Abstract
IntroductionThere is no consensus on the optimal treatment for acute ischemic stroke (AIS) large vessel occlusions (LVOs) or near-occlusions with underlying intracranial atherosclerotic stenosis (ICAS). We report the first American series using intra-arterial (IA) glycoprotein IIb/IIIa inhibitors (GPIs) as a stand-alone revascularization technique for ICAS presenting with large vessel ischemic syndromes.MethodsRecords at two centers of 140 patients presenting with AIS undergoing stroke intervention from January 2017 to June 2019 were retrospectively reviewed. Patients treated with IA GPIs were identified, and baseline factors, imaging, procedural characteristics, hospital course, and outcomes were collected. Six patients with ICAS underlying their acute symptomatic near occlusion or LVO were treated with IA GPI. Four near-occlusions were treated with IA GPI as the first-line therapy, while two LVOs were treated with IA GPI as an adjunct therapy to thrombectomy.ResultsThe mean age was 61.3 years (range 36-79), presentation National Institute of Health Stroke Scale (NIHSS) was 10 (4-18), time from last seen well to treatment was 434.5 minutes (164-1290), and time from groin puncture to revascularization was 67.3 minutes (26-94). Three patients received intravenous (IV) tissue plasminogen activator (tPA), and all patients received an IA weight-based GPI infusion. Five patients had thrombolysis in cerebral ischemia (TICI) 3, and one patient had TICI 2b. The mean discharge NIHSS was 2.5 (0-8). The mean modified Rankin scale was 1.3 (range 0-4) at discharge and .8 at three months. No patients had a postprocedural symptomatic hemorrhage.ConclusionOur results highlight the utility of IA GPI administration as the first-line therapy for symptomatic ICAS near occlusions or as a rescue technique after failed thrombectomy for LVO patients suspected of underlying ICAS.
Highlights
There is no consensus on the optimal treatment for acute ischemic stroke (AIS) large vessel occlusions (LVOs) or near-occlusions with underlying intracranial atherosclerotic stenosis (ICAS)
Symptomatic patients presenting to our emergency department as stroke alerts with National Institute of Health Stroke Scale (NIHSS) scores ≥ 4 and computed tomography angiogram (CTA) demonstrating that either high-grade large vessel intracranial stenosis (≥ 70% stenosis defined by the WASID (Warfarin-Aspirin Symptomatic Intracranial Disease) criteria) or large vessel occlusions were analyzed
Inclusion criteria for endovascular therapy were the following: presentation within six hours of stroke onset for anterior circulation stroke; baseline NIHSS ≥ 4 with no hemorrhage or large territory infarct detected on cranial CT; occlusion or near occlusion of the internal carotid artery (ICA) or middle cerebral artery (MCA) artery detected with CTA and confirmed via catheter angiography; baseline modified Rankin Scale score ≤ 2
Summary
Records at two centers of 140 patients presenting with AIS undergoing stroke intervention from January 2017 to June 2019 were retrospectively reviewed. Six patients with ICAS underlying their acute symptomatic near occlusion or LVO were treated with IA GPI. Records of 140 patients presenting with AIS who underwent acute stroke intervention at two comprehensive stroke centers between January 2017 and June 2019 were retrospectively reviewed. Patients with NIHSS below 6 were taken to intervention based on CTA and CT perfusion imaging confirming LVO or near-occlusion with corresponding large perfusion deficit in the setting of debilitating clinical symptoms such as aphasia or waxing and waning symptoms considered harbingers of early neurological decline
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