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Ischemic stroke
ORIGINAL RESEARCH
Emergency carotid artery stenting in patients with acute ischemic stroke due to occlusion or stenosis of the proximal internal carotid artery: a single-center experience Seungnam Son,1,2 Dae Seob Choi,2,3,4 Min Kyun Oh,2,4,5 Soo-Kyoung Kim,1,2 Heeyoung Kang,1,4 Ki-Jong Park,1,4 Nack-Cheon Choi,1,2,4 Oh-Young Kwon,1,4 Byeong Hoon Lim1,2,4 1
Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea 2 Gyeongnam Regional Cardiocerebrovascular Disease Center, Jinju, Korea 3 Department of Radiology, Gyeongsang National University School of Medicine, Jinju, Korea 4 Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea 5 Rehabilitation Medicine, Gyeongsang National University School of Medicine, Jinju, Korea Correspondence to Dr Dae Seob Choi, Department of Radiology, Gyeongsang National University School of Medicine, 79 Gangnam-ro, Jinju 660-702, South Korea; [email protected] Received 28 January 2014 Revised 27 February 2014 Accepted 28 February 2014
ABSTRACT Background The feasibility, safety and effectiveness of emergency carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to proximal internal carotid artery (ICA) stenosis or occlusion are still controversial. In this study we analyzed our experience with eCAS in patients with AIS. Methods Twenty-two eCAS procedures for proximal ICA stenosis or occlusion were performed in 22 patients at our institution between January 2011 and November 2013. The mean time from stroke symptom onset to presentation was 204 min (range 50–630 min) and the mean initial score on the National Institutes of Health Stroke Scale (NIHSS) was 12.55 (range 5–23). Ten patients had total occlusion of the proximal ICA and the remaining 12 patients had near total occlusion or severe stenosis (mean degree 90.7%, range 80–100%). Eleven patients also had tandem occlusion on the more distal intracranial arteries. Results Successful stent insertion was achieved in all patients and additional thrombectomy using a Solitaire stent or Penumbra aspiration catheter achieved a Thrombolysis In Cerebral Infarction grade of more than 2a in all patients with distal tandem occlusion. Procedure-related complications occurred in one patient (cerebral hyperperfusion syndrome) who recovered successfully. The mean NIHSS score at discharge was 3.55 (range 0–18). The mean modified Rankin Scale score at 3 months was 1±1.67 (range 0–6). Conclusions eCAS in patients with AIS due to proximal ICA stenosis or occlusion appears to be a technically feasible and effective method for achieving good clinical outcomes.
INTRODUCTION
To cite: Son S, Choi DS, Oh MK, et al. J NeuroIntervent Surg Published Online First: [please include Day Month Year] doi:10.1136/ neurintsurg-2014-011141
Early recanalization of an occluded artery is important for improving functional outcome and reducing mortality in patients with acute ischemic stroke (AIS).1 However, the clinical outcome after medical treatment is usually very poor in cases of AIS induced by occlusion or stenosis of the proximal internal carotid artery (ICA) that results in severe neurological symptoms and is usually not accessible by recombinant tissue plasminogen activator (rtPA) thrombolysis.2 3 In recent years the feasibility, safety and effectiveness of emergency
Son S, et al. J NeuroIntervent Surg 2014;0:1–7. doi:10.1136/neurintsurg-2014-011141
carotid artery stenting (eCAS) with/without additional intra-arterial (IA) thrombolysis/thrombectomy have been studied extensively and both technically and clinically promising results have been reported.4–17 In addition, it was reported that early CAS (within 2 days) carries no additional risks compared with CAS after 2 days or any other intervention timing up to 90 days.18 Thus, a recent early treatment guideline considers this technique in patients with AIS resulting from cervical atherosclerosis or dissection.19 However, in actual clinical practice there are several concerns when considering eCAS in patients with AIS, and clinicians usually hesitate to decide on the procedure.20 The concerns include the procedure’s technical feasibility (eg, the success of stent insertion under severe stenosis or occlusion and the distal embolization caused by manipulation of highly vulnerable plaque), safety (eg, the potential risk of developing acute in-stent stenosis due to the lack of antiplatelet premedication), related complications (eg, cerebral hyperperfusion syndrome (CHS)) and effectiveness for improving patients’ neurological deficits and long-term follow-up. In this study we retrospectively analyzed 22 patients with AIS caused by proximal ICA occlusion or severe stenosis and treated with eCAS within the past 3 years. The effectiveness, safety and clinical outcomes of eCAS were assessed.
