International Journal of Neuroscience
ISSN: 0020-7454 (Print) 1543-5245 (Online) Journal homepage: http://www.tandfonline.com/loi/ines20
Management of tandem internal carotid and middle cerebral arterial occlusions with endovascular multimodal reperfusion therapy Qiuji Shao, Liangfu Zhu, Tianxiao Li, Ziliang Wang, Li Li, Weixing Bai & Yingkun He To cite this article: Qiuji Shao, Liangfu Zhu, Tianxiao Li, Ziliang Wang, Li Li, Weixing Bai & Yingkun He (2015): Management of tandem internal carotid and middle cerebral arterial occlusions with endovascular multimodal reperfusion therapy, International Journal of Neuroscience, DOI: 10.3109/00207454.2015.1121387 To link to this article: http://dx.doi.org/10.3109/00207454.2015.1121387
Accepted author version posted online: 17 Nov 2015. Published online: 13 Dec 2015. Submit your article to this journal
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ines20 Download by: [University of Nebraska, Lincoln]
Date: 15 December 2015, At: 04:52
International Journal of Neuroscience, 2015; Early Online: 1–7 Copyright © 2015 Taylor and Francis ISSN: 0020-7454 print / 1543-5245 online DOI: 10.3109/00207454.2015.1121387
ORIGINAL ARTICLE
Management of tandem internal carotid and middle cerebral arterial occlusions with endovascular multimodal reperfusion therapy Downloaded by [University of Nebraska, Lincoln] at 04:52 15 December 2015
Qiuji Shao, Liangfu Zhu, Tianxiao Li,∗ Ziliang Wang, Li Li, Weixing Bai, and Yingkun He Department of Interventional Therapy, Henan Provincial People’s Hospital, Zhengzhou University, Zhengzhou, China The aim of this study was to evaluate the safety and efficacy of multimodal reperfusion therapy (MMRT) for tandem internal carotid artery and middle cerebral arterial (TIM) occlusions. Cases of TIM occlusion were collected and retrospectively reviewed. The analyzed objects included etiology, sites of tandem occlusion, collateral flow, location and size of infarcts. Combined with mechanical recanalization techniques and its complications, the National Institute of Health Stroke Scale (NIHSS) score and imaging data that was derived pre- and post-procedure were further contrasted. The study enrolled six patients with TIM occlusions. The mean NIHSS score on admission was 17 (range 13–20) and the median time from puncture to recanalization was 141 min (range 60–230). The substantial recanalization rate (Thrombolysis in Cerebral Infarction 2b or 3) was 83.3% and no symptomatic intracerebral hemorrhage was observed. The mean NIHSS score after three days was 14 (range 10–19) and 9 (range 3–17) following discharge. However, one patient died of pulmonary infection one month after discharge. For the five patients who survived, the modified Rankin Scale was evaluated at three months, with scores of 3, 1, 3, 5 and 3, respectively. It is concluded that endovascular therapy for acute TIM occlusions are complex, MMRT may be relatively safe and effective. KEYWORDS: tandem occlusions, acute stroke, multimodal, mechanical thrombectomy
Introduction Acute ischemic stroke caused by tandem internal carotid artery and middle cerebral arterial (TIM) occlusions has features of severe neurological deficits, a significant thrombus burden, a large lesion volume and poor outcomes. Recanalization of these arteries in a timely manner has become the core strategy aimed at improving clinical outcomes [1]. Due to the significant clot burden, it is challenging to obtain a good prognosis when presented by TIM occlusions by intravenous thrombolysis [2–4]. Although single modal mechanical thrombectomy devices (e.g., the Penumbra system or Solitaire Flow Restoration) have been widely applied in the treatment of acute ischemic stroke [5–8], studies of the recanalization of TIM occlusions by retrieval devices remain very limited [9,10]. Received 4 May 2015; revised 29 September 2015; accepted 13 November 2015; publish online 11 December 2015. ∗ Correspondence: Tianxiao Li, Department of Interventional Therapy, Henan Provincial People’s Hospital Affiliated to Zhengzhou University, Zhengzhou, China. E-mail: [email protected]
Multimodal reperfusion therapy (MMRT) is an advanced concept for the management of acute large intracranial vessel occlusion. Theoretically, it should display certain advantages when targeting such complex vascular conditions. However, to date, endovascular access, recanalization sequence, endovascular techniques and complications from this novel reperfusion strategy still require more detailed study. Therefore, we have undertaken to evaluate the safety and efficacy of MMRT for TIM occlusions, and report on our findings in this study.
