Intracranial Embolization Research Articles

Clinical Application of Insertion Force Sensor System for Coil Embolization of Intracranial Aneurysms.

In endovascular embolization for intracranial aneurysms, it is important to properly control the coil insertion force. However, the force can only be subjectively detected by the subtle feedback experienced by neurointerventionists at their fingertips. The authors envisioned a system that would objectively sense and quantify that force. In this article, coil insertion force was measured in cases of intracranial aneurysm using this sensor, and its actual clinical application was investigated. The sensor consists of a hemostatic valve (Y-connector). A little flexure was intentionally added in the device, and it creates a bend in the delivery wire. The sensor measures the change in the position of the bent wire depending on the insertion force and translates it into a force value. Using this, embolization was performed for 10 unruptured intracranial aneurysms. The sensor adequately recorded the force, and it reflected the operators' usual clinical experience. The presence of the sensor did not affect the procedures. The sensor enabled the operators to objectively note and evaluate the insertion force and better cooperative handling was possible. Additionally, other members of the intervention team shared the information. Force records demonstrated the characteristic patterns according to every stage of coiling (framing, filling, and finishing). The force sensor system adequately measured coil insertion force in intracranial aneurysm coil embolization procedures. The safety of this sensor was demonstrated in clinical application for the limited number of patients. This system is useful adjunct for assisting during coil embolization for an intracranial aneurysm.

Stroke etiology and collaterals: atheroembolic strokes have greater collateral recruitment than cardioembolic strokes

Chronic hypoperfusion from athero-stenotic lesions is thought to lead to better collateral recruitment compared to cardioembolic strokes. It was sought to compare collateral flow in stroke patients with atrial fibrillation (AF) versus stroke patients with cervical atherosclerotic steno-occlusive disease (CASOD). This was a retrospective review of a prospectively collected endovascular database. Patients with (i) anterior circulation large vessel occlusion stroke, (ii) pre-treatment computed tomography angiography (CTA) and (iii) intracranial embolism from AF or CASOD were included. CTA collateral patterns were evaluated and categorized into two groups: absent/poor collaterals (CTA collateral score 0-1) versus moderate/good collaterals (CTA collateral score 2-4). CT perfusion was also utilized for baseline core volume and evaluation of infarct growth. A total of 122 patients fitted the inclusion criteria, of whom 88 (72%) had AF and 34 (27%) CASOD. Patients with AF were older (P < 0.01) and less often males or smokers (P = 0.04 and P < 0.01 respectively). Baseline National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were comparable between groups. Collateral scores were lower in the AF group (P = 0.01) with patients having poor collaterals in 28% of cases versus 9% in the CASOD group (P = 0.03). Mortality rates (20% vs. 0%; P = 0.02) were higher in the AF patients whilst rates of any parenchymal hemorrhage (6% vs. 26%; P < 0.01) were higher in the CASOD group. On multivariable analysis, CASOD was an independent predictor of moderate/good collaterals (odds ratio 4.70; 95% confidence interval 1.17-18.79; P = 0.03). Atheroembolic strokes seem to be associated with better collateral flow compared to cardioembolic strokes. This may in part explain the worse outcomes of AF-related stroke.

Bench-top Comparison of Physical Properties of 4 Commercially-Available Self-Expanding Intracranial Stents

PurposeTo better understand the performance of four commercially available neurovascular stents in intracranial aneurysm embolization, the stents were compared in terms of their basic morphological and mechanical properties.Materials and MethodsFour different types of stents that are currently being used for cerebral aneurysm embolization were prepared (two stents per type). Two were laser-cut stents (Neuroform and Enterprise) and two were braided from a single nitinol wire (LEO and LVIS stents). All were subjected to quantitative measurements of stent size, pore density, metal coverage, the force needed to load, push, and deploy the stent, radial force on deployment, surface roughness, and corrosion resistance.ResultsCompared to their nominal diameters, all stents had greater diameters after deployment. The length generally decreased after deployment. This was particularly marked in the braided stents. The braided stents also had higher pore densities than the laser-cut stents. Metal coverage was highest in the LEO stent (14%) and lowest in the Enterprise stent (5%). The LIVS stent had the highest microcatheter loading force (81.5 gf). The LEO stent had the highest passage force (55.0 gf) and deployment force (78.9 gf). The LVIS and LEO stents had the highest perpendicular (37.1 gf) and circumferential (178.4 gf) radial forces, respectively. The Enterprise stent had the roughest stent wire, followed by the LVIS, LEO, and Neuroform stents.ConclusionThe four neurovascular stent types differed in terms of morphological and physical characteristics. An understanding of this diversity may help to decide which stent is most suitable for specific clinical situations.