MATERIALS AND METHODS Patients One hundred and thirty-six CAS procedures were performed in 129 patients at our institution between January 2011 and November 2013. Of these, 28 were performed as an emergency procedure in 28 patients who arrived within 8 h of stroke symptom onset or with unclear-onset stroke within 12 h from ‘last normal time’ according to a review of MRIs and perfusion MRIs. We reviewed all clinical and angiographic data of the patients. Five eCAS cases were excluded because they were performed for the easy assessment of more distal intracranial occlusion by stroke causes other than proximal ICA occlusion or stenosis. All of the excluded patients had proximal ICA stenosis (mean degree of stenosis 62%, range 50–80%) with combined occlusion of the middle 1
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Ischemic stroke cerebral artery (MCA). However, all of these patients had definite cardiogenic embolic sources, and the margin of the stenotic portion was smooth rather than ulcerative. We decided that the mechanism of infarction in these patients was cardiogenic embolism and performed eCAS merely to facilitate assessment. These patients were therefore excluded. In addition, one patient who received eCAS due to proximal ICA occlusion and was transferred to another institution immediately after the procedure was also excluded because we could not obtain any information regarding follow-up results. Ultimately, 22 patients who underwent eCAS as a primary treatment for stroke were included in this study (table 1). Twenty patients arrived within 8 h of stroke symptom onset and the remaining two patients arrived with unclear-onset stroke within 12 h from last normal time. The patient group consisted of 20 men (90.9%) and two women (9.1%) with a mean age of 71.2 years (range 41–85 years). Five patients (23%) had prior stroke or a transient ischemic attack (TIA). Stroke risk factors included hypertension (59.0%), diabetes (45.5%), smoking (27.3%), hyperlipidemia (27.3%) and cardiac disease (27.3%). In addition, two patients were diagnosed with cancer of the head or neck and had received radiotherapy previously (9.1%), but we could not determine if the stenosis was caused by radiation or atherosclerosis due to patency of the contralateral ICA and multiple atherosclerogenic risk factors. The causes of ICA occlusion or stenosis were atherosclerosis and/or radiation-induced carotid stenosis in 20 patients (90.9%) and ICA dissection in two patients (9.1%). The mean time from stroke symptom onset to presentation was 204 min (range 50–630 min) and the mean±SD initial National Institutes of Health Stroke Scale (NIHSS) score was 12.55±5.32 (range 5–23; table 1). All patients underwent MRI examinations according to the acute stroke protocol of our institution using a 1.5 Tesla magnet MRI (Magnetom Avanto; Siemens Medical Solutions, Erlangen, Germany). The acute stroke MRI protocol consisted of b0 and b1000 diffusion-weighted images (DWIs), gradient echo images, fluid-attenuated inversion recovery (FLAIR) images, gadolinium (Gadovist, Gadobutrol; Schering, Berlin, Germany)-enhanced T1-weighted images and gadoliniumenhanced magnetic resonance angiography (MRA) of the entire neck and intracranial arteries and/or perfusion-weighted MR images (PWI). The initial lesions on DWI included territorial lesions on the MCA in seven patients, border zone infarction in nine patients and multiple focal infarctions in six patients. The patients did not show any signal intensity changes on FLAIR images and the volume of DWI-PWI mismatch was more than 50%. If an ICA occlusion was observed on MRA we decided on immediate IA intervention. Twelve of the 22 patients received intravenous (IV) thrombolytic therapy using rtPA (Actylase; Boehringer Ingelheim, Basel, Switzerland). The mean time from presentation to femoral puncture was 105.4 min (range 40–320 min). The premedication protocols for eCAS differed according to the use of rtPA. If a patient received rtPA, only loading doses of atorvastatin (80 mg/day) were prescribed. In addition, the maintenance dose of clopidogrel (75 mg) with aspirin (100 mg) and atorvastatin (80 mg/day) was started 24 h after rtPA infusion. However, if the patient did not receive rtPA, a loading dose of clopidogrel (600 mg) with aspirin (300 mg) and atorvastatin (80 mg/day) was prescribed and the maintenance dose of clopidogrel (75 mg) with aspirin (100 mg) and atorvastatin (80 mg/day) was continued the day after eCAS.
