Treatment of Acute Cerebral Artery Occlusion With a Fully Recoverable Intracranial Stent

Abstract

HomeCirculationVol. 121, No. 23Treatment of Acute Cerebral Artery Occlusion With a Fully Recoverable Intracranial Stent Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBTreatment of Acute Cerebral Artery Occlusion With a Fully Recoverable Intracranial StentA New Technique Panagiotis Papanagiotou, Christian Roth, Silke Walter, Stefanie Behnke, Maria Politi, Klaus Fassbender, Anton Haass and Wolfgang Reith Panagiotis PapanagiotouPanagiotis Papanagiotou From the Clinic for Diagnostic and Interventional Neuroradiology (P.P., C.R., M.P., W.R.) and Clinic for Neurology (S.W., S.B., K.F., A.H.), Saarland University Hospital, Homburg, Germany. Search for more papers by this author , Christian RothChristian Roth From the Clinic for Diagnostic and Interventional Neuroradiology (P.P., C.R., M.P., W.R.) and Clinic for Neurology (S.W., S.B., K.F., A.H.), Saarland University Hospital, Homburg, Germany. Search for more papers by this author , Silke WalterSilke Walter From the Clinic for Diagnostic and Interventional Neuroradiology (P.P., C.R., M.P., W.R.) and Clinic for Neurology (S.W., S.B., K.F., A.H.), Saarland University Hospital, Homburg, Germany. Search for more papers by this author , Stefanie BehnkeStefanie Behnke From the Clinic for Diagnostic and Interventional Neuroradiology (P.P., C.R., M.P., W.R.) and Clinic for Neurology (S.W., S.B., K.F., A.H.), Saarland University Hospital, Homburg, Germany. Search for more papers by this author , Maria PolitiMaria Politi From the Clinic for Diagnostic and Interventional Neuroradiology (P.P., C.R., M.P., W.R.) and Clinic for Neurology (S.W., S.B., K.F., A.H.), Saarland University Hospital, Homburg, Germany. Search for more papers by this author , Klaus FassbenderKlaus Fassbender From the Clinic for Diagnostic and Interventional Neuroradiology (P.P., C.R., M.P., W.R.) and Clinic for Neurology (S.W., S.B., K.F., A.H.), Saarland University Hospital, Homburg, Germany. Search for more papers by this author , Anton HaassAnton Haass From the Clinic for Diagnostic and Interventional Neuroradiology (P.P., C.R., M.P., W.R.) and Clinic for Neurology (S.W., S.B., K.F., A.H.), Saarland University Hospital, Homburg, Germany. Search for more papers by this author and Wolfgang ReithWolfgang Reith From the Clinic for Diagnostic and Interventional Neuroradiology (P.P., C.R., M.P., W.R.) and Clinic for Neurology (S.W., S.B., K.F., A.H.), Saarland University Hospital, Homburg, Germany. Search for more papers by this author Originally published15 Jun 2010https://doi.org/10.1161/CIRCULATIONAHA.110.948166Circulation. 2010;121:2605–2606A 42-year-old woman was referred to our institution with sudden onset of ataxia, facial paresis, horizontal gaze palsy, and progressive dysarthria. The patient worsened within a few minutes, with appearance of left hemiparesis. The National Institutes of Health Stroke Scale Score was 13.On computer tomography scan 2 hours after stroke onset, no brain stem lesion or intracranial bleeding was visible. Computed tomographic angiography revealed a mid basilar vessel occlusion, which suggested embolic basilar artery occlusion. A 4-vessel angiogram with a 5F diagnostic catheter confirmed the basilar artery occlusion and depicted more precisely the location of the thrombus (Figure 1A). Download figureDownload PowerPointFigure 1. A, Digital subtraction angiography after vertebral injection demonstrates a mid basilar vessel occlusion. B, The angiogram after placement of the stent from the left P1 segment (white arrow) into the basilar artery showed flow restoration of the basilar artery with a narrowing in the middle part of the vessel due to compression of the thrombus into the arterial wall (black arrows). C, Postprocedure angiography after removal of the stent showed complete recanalization of the basilar artery occlusion. The P2 segment of the right posterior cerebral artery is filled by the right carotid internal artery.To treat the patient, a 6F guiding catheter was inserted into the right vertebral artery. A 0.021-inch Rebar 27 microcatheter (ev3, Irvine, Calif) coaxially loaded over a 0.14-inch Silverspeed microwire (ev3, Irvine, Calif) was placed directly into the thrombus. Tissue plasminogen activator (40 mg/30 min) was administered intra-arterially. No recanalization was noticed on the control angiogram. After the unsuccessful intra-arterial thrombolysis, we performed stent-assisted mechanical recanalization with the Solitaire FR revascularization device (ev3, Irvine, Calif). The Solitaire FR is a new self-expanding, fully retrievable nitinol stent based on the Solitaire AB that is commonly used for stent-assisted treatment of intracranial aneurysms. A Rebar 27 microcatheter was navigated past the thrombus into the left P1 segment. The stent was placed and deployed from the left P1 segment into the basilar artery, with the middle third of the device residing within the thrombus formation. The subsequent angiogram showed flow restoration of the basilar artery with a narrowing in the middle part of the vessel due to compression of the thrombus into the arterial wall (Figure 1B). To withdraw the thrombus, the unfolded Solitaire stent and the Rebar microcatheter were slowly pulled into the guide catheter with constant aspiration with a 50-mL syringe from the guide catheter. Withdrawal was possible with minor effort and was observed under continuous fluoroscopy. It was evident that the device gently followed the course of the vessels without vessel