose— Previous work that predated the availability of the safer stent-retriever devices has suggested that general anesthesia (GA) may have a negative impact on outcomes in patients with acute ischemic stroke undergoing endovascular therapy. Methods— We reviewed demographic, clinical, procedural (GA versus local anesthesia [LA], etc), and site-adjudicated angiographic and clinical outcomes data from consecutive patients treated with the Solitaire FR device in the investigator-initiated North American SOLITAIRE Stent-Retriever Acute Stroke (NASA) Registry. The primary outcomes were 90-day modified Rankin Scale, mortality, and symptomatic intracranial hemorrhage. Results— A total of 281 patients from 18 centers were enrolled. GA was used in 69.8% (196/281) of patients. Baseline demographic and procedural factors were comparable between the LA and GA groups, except the former demonstrated longer time-to-groin puncture (395.4±254 versus 337.4±208 min; P=0.04), lower National Institutes of Health Stroke Scale (NIHSS; 16.2±5.8 versus 18.8±6.9; P=0.002), lower balloon-guide catheter usage (22.4% versus 49.2%; P=0.0001), and longer fluoroscopy times (39.5±33 versus 28±22.8 min; P=0.008). Recanalization (thrombolysis in cerebral infarction ≥2b; 72.94% versus 73.6%; P=0.9) and rate of symptomatic intracranial hemorrhage (7.1% versus 11.2%; P=0.4) were similar but modified Rankin Scale ⩽2 was achieved in more LA patients, 52.6% versus 35.6% (odds ratio, 1.4 [1.1–1.8]; P=0.01). In multivariate analysis, hypertension, NIHSS, unsuccessful revascularization, and GA use (odds ratio, 3.3 [1.6–7.1]; P=0.001) were associated with death. When only anterior circulation and elective GA patients were included, there was a persistent difference in good outcomes in favor of LA patients (50.7% versus 35.5%; odds ratio, 1.3 [1.01–1.6]; P=0.04). Conclusions— The NASA Registry has demonstrated that clinical outcomes and survival are significantly better in patients treated with LA, without increased symptomatic intracranial hemorrhage risk. Future trials should prospectively evaluate the effect of GA on outcomes.

Vertebral Artery Stenting for the Treatment of Bow Hunter’s Syndrome: Report of 4 Cases

Bow hunters syndrome (BHS) is a rare condition resulting from vertebrobasilar insufficiency secondary to mechanical occlusion or stenosis of the vertebral artery (VA) due to head rotation. Traditionally, surgical intervention with C1-C2 fusion or VA decompression was the mainstay of therapy. Endovascular intervention was rarely performed to treat BHS. We reviewed the neurointerventional database from July 2005 to October 2010 to identify all cases of BHS treated with VA stenting. Here we report clinical, technical, and outcome data for 4 patients with BHS who were treated with VA stenting. In all 4 of these patients, stenting was performed in the V2 segment (C2-C6) of the VA without significant technical difficulties. All patients reported symptomatic relief, and only minor or no residual stenosis was detected by dynamic digital subtraction angiography. Our findings indicate that VA stenting for the treatment of BHS is feasible, safe, and clinically effective. Endovascular techniques might offer an alternative, minimally invasive therapy for the treatment of BHS.

Dissecting Aneurysms of Posterior Cerebral Artery: Clinical Presentation, Angiographic Findings, Treatment, and Outcome

Background: The dissecting posterior cerebral artery (PCA) aneurysms are very rare. These aneurysms pose significant treatment challenge and need careful evaluation to formulate an optimal treatment plan in case of ruptured or un-ruptured presentations. Methods: Retrospective review of a prospectively collected data. Results: Seven patients with dissecting aneurysms of the PCA were identified. Six out of seven presented with subarachnoid hemorrhage (SAH) and one with ischemic stroke. Three out of seven were treated with endovascular coil embolization without sacrifice of the parent artery and the rest had parent artery occlusion (PAO) with coil embolization. None of the patients developed new neurological deficits post-procedure. Aneurysm re-occurred in two patients that were treated without PAO. Conclusion: Endovascular treatment of the dissecting PCA aneurysm is safe and feasible. It can be performed with or without PAO. Recurrence is more common without PAO and close follow-up is warranted.

Safety and feasibility of simultaneous ipsilateral proximal carotid artery stenting and cerebral aneurysm coiling

Coexistence of cerebral aneurysm and carotid artery disease may be encountered in clinical practice. Theoretical increase in aneurysmal blood flow may increase risk of rupture if carotid artery disease is treated first. If aneurysm coiling is performed first, stroke risk may increase while repeatedly crossing the diseased artery. It is controversial which disease to treat first, and whether it is safe to treat both simultaneously via endovascular procedures. We document the safety and feasibility of such an approach. Review of collected neurointerventional database at our institution was performed for patients who underwent both carotid artery stenting (CAS) and aneurysm coil embolization (ACE) simultaneously. All patients underwent carotid stenting followed by aneurysm coiling in the same setting. Demographic, clinical data, and outcome measures including success rate and periprocedural complications were collected. Five hundred and ninety aneurysms coiling were screened for patients who underwent combined CAS and ACE. Ten patients were identified. Mean age was 67.7 years (range 51–89). The success rate for stenting and coiling was 100% with no immediate complications. The coiling procedure time was extended by an average of 45 min for performing both procedures jointly. No stroke, TIAs, or aneurysmal rebleeding was found on their most recent follow up. Our case series demonstrates that it is safe and feasible to perform CAS and ACE simultaneously as one procedure which may avoid unwanted risk of treating either disease at two separate time sessions.