Intervention protocol All procedures were performed by an experienced neurointerventionist and a neurologist who was a trained neurointerventionist 2
using a biplane angiography system (Artis Zee Biplane; Siemens). First, the femoral artery was punctured under local anesthesia and a femoral sheath was placed. In subjects with total occlusion, diagnostic angiography was performed to confirm the collateral vessels. When patients scored 3, we performed medical therapy using a volume expander and administered vasopressor agents to enhance the collateral flow. Another concern is distal embolization caused by manipulation of highly vulnerable plaque. In elective CAS the EPD is commonly used to prevent distal embolization. However, the use of EPD has been reported only in three recent studies in selected patients5 8 9 and only one patient suffered distal embolization.5 In our opinion, the prevalence of distal embolization has been significantly underestimated in these previous studies. During the procedure, distal embolization is difficult to detect. IA intervention in patients with AIS is a complex and timesensitive procedure and the tandem occlusion of the distal artery could mask an additional embolic occlusion. We did not use an EPD in our first six cases but did in eight of the following 16 eCAS cases. We suggest the use of EPD in eCAS even if distal tandem occlusion coexists because the clot burden can be reduced and easier thrombolysis/thrombectomy to the distal occlusion can be performed. The use of dual antiplatelet agents is recommended before and after CAS to prevent acute or chronic in-stent thrombosis.26 However, the ideal medical regimen in eCAS is not established. In this study we did not prescribe any antiplatelet agent for patients who received rtPA therapy before eCAS. The patients who did not receive rtPA therapy were prescribed a loading dose of antiplatelet agents, 600 mg clopidogrel with 300 mg aspirin. A loading dose of 300–600 mg clopidogrel rapidly inhibits platelet aggregation but we preferred 600 mg based on the good clinical results obtained in a coronary stenting study.27 Acute or delayed thrombotic complications as well as hemorrhagic events were not observed in this study. 6
CHS is a potentially fatal complication of CAS. The known risk factors of CHS are long-standing hypertension, diabetes mellitus, older age, high-grade stenosis with poor collateral circulation, reduced vasoreactivity and symptomatic lesions.28 The patients with AIS due to stenosis or occlusion of the proximal ICA usually had multiple risk factors, so the occurrence of CHS among patients with AIS who receive eCAS is possibly higher than reported. Many previous studies have not mentioned the prevalence of CHS. However, the development of intracerebral hemorrhage, the most fatal form of CHS, has been reported for 21 patients in 10 studies,5–9 11–14 16 and symptomatic hemorrhage developed in 10 patients5 6 12 13 16 and was mostly fatal. Thus, conducting intensive post-procedural care such as full monitoring, frequent neurological assessment and strict BP control is important for achieving good clinical outcomes. Information regarding long-term results such as restenosis of the inserted stent and stroke recurrence in patients receiving eCAS is lacking. The main focus of previous studies has been the procedure itself and short-term clinical results; information regarding follow-up vascular investigations has been reported in only four studies.4 5 9 10 Of the patients included in these studies, only one showed asymptomatic moderate stenosis of approximately 40%.5 In addition, stroke recurrence on the ipsilateral side of eCAS was reported in only two cases in a previous study (1 month and 2 months after eCAS).9
CONCLUSION This study has several limitations, including retrospective data collection, absence of a control group and small number of patients. However, the results indicate that eCAS in patients with AIS due to proximal ICA stenosis or occlusion is a technically feasible and effective method for obtaining good clinical outcomes after stroke. Contributors Study conception and design: DSC, BHL. Data collection: all authors. Data analysis and interpretation: SS, DSC, N-CC. Literature research: SS, O-YK. Drafting the manuscript: SS. Revision of the manuscript for important intellectual content: SS, DSC, MKO, K-JP. Approval of final version of manuscript: all authors. Competing interests None. Patient consent Informed consent was obtained from at least two legal representatives of each patient before the procedure. Ethics approval This study was approved by the Gyeongsang National University Hospital Institutional Review Board. Provenance and peer review Not commissioned; externally peer reviewed. Data sharing statement Unpublished anonymised/de-identified data may be available. This would be on a per-request basis. Please email the corresponding author for the data.
