Internal Carotid Artery Terminus Research Articles

Endovascular Recanalization for Acute Internal Carotid Artery Terminus Occlusion: A Subgroup Analysis From the Direct-MT Trial.

BACKGROUND:The efficacy of endovascular recanalization for internal carotid artery (ICA) terminus occlusion has not been completely evaluated.OBJECTIVE:To investigate the efficacy of endovascular recanalization for ICA terminus occlusion.METHODS:Data from Direct-MT, a randomized controlled trial, were applied. ICA terminus occlusions were diagnosed with preprocedure computed tomography angiography by the core laboratory. We dichotomized the ICA terminus occlusions into 2 groups (non-T and T) and analyzed the differences between them. Single-factor analysis and multiple logistic regression were applied to detect independent factors for clinical outcomes and futile recanalization.RESULTS:The rates of first-pass effect, successful recanalization, good clinical outcome, mortality, and futile recanalization were 22.3% (50 of 224), 83.0% (181 of 224), 24.6% (55 of 224), 26.7% (60 of 224), and 69.6% (126 of 181), respectively. Baseline National Institutes of Health Stroke Scale (negative factor; odds ratio [OR] 0.89; 95% CI 0.84-0.95; P < .001), hypertension (negative factor; OR 0.38; 95% CI 0.18-0.80; P = .010), Alberta Stroke Program Early CT Score ≥ 6 (OR 3.68; 95% CI 1.29-10.5; P = .014), tirofiban use (OR 2.46; 95% CI 1.16-5.19; P = .018), first-pass effect (OR 2.87; 95% CI 1.28-6.41; P = .010), and final extended thrombolysis in cerebral infarction ≥ 2b (OR, 3.50; 95% CI 1.17-10.4; P = .024) were independent factors for good clinical outcome. Baseline National Institutes of Health Stroke Scale (OR 1.12; 95% CI 1.05-1.20; P = .004), Alberta Stroke Program Early CT Score < 6 (OR 4.68; 95% CI 1.51-14.5; P = .007), tirofiban use (negative factor; OR 0.39; 95% CI 0.18-0.86; P = .020), and first-pass effect (negative factor; OR 0.44; 95% CI 0.19-0.99; P = .047) were independent factors for futile recanalization.CONCLUSION:More efforts in modifiable factors should be made to improve the efficacy of endovascular recanalization for better clinical outcomes and less futile recanalization in ICA terminus occlusions.

Orbital inflammatory syndrome after mechanical thrombectomy of acute carotid occlusion

Introduction: Orbital ischemic syndrome (OIS) is a rare disorder that presents with acute loss of visual acuity, chemosis, proptosis, ptosis and ophtalmoparesis. We present a case with acute onset of orbital inflammation following mechanical thrombectomy that mimicked an OIS, except for the absence of vision loss. Case report: A 65-year-old woman presented to our emergency department after an episode of transient dysarthria and left-sided hemiparesis and paresthesia that lasted about forty minutes. Head computed tomography showed no signs of intracranial bleeding or acute ischemia. CT angiogram showed occlusion of the right ICA terminus. Mechanical thrombectomy was then performed and the clot was removed with combined technique. Eight hours later, she developed orbital pain, ptosis, chemosis and complete ophthalmoplegia of the right eye. She had no diplopia, visual acuity and funduscopic examination were normal and there was no audible bruit in the orbit. Brain MRI performed showed hyperintensity of orbital fat along with hyperintensity and enlargement of all the extraocular There were no signs of orbital infarction and the optic nerve was structurally normal. Time of flight magnetic resonance angiography revealed reduced calibre of the distal portion of ICA, with associated contrast enhancement on vessel wall imaging. She was started on intravenous dexamethasone with full recovery two days later. Discussion: We present the case of an orbital inflammatory syndrome after mechanical thrombectomy. The mechanical stress exerted by endovascular devices has been associated with endothelial damage that correlates with vessel wall thickening and contrast enhancement in high resolution MRI studies. The temporal correlation with mechanical thrombectomy, the absence of vision loss or orbital infarction and the good clinical response to steroids support the hypothesis of an internal carotid artery wall inflammation due to endovascular manipulation of the stent retriever to be responsible for this acute orbital syndrome. This case highlights the need for close postprocedural monitoring after MT and the consideration of orbital inflammation secondary to endovascular devices in the differential diagnosis of an acute orbital syndrome. Further studies are needed to understand the long-term consequences of arterial wall lesions associated with these devices.

