Internal Carotid Artery Terminus Occlusion Research Articles

The Prognostic Value of CT-Angiographic Parameters After Reperfusion Therapy in Acute Ischemic Stroke Patients With Internal Carotid Artery Terminus Occlusion: Leptomeningeal Collateral Status and Clot Burden Score

BackgroundThe objective of this study was to investigate the prognostic value of computed tomographic angiography (CTA) based on leptomeningeal collateral (LMC) status and other parameters in acute ischemic stroke (AIS) patients with internal carotid artery (ICA) terminus occlusion treated with endovascular treatment (EVT). MethodsAll eligible patients from January 2013 to December 2017 undergoing EVT were retrospectively reviewed. The regional leptomeningeal score was used to assess the LMCs on baseline CTA. The collateral status measured by the LMC score (0-20) was trichotomized into 3 groups: good (17-20), intermediate (11-16), and poor (0-10). ResultsOur sample included a total of 119 eligible patients (60 males; mean age, 73 years) with a median baseline National Institute of Health Stroke Scale (NIHSS) score of 14. Patients with a good LMC score had a lower baseline mean NIHSS score, a higher mean Alberta Stroke Program Early CT score, and a higher mean clot burden score (CBS). Baseline NIHSS score <15 (odds ratio [OR] 3.69 95% confidence ratio [CI]: 1.32-10.29, P = .013), CBS ≥ 6 (OR 3.97 95%CI: 1.05-14.99, P = .042), good LMC score (OR 5.14 95%CI: 1.62-16.26, P = .005) and successful recanalization (OR 11.55 95%CI: 2.72-48.99 P = .001) were independent predictors of good clinical outcomes. ConclusionsCTA-based LMC status and CBS are powerful predictors of clinical outcomes in patients with an acute ICA terminus occlusion treated with EVT.

Cervical ICA pseudo-occlusion on single phase CTA in patients with acute terminal ICA occlusion: what is the mechanism and can delayed CTA aid diagnosis?

BackgroundSingle-phase CT angiography (CTA) forms the basis of hyperacute stroke imaging but many patients with terminal internal carotid artery (ICA) occlusion exhibit a pseudo-occlusion of the cervical ICA whereby a...

Is bridging therapy still required in stroke due to carotid artery terminus occlusions?

IntroductionStudies comparing endovascular stroke treatment using mechanical thrombectomy (MT) with or without prior IV tissue plasminogen activator (tPa) have included only 30% of internal carotid artery terminus occlusions (ICA-O), a...

Diagnostic accuracy of emergency CT angiography for presumed tandem internal carotid artery occlusion before acute endovascular therapy

BackgroundExtracranial internal carotid artery (ICA) occlusion can be overestimated on emergent single phase CT angiography (CTA) of stroke patients with isolated intracranial ICA occlusion. We aimed to measure the ability...

Correlation of Tmax volumes with clinical outcome in anterior circulation stroke.

Background and PurposeThe recent thrombectomy trials have shown that perfusion imaging is helpful in proper patient selection in thromboembolic stroke. In this study, we analyzed the correlation of pretreatment T max volumes in MR and CT perfusion with clinical outcome after thrombectomy.MethodsForty‐one consecutive patients with middle cerebral artery occlusion (MCA) or carotid T occlusion treated with thrombectomy were included. T max volumes at delays of >4, 6, 8, and 10 s as well as infarct core and mismatch ratio were automatically estimated in preinterventional MRI or CT perfusion using RAPID software. These perfusion parameters were correlated with clinical outcome. Outcome was assessed using modified Rankin scale at 90 days.ResultsIn patients with successful recanalization of MCA occlusion, T max > 8 and 10 s showed the best linear correlation with clinical outcome (r = 0.75; p = .0139 and r = 0.73; p = .0139), better than infarct core (r = 0.43; p = .2592). In terminal internal carotid artery occlusions, none of the perfusion parameters showed a significant correlation with clinical outcome.Conclusions T max at delays of >8 and 10 s is a good predictor for clinical outcome in MCA occlusions. In carotid T occlusion, however, T max volumes do not correlate with outcome.

Proximal flow to middle cerebral artery is associated with higher thrombus density in terminal internal carotid artery occlusion.

Proximal collaterals may determine the composition of occluding thrombi in acute ischemic stroke (AIS) in addition to source, hematocrit, time, and medication. Here, we performed a retrospective study of 39 consecutive patients with radiological evidence of I‐, L‐, and T‐type terminal internal carotid artery occlusion. Middle cerebral artery (MCA) thrombus density was assessed on noncontrast enhanced CT and proximal collaterals on CT angiography. In patients with presence of proximal collaterals to the MCA we detected more hyperdense clots (P = 0.003) and a higher frequency of leptomeningeal collaterals (P = 0.008). We expand the spectrum of factors that potentially determine clot perviousness and evolution of ischemic stroke.