REFERENCES 1 2
3
4
5 6
7
Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 2007;38:967–73. Meyer FB, Sundt TM Jr, Piepgras DG, et al. Emergency carotid endarterectomy for patients with acute carotid occlusion and profound neurological deficits. Ann Surg 1986;203:82–9. Pechlaner R, Knoflach M, Matosevic B, et al. Recanalization of extracranial internal carotid artery occlusion after i.v. thrombolysis for acute ischemic stroke. PLoS ONE 2013;8:e55318.. Hayashi K, Kitagawa N, Takahata H, et al. Endovascular treatment for cervical carotid artery stenosis presenting with progressing stroke: three case reports. Surg Neurol 2002;58:148–54. Imai K, Mori T, Izumoto H, et al. Emergency carotid artery stent placement in patients with acute ischemic stroke. AJNR Am J Neuroradiol 2005;26:1249–58. Nedeltchev K, Brekenfeld C, Remonda L, et al. Internal carotid artery stent implantation in 25 patients with acute stroke: preliminary results. Radiology 2005;237:1029–37. Jovin TG, Gupta R, Uchino K, et al. Emergent stenting of extracranial internal carotid artery occlusion in acute stroke has a high revascularization rate. Stroke 2005;36:2426–30.
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Dabitz R, Triebe S, Leppmeier U, et al. Percutaneous recanalization of acute internal carotid artery occlusions in patients with severe stroke. Cardiovasc Intervent Radiol 2007;30:34–41. Nikas D, Reimers B, Elisabetta M, et al. Percutaneous interventions in patients with acute ischemic stroke related to obstructive atherosclerotic disease or dissection of the extracranial carotid artery. J Endovasc Ther 2007;14:279–88. Wang H, Wang D, Fraser K, et al. Emergent combined intracranial thrombolysis and carotid stenting in the hyperacute management of stroke patients with severe cervical carotid stenosis. AJNR Am J Neuroradiol 2007;28:1162–66. Lee HO, Koh EJ, Choi HY. Emergency carotid artery stent insertion for acute ICA occlusion. J Korean Neurosurg Soc 2010;47:428–32. Papanagiotou P, Roth C, Walter S, et al. Carotid artery stenting in acute stroke. J Am Coll Cardiol 2011;58:2363–9. Cohen JE, Gomori M, Rajz G, et al. Emergent stent-assisted angioplasty of extracranial internal carotid artery and intracranial stent-based thrombectomy in acute tandem occlusive disease: technical considerations. J NeuroIntervent Surg 2013;5:440–6. Hwang SB, Kwak HS, Chung GH. Forced suction thrombectomy after carotid stenting in patients with massive thrombus and acute extracranial internal carotid artery occlusion. J Neurointerv Surg 2013;5:426–9. Kwak HS, Hwang SB, Jin GY, et al. Predictors of functional outcome after emergency carotid artery stenting and intra-arterial thrombolysis for treatment of acute stroke associated with obstruction of the proximal internal carotid artery and tandem downstream occlusion. AJNR Am J Neuroradiol 2013;34:841–6. Stampfl S, Ringleb PA, Mőhlenbruch M, et al. Emergency cervical internal carotid artery stenting in combination with intracranial thrombectomy in acute stroke. AJNR Am J Neuroradiol 2013 Oct 24 [Epub ahead of print] http://dx.doi.org/10.3174/ajnr. A3763. Hauck EF, Natarajan SK, Ohta H, et al. Emergent endovascular recanalization for cervical internal carotid artery occlusion in patients presenting with acute stroke. Neurosurgery 2011;69:899–907.