Technical note and first results on JET 7 thromboaspiration device for T-ICA occlusions

BackgroundTo describe technical features and initial results of a novel large-bore reperfusion catheter as first thromboaspiration approach for endovascular stroke treatment in terminal internal carotid artery (T-ICA) occlusions.MethodsAll patients treated with A Direct Aspiration first-Pass Technique (ADAPT) using JET 7 “Standard Tip” Penumbra Reperfusion catheter for acute T-ICA occlusion were retrospectively included in the study. Baseline data, puncture to recanalization time, number of attempts, switch to second device/technique rate and successful recanalization rate were assessed. Successful recanalization was defined by a thrombolysis in cerebral infarction (TICI) score ≥ 2b and favorable functional outcome was defined according to modified Rankin scale (score, 0–2). Catheter specifics and thromboaspiration reperfusion technique with JET 7 were reported.ResultsA total of 21 patients who underwent ADAPT with JET 7 Reperfusion catheter were enrolled for the final analysis. ADAPT was performed as first approach in all cases (100%). First attempt successful recanalization (eTICI ≥2b) was obtained in 90,5% of cases. Mean puncture to recanalization time was 16 minutes. Final successful recanalization was reached in 96.5%. Functional independence at 90 was achieved in 57,1% cases. Symptomatic intracranial hemorrhage occurred in one patient within 24 h.ConclusionThe large-bore JET 7 reperfusion catheter could be considered as first-line in patients with acute T-ICA occlusion, allowing rapid recanalization and low rate of rescue therapy with stent retriver. Further series and/or trial evaluation are required to confirm our results.

Surgical Approaches to Pediatric Moyamoya Disease

Moyamoya disease(MMD)is a chronic, occlusive cerebrovascular disease with unknown etiology, characterized by progressive stenosis of the internal carotid artery terminus and abnormal vascular network formation at the base of the brain. MMD has bimodal age distribution, with peaks in children and young adults, and surgical revascularization is a reasonable management choice for pediatric and adult patients with ischemic MMD. The superficial temporal artery-middle cerebral artery anastomosis with indirect pial synangiosis(combined revascularization)is a preferred surgical procedure for adult and pediatric MMD patients, providing early cerebral hemodynamic improvement and long-term favorable outcomes. Pediatric patients with MMD can present intrinsic postoperative hemodynamic complications, such as watershed shift ischemia and transient global hypoperfusion, even after successful revascularization. Therefore, perioperative management based on the early hemodynamic study is critical to avoid surgical complications, including perioperative cerebral infarction.

Imaging features of adult moyamoya disease patients with anterior intracerebral hemorrhage based on high-resolution magnetic resonance imaging

This study aimed to identify the high-resolution magnetic resonance imaging (HRMRI) features of moyamoya disease (MMD) patients with anterior intracerebral hemorrhage (ICH) and attempted to reveal potential mechanisms of anterior ICH. Eligible adult MMD patients were consecutively included, and the morphological features of lenticulostriate arteries (LSAs), vessel wall structure of terminal internal carotid artery (ICA) and periventricular anastomosis were evaluated by HRMRI. 78 MMD patients containing 21 patients with anterior ICH, 31 ischemic patients and 26 asymptomatic patients were included. The mean value of total length of LSAs in anterior ICH group (90.79 ± 37.00 mm) was distinctively lower (p < 0.001) compared with either ischemic group (138.04 ± 46.01 mm) or asymptomatic group (170.50 ± 39.18 mm). Lumen area of terminal ICA was significantly larger (p < 0.001) in hemorrhagic group (4.33 ± 2.02 mm2) compared with ischemic group (2.29 ± 1.17 mm2) or asymptomatic group (3.00 ± 1.34 mm2). Multivariate analysis revealed the total length of LSAs (OR 0.689, 95%CI, 0.565–0.840; p < 0.001) and lumen area of terminal ICA (OR 2.085, 95%, 1.214–3.582; p = 0.008) were significantly associated with anterior ICH. Coexistence of reduced LSAs and relatively preserved lumen area of terminal ICA with an AUC of 0.901 (95%CI, 0.812–0.990) could be a potential predictor of anterior ICH in MMD patients.