Risk Factors after Reduction to Single Antiplatelet Therapy for Postoperative Ischemia of Intracranial Stent-assisted Coil Embolization

Risk Factors after Reduction to Single Antiplatelet Therapy for Postoperative Ischemia of Intracranial Stent-assisted Coil Embolization

Carotid artery stenting versus no stenting assisting thrombectomy for acute ischaemic stroke: protocol for a systematic review of randomised clinical trials with meta-analyses and trial sequential analyses.

BackgroundIn patients with intracranial large vessel arterial occlusion, ipsilateral extracranial carotid artery occlusions or near-occlusions pose a significant hurdle in endovascular management of acute ischaemic stroke. Stenting of the carotid lesion may be beneficial in this situation to provide a stable access for introducing catheters through the carotid lesion into the intracranial vasculature and the target occlusion. Furthermore, carotid stenting may ensure ample blood flow for wash-out of clot material and reperfusion of the ischaemic penumbral tissue. However, antiplatelet therapy administered to prevent stent thrombosis and sudden increase in blood flow after reopening of the carotid lesion may increase the risk for intracranial haemorrhagic complications. This review aims to assess the benefits and harms of carotid stenting vs. no stenting assisting thrombectomy for acute ischaemic stroke.MethodsInternational and regional electronic databases will be searched to identify eligible randomised clinical trials. To identify further published, unpublished, or on-going and planned trials searches of Google Scholar, Worldwide Food and Drug Administrations, Worldwide Medicines Agencies, company homepages, reference lists, conference proceedings, and the Science Citation Index cited reference search index will be conducted. Manufacturers of relevant interventional equipment, authors, colleagues, and researchers active in the field will be contacted. No language restrictions will be applied to these searches. Randomised clinical trials will be included for assessing benefits and harms and quasi-randomised studies, and observational studies will be included for assessing harms of the intervention. Meta-analyses will be performed according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, and Trial Sequential Analyses will be conducted to control the risk of random errors and prevent premature statements of superiority of the experimental or control intervention or premature statement of futility. The quality of the evidence will be evaluated with the Grading of Recommendations Assessment, Development, and Evaluation.DiscussionThis systematic review of carotid stenting in endovascular management of acute ischaemic stroke in patients with concomitant extracranial carotid lesions and intracranial embolism will assess benefits and harms of this intervention and assesses whether carotid stenting should be encouraged or avoided in acute ischaemic stroke and identify targets for further research.Systematic review registrationPROSPERO CRD42016033346 Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-016-0388-0) contains supplementary material, which is available to authorized users.

Coil embolization through the Marathon microcatheter: Advantages and pitfalls.

Due to technical limitations, small, distal, and tortuous intracranial pathology is sometimes out of reach of the current armamentarium of microcatheters designed for intracranial coil embolization. The Marathon microcatheter (Medtronic, Minneapolis, Minnesota, USA), designed specifically for the delivery of Onyx, is longer and more flexible than most coil delivery catheters. We report on nine patients (three with arteriovenous fistula, three with arteriovenous malformation, two with intracranial aneurysm, and one with tumor) where Marathon was used to deliver commercially available platinum coils. We also conducted laboratory compatibility testing and conclude that the Marathon can be used as a coil delivery catheter for Barricade coils (Blockade Medical, Irvine, California, USA) with diameter less than 0.012 in.