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Wach MM, Dumont TM, Mokin M, et al. Early carotid angioplasty and stenting may offer non-inferior treatment for symptomatic cases of carotid artery stenosis. J Neurointerv Surg 2013 May 24 [Epub ahead of print]. Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870–947. Rahme R, Abruzzo TA, Ringer AJ. Acute ischemic stroke in the setting of cervical carotid occlusion: a proposed management strategy. World Neurosurg 2011;76: S60–65. Zaidat OO, Yoo AJ, Khatri P, et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke 2013;44:2650–63. Meves SH, Muhs A, Federlein J, et al. Recanalization of acute symptomatic occlusions of the internal carotid artery. J Neurol 2002;249:188–92. Ratanaprasatporn L, Grossberg JA, Spader HS, et al. Endovascular treatment of acute carotid occlusion. Clin Neurol Neurosurg 2013;115:2521–3. Kim JT, Park MS, Choi KH, et al. Clinical implications of collateral middle cerebral artery flow in acute ischaemic stroke with internal carotid artery occlusion. Eur J Neurol 2010;18:1384–90. Bang OY, Saver JL, Kim SJ, et al. Collateral flow predicts response to endovascular therapy for acute ischemic stroke. Stroke 2011;42:693–9. Brott TG, Halperin JL, Abbara S, et al. ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/ CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. J Am Coll Cardiol 2011;57; e16–94. Angiolillo DJ, Fernández-Ortiz A, Bernardo E, et al. High clopidogrel loading dose during coronary stenting: effects on drug response and interindividual variability. Eur Heart J 2004;25:1903–10. Moulakakis KG, Mylonas SN, Sfyroeras GS, et al. Hyperperfusion syndrome after carotid revascularization. J Vasc Surg 2009;49:1060–8.
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Emergency carotid artery stenting in patients with acute ischemic stroke due to occlusion or stenosis of the proximal internal carotid artery: a single-center experience Seungnam Son, Dae Seob Choi, Min Kyun Oh, et al. J NeuroIntervent Surg published online March 14, 2014
doi: 10.1136/neurintsurg-2014-011141
Updated information and services can be found at: http://jnis.bmj.com/content/early/2014/03/14/neurintsurg-2014-011141.full.html
These include:
References
This article cites 26 articles, 10 of which can be accessed free at: http://jnis.bmj.com/content/early/2014/03/14/neurintsurg-2014-011141.full.html#ref-list-1
P
Ischemic stroke
ORIGINAL RESEARCH
Emergency carotid artery stenting in patients with acute ischemic stroke due to occlusion or stenosis of the proximal internal carotid artery: a single-center experience Seungnam Son,1,2 Dae Seob Choi,2,3,4 Min Kyun Oh,2,4,5 Soo-Kyoung Kim,1,2 Heeyoung Kang,1,4 Ki-Jong Park,1,4 Nack-Cheon Choi,1,2,4 Oh-Young Kwon,1,4 Byeong Hoon Lim1,2,4 1
Department of Neurology, Gyeongsang National University School of Medicine, Jinju, Korea 2 Gyeongnam Regional Cardiocerebrovascular Disease Center, Jinju, Korea 3 Department of Radiology, Gyeongsang National University School of Medicine, Jinju, Korea 4 Gyeongsang Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Korea 5 Rehabilitation Medicine, Gyeongsang National University School of Medicine, Jinju, Korea Correspondence to Dr Dae Seob Choi, Department of Radiology, Gyeongsang National University School of Medicine, 79 Gangnam-ro, Jinju 660-702, South Korea; [email protected] Received 28 January 2014 Revised 27 February 2014 Accepted 28 February 2014
