Mechanical Thrombectomy of Carotid Terminus Occlusion Using Direct Aspiration Technique—Video Illustration: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Sami Al Kasab ◽  
Mithun Sattur ◽  
Guilherme Porto ◽  
Alejandro M Spiotta ◽  
Adam Arthur ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Infarct Volume ◽  
Standard Of Care ◽  
Response To Treatment ◽  
Anterior Communicating Artery ◽  
Stroke Severity ◽  
Vessel Occlusion ◽  
Aspiration Technique ◽  
Intravenous Alteplase ◽  
Worse Prognosis

Abstract Acute carotid terminus occlusion (CTO) is responsible for up to 5% of acute ischemic strokes secondary to emergent large vessel occlusion (ELVO) and up to 20% of acute internal carotid artery (ICA) occlusions.1 The term “CTO” has also been used to describe occlusions in the supra-clinoid segment or at the bifurcation of the ICA. Compared to other ELVOs, patients with CTO present with higher stroke severity and larger infarct volume, likely to be a result of disruption of direct Circle of Willis collaterals across the anterior communicating artery (AComA) and posterior communicating artery (PComA).2,3  Similary, CTO is usually associated with worse prognosis compared to other ELVOs in general. With regard to response to treatment, previous studies have reported significantly lower recanalization rates with intravenous alteplase with CTO compared to M1 segment occlusion. With regard to the safety and efficacy of mechanical thrombectomy, prior reports provide conflicting results with some reporting lower successful recanalization rates with CTO compared to M1 occlusion, and others reporting similar results. In our experience, we have found that successful recanalization of CTO can be achieved with a similar approach to M1 occlusions utilizing a direct aspiration first pass technique (ADAPT).3,4 Herein, we present a case of CTO for which we performed mechanical thrombectomy using ADAPT. This procedure was an emergent standard of care procedure for which a consent was not required and so not obtained.

Revascularization and functional outcomes after mechanical thrombectomy for acute ischemic stroke in elderly patients

2020 ◽  
Vol 132 (4) ◽  
pp. 1182-1187 ◽  
Author(s):  
Carrie E. Andrews ◽  
Nikolaos Mouchtouris ◽  
Evan M. Fitchett ◽  
Fadi Al Saiegh ◽  
Michael J. Lang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Elderly Patients ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Multivariate Logistic Regression Analysis ◽  
Standard Of Care ◽  
Stroke Severity ◽  
Vessel Occlusion ◽  
Younger Patients ◽  
Success Of Treatment

OBJECTIVEMechanical thrombectomy (MT) is now the standard of care for acute ischemic stroke (AIS) secondary to large-vessel occlusion, but there remains a question of whether elderly patients benefit from this procedure to the same degree as the younger populations enrolled in the seminal trials on MT. The authors compared outcomes after MT of patients 80–89 and ≥ 90 years old with AIS to those of younger patients.METHODSThe authors retrospectively analyzed records of patients undergoing MT at their institution to examine stroke severity, comorbid conditions, medical management, recanalization results, and clinical outcomes. Univariate and multivariate logistic regression analysis were used to compare patients < 80 years, 80–89 years, and ≥ 90 years old.RESULTSAll groups had similar rates of comorbid disease and tissue plasminogen activator (tPA) administration, and stroke severity did not differ significantly between groups. Elderly patients had equivalent recanalization outcomes, with similar rates of readmission, 30-day mortality, and hospital-associated complications. These patients were more likely to have poor clinical outcome on discharge, as defined by a modified Rankin Scale (mRS) score of 3–6, but this difference was not significant when controlled for stroke severity, tPA administration, and recanalization results.CONCLUSIONSOctogenarians, nonagenarians, and centenarians with AIS have similar rates of mortality, hospital readmission, and hospital-associated complications as younger patients after MT. Elderly patients also have the capacity to achieve good functional outcome after MT, but this potential is moderated by stroke severity and success of treatment.

scholarly journals Inadvertent Stent Retriever Detachment: A Multicenter Case Series and Review of Device Experience FDA Reports

2015 ◽  
Vol 4 (3-4) ◽  
pp. 75-82 ◽  
Author(s):  
Hesham Masoud ◽  
Thanh N. Nguyen ◽  
Coleman O. Martin ◽  
William E. Holloway ◽  
Sudheer Ambekar ◽  
...  
Keyword(s):  
First Generation ◽  
Mechanical Thrombectomy ◽  
Rare Complication ◽  
Case Series ◽  
Standard Of Care ◽  
Stent Retriever ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
The Us ◽  
Solitaire Fr

