P. Machi

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.

Neuroform Stent−Assisted Coiling of Unruptured Intracranial Aneurysms: Short- and Midterm Results from a Single-Center Experience with 68 Patients

BACKGROUND AND PURPOSE: Intracranial stent placement assists in the coiling of wide-neck aneurysms and aids in reconstructing and protecting the parent artery. In this study, we analyze our experience in the use of the Neuroform system. MATERIALS AND METHODS: Records of patients treated with a Neuroform stent from June 2003 to September 2007 were retrieved from a data base for analysis of population characteristics, occurrence of complications, and acute and midterm angiographic results. RESULTS: Sixty-eight patients harboring 76 aneurysms located primarily in the anterior circulation were treated. There were 5 cases (6.6%) of clot formation after deployment (1 with a permanent neurologic deficit), 1 case of perioperative stent displacement with hemorrhage, and 5 cases (6.6%) of transient neurologic deficit due to thromboembolic events. The morbidity-mortality rate at discharge was 2.9%. One patient presented with a delayed in-stent thrombosis, and 3 others, with silent stenosis. Twenty-four aneurysms (31.6%) were completely occluded in the initial embolization. However, a marked increase in the occlusion rate was observed, with 44 of the 68 aneurysms (64.7%) examined at the 18-month follow-up and 26 of the 46 aneurysms (56.5%) examined in the 3-year follow-up presenting with complete occlusion. At the end of the study, a neck remnant was present in 6 aneurysms (13%) and a residual sac, in 7 (15.2%). Mean follow-up time was 25.7 months. CONCLUSIONS: The present series demonstrates the relative safety and feasibility of the Neuroform stent−assisted coiling technique, which seems to provide better results over coiling alone for wide-neck aneurysms. Angiographic results improve with time due to progressive thrombosis of the aneurysm.

Stent Retrievers in Acute Ischemic Stroke: Complications and Failures during the Perioperative Period

BACKGROUND AND PURPOSE: Stent retriever–assisted thrombectomy promotes high recanalization rates in acute ischemic stroke. Nevertheless, complications and failures occur in more than 10% of procedures; hence, there is a need for further investigation. MATERIALS AND METHODS: A total of 144 patients with ischemic stroke presenting with large-vessel occlusion were prospectively included. Patients were treated with stent retriever–assisted thrombectomy ± IV fibrinolysis. Baseline clinical and imaging characteristics were incorporated in univariate and multivariate analyses. Predictors of recanalization failure (TICI 0, 1, 2a), and of embolic and hemorrhagic complications were reported. The relationship between complication occurrence and periprocedural mortality rate was studied. RESULTS: Median age was 69.5 years, and median NIHSS score was 18 at presentation. Fifty patients (34.7%) received stand-alone thrombectomy, and 94 (65.3%) received combined therapy. The procedural failure rate was 13.9%. Embolic complications were recorded in 12.5% and symptomatic intracranial hemorrhage in 7.6%. The overall rate of failure, complications, and/or death was 39.6%. The perioperative mortality rate was 18.4% in the overall cohort but was higher in cases of failure (45%; P = .003), embolic complications (38.9%; P = .0176), symptomatic intracranial hemorrhages (45.5%; P = .0236), and intracranial stenosis (50%; P = .0176). Concomitant fibrinolytic therapy did not influence the rate of recanalization or embolic complication, or the intracranial hemorrhage rate. Age was the only significant predictive factor of intracranial hemorrhage (P = .043). CONCLUSIONS: The rate of perioperative mortality was significantly increased in cases of embolic and hemorrhagic complications, as well as in cases of failure and underlying intracranial stenoses. Adjunctive fibrinolytic therapy did not improve the recanalization rate or collateral embolic complication rate. The rate of symptomatic intracranial hemorrhage was not increased in cases of combined treatment.

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

BACKGROUND AND AIMSnNew 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.nnnMETHODSnFifty 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.nnnRESULTSnAt 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%.nnnCONCLUSIONnThe 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.

Endovascular treatment of tandem occlusions of the anterior cerebral circulation with solitaire FR thrombectomy system. Initial experience

PURPOSEnThe optimal treatment in the acute phase of cervical internal carotid occlusion associated with intracranial obstruction is a matter of debate. In this study, we report our experience using the Solitaire FR revascularization device and synchronous intravenous fibrinolysis. The distal occlusion was treated with Solitaire FR before the proximal one in all cases, a technique not reported so far in the literature.nnnMETHODSnWe examined all cases of tandem occlusion treated in our institution between November 2009 and November 2010. The proximal occlusion was treated using manual thromboaspiration in order to achieve intracranial recanalization as rapid as possible. When necessary, stenting was performed after the reconstitution of the intracranial vessel. Morphological and clinical results were recorded in the immediate post-operative phase and at the three-month follow-up. Clinical success was defined as a mRS at 3 months≤2.nnnRESULTSnFour male and six female patients were treated (mean age 66 years). The cervical carotid was recanalized in all cases and the intracranial vessel (TICI≥2b) in eight. Adverse events were recorded in four patients of which three were asymptomatic. These included two cases of subarachnoid hemorrhage, one case of traumatic dissection, and one case of fatal intra-cerebral hemorrhage seven days following the procedure. At the three-month follow-up a mRS≤2 was observed in four patients.nnnCONCLUSIONSnThe described approach for the treatment of tandem occlusions is promising with regard to both morphological and clinical assessments and thus may be considered a valid tool in acute stroke.

