Parenchymal hematoma (PH) is a rare but dreadful complication of acute ischemic stroke with
unclear underlying mechanisms. We aimed to study the incidence and predictors of PH after mechanical ...thrombectomy.
Data from a prospective observational multicenter registry was screened to identify acute ischemic stroke
patients with an anterior circulation large vessel occlusion who underwent mechanical thrombectomy. Clinical, imaging, and procedural characteristics were used for the analysis, including brain imaging systematically performed at 24 hours. PH occurrence was assessed according to ECASS (European Collaborative Acute Stroke Study) criteria. Univariate and multivariable analyses were performed to identify predictors of PH.
A total of 1316 patients were included in the study. PH occurred in 153 out of 1316 patients (11.6%) and was
associated with a lower rate of favorable outcome and increased mortality. On multivariable analysis, age (per 1 year increase, odds ratio OR, 1.01; 95% CI, 1.00–1.03; P=0.05), current smoking (OR, 2.02; 95% CI, 1.32–3.09; P<0.01), admission Alberta Stroke Program Early CT Score (per a decrease of 1 point, OR, 1.70; 95% CI, 1.18–2.44; P<0.01), general anesthesia (OR, 1.98; 95% CI, 1.36–2.90; P<0.001), angiographic poor collaterals (OR, 2.13; 95% CI, 1.36–3.33; P<0.001) and embolization in new territory (OR, 2.94; 95% CI, 1.70–5.10; P<0.001) were identified as independent predictors of PH.
PH occurred at a rate of 11.6% after mechanical thrombectomy, with high morbidity and mortality. Our
study identified clinical, radiological, and procedural predictors of PH occurrence that can serve as the focus of future periprocedural management studies with the aim of reducing its occurrence.
Middle cerebral artery M2-segment occlusions represent an important subgroup of patients with acute stroke with large-vessel occlusion. The safety of mechanical thrombectomy, especially contact ...aspiration (CA), in such distal intracranial occlusions is still under debate. We compared reperfusion, adverse events, neurological recovery, and functional outcome of patients with isolated M2 occlusions according to the first-line strategy mechanical thrombectomy devices (CA versus stent retriever SR).
This is a post hoc analysis of the ASTER trial (Contact Aspiration Versus Stent Retriever for Successful Revascularization). The primary outcome was successful reperfusion at the end of all endovascular procedures, defined as modified Thrombolysis in Cerebral Infarction (mTICI) scores 2b/3. Secondary outcomes were mTICI 2c/3 and mTICI 3, 90-day functional outcome, assessed with the modified Rankin Scale score. Safety outcomes included 90-day mortality and any symptomatic intracerebral hemorrhage.
Seventy-nine patients were included: 48 were allocated to the CA group and 31 to the SR group. There were no significant differences between CA and SR groups in reperfusion after all endovascular procedures regarding mTICI 2b/3 (89.6% versus 83.9%;
=0.36), mTICI 2c/3 (54.2% versus 54.8%;
=0.90), and mTICI 3 (35.4% versus 41.9%;
=0.36) rates. There were no significant differences between CA and SR groups in 90-day modified Rankin Scale ≤2 rate (54.4% versus 50.0%;
=0.84), 24-hour change in National Institutes of Health Stroke Scale (mean difference, -3.9; 95% confidence interval, -7.9 to 0.01), and Alberta Stroke Program Early Computed Tomography score (mean difference, 0.9; 95% confidence interval, -0.1 to 2.0) scores. Safety parameters were well balanced between the 2 groups except for a higher 90-day mortality rate in the CA group (19.6% versus 3.3%;
=0.078).
First-line mechanical thrombectomy with CA compared with SR did not result in an increased successful revascularization rate in patients with acute stroke with isolated M2 occlusion.
