Sang Min Sung

Emergent intracranial stenting for acute M2 occlusion of middle cerebral artery

OBJECTIVE Intracranial stenting is a possible option as a rescue strategy for acute secondary division (M2) occlusion of middle cerebral artery (MCA) when intravenous thrombolysis is ineffective or contraindicated. METHODS We reviewed 10 patients of acute M2 occlusion treated by intracranial stenting who were ineligible for intravenous thrombolysis or resistant to intravenous thrombolysis. All patients underwent intracranial stenting with the Wingspan stent system. We analyzed clinical and angiographic outcomes. RESULTS The mean NIHSS score on admission was 13.8 points (range 6-23). The occlusion sites were located in the superior division (n=4, left: 3, right: 1), the middle division (n=1, right) and the inferior division (n=5, all: right) of MCA. The mean time interval from stroke symptom onset to stenting was 348.9 ± 90.4 min. Successful recanalization was achieved in all patients. No intracranial hemorrhage, vessel perforations or dissections occurred in any patient. One patient developed acute thrombosis in distal ICA of the stented side at 4 days after a stent placement and was managed with mechanical thrombectomy. All patients improved on the NIHSS (mean amount: 8.8) and to the NIHSS score of 5 ± 4.6 (median 4.5, range 0-15) at 7 days. At discharge, an mRS of ≤ 3 was achieved in 8 patients (80%) and an mRS of ≤ 2 was achieved in 6 patients (60%). CONCLUSIONS Endovascular recanalization with a Wingspan stent can be a safe and feasible procedure for acute M2 occlusion when intravenous thrombolysis is ineffective or not available.

Functional outcome after recanalization for acute pure M1 occlusion of the middle cerebral artery as assessed by collateral CTA flow

OBJECTIVE Collateral flow is important for ischemic brain tissue after an acute occlusion of the cerebral artery. The purpose of this study was to evaluate baseline collateral flow, on CT angiography (CTA), as a predictor of functional outcome in patients who had endovascular recanalization, after acute pure first segment (M1) occlusion of the middle cerebral artery (MCA). METHODS Thirty patients with acute pure M1 occlusion treated by endovascular recanalization, who were ineligible for intravenous thrombolysis or resistant to intravenous thrombolysis, were reviewed. The relationship between baseline collateral flow, on CTA, and functional outcome, was analyzed. In addition, other factors affecting clinical outcome were assessed. RESULTS The mean NIHSS score on admission was 16.87±4.86 (7-24). The mean time interval between onset of stroke symptoms and recanalization was 324.37±68.38 (210-463) min. Successful recanalization (TICI 2b-3) was achieved in 18 patients (60%). Twenty-seven of 30 patients improved their NIHSS score (mean 8.4); NIHSS score 8.9±5.4 (median 10, range 0-16) at seven days. Two patients had aggravated symptoms and one patient had no change on the NIHSS score. At 90 days after recanalization, a modified Rankin Scale (mRS) of ≤3 was achieved in 15 patients (50%) and a mRS of ≤2 was achieved in nine patients (30%). Symptomatic intra-cerebral hemorrhage occurred in two patients (6.7%). Multivariate regression analysis showed an initial NIHSS score (p=0.004), grade of baseline collateral flow on CTA (p=0.025), presence of diabetes mellitus (p=0.037), and TICI scale (p=0.049) were factors associated with an improved NIHSS. For the mRS at 90 days, only the grade of the baseline collateral flow on CTA was associated with a good functional outcome (p=0.013). CONCLUSIONS The results of this study suggest that the grade of baseline collateral flow, on CTA, is an independent predictor of functional outcome for endovascular recanalization of acute pure M1 occlusion of the middle cerebral artery.