Mechanical thrombectomy using retrievable stents or stent retriever devices has become the mainstay of intra-arterial therapy for acute ischemic stroke. The recent publication of a series of positive trials supporting intra-arterial therapy as standard of care for the treatment of large vessel occlusion will likely further increase stent retriever use. Rarely, premature stent detachment during thrombectomy may be encountered. In our multicenter case series, we found a rate of detachment of less than 1% (n = 7/1,067), and all were first-generation Solitaire FR devices. A review of the US Food and Drug Administration database of device experience yielded 90 individual adverse reports of detachment. There were 82, 1 and 7 detachments of Solitaire FR (first generation), Solitaire FR2 (second generation) and Trevo devices, respectively. We conclude with a brief overview of the technical and procedural considerations which may be helpful in avoiding this rare complication.

scholarly journals Cerebral endothelial cell-derived small extracellular vesicles enhance neurovascular function and neurological recovery in rat acute ischemic stroke models of mechanical thrombectomy and embolic stroke treatment with tPA

2021 ◽  
pp. 0271678X2199298
Author(s):  
Chao Li ◽  
Chunyang Wang ◽  
Yi Zhang ◽  
Owais K Alsrouji ◽  
Alex B Chebl ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Extracellular Vesicles ◽  
Mechanical Thrombectomy ◽  
Infarct Volume ◽  
Artery Occlusion ◽  
Therapeutic Effects ◽  
Vessel Occlusion ◽  
Healthy Human ◽  
Stroke Treatment

Treatment of patients with cerebral large vessel occlusion with thrombectomy and tissue plasminogen activator (tPA) leads to incomplete reperfusion. Using rat models of embolic and transient middle cerebral artery occlusion (eMCAO and tMCAO), we investigated the effect on stroke outcomes of small extracellular vesicles (sEVs) derived from rat cerebral endothelial cells (CEC-sEVs) in combination with tPA (CEC-sEVs/tPA) as a treatment of eMCAO and tMCAO in rat. The effect of sEVs derived from clots acquired from patients who had undergone mechanical thrombectomy on healthy human CEC permeability was also evaluated. CEC-sEVs/tPA administered 4 h after eMCAO reduced infarct volume by ∼36%, increased recanalization of the occluded MCA, enhanced cerebral blood flow (CBF), and reduced blood-brain barrier (BBB) leakage. Treatment with CEC-sEVs given upon reperfusion after 2 h tMCAO significantly reduced infarct volume by ∼43%, and neurological outcomes were improved in both CEC-sEVs treated models. CEC-sEVs/tPA reduced a network of microRNAs (miRs) and proteins that mediate thrombosis, coagulation, and inflammation. Patient-clot derived sEVs increased CEC permeability, which was reduced by CEC-sEVs. CEC-sEV mediated suppression of a network of pro-thrombotic, -coagulant, and -inflammatory miRs and proteins likely contribute to therapeutic effects. Thus, CEC-sEVs have a therapeutic effect on acute ischemic stroke by reducing neurovascular damage.

Abstract W P21: Should We Perform Thrombectomy In Patients With Wake-up Strokes? A Case Series Using Ct Perfusion For Patient Selection

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Gabriel Vidal ◽  
James Milburn ◽  
Garrett Bennett ◽  
Vivek Sabharwal ◽  
Mustafa Al Hasan
Keyword(s):  
Risk Factors ◽  
Ct Perfusion ◽  
Medical Center ◽  
Case Series ◽  
Stroke Severity ◽  
Vessel Occlusion ◽  
Single Center Experience ◽  
Aspiration Technique ◽  
Group 2

