Internal Carotid Artery Occlusion Research Articles

Microsurgical Clipping of Blood Blister-like Anterior Communicating Artery Aneurysm in a Patient with Total Occlusion of Left Internal Carotid Artery Aneurysm.

Blister-like aneurysms represent a rare subtype characterized by a wide neck and dissecting appearance, predisposing them to perioperative rebleeding due to fragile walls. These aneurysms predominantly occur at non-branching sites of the internal carotid artery (ICA). Still, they may also manifest at atypical locations, including the anterior communicating artery (AComA), anterior cerebral artery, middle cerebral artery, posterior cerebral artery, and basilar artery.1 Treatment of blister-like aneurysms typically involves a combination of microsurgery and endovascular procedures, with no universally established optimal therapeutic approach. Because of the total occlusion of the left ICA and both cerebral hemispheres supply from the right ICA through the anterior communicating artery, we choose microsurgery to avoid thrombotic endovascular complications. Andaluz etal. presented a case series of 5 patients with blister AComA aneurysms who underwent microsurgical intervention.2 We present a challenging case of a 64-year-old man with thick subarachnoid hemorrhage and total and chronic thrombosis of the left ICA that came with a blister-like AComA aneurysm. This patient underwent microsurgical clipping of an aneurysm (Video 1). In our center, lateral supraorbital craniotomy, described by Hernesniemi etal.3 is the preferred surgical approach for most anterior circulation aneurysms. Under general anesthesia and in a supine position, the head was fixed using Sugita then the head and shoulder were elevated above to the cardiac level, rotated 30° to the contralateral side, and tilted slightly with some degree of flexion or extension depending on surgical preferences. A curvilinear frontotemporal skin incision behind the hairline was performed. Preserving facial nerve branches, a myocutaneous flap was reflected anteriorly to the superior orbital rim. One bur hole was set below the posterior extension of the superior temporal line and a modified 4 x 4 cm craniotomy was performed using a conventional craniotomy. The sphenoid ridge was drilled off using a diamond bur maximizing the surgical corridor. Dura was opened in a semilunar fashion and reflected anterolaterally. Dissection was started in the basal frontal surface and arachnoid dissection along the optic nerve and the optic-carotid triangle proceeded. We routinely dissected and opened the lamina terminalis posterior to optic chiasma for further cerebrospinal fluid drainage. Wide Sylvian fissure dissection was performed to minimize brain retraction. Sharp arachnoid dissection over the right A1 to AComA complex and optic chiasma was carried out and then proximal control is achieved with a temporary clip. During aneurysm surgery, an intraoperative rupture occurred that was controlled with a temporary clip. Sharp aneurysm dissection and then aneurysm clipping is made under the temporary clip. Six days after the operation, the patient was discharged home without any neurologic deficit.

Predictors of prognosis in stroke patients with tandem lesions who undergo emergent stenting.

The optimal endovascular approach for tandem lesions (extracranial internal carotid artery and intracranial large vessel occlusion) is not clear. Aims: The aim was to evaluate the follow-up results of stroke patients with tandem lesions who underwent emergent stenting of extracranial lesions with antithrombotic therapy combined with intracranial MT. Outcomes and predictors of poor prognosis and mortality compared with those of good prognosis at 90days, 1year, and 2years were assessed. A modified Rankin scale (mRS) score was used. Symptomatic intracranial hemorrhage (sICH), National Institutes of Health Stroke Scale (NIHSS) scores at admission and at 24h, successful recanalization, asymptomatic ICH, embolization, malignant infarction, decompression, in-stent restenosis and extracranial complications were also evaluated. The best age cutoff for predicting mortality was analyzed. A total of 71 subjects were included. Using patients with a good prognosis as a reference, the independent variables predicting a poor prognosis were a high 24-h NIHSS score and extracranial complications at all timepoints (3-month, 1-year, and 2-year follow-up). The most appropriate age cutoff for predicting 1-year mortality was 67years [AUC = 0.802 (95% CI = 0.684-0.920); p < .001]. The age cutoff determined for the first year was correlated with the prediction of mortality in the third month and the second year. No significant association was observed between sICH and the groups. In this study, the 24-h NIHSS score after reperfusion and age were predictors of poor prognosis and mortality in stroke patients with tandem lesions who underwent emergent stenting during thrombectomy.