Emergent Recanalization with Stenting for Acute Stroke due to Athero-Thrombotic Occlusion of the Cervical Internal Carotid Artery : A Single Center Experience

Objective The purpose of this study is to demonstrate the technical feasibility and clinical efficacy of emergent carotid angioplasty and stenting (CAS) for acute stroke due to athero-thrombotic occlusion of the cervical internal carotid artery (ICA). Methods Review of medical records identified 17 patients who underwent emergent CAS for treatment of athero-thrombotic occlusion of the cervical ICA with acute stroke between 2009 and 2013. Eleven patients (64.7%) presented with concomitant intracranial artery occlusion, which was treated primarily by mechanical thrombectomy after CAS. Results Successful revascularization of the cervical ICA with emergent CAS was achieved in all patients. After CAS, intracranial recanalization with Thrombolysis in Cerebral Infarction ≥2b flow was achieved in four of the 11 patients (36.4%). The overall recanalization rate (cervical ICA and intracranial artery) was 10 of 17 patients (58.8%). Symptomatic intracranial hemorrhage occurred in two patients (11.8%), resulting in death. Ten patients (58.8%) showed improvement (decrease in NIHSS score of ≥4 points) at seven days after recanalization. Nine patients (52.9%) showed a favorable outcome (mRS ≤2) at the last follow-up. A favorable outcome (mRS ≤2) was obtained in four of the six patients with isolated cervical ICA occlusion (4/6, 66.7%) and five of 11 patients with intracranial tandem occlusion (5/11, 45.5%). Conclusion Emergent CAS for acute stroke due to athero-thrombotic occusion of the cervical ICA showed a good technical feasibility and favorable clinical outcome.

Recanalization with Wingspan stent for acute middle cerebral artery occlusion in failure or contraindication to intravenous thrombolysis: a feasibility study.

BACKGROUND AND PURPOSE: Recanalization with the Wingspan stent, which can be deployed rapidly and safely, is an option for treating acute ischemic stroke when intravenous thrombolysis has failed or is contraindicated. This study was performed to evaluate feasibility, efficacy, and safety of recanalization for acute middle cerebral artery occlusion using the Wingspan stent. MATERIALS AND METHODS: We collected 10 patients with acute MCA occlusion in whom recanalization was not achieved with a standard intravenous thrombolysis, or who were ineligible for intravenous thrombolysis, or who presented after 3 hours of symptom onset and in whom the stent placement could be completed within 8 hours from symptom onset. We analyzed angiographic and clinical results. RESULTS: Successful recanalization with the Wingspan stent was achieved in all patients. The mean NIHSS score on admission was 12.7 points (range 4–21). The occlusion sites were located in the 1st segment (n = 7; 2 left, 5 right) and 2nd segment (n = 3, all right) of the MCA. The mean time interval from stroke symptom onset to stent placement was 344.8 ± 76.3 minutes. No intracranial hemorrhage, vessel perforations, or dissections occurred in any patient. Nine patients improved on the NIHSS at 7 days. One patient did not have a change in the NIHSS score, even though the occluded artery was completely recanalized. At 7 days, the NIHSS score of all patients was 4.4 ± 4.7 (median 4, range 0–13). At discharge, an mRS of ≤3 was achieved in all patients and an mRS of ≤2 was achieved in 7 patients (70%). CONCLUSIONS: This small case series demonstrates the feasibility of using the Wingspan stent safely and effectively for MCA occlusions when standard treatments are ineffective or not available.

Clinical predictors for favorable outcomes from endovascular recanalization in wake-up stroke