TREVO stent-retriever mechanical thrombectomy for acute ischemic stroke secondary to large vessel occlusion registry

Background Recent randomized clinical trials (RCTs) demonstrated the efficacy of mechanical thrombectomy using stent-retrievers in patients with acute ischemic stroke (AIS) with large vessel occlusions; however, it remains unclear if these results translate to a real-world setting. The TREVO Stent-Retriever Acute Stroke (TRACK) multicenter Registry aimed to evaluate the use of the Trevo device in everyday clinical practice. Methods Twenty-three centers enrolled consecutive AIS patients treated from March 2013 through August 2015 with the Trevo device. The primary outcome was defined as achieving a Thrombolysis in Cerebral Infarction (TICI) score of ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS), mortality, and symptomatic intracranial hemorrhage (sICH). Results A total of 634patients were included. Mean age was 66.1±14.8 years and mean baseline NIH Stroke Scale (NIHSS) score was 17.4±6.7; 86.7% had an anterior circulation occlusion. Mean time from symptom onset to puncture and time to revascularization were 363.1±264.5 min and 78.8±49.6 min, respectively. 80.3% achieved TICI ≥2b. 90-day mRS ≤2 was achieved in 47.9%, compared with 51.4% when restricting the analysis to the anterior circulation and within 6 hours (similar to recent AHA/ASA guidelines), and 54.3% for those who achieved complete revascularization. The 90-day mortality rate was 19.8%. Independent predictors of clinical outcome included age, baseline NIHSS, use of balloon guide catheter, revascularization, and sICH. Conclusion The TRACK Registry results demonstrate the generalizability of the recent thrombectomy RCTs in real-world clinical practice. No differences in clinical and angiographic outcomes were shown between patients treated within the AHA/ASA guidelines and those treated outside the recommendations.

Downward migration of carotid stent on 8 months follow-up imaging: possible stent "watermelon- seeding" effect.

One method used to treat atherosclerotic carotid disease is carotid artery stenting (CAS). A rarely encountered limitation of this technique is stent migration. Here, we present a rare case of carotid stent downward migration found on follow‐up imaging 8 months post operation.

Endovascular therapy for chronic cerebrospinal venous insufficiency in multiple sclerosis.

Recent reports have emerged suggesting that multiple sclerosis (MS) may be due to abnormal venous outflow from the central nervous system, termed chronic cerebrospinal venous insufficiency (CCSVI). These reports have generated strong interest and controversy over the prospect of a treatable cause of this chronic debilitating disease. This review aims to describe the proposed association between CCSVI and MS, summarize the current data, and discuss the role of endovascular therapy and the need for rigorous randomized clinical trials to evaluate this association and treatment.

O-032 Predictors of Poor Outcomes Despite Successful Recanalization in Patients with Acute Ischemic Stroke