The presence of coexisting ICA occlusion (ICAO) is the main associated factor of posterior cerebral artery (PCA) aneurysm rupture

Posterior cerebral artery (PCA) aneurysms are rare but clinically significant due to their critical location and complex management. The risk factor of the PCA aneurysms rupture remains unclear. This study aimed to investigate the associated factor of PCA aneurysms rupture in a large Chinese cohort. We conducted a cross-sectional study including patients diagnosed with PCA aneurysms between January 2017 and December 2020. The study population comprised 143 patients, with 95 in the ruptured group and 48 in the unruptured group. Data on demographic characteristics, aneurysm features, medical history, and treatment outcomes were collected and analyzed using SPSS 27.0. Univariate and multivariate logistic regression analyses were performed to identify associated factors for PCA aneurysm rupture. The presence of coexisting internal carotid artery occlusion (ICAO) was identified as an independent associated factor for PCA aneurysm rupture (odds ratio [OR]= 4.74, 95% confidence interval [CI] 1.22-18.42, P= 0.03). Ischemic stroke (OR=0.44, 95% CI: 0.20-0.97, P= 0.02) and multiple aneurysms (OR=0.41, 95% CI: 0.19-0.87, P= 0.04) were found to be potential protective factors against rupture. The study also revealed a higher incidence of ICAO in the ruptured group (18.9%) compared to the unruptured group (6.3%), indicating a significant association with aneurysm rupture. This is the first multicenter study to highlight the coexistence of ICAO as a major associated factor for PCA aneurysm rupture in the Chinese population.

Controversies in the management strategy for symptomatic chronic internal carotid artery occlusion.

Controversies in the management strategy for symptomatic chronic internal carotid artery occlusion.

Meta-analysis on the primary approach: Aspiration versus stent retrieval for internal carotid artery occlusion.

Previous studies have not provided consistent findings regarding the efficacy of aspiration thrombectomy versus stent retriever thrombectomy in patients with acute internal carotid artery occlusion. This study aimed to evaluate the preferable endovascular technique (aspiration or stent retriever) and the impact of stent retriever utilization on both clinical and angiographic outcomes. We collected potential scholarly articles from a variety of databases including the PubMed, Web of Science, Embase, Cochrane Library, ClinicalTrials.gov, and the World Health Organization, International Clinical Trials Registry Platform. The search spanned from the establishment of electronic databases up to March 2024. Additionally, gray literature was sourced from the references cited in the included literature reports. Statistical analysis of the combined data was performed using STATA version 11.0 (Stata Corporation, TX). Our analysis comprises a total of 4 studies, involving 759 participants in total. Among these individuals diagnosed with internal carotid artery occlusion, 435 were assigned to the aspiration group, while 324 were designated to the stent retriever group. The findings indicated a significant increase in the rate of successful reperfusion in the stent retriever group compared to the aspiration group. Furthermore, it was observed that the incidence of overall complications, intracerebral hemorrhage, embolization formation, puncture to reperfusion time, and onset to reperfusion time in the stent retriever group did not significantly exceed that in the aspiration group. In our review on intracranial internal carotid artery occlusion, stent retrievers outperformed direct aspiration in achieving successful reperfusion. However, further studies evaluating the effects of different approaches to internal carotid artery clot removal are required to confirm these results.

Point-of-care ultrasound of the common carotid arteries for detection of large vessel occlusion stroke: Results of the POCUS-LVO study.