Patient Selection for Stroke Endovascular Therapy— DWI-ASPECTS Thresholds Should Vary among Age Groups: Insights from the RECOST Study

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate the benefits of endovascular intervention in large-vessel occlusion strokes, depending on age class. MATERIALS AND METHODS: A clinical management protocol including intravenous treatment and mechanical thrombectomy was instigated in our center in 2009 (Prognostic Factors Related to Clinical Outcome Following Thrombectomy in Ischemic Stroke [RECOST] study). All patients with acute ischemic stroke with an anterior circulation major-vessel occlusion who presented within 6 hours were evaluated with an initial MR imaging examination and were analyzed according to age subgroups (younger than 50 years, 50–59 years, 60–69 years, 70–79 years; 80 years or older). The mRS score at 3 months was the study end point. RESULTS: One hundred sixty-five patients were included in the analysis. The mean age was 67.4 years (range, 29–90 years). The mean baseline NIHSS score was 17.24 (range, 3–27). The mean DWI-derived ASPECTS was 6.4. Recanalization of TICI 2b/3 was achieved in 80%. At 3 months, 41.72% of patients had a good outcome, with a gradation of prognosis depending on the age subgroup and a clear cutoff at 70 years. Only 19% of patients older than 80 years had a good outcome at 3 months (mean ASPECTS = 7.4) with 28% for 70–79 years (mean ASPECTS = 6.8), but 58% for 60–69 years (mean ASPECTS = 6), 52% for 50–59 years (mean ASPECTS = 5.91), and 72% for younger than 50 years (mean ASPECTS = 6.31). In contrast, the mortality rate was 35% for 80 years and older, and 26% for 70–79 versus 5%–9% for younger than 70 years. CONCLUSIONS: The elderly may benefit from thrombectomy when their ischemic core volume is low in comparison with younger patients who still benefit from acute recanalization despite larger infarcts. Stroke volume thresholds should, therefore, be related and adjusted to the patients age group.

Extra-Aneurysmal Flow Modification Following Pipeline Embolization Device Implantation: Focus on Regional Branches, Perforators, and the Parent Vessel

BACKGROUND AND PURPOSE: Flow-diverter technology has proved to be a safe and effective treatment for intracranial aneurysm based on the concept of flow diversion allowing parent artery and collateral preservation and aneurysm healing. We investigated the patency of covered side branches and flow modification within the parent artery following placement of the Pipeline Embolization Device in the treatment of intracranial aneurysms. MATERIALS AND METHODS: Sixty-six aneurysms in 59 patients were treated with 96 Pipeline Embolization Devices. We retrospectively reviewed imaging and clinical results during the postoperative period at 6 and 12 months to assess flow modification through the parent artery and side branches. Reperfusion syndrome was assessed by MR imaging and clinical evaluation. RESULTS: Slow flow was observed in 13 of 68 (19.1%) side branches covered by the Pipeline Embolization Device. It was reported in all cases of anterior cerebral artery coverage, in 3/5 cases of M2-MCA coverage, and in 5/34 (14.7%) cases of ophthalmic artery coverage. One territorial infarction was observed in a case of M2-MCA coverage, without arterial occlusion. One case of deep Sylvian infarct was reported in a case of coverage of MCA perforators. Two ophthalmic arteries (5.9%) were occluded, and 11 side branches (16.2%) were narrowed at 12 months follow-up; patients remained asymptomatic. Parent vessel flow modification was responsible for 2 cases (3.4%) of reperfusion syndrome. Overall permanent morbidity and mortality rates were 5.2% and 6.9%, respectively. We did not report any permanent deficit or death in case of slow flow observed within side branches. CONCLUSIONS: After Pipeline Embolization Device placement, reperfusion syndrome was observed in 3.4%, and territorial infarction, in 3.4%. Delayed occlusion of ophthalmic arteries and delayed narrowing of arteries covered by the Pipeline Embolization Device were observed in 5.9% and 16.2%, respectively. No permanent morbidity or death was related to side branch coverage at midterm follow-up.

Endovascular Management of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection Using a Distal to Proximal Approach: Insight from the RECOST Study.