Evaluation of Stent Apposition in the LVIS Blue Stent-Assisted Coiling of Distal Internal Carotid Artery Aneurysms : Correlation with Clinical and Angiographic Outcomes.

To evaluate the stent apposition of a low-profile visualized intraluminal support (LVIS) device in distal internal carotid artery (ICA) aneurysms, examine its correlation with clinical and angiographic outcomes, and determine the predictive factors of ischemic adverse events (IAEs) related to stent-assisted coiling. We retrospectively analyzed a prospectively maintained database of 183 patients between January 2017 and February 2020. The carotid siphon from the cavernous ICA to the ICA terminus was divided into posterior, anterior, and superior bends. The anterior bends were categorized into angled (V) and non-angled (C, U, and S) types depending on the morphology and measured angles. Complete stent apposition (CSA) and incomplete stent apposition (ISA) were evaluated using unsubtracted angiography and flat-panel detector computed tomography. Dual antiplatelet therapy with aspirin 200 mg and clopidogrel 75 mg was administered. Clopidogrel resistance was defined as fewer responders (≥10%, <40%) and non-responders (<10%) based on the percent inhibition (%INH) of the VerifyNow system. These were counteracted by a dose escalation to 150 mg for fewer responders or substitution with cilostazol 200 mg for non-responders. IAEs included intraoperative in-stent thrombosis, transient ischemic attack, cerebral infarction, and delayed in-stent stenosis. A multivariate logistic regression analysis was used to determine the predictive factors for ISA and IAEs. There were 33 ISAs (18.0%) and 27 IAEs (14.8%). The anterior bend angle was narrower in ISA (-4.16°±25.18°) than in CSA (23.52°±23.13°) (p<0.001). The V- and S-types were independently correlated with the ISA (p<0.001). However, treatment outcomes, including IAEs (15.3% vs. 12.1%), aneurysmal complete occlusion (91.3% vs. 88.6%), and recanalization (none of them), did not differ between CSA and ISA (p>0.05). The %INH of 27 IAEs (13.78%±14.78%) was significantly lower than that of 156 non-IAEs (26.82%±20.23%) (p<0.001). Non-responders to clopidogrel were the only significant predictive factor for IAEs (p=0.001). The angled and tortuous anatomical peculiarity of the carotid siphon caused ISA of the LVIS device; however, it did not affect clinical and angiographic outcomes, while the non-responders to clopidogrel affected the IAEs related to stent-assisted coiling.

Intra-Arterial Injection of Thrombin as Rescue Therapy of Vessel Perforation during Mechanical Thrombectomy for Acute Ischemic Stroke.

Background: Vessel perforation during stent mechanical thrombectomy (MT) is a rare and disastrous complication. A routine rescue strategy includes balloon occlusion for tamponade, procedure suspension, and lowering or normalizing blood pressure. However, this complication is still associated with poor outcome and high mortality. Objective: We present our experience with intra-arterial injection of thrombin in the treatment of vessel perforation secondary to microcatheter/microwire perforation, which prevents further deterioration in clinical outcomes. Methods: Cases with intraprocedural vessel perforation during mechanical thrombectomy were included in the final analysis. Clinical data, procedural details, and radiographic and clinical outcomes were collected. Results: Four patients with intraprocedural vessel perforation were included. Intraprocedural perforations occurred at the distal middle cerebral artery in two cases: the A2 segment in one case and the internal carotid artery terminus in one case. The etiology of four cases was intracranial atherosclerotic stenosis (ICAS). The ruptured vessels were effectively occluded in all cases. Endovascular therapy was continued in three cases, and mTICI ≥ 2b recanalization was achieved in all cases. The culprit artery was kept patent on CTA for 72 h post-operation. No active bleeding was detected on follow-up CT post-operation. During the 90-day follow-up period, one patient died, modified Rankle Scare (mRS) 3 was observed in two patients, and mRS 4 was observed in one patient. Conclusions: The key benefit of this method is occluding the ruptured vessel without affecting the following MT. We propose that intra-arterial injection of prothrombin may be simple yet effective in managing vessel perforation complications during MT.