Ischemic strokes with tandem occlusions are associated with a poor prognosis. Recent studies demonstrating the effectiveness of endovascular treatment for large vessel occlusions have shown less ...impressive results in patients with tandem occlusions than in those with isolated intracranial occlusions. Also, the indications and effects of carotid stenting remain unclear.
From a prospectively gathered registry, we analyzed data of 70 consecutive patients who underwent mechanical endovascular treatment for acute stroke with tandem occlusions from November 2011 to August 2014. Clinical (including demographics, National Institutes of Health Stroke Scale (NIHSS), and stroke etiology), imaging (including diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score), and endovascular treatment data were assessed and reviewed in consensus by 2 observers. Good clinical outcome was defined as a modified Rankin Scale of ≤2 at 3-month follow-up.
At 3-month follow-up, 50.8% had a poor clinical outcome, including death in 13.4%. Lower NIHSS (initial, at day 1, and at discharge) and successful recanalization (thrombolysis in cerebral infarction 2b-3) were associated with a good clinical outcome (p < 0.05). There were no statistically significant differences between patients with a good or poor clinical outcome in terms of intravenous (IV) tissue plasminogen activator use, delay between symptom onset and recanalization, and endovascular technique including the carotid stenting.
Despite the recent randomized control trials demonstrating the effectiveness of thrombectomy, there is still a research gap about tandem occlusions. This subtype of stroke, which usually responds poorly to IV thrombolysis, is also difficult to treat by endovascular means. Guidelines for the endovascular management of tandem occlusions are needed.
To investigate in routine care the efficacy and safety of IV thrombolysis (IVT) with tenecteplase prior to mechanical thrombectomy (MT) in patients with large vessel occlusion acute ischemic strokes ...(LVO-AIS), either secondarily transferred after IVT or directly admitted to a comprehensive stroke center (CSC).
We retrospectively analyzed clinical and procedural data of patients treated with 0.25 mg/kg tenecteplase within 270 minutes of LVO-AIS who underwent brain angiography. The main outcome was 3-month functional independence (modified Rankin Scale score ≤2). Recanalization (revised Treatment in Cerebral Ischemia score 2b-3) was evaluated before (pre-MT) and after MT (final).
We included 588 patients (median age 75 years interquartile range (IQR) 61-84; 315 women 54%; median NIH Stroke Scale score 16 IQR 10-20), of whom 520 (88%) were secondarily transferred after IVT. Functional independence occurred in 47% (n = 269/570; 95% confidence interval CI 43.0-51.4) of patients. Pre-MT recanalization occurred in 120 patients (20.4%; 95% CI 17.2-23.9), at a similar rate across treatment paradigms (direct admission, n = 14/68 20.6%; secondary transfer, n = 106/520 20.4%;
> 0.99) despite a shorter median IVT to puncture time in directly admitted patients (38 IQR 23-55 vs 86 IQR 70-110 minutes;
< 0.001). Final recanalization was achieved in 492 patients (83.7%; 95%CI 80.4-86.6). Symptomatic intracerebral hemorrhage occurred in 2.5% of patients (n = 14/567; 95% CI 1.4-4.1).
Tenecteplase before MT is safe, effective, and achieves a fast recanalization in everyday practice in patients secondarily transferred or directly admitted to a CSC, in line with published results. These findings should encourage its wider use in bridging therapy.
This study provides Class IV evidence that tenecteplase within 270 minutes of LVO-AIS increases the probability of functional independence.
Self-expandable stents have broadened the spectrum of endovascular treatment of intracranial aneurysms. However, procedures involving double stenting in Y/X configurations carry a relatively high ...risk of procedural complications. The Neuroform ATLAS, the evolution of Neuroform EZ, is a nitinol self-expanding hybrid/open cell stent which can be delivered through a low profile 0.017 inch catheter. We present our experience in the treatment of intracranial aneurysms with this stent in Y and X configurations.
We prospectively maintained a database from consecutive patients who underwent double stent assisted coiling with the Neuroform ATLAS, from July 2015 to February 2019. Clinical and angiographic results were analyzed.