The authors analyzed all carotid artery dissection tandem occlusion strokes and isolated anterior circulation occlusions from their ongoing prospective stroke data base. For carotid artery dissection, the revascularization procedure consisted of initial distal recanalization by a stent retriever in the intracranial vessel. Following assessment of the circle of Willis, ICA stent placement was only performed in case of insufficiency. Two hundred fifty-eight patients with an anterior circulation stroke were analyzed, including 20 with carotid artery dissection–related occlusion. Only 5 carotid artery dissections (25%) necessitated cervical stent placement. No early ipsilateral stroke recurrence was recorded, despite the absence of stent placement in 15 patients (75%) with carotid artery dissection. Mechanical endovascular treatment of carotid artery dissection tandem occlusions is safe and effective compared with isolated anterior circulation occlusion stroke therapy. The authors favor a complete evaluation of the circle of Willis in these patients, which requires a contralateral femoral puncture, allowing selective contralateral common carotid and vertebrobasilar catheterizations. BACKGROUND AND PURPOSE: Internal carotid artery dissection is a common cause of stroke in young adults. It may be responsible for tandem occlusion defined by a cervical steno-occlusive carotid wall hematoma associated with an intracranial large-vessel stroke. Intravenous thrombolysis is associated with a poor clinical outcome in these cases, and endovascular treatment has not been specifically evaluated to date. Our aim was to evaluate endovascular treatment technical and clinical efficiency in this specific occlusion topography, in comparison with treatment of isolated anterior circulation stroke. MATERIALS AND METHODS: As part of our ongoing prospective stroke data base started in August 2009 (Prognostic Factors Related to Clinical Outcome Following Thrombectomy in Ischemic Stroke [RECOST] Study), we analyzed all carotid artery dissection tandem occlusion strokes and isolated anterior circulation occlusions. All patients were selected for endovascular treatment according to clinical-radiologic mismatch, NIHSS ≥ 7 and DWI-ASPECTS ≥5, within 6 hours after onset. For carotid artery dissection, the revascularization procedure consisted first of distal recanalization by a stent retriever in the intracranial vessel. Following assessment of the circle of Willis, internal carotid artery stent placement was only performed in case of insufficiency. Carotid artery dissection treatment efficacy, safety, and clinical outcome were compared with the results of the isolated anterior circulation occlusion cohort. RESULTS: Two hundred fifty-eight patients with an anterior circulation stroke were analyzed, including 57 with tandem occlusions (22%); among them, 20 were carotid artery dissection–related occlusions (7.6%). The median age of patients with tandem occlusions with internal carotid dissection was 52.45 versus 66.85 years for isolated anterior circulation occlusion (P < .05); the mean initial NIHSS score was 17.53 ± 4.11 versus 17.55 ± 4.8 (P = .983). The median DWI-ASPECTS was 6.05 versus 6.64 (P = .098), and the average time from onset to puncture was 4.38 for tandem occlusions versus 4.53 hours in isolated anterior circulation occlusion (P = .704). Complication rates and symptomatic intracranial hemorrhage were comparable in both groups (5% versus 3%, P = .49). The duration of the procedure was significantly prolonged in case of tandem occlusion (80.69 versus 65.45 minutes, P = .030). Fourteen patients with carotid artery dissection (70%) had a 3-month mRS of ≤ 2, without a significant difference from patients with an isolated anterior circulation occlusion (44%, P = .2). Only 5 carotid artery dissections (25%) necessitated cervical stent placement. No early ipsilateral stroke recurrence was recorded, despite the absence of stent placement in 15 patients (75%) with carotid artery dissection. CONCLUSIONS: Mechanical endovascular treatment of carotid artery dissection tandem occlusions is safe and effective compared with isolated anterior circulation occlusion stroke therapy. Hence, a more conservative approach with stent placement only in cases of circle of Willis insufficiency may be a reliable and safe strategy.

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.

LEO Baby Stent Use following Balloon-Assisted Coiling: Single- and Dual-Stent Technique—Immediate and Midterm Results of 29 Consecutive Patients

BACKGROUND AND PURPOSE: We report our preliminary results in terms of safety and efficacy in using the low-profile LEO Baby stent for the treatment of large-neck and complex intracranial aneurysms with balloon-then-stent-assisted coiling and single- or dual-stent-assisted coiling. MATERIALS AND METHODS: Clinical and radiologic data of all consecutive patients treated at our institution from September 2012 to October 2013 for an intracranial aneurysm by using a LEO Baby stent were retrospectively analyzed. Immediate and midterm clinical and anatomic follow-up of each patient is reported. RESULTS: Twenty-nine patients with 29 aneurysms were treated with LEO Baby stents at our institution. The mean age of patients was 48 years; 20 patients were women (71%). One patient was treated in the acute phase of a subarachnoid hemorrhage. In 8 procedures, a double-lumen-catheter balloon was used for balloon-then-stent-assisted coiling. In 3 cases, a LEO Baby stent was used in a Y-, T-, and telescopic dual-stent configuration. In 18 cases, a single LEO Baby stent was used. In 2 cases, technical failure to deploy the stent resulted in acute parent artery thrombosis. In 3 further cases, thromboembolic complications occurred intraoperatively. MR imaging and angiographic midterm follow-up showed complete aneurysm occlusion for 96% of the followed patients (27/29). Clinical outcome was favorable for all patients followed up. CONCLUSIONS: Results obtained in our study by using the LEO Baby stent for balloon-then-stent and single- or dual-stent-assisted coiling of complex and distally located intracranial aneurysms are encouraging. Incomplete or inadequate opening of the device is a potential cause of laminar blood flow alteration and thrombus formation.