Materials and methods Between November 2011 and October 2014, cases of TIM occlusion were recruited at our center and retrospectively reviewed, which were performed with MMRT that met the following criteria: (1) age ≤ 70; (2) acute stroke that presented within 6 h of initial stroke symptom onset; (3) an National Institute of Health Stroke Scale (NIHSS) score ≥10, or persistent progression of 1
2
Q. Shao et al.
Table 1. The basic clinical data of patients with TIM occlusions.
Sex
Age
Occlusion
Stroke etiology (TOSAT)
1
F
36
R-ICA+MCA
Dissection
2
M
49
R-ICA+MCA
3
M
65
L-ICA+MCA
4
M
61
R-ICA+MCA
5
F
70
R-ICA+MCA
6
M
80
R-ICA+MCA
Atherosclerotic thromboembolism Atherosclerotic thromboembolism Atherosclerotic thromboembolism Cardiogenic thromboembolism Cardiogenic thromboembolism
Downloaded by [University of Nebraska, Lincoln] at 04:52 15 December 2015
Patient No.
NIHSS Thrombolytic score at therapy admission
Infarction site and full-size
Qureshi grade
Frontal and temporal cortices; large Basal ganglia; medium
4A
–
17
5
–
18
Frontal and temporal cortices; multiple Basal ganglia; large
4A
–
17
4A
–
20
4B
Urokinase
13
4B
–
15
Centrum semiovale; medium Frontal and temporal cortices; medium
Note: M: male; F: female; L: left; R: right; ICA: internal carotid artery; MCA middle cerebral artery; large: more than a lobe, the cross-sectional maximum diameter >5.0 cm; medium: less than a lobe, the cross-sectional maximum diameter >3 cm and ≤5 cm; the cross-sectional maximum diameter >1.5 cm and ≤3 cm; 4A: ICA occlusion, collaterals fill middle cerebral artery; 4B: internal carotid artery occlusion, collaterals fill anterior cerebral artery; 5: ICA occlusion, no collaterals; –: no thrombolytic therapy; NIHSS: National Institute of Health Stroke Scale.
more than 1 h; (4) exclusion of cerebral hemorrhage or other intracranial diseases by computed tomography (CT) scan, the early low density infarction area that was less than one third of the middle cerebral artery (MCA) territory; (5) TIM occlusion, which was confirmed by digital subtraction angiography (DSA); and (6) all subjects signed an informed consent document.
Patient assessment and treatment TOAST (trial of org 10172 in acute stroke treatment) classification and Qureshi were used to diagnose the pathogenesis and evaluate the collateral flow, respectively [11,12]. Moreover, the maximum diameter of the infarct was measured under an imaging system (Table 1). The NIHSS score was performed on admission and a loading dose of 300 mg clopidogrel was taken via an oral or nasogastric tube before endovascular treatment for patients that were not on a routine anti-platelet regimen. Intravenous heparin at a dose of 3000 U was given immediately after establishing femoral access and then 1000 U/h of heparin was added. Post-operative management was the same as that given for routine neurological therapy of acute cerebral infarct. Dual antiplatelet medication (i.e. aspirin 100 mg/day and clopidogrel 75 mg/day) was administered for three month after a CT brain scan showed no hemorrhage. Then clopidogrel was discontinued and aspirin (100 mg/day) was continued chronically. Computed tomography (CT) or magnetic resonance imaging (MRI) scans (including diffusion weighted imaging (DWI) sequences) and magnetic resonance angiography (MRA) for all patients were performed immediately to exclude incidence of intracranial hem-
orrhage or major ischemic infarction (i.e. an acute ischemic change in more than a third of the MCA territory), and then DSA was performed to verify the occlusion sites of the large artery under local or general anesthesia.