Background and objectives: Approximately 25% of patients who present with acute ischemic stroke are wake-up strokes. These patients are often not treated with IV thrombolytics because of unclear onset of symptoms. Little data exists on endovascular therapy as acute treatment for this population, particularly with an aspiration technique. The objective of this study is to compare outcomes of patients who presented with wake-up strokes due to large vessel occlusion treated with neuroendovascular procedures versus those who received conservative treatment, based on a 2-year (2012-2013), single center experience at Ochsner Medical Center in New Orleans, LA. Method: 24 consecutive patients, who presented with wake-up strokes, were outside the IV tPA window, and had both CTA confirmed intracranial LVO and CT-perfusion data upon arrival to our institution were retrospectively studied. Patients with hemorrhages, tandem lesions, or high-grade carotid stenosis were excluded from this analysis. Decision to perform endovascular treatment was made by the vascular neurologist and neuro-interventionalist based on stroke severity and CTA/perfusion data. Patients in group 1 (n = 8) underwent endovascular revascularization procedures; patients in group 2 (n = 16) were treated conservatively (medical management alone). Presentation NIHSS, risk factors, mortality, discharge NIHSS, discharge mRS, and follow up mRS were compared. Results: There were no statistical differences in patient population regarding age, gender, and risk factors. There was no statistical difference in their initial NIHSS (16.8 vs. 21.8, p=0.05162), or mortality (0% vs 21%, pr=0.262). The two groups were statistically different in their discharge NIHSS (7.25 vs 21.81, p<0.00045), discharge mRS (2 vs 5, p<0.00001), clinic follow up mRS (1.37 vs 4.94, p<0.00001), and good outcome at discharge (mRS 0-2)(75% vs 0%, pr<0.0002). Conclusion: Patients with wake-up strokes, LVO, and favorable CT-perfusion data who underwent neuroendovascular reperfusion treatment had significantly better outcomes in our population, despite similar stroke severity at presentation. This suggests that with careful selection, neuroendovascular therapy for wake-up strokes may lead to improved outcomes.

scholarly journals Stroke in COVID-19: a single-centre initial experience in a hotspot of the pandemic

2020 ◽  
Vol 5 (4) ◽  
pp. 331-336 ◽  
Author(s):  
Ivo Bach ◽  
Pratibha Surathi ◽  
Nora Montealegre ◽  
Osama Abu-Hadid ◽  
Sara Rubenstein ◽  
...  
Keyword(s):  
Respiratory Symptoms ◽  
Mechanical Thrombectomy ◽  
Clinical Laboratory ◽  
Severe Disease ◽  
Nasopharyngeal Swab ◽  
Single Centre ◽  
Vessel Occlusion ◽  
Global Pandemic ◽  
Imaging Characteristics ◽  
Intravenous Alteplase

BackgroundCOVID-19, caused by SARS-CoV-2, is a global pandemic that has been an immense burden on healthcare systems all over the world. These patients may be at higher risk for acute ischaemic stroke (AIS). We present our experience with AIS in patients with COVID-19.MethodsWe reviewed all patients admitted to our hospital during a 6-week period with a positive nasopharyngeal swab test for SARS-CoV-2. Among these patients, we identified AIS. We reviewed the demographics, clinical, laboratory, imaging characteristics, treatments received and outcomes of AIS in patients with COVID-19.ResultsWe identified 683 patients admitted with COVID-19 during the study period, of which 20 patients had AIS. Large-vessel occlusion (LVO) was noted in 11 patients (55%). Intravenous alteplase was administered in four patients (20%) and mechanical thrombectomy was performed in five patients (25%). Respiratory symptoms preceded the onset of AIS in most of the patients (70%) by 1 to 21 days. Mortality in patients with AIS was 50% compared with 26% of all COVID-19 admissions. Most of these patients died due to non-neurological causes (70%). Three patients with AIS had clinical and imaging findings consistent with COVID-19, but were negative for multiple nasopharyngeal swab tests.InterpretationLVO was more common in patients with AIS and COVID-19. They had more severe disease and higher mortality rates. Most of the patients had respiratory symptoms preceding AIS by days to weeks. This could explain certain patients with clinical picture of COVID-19 but negative nasopharyngeal swab tests.

The Safety and Feasibility of Mechanical Thrombectomy for Mild Acute Ischemic Stroke With Large Vessel Occlusion

Neurosurgery ◽  
2019 ◽  
Vol 86 (6) ◽  
pp. 802-807 ◽  
Author(s):  
Gabor Toth ◽  
Santiago Ortega-Gutierrez ◽  
Jenny P Tsai ◽  
Russell Cerejo ◽  
Sami Al Kasab ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Infarct Volume ◽  
Invasive Procedure ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Significant Difference

