Intracranial Large Artery Occlusion Research Articles

Mechanical thrombectomy and rescue therapy for intracranial large artery occlusion with underlying atherosclerosis

ObjectiveTo investigate the safety and efficacy of mechanical thrombectomy plus rescue therapy for intracranial large artery occlusion (ILAO) with underlying intracranial atherosclerosis (ICAS).MethodsPatients enrolled in the intervention group of EAST...

New Opportunities of Endovascular Recanalization Techniques in the Management of Ischemic Stroke

Currently, there are a limited number of treatments for ischemic stroke. Intravenous thrombolytic therapy is the most effective method. However, its efficacy is very low in the case of stroke caused by occlusion of large intracranial arteries. Previous studies of endovascular recanalization techniques in the treatment of stroke, particularly randomized controlled trials (RCTs), such as IMS-3, SYNTHESIS Expansion, and MR RESCUE, have shown negative results. The results of other RCTs (MR CLEAN, ESCAPE, EXTENDIA, SWIFT PRIME, and REVASCAT) published in 2015 demonstrated that, in the case of careful selection of patients with verified occlusion of large intracranial arteries, endovascular recanalization significantly improves stroke outcomes.

Predictive Value of Computed Tomography Angiography–Determined Occlusion Type in Stent Retriever Thrombectomy

We investigated whether occlusion type identified with computed tomography angiography (CTA-determined occlusion type) could predict endovascular treatment success using stent retriever (SR) thrombectomy. Consecutive patients with stroke who underwent CTA and then endovascular treatment for intracranial large artery occlusion were retrospectively reviewed. CTA-determined occlusion type was classified into truncal-type occlusion or branching-site occlusion and compared with digital subtraction angiography-determined occlusion type during endovascular treatment. Three rapidly- and readily-assessable pre-procedural findings (CTA-determined occlusion type, atrial fibrillation, and hyperdense artery sign), which may infer occlusion pathomechanism (embolic versus nonembolic) before endovascular treatment, were evaluated for association with SR success along with stroke risk factors and laboratory results. In addition, the predictive power of the 3 pre-procedural findings for SR success was compared with receiver operating characteristic curve analyses. A total of 238 patients (mean age, 70.0 years; male patients, 52.9%) were included in this study. CTA-determined occlusion type corresponded adequately with digital subtraction angiography-determined occlusion type (P=0.453). Atrial fibrillation (odds ratio, 2.66; 95% confidence interval, 1.25-5.66) and CTA-determined branching-site occlusion (odds ratio, 8.20; confidence interval, 3.45-19.5) were independent predictors for SR success. For predicting SR success, the area under the receiver operating characteristic curve value for CTA-determined branching-site occlusion (0.695) was significantly greater than atrial fibrillation (0.594; P=0.038) and hyperdense artery sign (0.603; P=0.023). CTA-determined branching-site occlusion was significantly associated with SR success. Furthermore, among the 3 rapidly- and readily-assessable pre-procedural findings, CTA-determined branching-site occlusion had the greatest predictive power for SR success.

Case Report of a Diffusion-Weighted Magnetic Resonance Imaging Negative Patient with an Acute Occlusion of a Large Intracranial Artery

Case Report of a Diffusion-Weighted Magnetic Resonance Imaging Negative Patient with an Acute Occlusion of a Large Intracranial Artery

Acute basilar artery occlusion: Endovascular Interventions versus Standard Medical Treatment (BEST) Trial-Design and protocol for a randomized, controlled, multicenter study.

Rationale Endovascular treatment plus standard medical therapy is superior to standard medical therapy alone for acute anterior proximal intracranial large artery occlusion strokes. The benefit of endovascular treatment in acute ischemic stroke caused by basilar artery occlusion remains unproven. Aim This study compares the safety and efficacy of endovascular treatment plus standard medical therapy versus standard medical therapy alone in acute ischemic stroke due to basilar artery occlusion. Design The study is a multicenter randomized control trial with blinded outcome assessment. A projected total 344 subjects with acute basilar arterial occlusion within 8 h of estimated occlusion time will be enrolled over three years in China. Patients will be assigned to endovascular treatment plus standard medical therapy and standard medical therapy alone group in 1:1 ratio for study centers. Study outcomes The primary outcome measure is a favorable functional outcome, defined as a modified Rankin Score of 0-3 at 90 days. The primary safety measure is mortality at 90 days. Trial registration ClinicalTrials.gov (NCT 02441556). Summary The BEST trial will provide valuable insights into the safety and efficacy of endovascular treatment for acute ischemic stroke patients with basilar artery occlusion.

Impact of Modified TICI 3 versus Modified TICI 2b Reperfusion Score to Predict Good Outcome following Endovascular Therapy.