Endovascular technique Through a transfemoral approach, an 8-Fr guiding catheter (i.e. Cordis, New Brunswick, NJ, USA) was placed at the proximal internal carotid artery (ICA) occlusion. A 0.014-inch micro-guidewire (synchro-14, Boston Scientific Inc., USA) was advanced over a rapid transit microcatheter (SL-10, Boston Scientific, USA) and carefully navigated through the MCA occlusion. The microcatheter tip was subsequently advanced over the micro-guidewire to the distal M2 segment of MCA, which was then gradually retreated to identify the distribution location of the clot via angiography. According to the occlusion site and length, strategies for endovascular treatment were determined and the mechanical maneuvers, which included Wallstent (Boston Scientific, Natikeshi, MA, USA), Solitaire AB (Covidien, Saint Louis, MO, USA), Apollo (MicroPort, Shanghai, China), Wingspan (Stryker, Natikeshi, MA, USA) and the Penumbra aspiration catheter (Penumbra, USA) were selected. In this study, MMRT was used to obtain recanalization of TIM occlusions in all patients by the antegrade approach that incorporated the concept of “first near then far” (Table 2).
Treatment evaluation The angiographic results were assessed independently by two experienced investigators in neuro-intervention. International Journal of Neuroscience
3
3
4
4
6
3
2
3
4
5
6
130
177
60
104
230
143
TO (min)
6.0
9.5
6.0
6.2
7.5
9.0
TOR (h) MT with manual aspiration device and Solitaire AB Stent placement and MT with Solitaire AB MT with the Penumbra system and Solitaire AB MT with the Penumbra system and Stent placement Stent placement and MT with Solitaire AB MT with the Penumbra system and Solitaire AB
MMRT techniques
2b
2b
3
3
3
2a
Post-operative TICI
No
No
Brain edema
Cerebral hemorrhage (PH1) No
Cerebral hemorrhage (PH1)
Complication
14
13
19
11
10
15
Three days NIHSS score
6
11
17
7
3
10
NIHSS score at discharge
3
–
5
3
1
3
mRS score at 90 days
Note: TOA: time from onset to admission; TO: time of operation (from puncture to recanalization); TOR: time from onset to recanalization; MT: mechanical thrombectomy; TICI: thrombolysis in cerebral infarction; PH1: a homogeneous hematoma covering 70 years and an initial higher NIHSS score. Additionally, factors such as age, extent of irreversible ischemia and pattern of collateral flow are closely related to clinical prognosis of acute stroke patients with endovascular treatment. Thus, strict selection of clinical indications in these patients required is particularly important to avoid futile recanalization.
Conclusions For this complex vascular problem, our results suggest that MMRT may be feasible and safe, and appears to benefit early neurological improvement in patients with TIM occlusions. Nevertheless, the main limitation of our study includes the small sample size, and that the study was a single-center and retrospective design. Further experience and prospective randomized studies might be necessary to verify the novel concept reported herein in the context of managing TIM occlusions.
Declaration of Interest The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper.
References 1. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 2007;38:967–73. 2. Rubiera M, Ribo M, Delgado-Mederos R, et al. Tandem internal carotid artery/middle cerebral artery occlusion: an independent predictor of poor outcome after systemic thrombolysis. Stroke 2006;37:2301–5.