Abstract BACKGROUND Prospective evidence to support mechanical thrombectomy (MT) for mild ischemic stroke with large vessel occlusion (LVO) is lacking. There is uncertainty about using an invasive procedure in patients with mild symptoms. OBJECTIVE To evaluate the safety and feasibility of MT in patients with mild symptoms and LVO. METHODS Our single-arm prospective pilot study recruited patients with LVO and initial National Institute of Health Stroke Scale (NIHSS) &lt;6, who underwent standard MT. Primary safety endpoints were symptomatic intracerebral hemorrhage (sICH), and/or worsening NIHSS by ≥4 points. Secondary endpoints included angiographic recanalization, NIHSS change, final infarct volume, and modified Rankin score (mRS). RESULTS We enrolled 20 patients (mean age 65.6 ± 12.3 yr; 45% females). Thrombolysis in Cerebral Ischemia 2B/3 thrombectomy was achieved in 95%. No patients suffered sICH. One patient (5%) had neurologic worsening within 24 h because of underlying intracranial stenosis. No other complications or safety concerns were identified. Median NIHSS was significantly better at discharge (0.5, P = .007) and at last follow-up (0, P &lt; .001) than before treatment (3). Mean post vs preintervention infarct volumes were small without significant difference (1.2 ml, P = .434). Most patients (85%) were discharged directly home. Excellent clinical outcome (mRS 0-1) at last follow-up was seen in 95% of patients. CONCLUSION This is one of the first specifically designed prospective studies showing that MT is safe and feasible in patients with low NIHSS and LVO. Chronic underlying vasculopathy may be a challenging dilemma. We observed excellent clinical and radiographic outcomes, but randomized controlled trials are needed to demonstrate the efficacy of MT in this unique cohort.

Endovascular mechanical thrombectomy for acute stroke in young children

2019 ◽  
Vol 11 (6) ◽  
pp. 554-558 ◽  
Author(s):  
Lisa R Sun ◽  
Ryan J Felling ◽  
Monica Smith Pearl
Keyword(s):  
Young Children ◽  
Acute Stroke ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Adult Size ◽  
Vessel Occlusion ◽  
Neurological Outcomes ◽  
Neurologic Outcomes ◽  
Mean Time ◽  
Infants And Young Children

BackgroundMechanical thrombectomy has emerged as a standard of care for acute stroke from large vessel occlusion in adults but remains controversial in children. Cerebral vessels are nearly adult size by 5 years of age but the technical feasibility of achieving recanalization in younger and smaller children with current endovascular tools remains unclear.ObjectiveTo systematically review the literature on mechanical thrombectomy for stroke in children less than 5 years of age.ResultsMechanical thrombectomy for acute stroke has been reported in 11 children under the age of 5 years (range 9 months to 4 years). The mean time from symptom onset to groin puncture was 12 hours (range 4–50 hours). Complete recanalization was achieved in 7/12 (58%) vessels attempted, and partial recanalization in 4/12 (33%). Two procedure related complications were reported, with small vessel size felt to be contributory to basilar vasospasm in one case. Favorable neurological outcomes were reported in 7 cases (64%).ConclusionsOur review of the literature demonstrates that mechanical thrombectomy for acute ischemic stroke may be feasible in carefully selected infants and young children less than 5 years of age using currently available devices. Efficacy in promoting better neurologic outcomes remains unproven, and other questions persist, including whether complications such as vasospasm occur more frequently in young children compared with adults. Further study is needed to determine the safety and efficacy of pediatric mechanical thrombectomy. These data suggest that young children should not be excluded from future studies or clinical treatment on the basis of age alone.

Onset to Reperfusion Time Was Not Important in Mechanical Thrombectomy for Elderly Patients: A Retrospective Multicenter Study in Tama Area, Tokyo

2018 ◽  
Vol 46 (1-2) ◽  
pp. 89-96 ◽  
Author(s):  
Satoshi Koizumi ◽  
Takahiro Ota ◽  
Keigo Shigeta ◽  
Tatsuo Amano ◽  
Masayuki Ueda ◽  
...  
Keyword(s):  
Elderly Patients ◽  
Scale Score ◽  
Mechanical Thrombectomy ◽  
Treatment Strategies ◽  
Onset Time ◽  
Standard Of Care ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Factors Affecting ◽  
Good Outcome

Background: Mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke with large vessel occlusion; however, evidence remains insufficient for MT for elderly patients, especially with respect to factors affecting their outcomes. Methods: This study was a retrospective analysis of a multicenter registry of MT, called Tama Registry of Acute Endovascular Thrombectomy. Patients were divided by their age into 2 groups: Nonelderly (NE; < 80) and elderly (E; ≥80). Factors related to a good outcome (modified Rankin scale score ≤2) were examined in each group. Onset to reperfusion time (OTR) was stratified into 4 categories: category 1, 0 – ≤180 min; category 2, > 180 – ≤360 min; category 3, > 360 min or onset time not identified; and category 4, effective recanalization not achievable. Results: 143 NE patients and 78 E patients were included in this study. The E group had less chance of achieving a good outcome (NE group 51%, E group 35%; p = 0.024). In the NE group, lower OTR category was an independent prognostic factor for good outcome (p = 0.037, OR = 1.09). However, in the E group, OTR category was not a significant predictor on multivariate analysis. Instead, effective recanalization (p = 0.0081, OR 1.40) and lower National Institute of Health Stroke Scale score at presentation (p = 0.0032, OR 1.02) were the independent predictors. Conclusions: In MT for elderly patients, effective recanalization improved the patients’ outcome but OTR affected less. Further studies are warranted to establish the appropriate patient selection and treatment strategies.