Determinants of Symptomatic Intracranial Hemorrhage After Endovascular Stroke Treatment: A Retrospective Cohort Study.

Background:Symptomatic intracranial hemorrhage (sICH) is a serious complication after endovascular treatment for ischemic stroke. We aimed to identify determinants of its occurrence and location.Methods:We retrospectively analyzed data from the Dutch MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) and MR CLEAN registry. We included adult patients with a large vessel occlusion in the anterior circulation who underwent endovascular treatment within 6.5 hours of stroke onset. We used univariable and multivariable logistic regression analyses to identify determinants of overall sICH occurrence, sICH within infarcted brain tissue, and sICH outside infarcted brain tissue.Results:SICH occurred in 203 (6%) of 3313 included patients and was located within infarcted brain tissue in 50 (25%), outside infarcted brain tissue in 23 (11%), and both within and outside infarcted brain tissue in 116 (57%) patients. In 14 patients (7%), data on location were missing. Prior antiplatelet use, baseline systolic blood pressure, baseline plasma glucose levels, post-endovascular treatment modified treatment in cerebral ischemia score, and duration of procedure were associated with all outcome parameters. In addition, determinants of sICH within infarcted brain tissue included history of myocardial infarction (adjusted odds ratio, 1.65 [95% CI, 1.06–2.56]) and poor collateral score (adjusted odds ratio, 1.42 [95% CI, 1.02–1.95]), whereas determinants of sICH outside infarcted brain tissue included level of occlusion on computed tomography angiography (internal carotid artery or internal carotid artery terminus compared with M1: adjusted odds ratio, 1.79 [95% CI, 1.16–2.78]).Conclusions:Several factors, some potentially modifiable, are associated with sICH occurrence. Further studies should investigate whether modification of baseline systolic blood pressure or plasma glucose level could reduce the risk of sICH. In addition, determinants differ per location of sICH, supporting the hypothesis of varying underlying mechanisms.Registration:URL: https://www.isrctn.com/; Unique identifier: ISRCTN10888758.

Hyperplastic Anterior Choroidal Artery—A Rare Variant Detected on MR Angiography

Introduction The anterior choroidal artery is a branch of the terminal internal carotid artery (ICA) that is often an incidentally detected anomaly. The hyperplastic variant has been linked with an increased risk of aneurysms. We explore the role of magnetic resonance (MR) angiography in the detection of this variant and its impact of presentation of patients. Patient Presentation A 62-year-old diabetic and hypertensive male came to the casualty with complaints of giddiness, left-sided weakness, and loss of coordination for the last 2 to 3 days. He was provisionally diagnosed with a posterior circulation stroke. Management and Outcome Magnetic resonance imaging of brain revealed an acute infarct in the right thalamus and the midbrain. Time-of-flight angiography sequences were done that showed hypoplasia of the A1 segment of the left anterior cerebral artery, fetal origin of the right posterior cerebral artery, narrowing of the left ICA, and a hyperplastic left anterior choroidal artery. He was managed conservatively with antiplatelets. He later underwent a digital subtraction angiography that revealed significant narrowing of the left ICA for which he was advised carotid stenting. However, the patient was unwilling for the procedure and was discharged on oral medication with stable vitals. Conclusion Anatomical variations in the intracranial vasculature impact ischemia territory and the approach to intracranial pathology. Hyperplastic anterior choroidal artery results from the abnormal persistence of fetal pattern of vascular supply. It is important to recognize the presence of a hyperplastic anterior choroidal artery as it impacts both disease presentation and management of these patients. MR angiography allows for noninvasive and reliable detection of these anomalies in patients without the risks associated with radiation or contrast exposure in conventional/computed tomography angiography.