C
2015 Taylor and Francis
7
3. Barreto AD, Albright KC, Hallevi H, et al. Thrombus burden is associated with clinical outcome after intra-arterial therapy for acute ischemic stroke. Stroke 2008;39:3231–5. 4. Kim, YS, Garami, Z, Mikulik R, et al. Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery/middle cerebral artery occlusion and isolated middle cerebral artery occlusion. Stroke 2005;36:869–71. 5. Behme D, Kowoll A, Mpotsaris A, et al. Multicenter clinical experience in over 125 patients with the Penumbra Separator 3D for mechanical thrombectomy in acute ischemic stroke. J Neurointerventional Surg 2014. doi: 10.1136/neurintsurg2014-011446. 6. Pereira VM, Gralla J, Davalos A, et al. Prospective, multicenter, single-arm study of mechanical thrombectomy using Solitaire Flow Restoration in acute ischemic stroke. Stroke 2013;44:2802–7. 7. Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. New England J Med 2015;372:1019–30. 8. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. New England J Med 2015;372:2285–95. 9. Mpotsaris A, Bussmeyer M, Buchner H, et al. Clinical outcome of neurointerventional emergency treatment of extra- or intracranial tandem occlusions in acute major stroke: antegrade approach with Wallstent and Solitaire stent retriever. Clin Neuroradiology 2013;23:207–15. 10. Malik AM, Vora NA, Lin R, et al. Endovascular treatment of tandem extracranial/intracranial anterior circulation occlusions: preliminary single-center experience. Stroke 2011;42:1653–7. 11. Han, SW, Nam HS, Kim SH, et al. Frequency and significance of cardiac sources of embolism in the TOAST classification. Cerebrovascular Diseases 2007;24:463–8. 12. Qureshi AI. New grading system for angiographic evaluation of arterial occlusions and recanalization response to intraarterial thrombolysis in acute ischemic stroke. Neurosurgery 2002;50:1405–14. 13. Zaidat OO, Lazzaro MA, Liebeskind DS, et al. Revascularization grading in endovascular acute ischemic stroke therapy. Neurology 2012;79(Suppl 1):S110–6. 14. Spiotta AM, Lena J, Vargas J, et al. Proximal to distal approach in the treatment of tandem occlusions causing an acute stroke. J Neurointerventional Surg 2014; doi:10.1136/neurintsurg2013-011040. 15. 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 Neurointerventional Surg 2013;5:440–6. 16. Machi P, Lobotesis K, Maldonado IL, et al. Endovascular treatment of tandem occlusions of the anterior cerebral circulation with solitaire FR thrombectomy system. Initial experience. Eur J Radiol 2012;81:3479–84. 17. Hwang SB, Kwak HS, Chung GH, et al. Forced suction thrombectomy after carotid stenting in patients with massive thrombus and acute extracranial internal carotid artery occlusion. J Neurointerventional Surg 2013;5:426–9. 18. Molina CA. Futile recanalization in mechanical embolectomy trials: a call to improve selection of patients for revascularization. Stroke 2010;41:842–3. 19. Hussein HM, Georgiadis AL, Vazquez G, et al. Occurrence and predictors of futile recanalization following endovascular treatment among patients with acute ischemic stroke: a multicenter study. Am J Neuroradiology 2010;31:454–8.
ISSN: 0020-7454 (Print) 1543-5245 (Online) Journal homepage: http://www.tandfonline.com/loi/ines20
Management of tandem internal carotid and middle cerebral arterial occlusions with endovascular multimodal reperfusion therapy Qiuji Shao, Liangfu Zhu, Tianxiao Li, Ziliang Wang, Li Li, Weixing Bai & Yingkun He To cite this article: Qiuji Shao, Liangfu Zhu, Tianxiao Li, Ziliang Wang, Li Li, Weixing Bai & Yingkun He (2015): Management of tandem internal carotid and middle cerebral arterial occlusions with endovascular multimodal reperfusion therapy, International Journal of Neuroscience, DOI: 10.3109/00207454.2015.1121387 To link to this article: http://dx.doi.org/10.3109/00207454.2015.1121387
Accepted author version posted online: 17 Nov 2015. Published online: 13 Dec 2015. Submit your article to this journal
Article views: 11
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ines20 Download by: [University of Nebraska, Lincoln]
Date: 15 December 2015, At: 04:52
International Journal of Neuroscience, 2015; Early Online: 1–7 Copyright © 2015 Taylor and Francis ISSN: 0020-7454 print / 1543-5245 online DOI: 10.3109/00207454.2015.1121387
ORIGINAL ARTICLE
Management of tandem internal carotid and middle cerebral arterial occlusions with endovascular multimodal reperfusion therapy Downloaded by [University of Nebraska, Lincoln] at 04:52 15 December 2015