ABSTRACT Background The feasibility, safety and effectiveness of emergency carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to proximal internal carotid artery (ICA) stenosis or occlusion are still controversial. In this study we analyzed our experience with eCAS in patients with AIS. Methods Twenty-two eCAS procedures for proximal ICA stenosis or occlusion were performed in 22 patients at our institution between January 2011 and November 2013. The mean time from stroke symptom onset to presentation was 204 min (range 50–630 min) and the mean initial score on the National Institutes of Health Stroke Scale (NIHSS) was 12.55 (range 5–23). Ten patients had total occlusion of the proximal ICA and the remaining 12 patients had near total occlusion or severe stenosis (mean degree 90.7%, range 80–100%). Eleven patients also had tandem occlusion on the more distal intracranial arteries. Results Successful stent insertion was achieved in all patients and additional thrombectomy using a Solitaire stent or Penumbra aspiration catheter achieved a Thrombolysis In Cerebral Infarction grade of more than 2a in all patients with distal tandem occlusion. Procedure-related complications occurred in one patient (cerebral hyperperfusion syndrome) who recovered successfully. The mean NIHSS score at discharge was 3.55 (range 0–18). The mean modified Rankin Scale score at 3 months was 1±1.67 (range 0–6). Conclusions eCAS in patients with AIS due to proximal ICA stenosis or occlusion appears to be a technically feasible and effective method for achieving good clinical outcomes.
INTRODUCTION
To cite: Son S, Choi DS, Oh MK, et al. J NeuroIntervent Surg Published Online First: [please include Day Month Year] doi:10.1136/ neurintsurg-2014-011141
Early recanalization of an occluded artery is important for improving functional outcome and reducing mortality in patients with acute ischemic stroke (AIS).1 However, the clinical outcome after medical treatment is usually very poor in cases of AIS induced by occlusion or stenosis of the proximal internal carotid artery (ICA) that results in severe neurological symptoms and is usually not accessible by recombinant tissue plasminogen activator (rtPA) thrombolysis.2 3 In recent years the feasibility, safety and effectiveness of emergency
Son S, et al. J NeuroIntervent Surg 2014;0:1–7. doi:10.1136/neurintsurg-2014-011141
carotid artery stenting (eCAS) with/without additional intra-arterial (IA) thrombolysis/thrombectomy have been studied extensively and both technically and clinically promising results have been reported.4–17 In addition, it was reported that early CAS (within 2 days) carries no additional risks compared with CAS after 2 days or any other intervention timing up to 90 days.18 Thus, a recent early treatment guideline considers this technique in patients with AIS resulting from cervical atherosclerosis or dissection.19 However, in actual clinical practice there are several concerns when considering eCAS in patients with AIS, and clinicians usually hesitate to decide on the procedure.20 The concerns include the procedure’s technical feasibility (eg, the success of stent insertion under severe stenosis or occlusion and the distal embolization caused by manipulation of highly vulnerable plaque), safety (eg, the potential risk of developing acute in-stent stenosis due to the lack of antiplatelet premedication), related complications (eg, cerebral hyperperfusion syndrome (CHS)) and effectiveness for improving patients’ neurological deficits and long-term follow-up. In this study we retrospectively analyzed 22 patients with AIS caused by proximal ICA occlusion or severe stenosis and treated with eCAS within the past 3 years. The effectiveness, safety and clinical outcomes of eCAS were assessed.