INCREASE ARTERIAL STIFFNESS IN MOYAMOYA DISEASE PRESENTING WITH HYPERTENSION AND STROKE: A NOVEL FINDING IN A VERY RARE CASE IN SINGAPORE

Objective: Arterial stiffness in Moyamoya disease (MMD) has not been described before in literature. We describe a young 42 year-old lady who initially presented as hypertensive urgency and recurrent stroke and was later diagnosed with MMD. We would like to highlight increased arterial stiffness as a cause of hypertension in patients with MMD. Design and method: This is a case report of a 42 year old lady 42 year Singaporean lady presented in 2015 with headache and transient ischemic attack(TIA) and systolic blood pressure was 200mmHg. She was diagnosed with hypertension at the age 28 years and started on telmisartan 40 mg OD. There was no end organ damage and secondary hypertension work up was negative. She has recurrent TIAs and was started on T. atorvastatin 40 mg ON and T clopidogrel 75 mg OD in Feb 2017. She presented with stroke in March 2019, and MRI revealed left posterior temporal-parietal infarct, MRA revealed severe stenosis of left terminal internal carotid artery(ICA). She presented with recurrent stroke in April 2019 and MRI/MRA revealed scattered acute infarcts in left MCA and ACA territories and severe steno-occlusive disease involving left ICA. She underwent left external carotid –internal carotid bypass in June 2019. In light of these findings, MMD was diagnosed. Results: She was started on T spironolactone and her blood pressure was kept in stable range of 130–150/80–95mmHg. An arterial stiffness study by SphygmoCor in June 2020 showed markedly increased arterial stiffness with markedly increased augmentation index, aortic augmentation pressure, aortic systolic pressure and aortic pulse pressure for the patient’s age. Conclusions: We present an interesting and rare case of hypertension in a young patient with MMD associated with increased arterial stiffness, with no renovascular disease. This is one of the first cases reported in MMD with increased arterial stiffness. We also highlighted genetic studies and case reports that have suggested that the histopathological process underlying Moyamoya vessels may also affect systemic vessels. We hope that this article will inspire more research on the relationship between MMD and hypertension, particularly in terms of how systemic vasculature is affected.

Hemichorea without MRI findings accompanied by significant internal carotid artery stenosis: A case report

Hemichorea is a clinical syndrome characterized by rapid, purposeless, irregular, and uncontrollable choreographic movements of the limbs and/or face, and it is frequently associated with cerebral infarction. We report here a case of acute hemichorea, as the first sign of severe stenosis of the contralateral terminal internal carotid artery without cerebral infarction, with complete remission after the endovascular intervention.

Simplified classification of cavernous internal carotid artery tortuosity: a predictor of procedural complexity and clinical outcomes in mechanical thrombectomy

ABSTRACT Objectives Thromboaspiration catheters are increasingly used for the endovascular treatment of large vessel stroke (LVS), while tortuous vascular anatomy still remains one major challenge in mechanical thrombectomy. Prompt assessing and understanding cavernous internal carotid artery (cICA) tortuosity may help to predict procedural complexities of mechanical thrombectomy and thus improve the clinical outcomes. Methods A retrospective review was performed on a cohort of LVS patients with thromboaspiration catheter. Simplified classification of cICA tortuosity was applied by measurement of the angle of the posterior genus (P) and the height from the peak of the posterior genu to the trough of the anterior genu (D). Statistical analyses were performed to analyze differences among the obtained types of cICA tortuosity regarding procedural characteristics and clinical outcomes. Results A total of 150 patients with LVS proximal to the internal ICA terminus and middle cerebral artery (MCA) were included in this study, and three types of cICA tortuosity were defined by the simplified classification. The index, such as patients ages and hypertension, procedural fluoroscopy time, the degree of cICA tortuosity, first-pass success, final reperfusion, and 90-day mortality showed significant differences among the three types (P < 0.05), while 90-day good outcome (mRS 0–2) only presented significant difference between Type I and Type III (P < 0.05). Conclusions The study indicated that the grading of cICA tortuosity is highly correlated with procedural complexity and clinical outcome in mechanical thrombectomy. The proposed classification system may be helpful in pre-procedure prognostication complexity and clinical outcomes. Abbreviations:LVS: large vessel stroke; cICA: cavernous internal carotid artery; mRS: modified Rankin Scale; AIS: acute ischemic stroke; MCA: middle cerebral artery; M1: first division of middle cerebral artery; M2: second division of middle cerebral artery; M3: third division of middle cerebral artery; TICI: Thrombolysis In Cerebral Infarction; TICI 2b: two-thirds of occluded territory reperfusion; DSA: digital subtraction angiography; FT: fluoroscopy time.