Qiuji Shao, Liangfu Zhu, Tianxiao Li,∗ Ziliang Wang, Li Li, Weixing Bai, and Yingkun He Department of Interventional Therapy, Henan Provincial People’s Hospital, Zhengzhou University, Zhengzhou, China The aim of this study was to evaluate the safety and efficacy of multimodal reperfusion therapy (MMRT) for tandem internal carotid artery and middle cerebral arterial (TIM) occlusions. Cases of TIM occlusion were collected and retrospectively reviewed. The analyzed objects included etiology, sites of tandem occlusion, collateral flow, location and size of infarcts. Combined with mechanical recanalization techniques and its complications, the National Institute of Health Stroke Scale (NIHSS) score and imaging data that was derived pre- and post-procedure were further contrasted. The study enrolled six patients with TIM occlusions. The mean NIHSS score on admission was 17 (range 13–20) and the median time from puncture to recanalization was 141 min (range 60–230). The substantial recanalization rate (Thrombolysis in Cerebral Infarction 2b or 3) was 83.3% and no symptomatic intracerebral hemorrhage was observed. The mean NIHSS score after three days was 14 (range 10–19) and 9 (range 3–17) following discharge. However, one patient died of pulmonary infection one month after discharge. For the five patients who survived, the modified Rankin Scale was evaluated at three months, with scores of 3, 1, 3, 5 and 3, respectively. It is concluded that endovascular therapy for acute TIM occlusions are complex, MMRT may be relatively safe and effective. KEYWORDS: tandem occlusions, acute stroke, multimodal, mechanical thrombectomy
Introduction Acute ischemic stroke caused by tandem internal carotid artery and middle cerebral arterial (TIM) occlusions has features of severe neurological deficits, a significant thrombus burden, a large lesion volume and poor outcomes. Recanalization of these arteries in a timely manner has become the core strategy aimed at improving clinical outcomes [1]. Due to the significant clot burden, it is challenging to obtain a good prognosis when presented by TIM occlusions by intravenous thrombolysis [2–4]. Although single modal mechanical thrombectomy devices (e.g., the Penumbra system or Solitaire Flow Restoration) have been widely applied in the treatment of acute ischemic stroke [5–8], studies of the recanalization of TIM occlusions by retrieval devices remain very limited [9,10]. Received 4 May 2015; revised 29 September 2015; accepted 13 November 2015; publish online 11 December 2015. ∗ Correspondence: Tianxiao Li, Department of Interventional Therapy, Henan Provincial People’s Hospital Affiliated to Zhengzhou University, Zhengzhou, China. E-mail: [email protected]
Multimodal reperfusion therapy (MMRT) is an advanced concept for the management of acute large intracranial vessel occlusion. Theoretically, it should display certain advantages when targeting such complex vascular conditions. However, to date, endovascular access, recanalization sequence, endovascular techniques and complications from this novel reperfusion strategy still require more detailed study. Therefore, we have undertaken to evaluate the safety and efficacy of MMRT for TIM occlusions, and report on our findings in this study.
Materials and methods Between November 2011 and October 2014, cases of TIM occlusion were recruited at our center and retrospectively reviewed, which were performed with MMRT that met the following criteria: (1) age ≤ 70; (2) acute stroke that presented within 6 h of initial stroke symptom onset; (3) an National Institute of Health Stroke Scale (NIHSS) score ≥10, or persistent progression of 1
2
Q. Shao et al.
Table 1. The basic clinical data of patients with TIM occlusions.
Sex
Age
Occlusion
Stroke etiology (TOSAT)
1
F
36
R-ICA+MCA
Dissection
2
M
49
R-ICA+MCA
3
M
65
L-ICA+MCA
4
M
61
R-ICA+MCA
5
F
70
R-ICA+MCA
6
M
80
R-ICA+MCA
Atherosclerotic thromboembolism Atherosclerotic thromboembolism Atherosclerotic thromboembolism Cardiogenic thromboembolism Cardiogenic thromboembolism
Downloaded by [University of Nebraska, Lincoln] at 04:52 15 December 2015
Patient No.
NIHSS Thrombolytic score at therapy admission
Infarction site and full-size
Qureshi grade
Frontal and temporal cortices; large Basal ganglia; medium
4A
–
17
5
–
18
Frontal and temporal cortices; multiple Basal ganglia; large
4A
–
17
4A
–
20
4B
Urokinase
13
4B
–
15
Centrum semiovale; medium Frontal and temporal cortices; medium
Note: M: male; F: female; L: left; R: right; ICA: internal carotid artery; MCA middle cerebral artery; large: more than a lobe, the cross-sectional maximum diameter >5.0 cm; medium: less than a lobe, the cross-sectional maximum diameter >3 cm and ≤5 cm; the cross-sectional maximum diameter >1.5 cm and ≤3 cm; 4A: ICA occlusion, collaterals fill middle cerebral artery; 4B: internal carotid artery occlusion, collaterals fill anterior cerebral artery; 5: ICA occlusion, no collaterals; –: no thrombolytic therapy; NIHSS: National Institute of Health Stroke Scale.
more than 1 h; (4) exclusion of cerebral hemorrhage or other intracranial diseases by computed tomography (CT) scan, the early low density infarction area that was less than one third of the middle cerebral artery (MCA) territory; (5) TIM occlusion, which was confirmed by digital subtraction angiography (DSA); and (6) all subjects signed an informed consent document.