The application of Silenz MR angiography in the follow-up assessment of intracranial aneurysms embolization

Objectives To explore the value of Silenz MRA in the follow-up assessment of intracranial aneurysms embolization. Methods Fifteen patients underwent coiled embolization were prospectively collected. Silenz and time of flight MRA (TOF MRA) were performed on the same day as DSA examination. Two neuro-radiologists scored the structures of peripheral vascular with a 4-score grading system and evaluate embolism status (two-grade montreal scale). The scores of vascular structures were compared using Wilcoxon signed rank tests. Weighted Kappa statistics was used to assess the inter-observer agreement on each MRA scoring, the inter-modality agreement between MRA and DSA, the inter-modality agreement between the MRA methods. Results There were 11 cases with complete occlusion, 4 cases with residual aneurysm revealed by DSA. For depiction, Silenz MRA was significantly better than TOF MRA [(3.50±0.62) vs. (3.00±0.63), Z=-3.12, P=0.002]. Inter-modality agreement of Silenz MRA and DSA was excellent (Kappa=0.82), while the agreement of TOF MRA and DSA was moderate(Kappa=0.60). Inter-modality agreement between Silenz MRA and TOF MRA was good (Kappa=0.76). Conclusions Silenz MRA is superior to TOF MRA for depiction of vascular structures and evaluation of embolism status, which is highly related with DSA. It has the value in the postoperative follow-up evaluation. Key words: Magnetic resonance angiography; Intracranial aneurysm; Embolization, therapeutic; Comparative study

Anesthesia for Deep Brain Stimulation

Deep brain stimulation is used in the treatment of patients with functional neurological disorders but has expanded to include many other disorders. The target site for stimulation is dependent on the disease and symptoms of each patient. The procedure includes imaging techniques to visualize and establish coordinates to the nuclei, electrophysiological guidance with microelectrode recordings, and testing of an awake patient. The goals of anesthesia are to provide optimal surgical conditions and patient comfort, facilitate target localization and diagnosis, and treat complications. The choice of anesthetic agents and techniques will depend not only on the specific patient population and stimulation target but also varies according to institutional practice. Monitored anesthesia care, conscious sedation, and general anesthesia have all been used successfully. Perioperative complications include intracranial hemorrhage, seizures, and venous air embolism. The anesthetic management will continue to evolve with new developments in surgical, imaging, and monitoring techniques, and the understanding of the effects of drugs on electrophysiological recordings.

Comprehensive analysis of intra-arterial treatment for acute ischemic stroke due to cervical artery dissection

ObjectiveThe safety and efficacy of intra-arterial treatment (IAT) in patients with acute ischemic stroke (AIS) due to cervical artery dissection (CeAD) has not been formally studied. The purpose of this...

Retrieval of a migrated coil with a handmade microwire-snare device.

Intraprocedural coil migration during endovascular treatment of intracranial aneurysms is associated with potential vessel occlusion and thromboembolic complications. There is no standard management strategy for coil migration. Here, we describe our experience with using a handmade microwire-snare device (HMD) to retrieve a migrated coil. The HMD consists of a 0.017-inch microcatheter, a 0.014-inch microwire, and a 4-0 silk thread. The ring of the microwire-snare device can open, close, and twist in a figure eight pattern for coil entwinement. In addition, the ring can be shaped as needed to navigate tortuous vessels or capture the migrated coil. The HMD was successfully used to retrieve two migrated coils. In the first case, the coil was displaced in the M2 branch of the middle cerebral artery. In the second case, the coil loop prolapsed into the parent artery. In both cases, control cerebral angiograms performed after retrieval confirmed the patency of the vessels and a lack of thromboembolic complications. At the 3-month follow-up, magnetic resonance angiography demonstrated stable patency of the affected vessels. The HMD is a cost-effective, easy-to-use, safe, and universally available device for retrieving migrated coil(s) during intracranial aneurysm embolization procedures.