displacement. Postprocedural angiography showed complete recanalization of the basilar artery occlusion (Figure 1C). Thrombus material was found in the stent (Figure 2). Download figureDownload PowerPointFigure 2. The Solitaire device with the removed thrombus.The duration of the procedure, including intra-arterial thrombolysis, was 50 minutes. After the procedure, the neurological examination performed by an experienced neurologist showed a National Institutes of Health Stroke Scale Score of 0. Control magnetic resonance imaging 1 day after treatment revealed a small hyperintensity on diffusion-weighted images that was not clinically relevant (Figure 3). The patient was discharged 4 days after the endovascular procedure. Download figureDownload PowerPointFigure 3. Diffusion-weighted images after the procedure revealed a small hyperintensity in the brain stem (arrow).Successful recanalization is associated with improved outcome after acute ischemic stroke.1 Mechanical thrombectomy techniques are widely used for treatment in case of failed recanalization after thrombolysis or in patients with contraindications for thrombolytic therapy.2 A variety of devices have been developed; however, recanalization rates remain decent, and the clots may adhere to the intima and become refractory to mechanical disruption or clot retrieval.Recent studies have reported positive outcomes with self-expanding stents in patients with acute intracranial occlusions.3 The first prospective trial of stent-assisted recanalization in acute ischemic stroke demonstrated a 100% recanalization rate in 20 patients.4 The study suggests that stent-assisted revascularization yields high recanalization rates with a reasonable safety profile.The application of self-expanding stents in acute stroke appears to have several advantages compared with other interventional techniques. First, stenting has a high reported rate of successful recanalization.3,4 Second, whereas other techniques often take hours to achieve recanalization, self-expanding stent implantation appears to produce immediate recanalization. However, there are important disadvantages to the use of stenting to treat acute stroke. The clot is only pressed to the vessel wall and not removed from the vessel, so there are concerns about early rethrombosis. Furthermore, placement of an intracranial stent may induce late in-stent stenosis. Finally, implantation of a permanent intracranial self-expanding stent requires aggressive antiplatelet therapy after placement.The Solitaire FR revascularization device is the only intracranial stent that is fully recoverable. Therefore, this device combines the advantages of prompt flow restoration and mechanical thrombectomy. Studies must demonstrate whether this promising new technique can serve as the treatment of the future in interventional acute stroke.*The first 2 authors contributed equally to this report.DisclosuresNone.FootnotesCorrespondence to Panagiotis Papanagiotou, MD, Clinic for Diagnostic and Interventional Neuroradiology, Saarland University Hospital, Kirrbergerstraße 1, Homburg, Germany. E-mail [email protected]References1 Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke. 2007; 38: 967–973.LinkGoogle Scholar2 Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS, Lutsep HL, Rymer MM, Higashida RT, Starkman S, Gobin YP; Multi MERCI Investigators, Frei D, Grobelny T, Hellinger F, Huddle D, Kidwell C, Koroshetz W, Marks M, Nesbit G, Silverman IE. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 2008; 39: 1205–1212.LinkGoogle Scholar3 Brekenfeld C, Schroth G, Mattle HP, Do DD, Remonda L, Mordasini P, Arnold M, Nedeltchev K, Meier N, Gralla J. Stent placement in acute cerebral artery occlusion: use of a self-expandable intracranial stent for acute stroke treatment. Stroke. 2009; 40: 847–852.LinkGoogle Scholar4 Levy EI, Siddiqui AH, Crumlish A, Snyder KV, Hauck EF, Fiorella DJ, Hopkins LN, Mocco J. First Food and Drug Administration-approved prospective trial of primary intracranial stenting for acute stroke: SARIS (stent-assisted recanalization in acute ischemic stroke). Stroke. 2009; 40: 3552–3556.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Adamou A, Gkana A, Mavrovounis G, Beltsios E, Kastrup A and Papanagiotou P (2022) Outcome of Endovascular Thrombectomy in Pre-stroke Dependent Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis, Frontiers in Neurology, 10.3389/fneur.2022.880046, 13 Jwa C, Kim J, Kang H, Bae I, Kim D and Moon B (2020) Permanent Stent Deployment for Preventing Vessel Reocclusion after Mechanical Thrombectomy in Acute Ischemic Stroke, The Nerve, 10.21129/nerve.2020.6.1.7, 6:1, (7-11), Online publication date: 30-Apr-2020. Zhu Y, Zhang H, Zhang Y, Wu H, Wei L, Zhou G, Zhang Y, Deng L, Cheng Y, Li M, Santos H and Cui W (2018) Endovascular Metal Devices for the Treatment of Cerebrovascular Diseases, Advanced Materials, 10.1002/adma.201805452, 31:8, (1805452), Online publication date: 1-Feb-2019. 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Roth C, Papanagiotou P, Behnke S, Walter S, Haass A, Becker C, Fassbender K, Politi M, Körner H, Romann M and Reith W (2010) Stent-Assisted Mechanical Recanalization for Treatment of Acute Intracerebral Artery Occlusions, Stroke, 41:11, (2559-2567), Online publication date: 1-Nov-2010. June 15, 2010Vol 121, Issue 23 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.110.948166PMID: 20547941 Originally publishedJune 15, 2010 PDF download Advertisement SubjectsAngiographyCardiopulmonary Resuscitation and Emergency Cardiac CareIschemic StrokeThrombosisTreatment