Patient assessment and treatment TOAST (trial of org 10172 in acute stroke treatment) classification and Qureshi were used to diagnose the pathogenesis and evaluate the collateral flow, respectively [11,12]. Moreover, the maximum diameter of the infarct was measured under an imaging system (Table 1). The NIHSS score was performed on admission and a loading dose of 300 mg clopidogrel was taken via an oral or nasogastric tube before endovascular treatment for patients that were not on a routine anti-platelet regimen. Intravenous heparin at a dose of 3000 U was given immediately after establishing femoral access and then 1000 U/h of heparin was added. Post-operative management was the same as that given for routine neurological therapy of acute cerebral infarct. Dual antiplatelet medication (i.e. aspirin 100 mg/day and clopidogrel 75 mg/day) was administered for three month after a CT brain scan showed no hemorrhage. Then clopidogrel was discontinued and aspirin (100 mg/day) was continued chronically. Computed tomography (CT) or magnetic resonance imaging (MRI) scans (including diffusion weighted imaging (DWI) sequences) and magnetic resonance angiography (MRA) for all patients were performed immediately to exclude incidence of intracranial hem-
orrhage or major ischemic infarction (i.e. an acute ischemic change in more than a third of the MCA territory), and then DSA was performed to verify the occlusion sites of the large artery under local or general anesthesia.
Endovascular technique Through a transfemoral approach, an 8-Fr guiding catheter (i.e. Cordis, New Brunswick, NJ, USA) was placed at the proximal internal carotid artery (ICA) occlusion. A 0.014-inch micro-guidewire (synchro-14, Boston Scientific Inc., USA) was advanced over a rapid transit microcatheter (SL-10, Boston Scientific, USA) and carefully navigated through the MCA occlusion. The microcatheter tip was subsequently advanced over the micro-guidewire to the distal M2 segment of MCA, which was then gradually retreated to identify the distribution location of the clot via angiography. According to the occlusion site and length, strategies for endovascular treatment were determined and the mechanical maneuvers, which included Wallstent (Boston Scientific, Natikeshi, MA, USA), Solitaire AB (Covidien, Saint Louis, MO, USA), Apollo (MicroPort, Shanghai, China), Wingspan (Stryker, Natikeshi, MA, USA) and the Penumbra aspiration catheter (Penumbra, USA) were selected. In this study, MMRT was used to obtain recanalization of TIM occlusions in all patients by the antegrade approach that incorporated the concept of “first near then far” (Table 2).
Treatment evaluation The angiographic results were assessed independently by two experienced investigators in neuro-intervention. International Journal of Neuroscience
3
3
4
4
6
3
2
3
4
5
6
130
177
60
104
230
143
TO (min)
6.0
9.5
6.0
6.2
7.5
9.0
TOR (h) MT with manual aspiration device and Solitaire AB Stent placement and MT with Solitaire AB MT with the Penumbra system and Solitaire AB MT with the Penumbra system and Stent placement Stent placement and MT with Solitaire AB MT with the Penumbra system and Solitaire AB
MMRT techniques
2b
2b
3
3
3
2a
Post-operative TICI
No
No
Brain edema
Cerebral hemorrhage (PH1) No
Cerebral hemorrhage (PH1)
Complication
14
13
19
11
10
15
Three days NIHSS score
6
11
17
7
3
10
NIHSS score at discharge
3
–
5
3
1
3
mRS score at 90 days
Note: TOA: time from onset to admission; TO: time of operation (from puncture to recanalization); TOR: time from onset to recanalization; MT: mechanical thrombectomy; TICI: thrombolysis in cerebral infarction; PH1: a homogeneous hematoma covering 70 years and an initial higher NIHSS score. Additionally, factors such as age, extent of irreversible ischemia and pattern of collateral flow are closely related to clinical prognosis of acute stroke patients with endovascular treatment. Thus, strict selection of clinical indications in these patients required is particularly important to avoid futile recanalization.