Timeline of blood pressure changes after intra-arterial therapy for acute ischemic stroke based on recanalization status.

There is sparse literature on the natural history of blood pressure (BP) after intra-arterial therapy (IAT) for acute ischemic stroke (AIS). A retrospective analysis was performed of patients with AIS who underwent IAT without endotracheal intubation for internal carotid artery terminus (ICA-T) or M1 middle cerebral artery occlusion from January 2008 to February 2012. Systolic BP (SBP) values at the beginning (First) and end (End) of IAT and for 36 h after the procedure were collected. Successful recanalization was defined as Thrombolysis In Cerebral Infarction (TICI) 2b-3. Sixty-two patients (14 (22.5%) ICA-T, 46 (74.2%) M1, 2 (3.2%) ICA-T+M1) met the study criteria and 37 (59.7%) achieved successful recanalization. The First and End SBP values were similar in the successful (Group R) and unsuccessful (Group NR) recanalization groups. Taking the whole cohort, End SBP was significantly lower than First SBP, but this decline was significant only in Group R. Subsequently, absolute SBP values in Group R were not significantly different from Group NR. However, when comparing the hourly decline of SBP with First SBP, Group R demonstrated a greater fall than Group NR and the decline was significantly different from hours 8 to 12 post-procedure. The SBP in Group NR then decreased further, and its difference from baseline was similar to Group R from hour 14 onwards. Mean SBP and SBP variability over 36 h were similar between the two groups. SBP falls significantly in patients with AIS with large vessel occlusion who recanalize with IAT. While SBP in non-recanalized patients also drops from baseline, it occurs to a lesser degree and stays higher only for a short period of time before falling to similar levels as in recanalized patients.

Differentiating Carotid Terminus Occlusions into Two Distinct Populations Based on Willisian Collateral Status.

Background and PurposeThe outcomes of acute internal carotid artery (ICA) terminus occlusions are poor. We classified ICA terminus occlusions into 2 groups according to the occlusion pattern of the circle of Willis and hypothesized that clinical outcomes would significantly differ between them.MethodsConsecutive patients with acute ICA terminus occlusions evaluated by baseline computed tomographic angiography were enrolled. We investigated the occlusion patterns in the circle of Willis, retrospectively classified patients into simple ICA terminus occlusion (STO; with good Willisian collaterals from neighboring cerebral circulation) and complex ICA terminus occlusion (CTO; with one or more of A2 anterior cerebral artery, fetal posterior cerebral artery occlusion, or hypoplastic/absent contralateral A1; or with poor collaterals from anterior communicating artery) groups, and compared their baseline characteristics and outcomes.ResultsThe STO group (n=58) showed smaller infarct volumes at 72 hours than the CTO group (n=34) (median, 81 mL [interquartile range, 38-192] vs. 414 mL [193-540], P<0.001) and more favorable outcomes (3-month modified Rankin Scale 0-3, 44.8% vs. 8.8%, P<0.001; 3-month mortality, 24.1% vs. 67.6%, P<0.001). In multivariable analyses, STO remained an independent predictor for favorable outcomes (odds ratio 6.1, P=0.010).ConclusionsFavorable outcomes in STO group suggested that the outcomes of acute ICA terminus occlusions depend on Willisian collateral status. Documenting the subtypes on computed tomographic angiography would help predict patient outcome.

What constitutes the M1 segment of the middle cerebral artery?

Intravenous tissue plasminogen activator has limited efficacy in fibrinolysis of large proximal intracranial thrombi. Thus, recent endovascular acute stroke trials restricted their selection criteria to patients with proximal occlusions in...

Endovascular Stroke Treatment Outcomes After Patient Selection Based on Magnetic Resonance Imaging and Clinical Criteria.