Background Recanalization of the occluded artery is a powerful predictor of good outcome in acute ischemic stroke secondary to large artery occlusions. Mechanical thrombectomy with stent-trievers results in higher recanalization rates and better outcomes compared to previous devices. However, despite successful recanalization rates (Treatment in Cerebral Infarction, TICI, score ≥ 2b) between 70 and 90%, good clinical outcomes assessed by modified Rankin Scale (mRS ≥ 2 is present in 40–50% of patients. We aimed to evaluate predictors of poor outcomes (mRS ≥ 2) despite successful recanalization (TICI ≥ 2b) in the acute stroke patients treated with the Solitaire device of the North American Solitaire Stent Retriever Acute Stroke (NASA) registry. Methods The NASA registry is a multicenter, non-sponsored, physician-conducted, post-marketing registry on the use of SOLITAIRE FR device in 354 acute, large vessels, ischemic stroke patients. Logistic regression was used to evaluate patient characteristics and treatment parameters for association with 90-day mRS score of 0–2 (good outcome) versus 3–6 (poor outcome) within patients who were recanalised successfully (Thrombolysis in Cerebral Infarction or TICI score 2b-3). Univariate tests were followed by development of a multivariable model based on stepwise selection with entry and retention criteria of p < 0.05 from the set of factors with at least marginal significance (p ≤ 0.10) on univariate analysis. The c-statistic was calculated as a measure of predictive power. Results Out of 354 patients, 256 (72.3%) were successfully recanalised (TICI ≥ 2b). Based on 90-day mRS score for 234 of these patients, there were 116 (49.6%) with mRS ≥2. Univariate analysis identified increased risk of mRS ≥2 for each of the following: age ≥ 80 years (upper quartile of data), occlusion site other than M1/M2, NIH Stroke Scale (NIHSS) score ≥ 18 (median), history of diabetes mellitus (DM), TICI = 2b, use of rescue therapy, not using a balloon-guided catheter (BCG) or intravenous tissue plasminogen activator (IV t-PA), and time to recanalization > 30 min (all p ≤ 0.05). Three or more passes was marginally significant (p = 0.097). In multivariable analysis, age ≥80 years, site other than M1/M2, initial NIHSS ≥18, DM, absence of IVtPA, use of rescue therapy and three or more passes were significant independent predictors of poor 90-day outcome in a model with good predictive power (c-index = 0.80). Conclusions Age, occlusion site, high NIHSS, diabetes, not receiving IVtPA, use of rescue therapy and three or more passes, were associated with poor 90-day outcome despite successful recanalization. Disclosures I. Linfante: None. G. Dabus: None. A. Starosciak: None. A. Castonguay: None. R. Gupta: None. C. Sun: None. C. Martin: None. W. Holloway: None. N. Mueller-Kronast: None. J. English: None. T. Malisch: None. F. Marden: None. H. Bozorgchami: None. A. Xavier: None. A. Rai: None. M. Froehler: None. A. Badruddin: None. T. Nguyen: None. M. Taqi: None. M. Abraham: None. V. Janardhan: None. H. Shaltoni: None. R. Novakovic: None. A. Yoo: None. O. Zaidat: None.

O-004 Analysis of M2 Occlusions within TREVO Acute Ischemic Stroke (TRACK) stent-retriever Thrombectomy Registry

Background and purpose Several recent randomized clinical trials have demonstrated the safety and efficacy of mechanical thrombectomy with stent retrievers for acute ischemic stroke patients with anterior circulation occlusions. However, these trials have limited enrollment of patients with M2 occlusions. Here, we sought to examine the clinical and angiographic outcomes of patients with M2 occlusions in the Trevo Acute Ischemic Stroke (TRACK) stent-retriever thrombectomy multicenter registry. Methods Data from the investigator-initiated TRACK Registry (631 consecutive AIS patients, 23 clinical centers) was used to examine and compare demographic, clinical, and angiographic outcomes of patients with M1 versus M2 occlusions who were treated with TREVO as first treatment device. Results Of the 631 patients enrolled in the TRACK registry, 84 (13.3%) had M2 and 344 (54.5%) had M1 occlusions. Mean age was similar between the M1 and M2 cohorts, 66.5 ± 14.4 and 64.7 ± 3.8 years (p = 0.34), respectively. M2 patients had a lower median baseline NIHSS at presentation (14 (IQR 7–9) versus 18(IQR 14–22), p ≤ 0.0001). Time of onset to groin puncture (347 ± 237.4 and 361 ± 232.3, p = 0.63) and total procedural time (85.9 ± 49.9 and 78.3 ± 64.5, p = 0.4) was similar between the M1 and M2 cohorts. The number of passes with TREVO device was greater in the M1 cohort (Median, 2 (IQR 1–3) versus 1(IQR 1–2), p = 0.01) as well as use of rescue therapy (20.2% versus 9.8%, p = 0.03). Patients with M2 occlusions achieved a higher rate of TICI 3 revascularization after the 1st pass with TREVO device compared to those with M1 occlusions (55.8% versus 40.4%, p = 0.01). There was no significant difference in time to revascularization (78.6 ± 50.7 versus 71.6 ± 45.3, p = 0.2), revascularization success (≥TICI 2 b) (80.5% versus 76.2%, p = 0.4), symptomatic intracranial hemorrhage (5.6% versus 6.0%, p = 0.9), 90 day modified Rankin Scale score 0–2 (51.0% versus 57.4%, p = 0.35), or mortality (16.1% versus 13.2%, p = 0.6) between the M1 and M2 groups, respectively. Conclusions Patients with M2 Occlusions are more likely to achieve complete recanalization from the first pass with Trevo stent retriever device than M1 occlusion. In addition, the M2 cohort had a numerically higher rate of good clinical outcome and less rate of mortality than M1 group. This substudy is limited by lack of a control M2 group without mechanical thrombectomy. Disclosures A. Castonguay: None. R. Nogueira: None. J. English: None. S. Satti: None. H. Farid: None. E. Veznedaroglu: None. M. Binning: None. A. Puri: None. N. Vora: None. R. Budzik: None. G. Dabus: None. I. Linfante: None. V. Janardhan: None. A. Alshekhlee: None. M. Abraham: None. R. Edgell: None. M. Taqi: None. R. El Khoury: None. M. Mokin: None. M. Mokin: None. A. Majjhoo: None. M. Kabbani: None. M. Froehler: None. I. Finch: None. S. Ansari: None. R. Novakovic: None. T. Nguyen: None. O. Zaidat: None.