scholarly journals Thrombectomy by primary aspiration technique in a patient with critical internal carotid artery stenosis

2021 ◽  
Author(s):  
Yasmim Nadime José Frigo ◽  
Hendrick Henrique Fernandes Gramasco ◽  
Igor Oliveira Fonseca ◽  
Mateus Felipe dos Santos ◽  
Rodrigo Bazan ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Neurological Deficits ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Clinical Prognosis ◽  
Aspiration Technique

Context: Stroke is one of the main leaders of death and disability in the world. Currently, mechanical thrombectomy with stent retrievers is the technique of choice for large vessel occlusion, however, the primary aspiration technique has been proposed as a fast and safe alternative. Case report: J.E.M, male, 57 years old, hypertensive, atrial fibrillation. Started claudication of neurological deficits, with intermittent paresthesia in left upper limb for 2 days. Admitted with NIHSS 2 (nasolabial sulcus erasure and hypoesthesia in LUL), in thrombolysis window, has seen in cerebral and neck angiotomography critical stenosis of the internal carotid artery and in CT scan with perfusion Mismatch volume 72 ml and infinite ratio. Since the patient did not have sufficient criteria for thrombolysis and since the clinical prognosis was unfavorable, a diagnostic arteriography was indicated, which showed ICAR stenosis 90%. The patient proceeded with angioplasty and stenting using the ADPAT technique and mechanical thrombectomy due to occlusion in segment M1 with total recanalization (TICI 3) and NIHSS after and at discharge of 0. Conclusion: The advent of thrombectomy impacts the improvement of functional dependence and the reduction of mortality, especially in stroke with large vessel occlusion, whose treatment with thrombolytic therapy only has a low chance of recanalization.

Abstract 131: TICI 2A Reperfusion Increases Risk of Parenchymal Hemorrhage After Endovascular Treatment for Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Erica Jones ◽  
Diogo Haussen ◽  
Raul Nogueira ◽  
Fadi Nahab ◽  
Michael Frankel ◽  
...  
Keyword(s):  
Infarct Size ◽  
Infarct Volume ◽  
Patient Characteristics ◽  
Reperfusion Therapy ◽  
Stroke Severity ◽  
Vessel Occlusion ◽  
Increased Risk ◽  
Increase Risk ◽  
Hemorrhage Risk ◽  
Post Hoc

Background: Endovascular reperfusion therapy (ERT) for acute large vessel occlusion limits infarct expansion and improves clinical outcomes but successful reperfusion may also increase risk of reperfusion injury and parenchymal hemorrhage (PH). We explored the association between levels of reperfusion and risk of PH. Methods: In a post-hoc analysis of the endovascular arm of the Interventional Management of Stroke-III randomized clinical trial, we assessed the association between levels of reperfusion (TICI0-1, 2A and 2B/3) and hemorrhage risk (PH1/2) in unadjusted and adjusted models controlling for stroke severity, final infarct volume (FIV) and level of occlusion. Results: Out of 434 participants who received ERT, 311 had documented TICI reperfusion grades (TICI 0-1: 84 [27%], TICI 2A: 108 [34.7%], TICI 2B/3: 119 [38.3%]). PH occurred in 42 (13.5%) patients. Patient characteristics are shown in Figure A. Higher reperfusion scores were associated with lower FIV (N=264, Mann-Whitney p<0.001 Figure B). Univariable predictors (p<0.10) of PH included FIV (p<0.0001), 24-hour NIHSS (p<0.0001) and TICI reperfusion grade (p=0.08). Compared to the TICI 0-1 group, TICI 2A was associated with higher odds of PH (OR=3.9, 1.26-12.1, p=0.014) while odds of PH in TICI 2B/3 reperfusion was similar to the TICI 0-1 category (OR=1.76, 0.73-4.26, p=0.2) after controlling for FIV or 24-hour NIHSS (Fig. C). Conclusions: Risk of PH appears to be highest in patients with intermediate levels of reperfusion even after adjusting for infarct size. While the reasons for this need investigating, we propose that the infarct size-mitigating effect of intermediate reperfusion may be partially offset by increased risk of PH. Our exploratory results emphasize the importance of achieving complete reperfusion during the treatment of acute LVO stroke patients.

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