Which imaging modality is optimal to select patients for endovascular stroke treatment remains unclear. To evaluate the effectiveness of specific magnetic resonance imaging (MRI) and clinical criteria in the selection of patients with acute ischemic stroke for thrombectomy. In this observational, single-center, prospective cohort study, we studied 72 patients with middle cerebral artery or terminal internal carotid artery occlusion using computed tomographic angiography, followed by core infarct volume determination by diffusion weighted MRI, who underwent thrombectomy after meeting institutional criteria from January 1, 2012, through December 31, 2014. In this period, 31 patients with similar ischemic strokes underwent endovascular treatment without MRI and are categorized as computed tomography only and considered in a secondary analysis. Patients were prospectively classified as likely to benefit (LTB) or uncertain to benefit (UTB) using diffusion-weighted imaging lesion volume and clinical criteria (age, National Institutes of Health Stroke Scale score, time from onset, baseline modified Rankin Scale [mRS] score, life expectancy). The 90-day mRS score, with favorable defined as a 90-day mRS score of 2 or less. Forty patients were prospectively classified as LTB and 32 as UTB. Reperfusion (71 of 103 patients) and prospective categorization as LTB (40 of 103 patients) were associated with favorable outcomes (P < .001 and P < .005, respectively). Successful reperfusion positively affected the distribution of mRS scores of the LTB cohort (P < .001). Reperfusion was achieved in 27 LTB patients (67.5%) and 24 UTB patients (75.0%) (P = .86). Favorable outcomes were obtained in 21 (52.5%) and 8 (25.0%) of LTB and UTB patients who were treated, respectively (P = .02). Favorable outcomes were observed in 20 of the 27 LTB patients (74.1%) who had successful reperfusion compared with 8 of the 24 UTB patients (33.3%) who had successful reperfusion (P = .004). The ratio of treated to screened patients was 1:3. Prospective classification as LTB by MRI and clinical criteria is associated with likelihood of favorable outcome after thrombectomy, particularly if reperfusion is successful. Selection of patients using MRI compares favorably with selection using computed tomographic techniques with the distinction that a higher proportion of screened patients were treated.

Direct Microsurgical Embolectomy for Acute Occlusion of the Internal Carotid Artery and Middle Cerebral Artery

Surgical embolectomy is the most promising therapy for physically removing emboli from major cerebral arteries. However, it requires an experienced surgical team, time-consuming steps, and is not incorporated into acute stroke therapy. We established seamless collaboration between services, refined surgical techniques, and conducted a prospective trial of emergency surgical embolectomy. Surgical indications included the presence of acute hemispheric symptoms, absence of low-density area on computed tomography, evidence of internal carotid artery terminus or proximal middle cerebral artery occlusion, and availability of resources to start surgery within 3 hours of symptom onset. The indications were confirmed by an interdisciplinary team. We assessed revascularization rates, time from admission to surgery and from surgery to recanalization, procedural complications, and clinical outcomes. Between 2005 and 2014, 14 consecutive patients with acute proximal middle cerebral artery or internal carotid artery terminus occlusion underwent emergency surgical embolectomy. All patients showed complete recanalization. Twelve patients survived and 7 had fair functional outcome (Rankin Scale score, ≤3). No significant procedural adverse events occurred. The mean times from admission to start of surgery, from surgery to recanalization, and from onset to recanalization were 14 minutes, 79 minutes, and 223 minutes, respectively. Our results suggest that microsurgical embolectomy can rapidly, safely, and effectively retrieve clots and deserves reappraisal, although the choice largely depends on local institutional expertise.

Large Volumes of Critically Hypoperfused Penumbral Tissue Do Not Preclude Good Outcomes After Complete Endovascular Reperfusion

Acute ischemic stroke patients with large volumes of severe hypoperfusion (Tmax>10 s>100 mL) on magnetic resonance imaging have a higher likelihood of intracranial hemorrhage and poor outcomes after reperfusion. We aim to evaluate the impact of the extent of Tmax>10 s CTP lesions in patients undergoing successful treatment. Retrospective database review of endovascular acute ischemic stroke treatment between September 2010 and March 2015 for patients with anterior circulation occlusions with baseline RAPID CTP and full reperfusion (mTICI 3). The primary outcome was the impact of the Tmax>10 s lesion spectrum on infarct growth. Secondary safety and efficacy outcomes included parenchymal hematomas and good clinical outcomes (90-day modified Rankin Scale score, 0-2). Of 684 treated patients, 113 patients fit the inclusion criteria. Tmax>10 s>100 mL patients (n=37) had significantly higher baseline National Institutes of Health Stroke Scale (20.7±3.8 versus 17.0±5.9; P<0.01), more internal carotid artery terminus occlusions (29% versus 9%; P=0.02), and larger baseline (38.6±29.6 versus 11.7±15.8 mL; P<0.01) and final (60.7±60.0 versus 29.4±33.9 mL; P<0.01) infarct volumes when compared with patients without Tmax>10 s>100 mL (n=76); however, the 2 groups were otherwise well balanced. There were no significant differences in infarct growth (22.1±51.6 versus 17.8±32.4 mL; P=0.78), severe intracranial hemorrhage (PH2: 2% versus 4%; P=0.73), good outcomes (90-day mRS score, 0-2: 56% versus 59%; P=0.83), or 90-day mortality (16% versus 7%; P=0.28). On multivariate analysis, only baseline National Institutes of Health Stroke Scale (odds ratio, 1.19; 95% confidence interval, 1.06-1.34; P<0.01) and baseline infarct core volume (odds ratio, 1.05; 95% confidence interval, 1.02-1.08; P<0.01) were independently associated with Tmax>10 s>100 mL. There was no association between Tmax>10 s>100 mL with any PH, good outcome, or infarct growth. In the setting of limited baseline ischemic cores, large Tmax>10 s lesions on computed tomographic perfusion do not seem to be associated with a higher risk of parenchymal hematomas and do not preclude good outcomes in patients undergoing endovascular reperfusion with contemporary technology.