Distal arterial occlusions can cause measurable changes in the flow wave profile in proximal segments of the feeding artery. Our objective was to study the diagnostic accuracy of point-of-care ultrasound (POCUS) of the common carotid arteries (CCA) for detection of anterior circulation large vessel occlusion (ac-LVO) in patients with suspected stroke. We conducted a prospective, single-center, observational study of adult patients with suspected stroke admitted in the emergency department. Flow wave profiles of both CCAs were generated by non-specialists using POCUS as soon as possible after admission. ac-LVO was defined as an internal carotid artery or M1 occlusion in CT- or MR-angiography. The diagnostic performances for detection of ac-LVO using flow wave parameters were calculated. Among 283 patients recruited during a 10-month period, 257 patients (91%) had CCA ultrasound images of sufficient quality and were included for analysis. The mean age was 75 years (IQR 62-83), 131 were female (51.0%), median baseline NIHSS was 2 (IQR 0-5). The most frequent final diagnosis was ischemic stroke (49.4%), ac-LVO was present in 30 patients (11.9%). The median duration of POCUS was 3 min (IQR 2-5). Among all flow wave parameters, the highest diagnostic accuracy for ac-LVO detection was found for end-diastolic velocity difference between sides (AUC = 0.90, 95%CI = 0.85-0.93), with a specificity of 83% (95%CI = 78-88%) at a predefined sensitivity threshold of 80%. POCUS of the CCA in patients with suspected stroke can predict the presence of ac-LVO. These results need to be replicated in a prehospital setting.

A Case of One-Stage Treatment for Six Cerebral Aneurysms of One Carotid Basin with Concomitant Occlusion of the Contralateral Internal Carotid Artery

A Case of One-Stage Treatment for Six Cerebral Aneurysms of One Carotid Basin with Concomitant Occlusion of the Contralateral Internal Carotid Artery

Is there a simple and accessible solution to improve acute infarct core imaging? The utility of steady-state CT angiographic source images obtained from a delayed phase acquisition.

Early identification and quantification of core infarct is of importance in stroke management for treatment selection, prognostication, and complication prediction. Non-contrast computed tomography (CT) (NCCT) remains the primary tool, but it suffers from limited sensitivity and inter-rater variability; CT perfusion is inconsistently available and commonly blighted by movement artefact. We assessed the performance of a standardised form of CT angiographic source imaging (CTASI) obtained through addition of a delayed phase at 40 seconds post-contrast injection (DP40) following fast-acquisition CT angiography. Contrast resolution between ischaemic and normal grey matter (GM) was compared qualitatively and quantitatively to NCCT. Using Alberta Stroke Program Early CT Score (ASPECTS), DP40 low density was compared to NCCT and venous phase CT perfusion source images (CTPSI) and to 24-hour NCCT ASPECTS in patients with timely endovascular recanalisation (Thrombolysis In Cerebral Infarction 2C/3). Seventy-four patients with a proximal middle cerebral artery or terminal internal carotid artery occlusion were included. The mean attenuation difference between ischaemic and normal GM increased from 4.86+/-3.12 HU (NCCT) to 9.30+/-3.14 HU (DP40) (p < 0.0001). Subjective assessment by two raters revealed that DP40 improved ischaemic tissue conspicuity in 39 to 41 (78-82%) of cases (kappa 0.805, standard error 0.108, 95% confidence interval: 0.593-1.000). The correlation between ASPECTS on baseline imaging and eventual 24-hour ASPECTS improved from R = 0.7197 for NCCT to R = 0.9875 for DP40 (z = 7.89, p < 0.0001). The correlation between DP40 and venous phase CTPSI ASPECTS was 0.9681, p < 0.0001. DP40 CTASI represent a simple technique for improving detection and estimation of extent of ischaemia over NCCT and show close correlation with surrogate measures of infarct core.

Outcome of acute ischemic stroke with absent opacification of the cervical internal carotid artery at CT-angiography after endovascular treatment.

Purpose: Occlusion of the distal internal carotid artery can simulate a proximal occlusion of its cervical tract on CT angiography in patients with acute ischemic stroke, that is, pseudo-occlusion. As true and false carotid occlusions can present similarly on non-invasive imaging in patients undergoing endovascular treatment for stroke, our study aimed to evaluate clinical and technical differences of these conditions and the possible consequences of a misdiagnosis. Methods: We retrospectively reviewed consecutive patients who underwent mechanical thrombectomy for acute ischemic stroke at a single center between July 2015 and May 2022 and included patients with absent opacification of the cervical carotid artery on CT-angiography. Digital subtraction angiography (DSA) imaging and procedural data were evaluated to define the actual localization of the occlusion. We compared imaging and clinical data between patients with true and false carotid occlusion, including collateral circulation at CTA, revascularization grade, and clinical outcome at 3months. Results: A total of 116 patients were included, 63 (54%) of whom had true occlusion of cervical internal carotid artery. Compared to the pseudo-occlusion group, collateral circulation at CTA was moderate to good in 75% of cases (vs 32%; p < 0.0001) and the mean ASPECT score at 24h was 7 versus 2 (p < 0.0001). Modified Rankin scale 0-2 at 90days was more frequent in patients with true occlusion than those with pseudo-occlusion (48 vs 11%; p = 0.0002). Conclusion: Pseudo-occlusion of the cervical internal carotid artery in patients with acute ischemic stroke appears to be associated with worst prognosis and poorer collateral circulation in comparison with tandem occlusion.