Automated detection of arterial landmarks and vascular occlusions in patients with acute stroke receiving digital subtraction angiography using deep learning

BackgroundDigital subtraction angiography (DSA) is the gold-standard method of assessing arterial blood flow and blockages prior to endovascular thrombectomy.ObjectiveTo detect anatomical features and arterial occlusions with DSA using artificial intelligence...

First-line Double Stentriever Thrombectomy for M1/TICA Occlusions

BackgroundMechanical thrombectomy is the standard of care for acute ischemic stroke due to large-vessel occlusion; however, mechanical thrombectomy fails to achieve adequate recanalization in nearly one third of these cases. Rescue therapy using two stentrievers simultaneously yields good results in clots refractory to single stentriever treatment. We aimed to determine the safety and efficacy of first-line double stentriever thrombectomy for acute occlusion of the M1 segment of the middle cerebral artery and/or terminal internal carotid artery (TICA).MethodsThis single-center study prospectively enrolled consecutive patients with a single M1/TICA occlusion to undergo double stentriever thrombectomy between May and October 2020. Outcomes included successful recanalization (modified thrombolysis in cerebral infarction, TICI 2b/3), first-pass effect, procedure times, number of device passes, symptomatic intracerebral hemorrhage, National Institutes of Health Stroke Scale Score (NIHSS) at discharge, 90-day functional independence (modified Rankin scale 0–2), and 90-day mortality.ResultsWe analyzed 39 patients median age 79 years (range 42–96 years); 23 (58.9%) female; 19 (48.7%) with TICA occlusions; 5 (12.8%) with mRS 3–5 at admission; mean NIHSS at admission, 17 ± 4.39). Mean time from symptom onset to final angiogram was 238.0 ± 94.6 min; mean intervention duration was 36.0 ± 24.2 min. The mean number of device passes was 1.5 ± 1.07. All patients had final TICI 2b/3, and 27 (69%) had TICI 2c/3 after the first pass. We observed 3 (7.9%) cases of intracerebral symptomatic hemorrhages. At 90 days, 16 (41%) patients were functionally independent and 9 (23%) had died. The percentage of patients with good clinical outcome at 90 days was 55.5% in the first-pass subgroup.ConclusionOur findings suggest that first-line double stentriever thrombectomy is safe and effective for M1/TICA occlusions.

Posterior Limb of Internal Capsule Infarct Predicts Functional Outcome in Acute Terminal Internal Carotid Artery Occlusion After Thrombectomy.

This study investigated the impact of posterior limb of internal capsule (PLIC) infarct on outcomes of acute internal carotid artery (ICA) occlusion after endovascular thrombectomy (EVT) and the diagnostic accuracy of pretreatment noncontrast computerized tomography (NCCT) and computerized tomography angiography (CTA) findings. Patients who underwent EVT for acute ICA occlusion between September 2014 and August 2020 were included in the study. The patients were dichotomized as PLIC infarct or spared. The risk factors for PLIC infarct were investigated, and the association between infarct patterns and clinical outcomes were assessed using logistic regression analysis. Pretreatment NCCT and CTA findings, including PLIC hypodensity, choroid plexus enhancement (CPE), and posterior cerebral artery (PCA) flow status, were calculated for diagnosis of PLIC infarct. Among 72 patients, the mean age was 70.9 years, and the mean stroke scale was 19.4. PLIC infarct was identified in 15 patients (20.8%). PLIC infarct was associated with worse 90-day functional outcome (P = 0.01, shift test). Lack of CPE is the only independent predictor of PLIC infarct (odds ratio: 127.48, P = 0.001). Lack of CPE and impaired PCA flow produce greater diagnostic accuracy for PLIC infarct than does NCCT hypodensity (area under the receiver operating characteristics curve: 0.85 and 0.76, P = 0.0005 and 0.02, respectively). In acute ICA occlusion, PLIC infarct is an independent risk factor for worse clinical outcome at 90 days. The lack of CPE was associated with PLIC infarct, and pretreatment CTA can be useful for early diagnosis.