BACKGROUND AND PURPOSE Patients who have acute stroke symptoms present on awakening are ineligible for standard intravenous thrombolysis due to the unclear onset time of symptoms. Some of these wake-up stroke (WUS) patients may benefit from endovascular recanalization. This study aimed to evaluate clinical predictors of outcomes from endovascular recanalization in WUS patients. METHODS Forty-one WUS patients with internal carotid (ICA) or middle cerebral artery (MCA) occlusion treated with endovascular recanalization were reviewed. Regression analysis was performed to measure clinical predictors of outcomes from endovascular recanalization in WUS patients. RESULTS The mean initial NIHSS score was 16.41±4.96 (5-24). The mean symptom recognition-to-door time (SRDT) was 108.85±65.80 (19-230)min. Successful recanalization (TICI 2b-3) was achieved in 29 patients (70.7%). Thirty-four patients improved on NIHSS (amount 7.59±4.84, range; 1-17) at 7days after recanalization. At 90days after recanalization, a mRS of ≤2 was achieved in 19 patients (46.3%) and a mRS of ≤3 was achieved in 24 patients (58.5%). No symptomatic intracerebral hemorrhage occurred. Multivariate regression analysis identified SRDT (P=0.019), successful recanalization (P=0.005), and hypertension (P=0.013) were factors associated with an improvement of the NIHSS score. For a good functional outcome at 90days, SRDT (P=0.036) and initial NIHSS score (P=0.016) were found to be significant predictors. CONCLUSIONS The results of this study suggest that the SRDT is an independent predictor of both an improvement of NIHSS score and a good functional outcome in endovascular recanalization for WUS patients.

Urgent Recanalization with Stenting for Severe Intracranial Atherosclerosis after Transient Ischemic Attack or Minor Stroke

OBJECTIVE Stenting of symptomatic intracranial stenosis has recently become an alternative treatment modality. However, urgent intracranial stenting in patients with intracranial stenosis following a transient ischemic attack (TIA) or minor stroke is open to dispute. We sought to assess the feasibility, safety, and effectiveness of urgent intracranial stenting for severe stenosis (>70%) in TIA or minor stroke patients. METHODS Between June 2009 and October 2010, stent-assisted angioplasty by using a balloon-expandable coronary stent for intracranial severe stenosis (>70%) was performed in 7 patients after TIA and 5 patients after minor stroke (14 stenotic lesions). Technical success rates, complications, angiographic findings, and clinical outcomes were retrospectively analyzed. RESULTS Stenting was successful in all 12 patients. The mean time from symptom onset to stenting was 2.1 days (1-8 days). Post-procedural angiography showed restoration to a normal luminal diameter in all patients. In-stent thrombosis occurred in one patient (n=1, 8.3%), and was lysed with abciximab. No device-related complications, such as perforations or dissections at the target arteries or intracranial hemorrhaging, occurred in any patient. The mortality rate was 0%. No patient had an ischemic event over the mean follow-up period of 12.5 months (range, 7-21 months), and follow-up angiography (n=7) revealed no significant in-stent restenosis (>50%). CONCLUSION Urgent recanalization with stenting is feasible, safe, and effective in patients with TIA or acute minor stroke with intracranial stenosis of ≥70%.

Percutaneous transluminal angioplasty and stenting for severe stenosis of the intracranial extradural internal carotid artery causing transient ischemic attack or minor stroke

The purpose of this study is to assess the technical feasibility and clinical efficacy of percutaneous transluminal angioplasty and stenting (PTAS) for symptomatic stenosis of the intracranial extradural (petrous and cavernous) internal carotid artery (ICA). Review of medical records identified 26 consecutive patients who underwent PTAS using a balloon-expandable coronary stent (n = 15, 57.7%) or a Wingspan self-expandable stent (n = 11, 42.3%) for treatment of severe stenosis (>70%) involving the intracranial extradural ICA. The inclusion criteria were transient ischemic attack with an ABCD2 score of ≥3 (n = 12, 46.2%) or minor stroke with an NIHSS score of ≤4 (n = 14, 53.8%). Technical success rates, complications, and angiographic and clinical outcomes were analyzed retrospectively. PTAS was technically successful in all patients. The mean stenosis ratio decreased from 77.1% to 10.0% immediately after PTAS. The overall incidence of procedural complications was 23.1%, and the postoperative permanent morbidity/mortality rate was 7.7%. A total of 22 patients were tracked over an average period of 29.9 months. During the observation period, 20 patients (90.9%) had no further cerebrovascular events and stroke recurrence occurred in two patients (9.1%), resulting in an annual stroke risk of 3.7%. Two cases (11.1%) of significant in-stent restenosis (>50%) were found on follow-up angiography (n = 18). PTAS for severe stenosis (>70%) involving the intracranial extradural ICA showed a good technical feasibility and favorable clinical outcome in patients with transient ischemic attack or minor stroke.