Evaluation of contralateral arterial flow compensation using transcranial Doppler in acute internal carotid artery occlusion and implications for neurological outcome

Acute internal carotid artery occlusion (AICAO) can result in malignant cerebral edema and unfavorable patient outcomes. This study evaluated the utility of transcranial Doppler (TCD) in assessing contralateral flow compensation and predicting outcomes in patients with AICAO. We enrolled 51 patients within 6 h of symptom onset and conducted TCD examinations to evaluate collateral circulation. Among the 51 patients, 40 (78.4%) had collateral flow. TCD showed excellent agreement with magnetic resonance angiography (MRA)/CT angiography (CTA) in assessing anterior communicating artery (ACoA) status (kappa = 0.873, p < 0.001). Our findings indicated that the absence of collaterals (OR = 7.649, p = 0.032), younger age (OR = 0.907, p = 0.048), and lower Alberta Stroke Program Early CT Score 24 h after onset (ASPECTs1) (OR = 0.276, p = 0.025) were independent predictors of malignant cerebral edema. Additionally, advanced age, elevated National Institutes of Health Stroke Scale Score (NIHSSs) in the Emergency Department, sole extracranial-to-intracranial collateral circulation (EICC), and absence ACoA were independently associated with worse outcomes (all p < 0.05). In conclusion, TCD evaluation of collateral circulation in AICAO patients can effectively predict the risk of malignant cerebral edema, with ACoA presence correlating with favorable outcomes and sole EICC linked to poorer prognosis. While age, NIHSSs and ASPECTs also contribute, TCD’s assessment of collaterals provides key insights for patient management.

Early Neurological Deterioration in Acute Ischemic Minor Stroke Patients with Large Vessel Occlusion Following Intravenous Thrombolysis.

Early identification of risk factors associated with early neurological deterioration (END) in patients with acute minor stroke and large vessel occlusion (LVO) receiving intravenous thrombolysis (IVT) could assist in formulating treatment decisions. Consecutive patients with acute minor stroke and LVO were extracted from a single-center prospective database spanning from January 2020 to December 2023. END was defined as an increase of ≥4 points in the National Institutes of Health Stroke Scale score from baseline or ≥2 points in any single National Institutes of Health Stroke Scale item, within 24 hours of IVT. Multivariate logistic regression analysis, adjusted for confounding variables, was employed to identify risk factors associated with END. A total of 163 patients were included in this study, of which 36 (22.1%) patients encountered END. Patients in the END group had a higher proportion of isolated internal carotid artery (ICA) occlusion (30.6% vs. 6.3%), delayed antiplatelet therapy (88.9% vs. 66.1%), and a larger Tmax > 4 seconds volume (142 vs. 114 mL) (all P < 0.05). Multivariate logistic regression analysis after adjusting for confounding factors showed that isolated (ICA) occlusion (adjusted odds ratio= 2.49, 95% confidence interval= 1.97-4.41; P < 0.001) and delayed antiplatelet therapy (adjusted odds ratio= 1.46, 95% confidence interval= 1.17-1.84; P < 0.001) were significantly associated with END. Isolated ICA occlusion and delayed antiplatelet therapy were significantly associated with END in minor stroke patients with LVO following IVT. Bridging thrombectomy and early administration of antiplatelet therapy may be considered reasonable strategies.

Intentional staged embolization via the "highway bypass" using a radial artery graft for a large posterior circulation aneurysm: illustrative case.