55 patients harboring 55 bifurcation aneurysms were treated with double stenting: 52 'Y' configurations, 3 'X' configurations. Deployment was successful in all cases. Post-treatment control angiography showed complete occlusion in 33 cases (60%), neck remnant in 8 cases (14.5%), and incomplete occlusion in 14 cases (25.4%). The overall symptomatic periprocedural complication rate was 12.7%. 38 aneurysms underwent follow-up (69%, mean duration 16 months): 33 aneurysms (87%) were completely occluded, 3 aneurysms (8%) had a neck remnant, and 2 aneurysms (5%) were incompletely occluded.
The Neuroform ATLAS is an effective device for treatment of bifurcation aneurysms, allowing good conformability, a high level of navigability, and easy mesh crossing to perform Y/X stenting procedures. The rate of procedural complications remains non-negligible, and an indication for a double stenting procedure should be carefully discussed in a multidisciplinary meeting.
The aim of this study was to report the results of a subgroup analysis of the ASTER2 trial (Effect of Thrombectomy With Combined Contact Aspiration and Stent Retriever vs Stent Retriever Alone on ...Revascularization in Patients With Acute Ischemic Stroke and Large Vessel Occlusion) comparing the safety and efficacy of the combined technique (CoT) and stent retriever as a first-line approach in internal carotid artery (ICA) terminus±M1-middle cerebral artery (M1-MCA) and isolated M1-MCA occlusions.
Patients enrolled in the ASTER2 trial with ICA terminus±M1-MCA and isolated M1-MCA occlusions were included in this subgroup analysis. The effect of first-line CoT versus stent retriever according to the occlusion site was assessed on angiographic (first-pass effect, expanded Treatment in Cerebral Infarction score ≥2b50, and expanded Treatment in Cerebral Infarction score ≥2c grades at the end of the first-line strategy and at the end of the procedure) and clinicoradiological outcomes (24-hour National Institutes of Health Stroke Scale, ECASS-III European Cooperative Acute Stroke Study grades, and 3-month modified Rankin Scale).
Three hundred sixty-two patients were included in the postsubgroup analysis according to the occlusion site: 299 were treated for isolated M1-MCA occlusion (150 with first-line CoT) and 63 were treated for ICA terminus±M1-MCA occlusion (30 with first-line CoT). Expanded Treatment in Cerebral Infarction score ≥2b50 (odds ratio, 11.83 95% CI, 2.32-60.12) and expanded Treatment in Cerebral Infarction score ≥2c (odds ratio, 4.09 95% CI, 1.39-11.94) were significantly higher in first-line CoT compared with first-line stent retriever in patients with ICA terminus±M1-MCA occlusion but not in patients with isolated M1-MCA.
First-line CoT was associated with higher reperfusion grades in patients with ICA terminus±M1-MCA at the end of the procedure.
URL: https://www.clinicaltrials.gov; Unique identifier: NCT03290885.
Endovascular treatment (EVT) is the primary approach used to treat indirect carotid-cavernous fistulas (CCFs). In this study, the authors evaluated the immediate and long-term efficacy and safety of ...different endovascular techniques for indirect CCFs.
The databases of two endovascular centers were retrospectively reviewed to collect the patients with indirect CCFs treated using endovascular techniques between 2013 and 2023. Demographics, clinical presentation, CCF features, EVT characteristics, and clinical and radiological outcomes were evaluated and analyzed. The analysis was performed to compare the clinical and radiological data between different endovascular approaches and different embolic materials.