E-070 Acute Recanalization with Stenting for Wake-up Stroke

Background Approximately 16% to 28% of acute ischemic stroke patients have symptoms on awakening. Because of unclear time of symptom onset, these patients are ineligible for standard intravenous thrombolysis. Some of these patients may be benefit from emergent endovascular recanalization with stenting. The purpose of this study was to evaluate the feasibility and safety of emergent endovascular recanalization for wake-up stroke (WUS). Methods We reviewed 10 patients with WUS and an occlusion in carotid and middle cerebral artery who were treated with stenting. We analyzed clinical and angiographic outcomes. Recanalization was evaluated by the Thrombolysis in Cerebral Infarction score. Clinical outcome was assessed at 90 days by the modified Rankin Scale. Results The median NIHSS score on admission was 19 points (range 8–24). The median time from stroke symptom recognition to arrival at emergency department was 144 min (range 57–230 min). The median time from stroke symptom recognition to recanalization was 312 min (range 227–344 min). The median time from last seen normal to recanalization was 11 h 23 min (range 495–830 min). Occlusion sites were supraclinoid ICA in 2 (all: left), proximal ICA in 3 (left: 2, right: 1) and M1 of MCA in 5 patients (left: 2, right: 3). Successful recanalization was achieved in all patients. A small subarachnoid haemorrhage occurred in 1 patient during intervention. No symptomatic ICH occurred in any patients. Neurologic improvements in the NIHSS score (median 9, range 4–17) at 7 days after stenting achieved in 7 patients. At 90 days, an mRS of ≤2 was achieved in 2 patients (20%). One patient died within hospital stay due to sepsis. Conclusion Emergent stenting can be feasible and possibly safe for achieving successful recanalization and improving on the NIHSS in patients with WUS. However, clinical outcome was still not satisfactory. Disclosures S. Sung: None. T. Lee: None.

E-006 Urgent recanalization using stents for acute internal carotid artery occlusion in progressive stroke patients

Background Re-establishing cerebral blood flow in a timely fashion during an acute stroke has been shown to be efficacious in improving patient outcomes. Complete occlusion of the internal carotid artery (ICA) in progressive stroke patients would be expected to bring about devastating neurological sequelae and probably not be compatible with survival unless it could be treated. We retrospectively analyzed the feasibility, safety and effectiveness of the urgent recanalization using stents for acute ICA occlusion in the progressive stroke syndromes. Methods Between January 2008 and December 2009, urgent recanalization using stents for acute ICA occlusion was performed in 21 progressive stroke patients. The group of patients comprised 16 men and five women, aged 52–83 years (mean age 68.8 years). The occlusion segments of ICA were extracranial in nine patients and intracranial in 12 patients. A 0.014 inch microwire was placed into the distal ICA or middle cerebral artery, crossing the occluded segment. The stent was then advanced over the microwire and deployed in the lesion. Results We achieved successfully complete recanalization using stents in 19 of 21 patients (90.1%). We could not advance the stent delivery system into the lesion in two patients because of the vascular tortuousness. During the procedure, ICA dissection occurred in two patients (9.5%) and was treated with additional stent placement. There was no symptomatic thromboembolic complication. Fifteen of 19 patients (78.9%) showed the stable or improved neurologic signs and favorable clinical outcomes. Four patients (21.1%) showed brain edema and aggravating neurologic signs and two of them (10.5%) expired due to massive brain edema and herniation. Conclusion Urgent recanalization using stents for acute ICA occlusion may salvage the vessel and promise better clinical outcome in the progressive stroke patients. Endovascular recanalization for ICA occlusion is feasible with acceptable early clinical result.