MATERIALS AND METHODS Patients One hundred and thirty-six CAS procedures were performed in 129 patients at our institution between January 2011 and November 2013. Of these, 28 were performed as an emergency procedure in 28 patients who arrived within 8 h of stroke symptom onset or with unclear-onset stroke within 12 h from ‘last normal time’ according to a review of MRIs and perfusion MRIs. We reviewed all clinical and angiographic data of the patients. Five eCAS cases were excluded because they were performed for the easy assessment of more distal intracranial occlusion by stroke causes other than proximal ICA occlusion or stenosis. All of the excluded patients had proximal ICA stenosis (mean degree of stenosis 62%, range 50–80%) with combined occlusion of the middle 1
Downloaded from jnis.bmj.com on June 16, 2014 - Published by group.bmj.com
Ischemic stroke cerebral artery (MCA). However, all of these patients had definite cardiogenic embolic sources, and the margin of the stenotic portion was smooth rather than ulcerative. We decided that the mechanism of infarction in these patients was cardiogenic embolism and performed eCAS merely to facilitate assessment. These patients were therefore excluded. In addition, one patient who received eCAS due to proximal ICA occlusion and was transferred to another institution immediately after the procedure was also excluded because we could not obtain any information regarding follow-up results. Ultimately, 22 patients who underwent eCAS as a primary treatment for stroke were included in this study (table 1). Twenty patients arrived within 8 h of stroke symptom onset and the remaining two patients arrived with unclear-onset stroke within 12 h from last normal time. The patient group consisted of 20 men (90.9%) and two women (9.1%) with a mean age of 71.2 years (range 41–85 years). Five patients (23%) had prior stroke or a transient ischemic attack (TIA). Stroke risk factors included hypertension (59.0%), diabetes (45.5%), smoking (27.3%), hyperlipidemia (27.3%) and cardiac disease (27.3%). In addition, two patients were diagnosed with cancer of the head or neck and had received radiotherapy previously (9.1%), but we could not determine if the stenosis was caused by radiation or atherosclerosis due to patency of the contralateral ICA and multiple atherosclerogenic risk factors. The causes of ICA occlusion or stenosis were atherosclerosis and/or radiation-induced carotid stenosis in 20 patients (90.9%) and ICA dissection in two patients (9.1%). The mean time from stroke symptom onset to presentation was 204 min (range 50–630 min) and the mean±SD initial National Institutes of Health Stroke Scale (NIHSS) score was 12.55±5.32 (range 5–23; table 1). All patients underwent MRI examinations according to the acute stroke protocol of our institution using a 1.5 Tesla magnet MRI (Magnetom Avanto; Siemens Medical Solutions, Erlangen, Germany). The acute stroke MRI protocol consisted of b0 and b1000 diffusion-weighted images (DWIs), gradient echo images, fluid-attenuated inversion recovery (FLAIR) images, gadolinium (Gadovist, Gadobutrol; Schering, Berlin, Germany)-enhanced T1-weighted images and gadoliniumenhanced magnetic resonance angiography (MRA) of the entire neck and intracranial arteries and/or perfusion-weighted MR images (PWI). The initial lesions on DWI included territorial lesions on the MCA in seven patients, border zone infarction in nine patients and multiple focal infarctions in six patients. The patients did not show any signal intensity changes on FLAIR images and the volume of DWI-PWI mismatch was more than 50%. If an ICA occlusion was observed on MRA we decided on immediate IA intervention. Twelve of the 22 patients received intravenous (IV) thrombolytic therapy using rtPA (Actylase; Boehringer Ingelheim, Basel, Switzerland). The mean time from presentation to femoral puncture was 105.4 min (range 40–320 min). The premedication protocols for eCAS differed according to the use of rtPA. If a patient received rtPA, only loading doses of atorvastatin (80 mg/day) were prescribed. In addition, the maintenance dose of clopidogrel (75 mg) with aspirin (100 mg) and atorvastatin (80 mg/day) was started 24 h after rtPA infusion. However, if the patient did not receive rtPA, a loading dose of clopidogrel (600 mg) with aspirin (300 mg) and atorvastatin (80 mg/day) was prescribed and the maintenance dose of clopidogrel (75 mg) with aspirin (100 mg) and atorvastatin (80 mg/day) was continued the day after eCAS.