The presence of significant tortuosity in access routes to aneurysms can interfere with catheter guidance and manipulation and significantly impact treatment strategies. In this report, the authors combined intentional staged aneurysm embolization with the construction of a new direct access route, which they call a "highway bypass," for a symptomatic posterior circulation cerebral aneurysm that was difficult to access with a catheter. Notably, the highway bypass is used for catheter passage, and technical tips should be considered. The patient had a symptomatic unruptured cerebral aneurysm in the first segment of the left posterior cerebral artery with bilateral internal carotid artery occlusion and severe tortuosity of the bilateral vertebral arteries. The highway bypass using a radial artery graft was performed in the first stage; in the second stage, the aneurysm was accessed using the graft, and embolization was performed. The catheter was passed through the graft without complications. The aneurysm was successfully embolized, no ischemic lesions were found in the postoperative images, and the patient was discharged without worsening neurological findings. Intentional staged aneurysm embolization combined with the highway bypass effectively treats aneurysms that are difficult to access. Anastomoses should be designed to allow catheters to pass through the graft. https://thejns.org/doi/10.3171/CASE24527.

Artificial dural regeneration matrix as a substitute for autologous tissue in indirect bypass in Moyamoya disease: Investigation of a rat model of chronic cerebral hypoperfusion

Indirect bypass using autologous tissue is effective in Moyamoya disease, especially among pediatric patients. This study aimed to evaluate the effectiveness of indirect bypass using DuraGen (absorbable artificial dura mater composed of collagen matrix), as a substitute for autologous tissue in a rat model of chronic cerebral hypoperfusion. Male Wistar rats were subjected to bilateral internal carotid artery occlusion and divided into three groups: a control group without bypass surgery, a group wherein indirect bypass was performed using the temporalis muscle (encephalo-myo-synangiosis [EMS] group), and a group wherein DuraGen was used (Dura group). The ratio of the number of vascular endothelial cells, detected by antibodies to CD31 and glucose transporter type 1 (Glut-1), on the operative side to that on the non-operative side was measured and compared between the three groups. The ratio of CD31-positive cells was 1.50 ± 0.13 and 1.92 ± 0.29 in the EMS and Dura groups, respectively, and that of Glut-1-positive cells was 1.32 ± 0.10 and 1.53 ± 0.18 in the EMS and Dura groups, respectively. No significant difference was observed in the ratio of vascular endothelial cells on the bypass side between the EMS and Dura groups. Indirect bypass with DuraGen resulted in an increased ratio of vascular endothelial cells, equivalent to that of an indirect bypass with the temporalis muscle in a rat model. Thus, in an actual indirect bypass for patients with Moyamoya disease, the use of DuraGen may produce the same angiogenesis as using autologous tissue.

Prognostic analysis of endovascular mechanical thrombectomy in stroke patients with acute internal carotid artery obstruction based on circle of Willis variation.

Endovascular mechanical thrombectomy (EVMT) is widely employed in patients with acute intracranial carotid artery occlusion (AIICAO). This study aimed to predict the outcomes of EVMT following AIICAO by utilizing anatomic classification of the circle of Willis and its relative position to the thrombus. In this study, we retrospectively analyzed a cohort of 108 patients with AIICAO who underwent endovascular mechanical thrombectomy (EVMT) at Shaoxing People's Hospital. Based on variations in the circle of Willis, as well as the size and location of the thrombus occluding the middle cerebral artery (MCA), anterior cerebral artery (ACA), and posterior cerebral artery (PCA), we classified AIICAO into four grades using digital subtraction angiography (DSA). EVMT was initiated upon admission, and baseline data including demographic characteristics, vascular risk factors, angiographic features, initial National Institutes of Health Stroke Scale (NIHSS) scores, Alberta Stroke Program Early CT Score (ASPECT), and etiology classification were compared across these four grades. The prognosis and mortality rates at 90 days post-stroke were evaluated for the different grades and within each grade, patients were further categorized into two subtypes based on vascular compensation and occluded vessels. Significant differences were observed among the four grades of Willis compensation concerning etiologic classification (p = 0.008), postoperative modified treatment in cerebral ischemia (mTICI, p = 0.017), postoperative symptomatic intracranial hemorrhage (sICH, p = 0.007), NIHSS score at admission (p = 0.001), and favorable outcomes at 90 days (modified Rankin Score 0-2) (p = 0.003). The mortality rate at 90 days exhibited a significant difference across the four grades of Willis compensation (p = 0.05). However, prognosis did not reveal any significant differences among the various subtypes within the same grade (p > 0.05). The assessment of the degree of Willis compensation can be improved by evaluating the integrity of the circle of Willis, as well as the size and location of the clot in cases of isolated internal carotid artery occlusion (iICAo). This approach provides valuable prognostic indicators and important insights for the pre-selection of patients prior to endovascular mechanical thrombectomy (EVMT).