Emergency endovascular revascularization of tandem occlusions: Internal carotid artery dissection and intracranial large artery embolism

Internal carotid artery dissection (ICAD) with concomitant occlusive intracranial large artery emboli is an infrequent cause of acute stroke, with poor response to intravenous thrombolysis. Reports on the management of this entity are limited. We present our recent experience in the endovascular management of occlusive ICAD and major intracranial occlusion. Consecutive anterior circulation acute stroke patients meeting Medical Center criteria for endovascular management of ICAD from June 2011 to June 2015 were included. Clinical, imaging, and procedure data were collected retrospectively under Institutional Review Board approval. The endovascular procedure for carotid artery revascularization and intracranial stent thrombectomy is described. Six patients met inclusion criteria (National Institutes of Health Stroke Scale score 12–24, time from symptom onset 2–8hours). Revascularization of the extracranial carotid dissection and stent thrombectomy were achieved in 5/6 patients, resulting in complete recanalization (Thrombolysis in Myocardial Infarction flow grade 3 in a mean 2.7hours), and modified Rankin Scale score 0–2 at 90 day follow-up. In one patient, attempts to microcatheterize the true arterial lumen failed and thrombectomy was therefore not feasible. No arterial dissection, arterial rupture or accidental stent detachment occurred, and there was no intracerebral hemorrhage or hemorrhagic transformation. Our preliminary data on this selected subgroup of patients suggest the presented approach is safe, feasible in a significant proportion of patients, and efficacious in achieving arterial recanalization and improving patient outcome. Crossing the dissected segment remains the most important limiting factor in achieving successful ICA recanalization. Further evaluation in larger series is warranted.

Treatment methods of residue or recurrence after intracranial aneurysm embolization

Objective To explore how to effectively manage the residual or recurrent intracranial aneurysms after embolization. Methods The treatment methods and clinical efficacy of 36 patients with residual or recurrent intracranial aneurysm after procedure at the Department of Neurosurgery, Tianjin Huanhu Hospital from June 2010 to June 2014 were analyze retrospectively. Among 36 patients, 12 underwent endovascular embolization, 15 underwent surgical clipping directly, and 9 could not be clipped directly were treated by extracranial and intracranial arterial bypass and aneurysm trapping or combined embolization. Results The Glasgow outcome scale (GOS) scores of 36 patients after procedure and at discharge showed that 32 (89%) recovered well, 3 (8%) had severe disability, and 1died (3%). They were followed up for an average of 2 years. Thirty-three patients (92%) recovered well, 2 (6%) had disability. During the follow-up period 3 had recurrent aneurysm, 2 of them were retreated by endovascular intervention, and 1 was treated with craniotomy clipping. Cerebrovascular examination revealed that all the grafts were patent. Conclusions For residual or recurrent intracranial aneurysms after embolization, the determination of treatment method should be based on the clinical status of patients, aneurysmal characteristics, surgical risk, and possibility of rerupture of aneurysms. The safe and effective personalized treatment can be performed in clinical practice by the methods of craniotomy or endovascular interventional therapy, and it will achieve a satisfactory clinical effect. Key words: Intracranial aneurysm; Recurrence; Embolization, therapeutic; Microsurgery

Dose reduction in cone-beam CT scanning for intracranial stent deployment before coil embolization of intracranial wide-neck aneurysms.

Flat panel detector (FD)-equipped angiography machines are increasingly used for neuro-angiographic imaging. During intracranial stent-assisted coil embolization procedures, it is very important to clearly and quickly visualize stent shape after deployment in the vessel. It is necessary to quickly visualize stents by cone-beam computed tomography (CBCT). The aim of this study was to compare CBCTs at 10 and 20 s, and to confirm that this method is useful for neuro-endovascular treatment procedures. We treated 30 patients with wide-necked intracranial aneurysms with a flexible, self-expanding neurovascular stent and subsequent aneurysm embolization with platinum micro-coils. We performed the CBCT after stent deployment. We compared the 10 s and 20 s CBCTs, using the full width one-half maximum (FWHM) visualization. Accurate stent placement with subsequent coil occlusion of the aneurysms was feasible in all patients. Stent struts were clearly visualized on both 10 s and 20 s CBCTs. Importantly, 10 s CBCT can reduce the radiation dose by about 42%, compared with 20 s CBCT. Performing 10 s CBCT with a 14% dilution of the contrast medium may significantly improve image acquisition during stent-assisted coil embolization. Reduced-dose, 10 s CBCT can visualize stents in clinical cases, while significantly reducing radiation exposure.