Recurrent Stroke in a Young Man with Moyamoya Disease on Medical Therapy: A Case Report

Moyamoya disease (MMD) is a rare intracranial vasculopathy characterized by the progressive occlusion of the terminal internal carotid arteries and their proximal branches. Various factors including genetic and inflammation are the proposed pathogenesis of MMD. We present a case of a 31-year-old man who had recurrent stroke secondary to MMD. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) demonstrated an infarct in the right middle cerebral artery (MCA) territory, and stenosis of the terminal right internal carotid artery (ICA) and its proximal branches. He initially declined surgical management and was treated with antiplatelet. After his third stroke, he finally underwent right superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery. He improved following rehabilitation with no further recurrence. The role of surgical revascularization in the prevention of stroke is well-described in the literature but evidence regarding medical therapy remain scarce and will be explored in this report.

Drug-Coated Balloon for the Treatment of Nonacute Symptomatic Intracranial Carotid Artery Terminus Occlusion: Initial Experience and Follow-Up Outcome.

BackgroundStudies on the recanalization for occlusion of the internal carotid artery terminus are scattered. Recently, drug-coated balloon (DCB) has been increasingly applied in the intracranial artery occlusion and achieved encouraging results. However, there seems no convincing data for the nonacute symptomatic internal carotid artery terminus occlusion (sICATO).ObjectiveTo assess the feasibility and effectiveness (safety) of DCB for patients with nonacute sICATO refractory to medical therapy.ApproachThis study included 30 patients with nonacute sICATO treated with DCBs and/or remedial stenting. The rate of successful recanalization, periprocedural complications, and clinical and vascular imaging follow-up outcomes were retrospectively analyzed.ResultsDrug-coated balloon (DCB) dilatation of nonacute sICATO gives a 100% rate of successful recanalization, with a low complication rate (10.00%), good clinical outcomes (86.20%), low restenosis/reocclusion rate (3.45%), and one asymptomatic ipsilateral infarction (3.45%).ConclusionDrug-coated balloon dilation seems to be the promising treatment option for nonacute sICATO considering its safety and feasibility.

Results of the pToWin Study: Using the pCONUS Device for the Treatment of Wide-Neck Intracranial Aneurysms.

Coil embolization has become a well-established option for the treatment of intracranial aneurysms. Yet, wide-neck bifurcation aneurysms (WNBAs) remain a challenge. The pCONUS is the first generation of a stent-like implant for the bridging of WNBAs to enable coiling. The pToWin study was a prospective, single-arm, multicenter study conducted to analyze the safety and efficacy of the pCONUS in the treatment of WNBAs. The primary effectiveness endpoint was the rate of adequate occlusion of the aneurysm at 3–6 and 7–12 months. The primary safety endpoint was the occurrence of major ipsilateral stroke or neurological death during the follow-up. A total of 115 patients were included. Aneurysm locations were the middle cerebral artery in 52 (45.2%), the anterior communicating artery in 35 (30.4%), the basilar artery in 23 (20%), the internal carotid artery terminus in three (2.6%), and the pericallosal artery in two (1.7%) patients. Treatment was successfully performed in all but one patient. The morbi-mortality rate was 1.9% and 2.3% at 3–6 and 7–12 months, respectively. Of the aneurysms, 75.0% and 65.6% showed adequate occlusion at 3–6 and 7–12 months, respectively. pCONUS offers a safe and reasonably effective treatment of WNBAs, demonstrated by acceptable adequate aneurysm occlusion and low rates of adverse neurologic events.