Successful endovascular stroke therapy in a 103-year-old woman

People older than 80 years of age constitute the most rapidly growing age group in the world. Several trials confirming superior efficacy of endovascular therapy did not have an upper...

Poor Collateral Circulation Assessed by Multiphase Computed Tomographic Angiography Predicts Malignant Middle Cerebral Artery Evolution After Reperfusion Therapies.

Collateral circulation (CC) has been associated with recanalization, infarct volume, and clinical outcome in patients undergoing acute reperfusion therapies. However, its relationship with the development to malignant middle cerebral artery infarction (mMCAi) has not been evaluated. Our aim was to determine the impact of CC using multiphase computed tomographic angiography (during the acute stroke phase in the prediction of mMCAi. Patients with consecutive acute stroke with <4.5 hours who were evaluated for reperfusion therapies and presented with an M1-MCA or terminal internal carotid artery occlusion by CTA were included. CC was evaluated on 6 grades by multiphase CTA according to the University of Calgary CC Scale; CC status was defined as poor (grades, 0-3) or good (grades, 4-5). The mMCAi was defined according to clinical and radiological criteria. Recanalization was assessed with transcranial Doppler at 24 hours and final Thrombolysis in Brain Ischemia score≥2b in patients undergoing endovascular reperfusion treatment. Eighty-two patients were included. Mean age was 65.1±13.83 years, median baseline National Institutes of Health Stroke Scale score was 18 (interquartile range, 13-20), and 67.9% M1 and 32.1% terminal internal carotid artery occlusions. Fifty-three patients received endovascular reperfusion treatment. Fifteen patients developed mMCAi. In the univariate analysis, patients with mMCAi had lower CC scores (2.29 versus 3.71; P=0.001). Endovascular reperfusion treatment was associated with lower rate of mMCAi development than only intravenous reperfusion treatment (9.4% versus 29.6%; P=0.028). Patients with poor CC had higher risk of developing mMCAi (13% versus 2%; P=0.001). On the multivariate analysis adjusted by age, vessel occlusion, baseline National Institutes of Health Stroke Scale, and recanalization, the presence of poor CC by multiphase CTA was the only independent predictor of mMCAi (P=0.048; odds ratio, 9.72; 95% confidence interval, 1.387-92.53). CC assessment by multiphase CTA independently predicts malignant MCA infarction progression. In patients with persistent occlusion after reperfusion therapies, the presence of poor CC may improve the early mMCAi detection and management.

Surgical embolectomy for internal carotid artery terminus occlusion.

The aim of this study was to assess the efficacy and safety of surgical embolectomy for internal carotid artery terminus (ICA-T) occlusion. Twenty-five consecutive patients with acute ischemic stroke attributed to embolic ICA-T occlusion who underwent surgical embolectomy were retrospectively reviewed. Twenty-four patients were examined based on magnetic resonance imaging, with one patient included based on a computed tomography scan. Recanalization rate, recanalization time, complications, National Institutes of Health Stroke Scale (NIHSS) score improvement at 1month, and modified Rankin Scale (mRS) at 3months were evaluated. Final recanalization status was Thrombolysis in Myocardial Infarction (TIMI) 3 in 24 patients (96%). Median recanalization time from symptom onset and from start of surgery was 281 and 79min, respectively. Two patients (8%) had major hemorrhagic complications related to surgery. Seventeen patients (68%) demonstrated NIHSS score improvement of more than 10 points at 1month. At 3months, eight patients (32%) were mRS 0-2, five patients (20%) were mRS 3, and three patients (12%) had died. Surgical embolectomy for ICA-T occlusion demonstrated a high complete recanalization rate and should be reconsidered as an additional therapeutic strategy to overcome this devastating situation.