Abstract WP393: Cervical Arterial Fibromuscular Dysplasia in a Bi-ethnic Population: a Retrospective Study in U.S.-Mexican Border

Background: There have been studies trying to characterize Fibromuscular Dysplasia (FMD), however most of them are based in mainly non-Hispanic samples. The objective of this study is to describe the epidemiology, clinical characteristics, angiographic findings, and associated vascular conditions of cervical arterial fibromuscular dysplasia in Hispanics in the US-Mexican border. Methods: We retrospectively reviewed the cerebral angiograms performed in our center in a period of 3.5 years under different indications (cervical and intracranial steno-occlusive arterial disease, intracranial vascular malformation, cranial and facial tumor embolization, and subarachnoid hemorrhage) looking for angiographic patterns of FMD involving the cervical (internal carotid and vertebral) arteries. Exclusion criteria included subjects younger than 18 years old. Patients were subdivided by their self-reported ethnicity in Hispanics and non Hispanics. Of those patients found to have FMD, we looked for the association with the demographics, co-morbidities and related supra-aortic vascular abnormalities. Results: We analyzed 467 angiograms among patients &gt;18 years of 323 (69.1%) were Hispanics and 144 (30.8%) were non-Hispanics. We found that 27 (8.3%) Hispanics patients with FMD involving the cervical arteries (internal carotid, vertebral artery isolated and in different combinations), while 20 (13.8%) cases of FMD among the non-Hispanics. There was no significant difference between the two groups regarding the frequency of FMD. In the Hispanic FMD group the mean age was 57.5 ± 15.76 years and 77.7% were females (p-value=0.007). The most common intracranial and cervical arterial conditions associated with FMD in the Hispanic group were aneurysms and arterial dissections that account for 60% and 25.9% respectively. There was a significant association between Hispanic with Female FMD and intracranial aneurysm (p=0.03). Conclusion: Our study suggests that FMD might follow the same demographic and clinical characteristics in Hispanics and non Hispanic populations in North-America. FMD in Hispanics has a clear predilection for women and intracranial aneurysm and supra-aortic arterial dissection are most commonly associated conditions.

Abstract TP7: Intraarterial Treatment for Acute Ischemic Stroke due to Dissection: Retrospective Series of 24 Cases

Introduction: Cervical artery dissection is a recognized cause of acute ischemic stroke (AIS). Intra-arterial treatment (IAT) may be a complementary option to IV tPA and antithrombotic therapy. Hypothesis/Purpose: To describe a large series of patients with dissection treated with IAT. Methods: Demographics, clinical characteristics, treatment, and outcomes were summarized for all dissection patients treated with IAT from 1/2010 - 5/2015. Outcomes included functional independence (modified Rankin score ≤ 2 at 90 days or discharge, or discharge home), recanalization, procedural complications, sICH, and mortality. Data are presented as median (interquartile range) or (n). Results: Of 161 patients with dissection, 24 (15%) were managed with IAT and comprise our population, which was primarily male (75%) aged 52 (42-59.5) and NIHSS of 13 (12 -16). Internal carotid artery dissections (ICAD, 18) were more common than vertebral artery dissections (VAD, 6); three patients had bilateral dissections (1 ICAD, 2 VAD). In all but two patients there was associated intracranial embolus. Dissections were idiopathic (17), traumatic (5) or cough-related (2). Eleven patients were treated with IV tPA. IAT techniques included thrombectomy (19), IA thrombolysis (17), stent (13), and angioplasty (7). The majority of patients had multiple techniques: 2 (2 -3). Functional independence was achieved in 63% (12/19). There were four deaths, none were attributable to IAT. There was one sICH and three procedural complications (2 groin pseudoaneurysm, one catheter induced acute dissection). Among the 6 VADs, 2 were left untreated and the remaining 4 were successfully recanalized (100%). All 6 VADs had a basilar artery occlusion; recanalization was successful in 2 and partial in 4 cases. Among the 18 ICADs, 6 were left untreated and the remaining 12 were successfully recanalized (100%). Sixteen of 18 ICADs had middle cerebral artery occlusion; recanalization was successful in 4, partial in 10, and unsuccessful in 2 cases. Conclusions: Despite the additional intravascular risk, outcomes appear to be similar to those presented in large RCTs with stroke from all causes, suggesting utility of IAT when performed in patients with dissection.