Conclusions For this complex vascular problem, our results suggest that MMRT may be feasible and safe, and appears to benefit early neurological improvement in patients with TIM occlusions. Nevertheless, the main limitation of our study includes the small sample size, and that the study was a single-center and retrospective design. Further experience and prospective randomized studies might be necessary to verify the novel concept reported herein in the context of managing TIM occlusions.
Declaration of Interest The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper.
References 1. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 2007;38:967–73. 2. Rubiera M, Ribo M, Delgado-Mederos R, et al. Tandem internal carotid artery/middle cerebral artery occlusion: an independent predictor of poor outcome after systemic thrombolysis. Stroke 2006;37:2301–5.
C
2015 Taylor and Francis
7
3. Barreto AD, Albright KC, Hallevi H, et al. Thrombus burden is associated with clinical outcome after intra-arterial therapy for acute ischemic stroke. Stroke 2008;39:3231–5. 4. Kim, YS, Garami, Z, Mikulik R, et al. Early recanalization rates and clinical outcomes in patients with tandem internal carotid artery/middle cerebral artery occlusion and isolated middle cerebral artery occlusion. Stroke 2005;36:869–71. 5. Behme D, Kowoll A, Mpotsaris A, et al. Multicenter clinical experience in over 125 patients with the Penumbra Separator 3D for mechanical thrombectomy in acute ischemic stroke. J Neurointerventional Surg 2014. doi: 10.1136/neurintsurg2014-011446. 6. Pereira VM, Gralla J, Davalos A, et al. Prospective, multicenter, single-arm study of mechanical thrombectomy using Solitaire Flow Restoration in acute ischemic stroke. Stroke 2013;44:2802–7. 7. Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. New England J Med 2015;372:1019–30. 8. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. New England J Med 2015;372:2285–95. 9. Mpotsaris A, Bussmeyer M, Buchner H, et al. Clinical outcome of neurointerventional emergency treatment of extra- or intracranial tandem occlusions in acute major stroke: antegrade approach with Wallstent and Solitaire stent retriever. Clin Neuroradiology 2013;23:207–15. 10. Malik AM, Vora NA, Lin R, et al. Endovascular treatment of tandem extracranial/intracranial anterior circulation occlusions: preliminary single-center experience. Stroke 2011;42:1653–7. 11. Han, SW, Nam HS, Kim SH, et al. Frequency and significance of cardiac sources of embolism in the TOAST classification. Cerebrovascular Diseases 2007;24:463–8. 12. Qureshi AI. New grading system for angiographic evaluation of arterial occlusions and recanalization response to intraarterial thrombolysis in acute ischemic stroke. Neurosurgery 2002;50:1405–14. 13. Zaidat OO, Lazzaro MA, Liebeskind DS, et al. Revascularization grading in endovascular acute ischemic stroke therapy. Neurology 2012;79(Suppl 1):S110–6. 14. Spiotta AM, Lena J, Vargas J, et al. Proximal to distal approach in the treatment of tandem occlusions causing an acute stroke. J Neurointerventional Surg 2014; doi:10.1136/neurintsurg2013-011040. 15. 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 Neurointerventional Surg 2013;5:440–6. 16. Machi P, Lobotesis K, Maldonado IL, et al. Endovascular treatment of tandem occlusions of the anterior cerebral circulation with solitaire FR thrombectomy system. Initial experience. Eur J Radiol 2012;81:3479–84. 17. Hwang SB, Kwak HS, Chung GH, et al. Forced suction thrombectomy after carotid stenting in patients with massive thrombus and acute extracranial internal carotid artery occlusion. J Neurointerventional Surg 2013;5:426–9. 18. Molina CA. Futile recanalization in mechanical embolectomy trials: a call to improve selection of patients for revascularization. Stroke 2010;41:842–3. 19. Hussein HM, Georgiadis AL, Vazquez G, et al. Occurrence and predictors of futile recanalization following endovascular treatment among patients with acute ischemic stroke: a multicenter study. Am J Neuroradiology 2010;31:454–8.