Optic-Pyramidal Syndrome and Ophthalmoplegia Due to Internal Carotid Artery Occlusion: A Case Report

This case report highlights the neuro-ophthalmological complications, associated with internal carotid artery occlusion, particularly optic-pyramidal syndrome. We present the case of a 73-year-old female patient with a history of hypertension, admitted for right-sided hemiparesis and decreased visual acuity in the left eye, accompanied by ptosis. Imaging revealed a left fronto temporal ischemic stroke with occlusion of the internal carotid artery. We draw practitioners' attention to the potential occurrence of ophthalmoplegia in cases of optic-pyramidal syndrome. A carotid occlusion with inadequate collateral circulation from the vertebrobasilar system could explain the symptomatology, which may be transient or, in rare cases, permanent.

Comprehensive multi-omics, behavioral and morphological analysis of the hazards of nano-plastics in mice with internal carotid artery occlusion.

Accumulation of nanoplastics (NPs) poses a severe threat to the homeostasis of the internal environment in patients with chronic diseases. The effects of NP contamination on health in chronically ill populations must urgently be elucidated. In this study, NPs injected via the tail vein were distributed in the brain and internal organs in a mouse model of chronic internal carotid occlusion. Mice with chronic internal carotid artery occlusion exposed to NPs showed behavioral abnormalities, such as depression and anxiety, thus indicating detrimental effects of NPs on the brain. Subsequently, we used proteomics and metabolomics to analyze the specific mechanisms underlying the damaging effects of NP deposition in the brain. The findings helped explain the differences in the underlying biochemical responses at the microscopic level in mice after NP exposure. The NPs not only accumulated in the brain and caused pathologic damage, but also contributed to accelerating atherosclerosis in the mouse model of internal carotid artery occlusion. This work confirms the risk of NPs in a model of internal carotid artery occlusion and elucidates the mechanism underlying this harm; moreover, it provides theoretical support for developing strategies to decrease microplastic intake in patients with internal carotid artery occlusion.

Enhanced Benefit of STA-MCA Bypass Surgery in Chronic Terminal Internal Carotid and/or Middle Cerebral Artery Occlusion Patients With Impaired Collateral Circulation: Introducing a Novel Assessment Approach for Collateral Compensation.

Background: Ischemic stroke is one of the major emergency diseases leading to death and disability worldwide, characterized by its acute onset and the urgent need for prompt medical intervention to reduce mortality and long-term disability. Chronic terminal internal carotid artery and/or middle cerebral artery occlusion (CTI/MCAO) is an important subtype of intracranial artery occlusive disease. The superficial temporal artery-to-MCA (STA-MCA) bypass has been proposed to improve cerebral blood flow (CBF) and cerebrovascular reserve (CVR), potentially enhancing neurological outcomes. However, its safety and efficacy in CTI/MCAO patients remain controversial. Methods: A total of 107 CTI/MCAO patients from Nanjing Brain Hospital, enrolled between July 2019 and June 2022, were divided into surgical and medical treatment groups. Cerebral perfusion and collateral formation were evaluated using pseudocontinuous arterial spin labeling (pCASL) and digital subtraction angiography (DSA). Modified Rankin scale (mRS) score and complication rates were compared between the two groups. In addition, correlations between Matsushima grades, early-arriving flow proportion (EFP), and lesion-side cerebrovascular (LCBV) scores were analyzed. Results: The surgical group showed significantly lower mRS scores than the medical group (p=0.018), with no significant differences in complication rates at the 6-month follow-up (p=0.861). CBF differed significantly among affected MCA segments (p < 0.001), particularly in the insular and opercular regions (M2-M3) (p=0.006). Matsushima grades in unilateral CTI/MCAO patients were negatively correlated with preoperative LCBV scores (γ s = -0.468, p=0.005) and EFP (γ s = -0.648, p=0.007). EFP demonstrated high accuracy in predicting LCBV scores in CTI/MCAO patients (AUC = 0.902, p=0.004). Conclusion: STA-MCA bypass surgery improved neurological outcomes in CTI/MCAO patients, particularly those with poor preoperative collateral compensation. EFP may serve as a reliable, noninvasive tool for assessing collateral circulation status in this population.