Intervention protocol All procedures were performed by an experienced neurointerventionist and a neurologist who was a trained neurointerventionist 2
using a biplane angiography system (Artis Zee Biplane; Siemens). First, the femoral artery was punctured under local anesthesia and a femoral sheath was placed. In subjects with total occlusion, diagnostic angiography was performed to confirm the collateral vessels. When patients scored 3, we performed medical therapy using a volume expander and administered vasopressor agents to enhance the collateral flow. Another concern is distal embolization caused by manipulation of highly vulnerable plaque. In elective CAS the EPD is commonly used to prevent distal embolization. However, the use of EPD has been reported only in three recent studies in selected patients5 8 9 and only one patient suffered distal embolization.5 In our opinion, the prevalence of distal embolization has been significantly underestimated in these previous studies. During the procedure, distal embolization is difficult to detect. IA intervention in patients with AIS is a complex and timesensitive procedure and the tandem occlusion of the distal artery could mask an additional embolic occlusion. We did not use an EPD in our first six cases but did in eight of the following 16 eCAS cases. We suggest the use of EPD in eCAS even if distal tandem occlusion coexists because the clot burden can be reduced and easier thrombolysis/thrombectomy to the distal occlusion can be performed. The use of dual antiplatelet agents is recommended before and after CAS to prevent acute or chronic in-stent thrombosis.26 However, the ideal medical regimen in eCAS is not established. In this study we did not prescribe any antiplatelet agent for patients who received rtPA therapy before eCAS. The patients who did not receive rtPA therapy were prescribed a loading dose of antiplatelet agents, 600 mg clopidogrel with 300 mg aspirin. A loading dose of 300–600 mg clopidogrel rapidly inhibits platelet aggregation but we preferred 600 mg based on the good clinical results obtained in a coronary stenting study.27 Acute or delayed thrombotic complications as well as hemorrhagic events were not observed in this study. 6
CHS is a potentially fatal complication of CAS. The known risk factors of CHS are long-standing hypertension, diabetes mellitus, older age, high-grade stenosis with poor collateral circulation, reduced vasoreactivity and symptomatic lesions.28 The patients with AIS due to stenosis or occlusion of the proximal ICA usually had multiple risk factors, so the occurrence of CHS among patients with AIS who receive eCAS is possibly higher than reported. Many previous studies have not mentioned the prevalence of CHS. However, the development of intracerebral hemorrhage, the most fatal form of CHS, has been reported for 21 patients in 10 studies,5–9 11–14 16 and symptomatic hemorrhage developed in 10 patients5 6 12 13 16 and was mostly fatal. Thus, conducting intensive post-procedural care such as full monitoring, frequent neurological assessment and strict BP control is important for achieving good clinical outcomes. Information regarding long-term results such as restenosis of the inserted stent and stroke recurrence in patients receiving eCAS is lacking. The main focus of previous studies has been the procedure itself and short-term clinical results; information regarding follow-up vascular investigations has been reported in only four studies.4 5 9 10 Of the patients included in these studies, only one showed asymptomatic moderate stenosis of approximately 40%.5 In addition, stroke recurrence on the ipsilateral side of eCAS was reported in only two cases in a previous study (1 month and 2 months after eCAS).9
CONCLUSION This study has several limitations, including retrospective data collection, absence of a control group and small number of patients. However, the results indicate that eCAS in patients with AIS due to proximal ICA stenosis or occlusion is a technically feasible and effective method for obtaining good clinical outcomes after stroke. Contributors Study conception and design: DSC, BHL. Data collection: all authors. Data analysis and interpretation: SS, DSC, N-CC. Literature research: SS, O-YK. Drafting the manuscript: SS. Revision of the manuscript for important intellectual content: SS, DSC, MKO, K-JP. Approval of final version of manuscript: all authors. Competing interests None. Patient consent Informed consent was obtained from at least two legal representatives of each patient before the procedure. Ethics approval This study was approved by the Gyeongsang National University Hospital Institutional Review Board. Provenance and peer review Not commissioned; externally peer reviewed. Data sharing statement Unpublished anonymised/de-identified data may be available. This would be on a per-request basis. Please email the corresponding author for the data.
REFERENCES 1 2
3
4
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Emergency carotid artery stenting in patients with acute ischemic stroke due to occlusion or stenosis of the proximal internal carotid artery: a single-center experience Seungnam Son, Dae Seob Choi, Min Kyun Oh, et al. J NeuroIntervent Surg published online March 14, 2014
doi: 10.1136/neurintsurg-2014-011141
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References
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