Ninety-eight patients were included in the study. EVT was successful in 95 patients (96.9%). Immediate complete obliteration of the CCF was achieved in 93.9% of patients, with 98% undergoing embolization with liquid embolic agents (LEAs) and 95.6% undergoing coiling alone. Complete CCF obliteration was higher in the transvenous than in the transarterial approach (94.3% vs 75%, p = 0.010). At ≥ 6 months follow-up, complete CCF obliteration was achieved in all patients (100%). The rate of procedure-related complications was higher following LEAs than with coiling alone (32.0% vs 15.6%). New cranial nerve (CN) palsy was diagnosed in 26.0% and 2.2% after embolization with LEAs and coiling alone, respectively (p = 0.001), with complete CN palsy recovery in 78.6%. Procedure-related intracranial hemorrhage occurred in 3 patients (3.1%). Two patients experienced an ischemic stroke following Onyx migration into the internal carotid artery. Ocular symptoms improved in 93% (83/89) of the patients who were followed.
In this study, complete obliteration of an indirect CCF was achieved in more than 90% of patients. Despite the occurrence of some new postprocedural ocular CN palsy, ocular symptoms improved in most patients in long-term follow-up. The transvenous approach was the most effective method for treating the indirect CCF. Coiling was safer than LEAs for the embolization of the indirect CCF.
Background and purpose
The DAWN trial recently showed compelling evidence in treating late window and wake‐up stroke patients with thrombectomy using a clinical‐imaging mismatch. The aim was to ...evaluate the results of thrombectomy for unknown‐onset strokes (UOS) treated in our centres after a diffusion weighted imaging/fluid attenuated inversion recovery (DWI‐FLAIR) mismatch based selection.
Methods
A multicentre, cohort study was performed of consecutive UOS treated by thrombectomy between 2012 and 2016. UOS with proximal anterior circulation occlusion discovered beyond 6 h from ‘last seen normal’ were compared with known‐onset strokes (KOS) for whom thrombectomy was started within 6 h from onset. Time intervals were recorded from first time found abnormal. Results were adjusted for age, diabetes, hypertension, National Institutes of Health Stroke Scale, site of occlusion, DWI Alberta Stroke Programme Early CT Score, intravenous thrombolysis and use of general anaesthesia.
Results
Amongst 1246 strokes with anterior circulation occlusion treated by thrombectomy, 277 were UOS, with a ‘last time seen well’ beyond 6 h and DWI‐FLAIR mismatch, and 865 were KOS who underwent groin puncture within 6 h. Favourable outcome was achieved less often in UOS than KOS patients (45.2% vs. 53.9%, P = 0.022). After pre‐specified adjustment, this difference was not significant (adjusted relative risk 0.91; 95% confidence interval 0.80–1.04; P = 0.17). No differences were found in secondary outcomes. Time intervals from first found abnormal were significantly longer in UOS.
Conclusion
Thrombectomy of UOS with anterior circulation occlusion and DWI‐FLAIR mismatch appears to be as safe and efficient as thrombectomy of KOS within 6 h from onset. This pattern of imaging could be used for patient selection when time of onset is unknown.
Background
Intradural spinal cord arteriovenous shunts represent a rare entity, particularly in the pediatric population, and clinical diagnosis can be challenging.
Methods
We report the analysis of ...clinical, angioarchitectural, procedural, and follow-up data in a population of 36 children managed by our team between 2002 and 2017.
Results
Hemorrhage occurred in 26 children (72%). Age at onset was 9.22 ± 3.65 years. Lesions were located at the thoracic level in 16 cases, at the cervical level in 15 cases, and the thoraco-lumbar region in 5 cases. A genetic or metameric syndrome was associated in 18 children (50%). Glue embolization provided complete occlusion in 5 children, subtotal in 7, and extensive in 14 without intraprocedural complications. We observed clinical normalization in 11 children, improvement in 11 cases, and stability in 3. Four children worsened during the follow-up, and one child died.
Conclusions
Endovascular staged glue embolization performed in experienced centers is safe in the treatment of pediatric intradural spinal cord arteriovenous shunts. Clinical and neuroradiological follow-up is mandatory, especially for pediatric patients.
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