Acute ischemic stroke with tandem/terminal ICA occlusion - CT perfusion based case selection for mechanical recanalization

Rapid reperfusion in a patient with a favorable penumbral pattern is crucial to achieving a good outcome in acute ischemic stroke. Recanalization rates for tandem and terminal internal carotid artery (ICA) occlusion are better with endovascular management as compared with intravenous tissue plasminogen activator (IV-tPA) alone. We hypothesize that tissue-based selection would enable the identification of the ideal patient most suited for reperfusion therapy. We present our series of patients who developed tandem or terminal ICA occlusion and were selected for endovascular management based on their computed tomography (CT) perfusion (CTP) imaging. In this prospective study, 14 (29.16%) of the 48 patients treated by endovascular intervention between January 2011 and March 2014 had either tandem or terminal ICA occlusion. In the tandem group, thrombolysis in cerebral infarction (TICI) 2b/3 reperfusion and a good outcome was observed in five (71.42%, n = 7) and six patients (85.71%, n = 6), respectively. Among the terminal ICA occlusion group, TICI 2b/3 reperfusion and a good outcome was observed in three (42.8%, n = 7) and two patients (28.5%, n = 7), respectively. In patients with early reperfusion, a strong correlation with a median difference of one, in cerebral blood volume (CBV) Alberta Stroke Program Early CT Score (ASPECTS) on CBV map and post-procedure 24-h non-contrast CT, was noted. The median imaging-to-puncture and puncture-to -meaningful reperfusion time was 70 and 68.5 min, respectively, and, overall, good outcomes were seen in 57.1% of the patients. The cerebral blood volume (CBV) core estimation reliably predicted the final infarct volume. The key reasons for the significantly better outcomes seen in our cohort were the stringent perfusion imaging-based patient selection and the rapid reperfusion.

Intra-Arterial Therapy for Cardioembolic Internal Carotid Artery Terminus Occlusion: The Past and Present Status in Real Practice

Intra-Arterial Therapy for Cardioembolic Internal Carotid Artery Terminus Occlusion: The Past and Present Status in Real Practice

Carotid I's, L's and T's: collaterals shape the outcome of intracranial carotid occlusion in acute ischemic stroke

BackgroundCollaterals may affect revascularization, ischemic severity, and clinical outcomes in acute stroke owing to internal carotid artery (ICA) occlusion.ObjectiveTo examine the hypothesis that morphology of occlusive thrombus and collateral flow...

Correlation of clot imaging with endovascular recanalization in internal carotid artery terminus occlusion

Background and purposeIn a swine stroke model we have previously demonstrated a high-intensity fluid attenuated inversion recovery (FLAIR) signal representing the erythrocyte component of the clot. We hypothesized that the...

Clot Length Distribution and Predictors in Anterior Circulation Stroke

Background and Purpose— Thin-section noncontrast computed tomography images can be used to measure hyperdense clot length in acute ischemic stroke. Clots ≥8 mm have a very low probability of intravenous tissue-type plasminogen activator recanalization and hence may benefit from a bridging intra-arterial approach. To understand the prevalence of such clots, we sought to determine the distribution and predictors of clot lengths in consecutive anterior circulation proximal artery occlusions. Methods— Of 623 consecutive patients with acute ischemic stroke, 53 met inclusion criteria: presentation &lt;8 hours from onset; intracranial internal carotid artery-terminus or proximal-middle cerebral artery occlusion; admission thin-slice noncontrast computed tomography (≤2.5 mm); and no intravenous tissue-type plasminogen activator pretreatment. For each patient, hyperdense clot length was measured and recorded along with additional relevant imaging and clinical data. Results— Mean age was 70 years, and mean time to computed tomography was 213 minutes. Median baseline National Institutes of Health Stroke Scale was 16.5. Occlusions were located in the internal carotid artery-terminus (34% [18 of 53]), middle cerebral artery M1 (49% [26 of 53]) and M2 segments (17% [9 of 53]). Hyperdense thrombus was visible in 96%, with mean and median clot lengths (mm) of 18.5 (±14.2) and 16.1 (7.6–25.2), respectively. Occlusion location was the strongest predictor of clot length (multivariate, P =0.02). Clot length was ≥8 mm in 94%, 73%, and 22% of internal carotid artery-terminus, M1, and M2 occlusions, respectively. Conclusions— The majority of anterior circulation proximal occlusions are ≥8 mm long, helping to explain the low published rates of intravenous tissue-type plasminogen activator recanalization. Internal carotid artery-terminus occlusion is an excellent marker for clot length ≥8 mm; vessel-imaging status alone may be sufficient. Thin-section noncontrast computed tomography seems useful for patients with middle cerebral artery occlusion because of the wide variability of clot lengths.