Bispectral index-guided fast track anesthesia by sevoflurane infusion combined with dexmedetomidine for intracranial aneurysm embolization: study protocol for a multi-center parallel randomized controlled trial

Background: After intracranial aneurysm embolization, rapid recovery from general anesthesia is necessary for timely monitoring of adverse events. Fast-track anesthesia using a balanced technique or combination of drugs at their minimum required dosages is preferred for these neurosurgical patients. However, fast-track anesthesia is still limited by a lack of standardization and quality control standards. Methods/Design: A multi-center, parallel, randomized controlled clinical trial will be conducted at Anhui Provincial Hospital and Renmin Hospital of Wuhan University, China. One hundred and twenty patients with intracranial aneurysm will be randomly assigned to a normal saline group and a dexmedetomidine group. General anesthesia will be induced intravenously with propofol. Additionally, either 1.0 μg/kg dexmedetomidine or normal saline will be delivered completely within 10 minutes before anesthesia induction. Once anesthesia has begun, dexmedetomidine (0.3 μg/kg per hour) or normal saline will be continuously infused. Intraoperatively, anesthesia will be maintained with 2-3% sevoflurane. Primary outcomes will be anesthesia time, operative time, time from the end of anesthesia until recovering spontaneous breathing, time until eye opening on command, and time until orientation to time and place. Secondary outcomes will be dose of sevoflurane, Visual Analogue Scale score, and bispectral index. Discussion: In this trial, we will assess the clinical efficacy of sevoflurane anesthesia with dexmedetomidine as a fast track anesthesia for intracranial aneurysm embolization. Trial registration: This protocol was registered at Chinese Clinical Trial Registry (identifier: ChiCTR-IPR-16008113) on 17 March 2016. Ethics: Written approval for this trial has been obtained from the Ethics Committee of the Anhui Provincial Hospital of China (approval No. 2015-31). This study will be performed in accordance with the guidelines of the Declaration of Helsinki, formulated by the World Medical Association. Informed consent: Prior to the trial, participants and their family members will be informed of the risks and benefits of this trial. Written informed consent will be obtained from each participant.

Multimodality Management of Cerebral Arteriovenous Malformations with Special Reference to AVM-Related Hemorrhages During Ongoing Staged Treatment.

In this study we report and analyze the results of a multimodality management concept for intracranial arteriovenous malformations (AVMs), including microsurgery, embolization, and gamma knife radiosurgery. The study population consists of a consecutive series of 294 patients treated for 304 intracranial AVMs over a 10-year period.

Abstract 19300: Real-life Evidence of Stroke Prevention in Patients With Atrial Fibrillation: The RELIEF Study