Abstract WMP90: Patients With MEVO Take Longer To Treat With Endovascular Thrombectomy Because Of A Longer Time To Identify Candidates For Therapy (door To Groin Puncture) As Well As Longer Procedural Times (groin Puncture To First Thrombectomy Pass)

Introduction: The seminal trials of thrombectomy in 2015/16 enrolled a relatively homogenous population of patients with acute ischemic stroke due to ICA terminus or M1 occlusion. However, with advancing technology and technique, EVT eligibility is broadening to include more distal occlusions also known as Medium Vessel Occlusions (MEVO). There may be unique challenges to identifying and treating MEVO patients as quickly as more proximal LVO patients. Here we compared speed of treatment for MEVO and LVO. Specifically, we evaluated time to identify candidates for EVT (Door to Groin Puncture) and the procedural speed (Puncture to first thrombectomy pass) in patients with proximal (ICA/M1) vs distal (M2/M3/M4) occlusions in the anterior circulation. Methods: Data obtained from the Providence Enterprise Stroke Registry included patients discharged from January 2015 to May 2021 with a diagnosis of ischemic stroke who had an occlusion in the ICA terminus, MCA M1, M2, M3 or M4 and were treated with EVT. Generalized linear models assessed if patients with an ICA terminus or M1 occlusion were more likely to have door to groin puncture (GP) in &lt; 60 minutes, GP to first pass (FP) in &lt;30 minutes or door to FP in &lt; 90 minutes compared to those who had M2, M3 or M4 occlusions. Transfers and inpatient strokes were excluded. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) are reported, adjusting for age, race/ethnicity, sex, and IV alteplase treatment. Results: A total of 1,035 (69.2%) patients with an M1/ICA terminus and 460 (30.8%) with M2, M3 or M4 occlusions were included. The M1/ICA terminus patients had greater likelihood of door to GP in &lt; 60 minutes (AOR=1.59, 95% CI: 1.20, 2.10), greater likelihood of GP to FP in &lt;30 min (AOR=1.25, 95% CI: 1.07, 1.46) and door to FP in&lt;90 minutes (AOR=1.38, 95% CI: 1.07, 1.78) compared to patients with M2, M3 or M4 occlusions. Conclusions: Patients with distal anterior circulation occlusions take longer to treat with Endovascular thrombectomy. This delay is driven by longer times required to identify candidates for therapy (Door to Groin Puncture) as well as longer procedural times (Groin Puncture to First Thrombectomy Pass). Future efforts are required to improve speed of identification and treatment for MEVO.

Abstract TP115: Variability Of Transcranial Doppler Criteria In The Determination Of Cerebral Circulatory Arrest

Introduction: Transcranial Doppler (TCD) is a commonly used testing modality in the diagnosis of cerebral circulatory arrest (CCA). There is currently no consensus in the United States for which vessels must be insonated to establish a CCA diagnosis. We evaluated TCD-CCA studies using four categories of vessel selection to determine which set of criteria would be most restrictive. Methods: We reviewed all TCD studies from our center that were performed for the evaluation of CCA. For each study, two readers determined whether the bilateral middle cerebral arteries (MCA) and the basilar artery demonstrated a pattern typical of CCA. In cases where one or more of these three primary vessels could not be located, specific proximal vessels were evaluated and used as a surrogate. Surrogate vessels for the MCAs included the ipsilateral carotid siphon and the terminal internal carotid artery. Surrogate vessels for the basilar artery required the evaluation of both intracranial vertebral arteries. A diagnosis of CCA was given according to four different criteria: absent diastolic flow in [1] bilateral MCAs and the basilar artery, [2] bilateral MCAs only, [3] the three primary vessels or a surrogate vessel when a primary vessel could not be located, and [4] bilateral MCAs or a surrogate vessel when either MCA could not be located. Results: Fifty-five TCD studies were included in this analysis. Of these, 17 studies were not able to insonate one of the three primary vessels. Seven of these incomplete studies included surrogate vessels for the absent primary vessel. When all three primary vessels were insonated, 17 studies were consistent with CCA. Twenty-four studies met CCA criteria when only the MCAs were evaluated, 19 studies met criteria when the primary vessels or a surrogate vessel were evaluated, and 26 studies met criteria when only the MCAs or their surrogate vessels were evaluated. Conclusion: The results of this analysis suggest that when different criteria for CCA are applied, the rates of CCA diagnosis change considerably. Since CCA is often a critical part of establishing death by neurologic criteria, it is important that national standards for a TCD protocol are established.