A Case of N-Butyl-2-Cyanoacrylate Embolization of a Lateral Posterior Choroidal Artery Aneurysm Associated with Internal Carotid Artery Occlusion

A Case of <i>N</i>-Butyl-2-Cyanoacrylate Embolization of a Lateral Posterior Choroidal Artery Aneurysm Associated with Internal Carotid Artery Occlusion

Randomized Clinical Trial of Extending the Time Window of Endovascular Therapy in the Triage of Late Presenting Stroke Beyond 24 h (SKIP-EXTEND): Rationale and Study Protocol

The therapeutic time window for endovascular therapy in acute stroke patients with large-vessel occlusion was extended to 24 hours from onset. Although a retrospective study showed the efficacy of endovascular therapy beyond 24 hours from the last known well, it remains unclear whether endovascular therapy is effective. Extending the time window of Endovascular therapy in the Triage of Late Presenting Strokes beyond 24 h (SKIP-EXTEND trial) aimed to clarify the efficacy of endovascular therapy compared to the best medical management. This is an investigator-initiated, multicenter, prospective, randomized, open-label, blinded end-point clinical trial. Eligibility criteria included adults and pre-stroke modified Rankin scale score ≤2 with internal carotid artery or M1 (horizontal or sphenoidal segment) occlusion beyond 24 to 72 hours of the last known well. The target enrollment is 260 patients, with 130 reeiving endovascular therapy and 130 receiving the best medical treatment. The primary outcome is the rate of favorable outcome defined as a modified Rankin scale score ≤2 at 90 days. The secondary outcomes are the ordinal logistic regression analysis of the modified Rankin scale score and the rate of recanalization at 48 hours. As safety outcomes, the rate of any and symptomatic intracranial hemorrhage at 24 hours and the rate of mortality at 90 days are assessed. This is the first randomized controlled trial to focus on the efficacy of endovascular therapy beyond 24 hours. Our results will not only benefit patients but also reduce healthcare costs. We believe that this novel study will be useful in clinical practice.

Factors Influencing Nerinetide Effect on Clinical Outcome in Patients Without Alteplase Treatment in the ESCAPE-NA1 Trial.

In the ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke) trial, treatment with nerinetide was associated with improved outcomes in patients who did not receive intravenous alteplase. We compared the effect of nerinetide on clinical outcomes in patients without concurrent intravenous alteplase treatment within different patient subgroups. ESCAPE-NA1 was a multicenter randomized trial in which acute stroke patients with baseline Alberta Stroke Program Early CT Score (ASPECTS) >4 undergoing endovascular treatment (EVT) were randomized to intravenous nerinetide or placebo. The primary outcome was independence (modified Rankin Scale [mRS] score 0-2) at 90 days. We assessed baseline, clinical, and imaging variables as predictors of outcome and for evidence of treatment effect modification. We constructed two multivariable models using variables known prior to randomization and variables known immediately post-EVT procedure to provide adjusted estimates of effect. We assessed for evidence of treatment effect modification using multiplicative interaction terms within each model. Four hundred forty-six patients were included in the analysis. Clinical outcomes were better in patients randomized to the nerinetide arm (mRS 0-2: 59.4% vs. 49.8%). There was possible treatment effect modification by ASPECTS score; patients with ASPECTS 8-10 showed a larger treatment effect compared to those with lower ASPECTS score. Younger age, lower NIHSS score, lower baseline serum glucose, absence of atrial fibrillation at baseline, higher ASPECTS score, middle cerebral artery (vs. internal carotid artery) occlusion, use of conscious or no sedation (vs. general anesthesia), and faster treatment were all predictors of favorable outcome. Patients in the nerinetide arm who were not treated with concurrent alteplase showed improved clinical outcomes and the treatment effect was larger among patients with favorable ASPECTS profiles.