Introduction: Limited data is available on real-world outcomes in rivaroxaban compared to vitamin K antagonist (VKA) users with non-valvular atrial fibrillation (NVAF). Hypothesis: To assess the effectiveness of newly initiated rivaroxaban or VKA therapy among NVAF patients. Methods: The ‘REal-LIfe Evidence on stroke prevention in patients with atrial Fibrillation’ (RELIEF) study was a retrospective analysis performed in the outpatient setting in Germany using data from the Primary Care Physician panel of a longitudinal electronic medical record database ( IMS Disease Analyzer). Patients had to be ≥18 years of age, newly initiated on rivaroxaban or a VKA (mostly phenprocoumon in Germany) between January 2012 and October 2013, have a diagnosis of NVAF on the day of the first qualifying anticoagulant prescription (index date) or anytime during the 365 days prior, and have follow-up ≥360 days after the index date. Patients were 1:1 propensity score matched. The primary endpoint was the composite of ischemic stroke (International Classification of Disease, Tenth Revision [ICD-10] code I63), transient ischemic attack (TIA) (ICD-10 code G45, except G45.3), intracerebral hemorrhage (ICD-10 code I61), other non-traumatic intracranial hemorrhage (ICD-10 code I62), systemic embolism (ICD-10 code I74) and myocardial infarction (ICD-10 codes I21, I22). Kaplan-Meier survival analysis on the primary endpoint in the matched cohorts was performed, and the time-to-event was reported as a hazard ratio (HR) and 95% confidence interval (CI). Results: A total of 1,039 VKA and 1,039 rivaroxaban users were included and 57 events (20 in rivaroxaban, 37 in VKA) were identified during a one-year follow-up. The incidence of the composite endpoint was significantly lower in rivaroxaban compared to VKA users (1.97 vs. 3.68 events/100 person-years) corresponding to a hazard ratio of 0.536 (95%CI: 0.311-0.923; p=0.0245). Ischemic stroke (0.69 vs. 1.58 events/100 person-years) and TIA (0.59 vs. 1.08 events/100 person-years) were less frequent in the rivaroxaban cohort . Conclusions: The findings indicate that rivaroxaban may be associated with superior effectiveness compared to a VKA when utilized in a real-world setting.

Thrombectomy assisted by carotid stenting in acute ischemic stroke management: benefits and harms.

Extracranial carotid artery occlusion or high-grade stenosis with concomitant intracranial embolism causes severe ischemic stroke and shows poor response rates to intravenous thrombolysis (IVT). Endovascular therapy (EVT) utilizing thrombectomy assisted by carotid stenting was long considered risky because of procedural complexities and necessity of potent platelet inhibition-in particular following IVT. This study assesses the benefits and harms of thrombectomy assisted by carotid stenting and identifies factors associated with clinical outcome and procedural complications. Retrospective single-center analysis of 47 consecutive stroke patients with carotid occlusion or high-grade stenosis and concomitant intracranial embolus treated between September 2011 and December 2014. Benefits included early improvement of stroke severity (NIHSS ≥ 10) or complete remission within 72 h and favorable long-term outcome (mRS ≤ 2). Harms included complications during and following EVT. Mean age was 64.3 years (standard deviation ±12.5), 40 (85%) patients received IVT initially. Median NIHSS was 16 (inter-quartile range 14-19). Mean time from stroke onset to recanalization was 311 min (standard deviation ±78.0). Early clinical improvement was detected in 22 (46%) patients. Favorable outcome at 3 months occurred in 32 (68%) patients. Expedited patient management was associated with favorable clinical outcome. Two (4%) patients experienced symptomatic hemorrhage. Eight (17%) patients experienced stent thrombosis. Four (9%) patients died. Thrombectomy assisted by carotid stenting seems beneficial and reasonably safe with a promising rate of favorable outcome. Nevertheless, adverse events and complications call for additional clinical investigations prior to recommendation as clinical standard. Expeditious patient management is central to achieve good clinical outcome.

Carotid stent-assisted thrombectomy in acute ischemic stroke.

Acute carotid occlusion or near-occlusion with concomitant intracranial embolism cause severe acute ischemic strokes in patients. These concomitant occlusions have suggested poor response to intravenous thrombolysis and complicate endovascular treatment. Nevertheless, endovascular stent-assisted thrombectomy may improve outcome in patients but the treatment is not without concerns. Required antiplatelet therapy to prevent stent thrombosis may increase the rate of intracranial hemorrhage, especially after recent thrombolysis. Furthermore, technical difficulties in access of the intracranial vasculature may cause adverse events, even in the hands of experienced interventionalists. These concerns currently defy the treatment in being recommended for general use and only on a compassionate basis. However, recent patient series have suggested reasonable safety and efficacy for carotid stent-assisted thrombectomy.