The TICI score is widely used to evaluate cerebral perfusion before and after the endovascular treatment of stroke. Recent studies showing the effectiveness and safety of mechanical thrombectomy combine modified TICI 2b and modified TICI 3 to assess the technical success of endovascular treatment. The purpose of this study was to determine how much clinical outcomes differ between patients achieving modified TICI 2b and modified TICI 3 reperfusion. We analyzed 222 consecutive patients with acute large intracranial artery occlusion of the anterior circulation having achieved modified TICI 2b or modified TICI 3 reperfusion after thrombectomy. The primary end point was the rate of favorable outcome defined as the achievement of a modified Rankin Scale score of 0-2 at 3 months. Patients with modified TICI 3 more often had favorable collateral circulation and atherosclerosis etiology, with a shorter time from onset to reperfusion than patients with modified TICI 2b (all P < .05). The number of total passes to achieve reperfusion was higher in the modified TICI 2b group (median, 2; interquartile range, 1-3, 1-9) versus (median, 1; interquartile range, 1-2, 1-8) in the modified TICI 3 group (P = .0002). Favorable outcome was reached more often for patients with modified TICI 3 than for those with modified TICI 2b (71.7% versus 50.5%, P = .001), with a similar difference when considering excellent outcome. In addition, patients with modified TICI 3 had a lower intracerebral hemorrhage rate (23.0% versus 45.0%, P < .001). Patients with modified TICI 3 reperfusion have better functional outcomes than those with modified TICI 2b. Given the improving reperfusion rates obtained with thrombectomy devices, future thrombectomy trials should consider modified TICI 2b and modified TICI 3 status separately.

Importance of truncal-type occlusion in stentriever-based thrombectomy for acute stroke.

To investigate whether angiographically defined occlusion type could predict of the etiology of acute intracranial large artery occlusion and the stentriever response. We reviewed consecutive patients with acute intracranial large artery occlusion who underwent endovascular treatment and examined their workups for embolic sources. Patient demographics, laboratory findings, hyperdense artery sign, and angiographic occlusion type (truncal-type or branching-site occlusion) were compared between embolic sources (+) and (-) groups. These variables were also compared between stentriever failure and success groups. Details of endovascular procedures were also compared according to occlusion type. A total of 259 patients (mean age 70.3 years; M:F = 132:127) were finally included. Of these patients, 216 (83.4%) were assigned to the embolic sources (+) group after thorough evaluation. Young age, no coronary artery disease, and truncal-type occlusion (odds ratio [OR] 9.07; 95% confidence interval [CI] 3.74-22.0) were independently associated with the embolic source (-) group. Of the overall group, 224 patients (86.5%) underwent stentriever-based endovascular treatment. Hypertension, diabetes, high C-reactive protein level, and truncal-type occlusion (OR 32.2; 95% CI 7.78-133.0) were independent predictors of stentriever failure. Truncal-type occlusion was associated with more reocclusion (77.3% vs 5.0%), resulting in recanalization failure by the stentriever (81.8% vs 20.3%), a longer puncture-to-recanalization time (118.0 vs 49.5 minutes), and more rescue treatment for final successful recanalization (78.9% vs 7.0%). Angiographic occlusion type is an independent predictor of stentriever refractoriness and of the underlying stroke mechanism.

Imaging Predictors for Atherosclerosis-Related Intracranial Large Artery Occlusions in Acute Anterior Circulation Stroke.

Imaging Predictors for Atherosclerosis-Related Intracranial Large Artery Occlusions in Acute Anterior Circulation Stroke.

New opportunities in the use of endovascular methods of recanalization in the management of ischemic stroke

Currently, there is a limited number of treatments for ischemic stroke. Intravenous thrombolytic therapy is the most effective method. However, its efficacy is very low in the case of stroke caused by occlusion of large intracranial arteries. Previous studies of endovascular recanalization methods in the treatment of stroke, particularly randomized controlled trials (RCTs), such as IMS-3, SYNTHESIS Expansion, and MR RESCUE, have shown negative results. The results of other RCTs (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, and REVASCAT) published in 2015 have shown that, in the case of careful selection of patients with verified occlusion of large intracranial arteries, endovascular recanalization significantly improves stroke outcomes.

Manual Aspiration Thrombectomy Using Penumbra Catheter in Patients with Acute M2 Occlusion : A Single-Center Analysis.

ObjectiveThe efficacy and safety of manual aspiration thrombectomy using Penumbra in an acute occlusion of large intracranial arteries has been proven in many previous studies. Our study aimed to retrospectively assess the efficacy and safety of manual aspiration thrombectomy using Penumbra in patients with small vessel occlusions (M2 segment of the MCA).MethodsWe conducted a retrospective review of 32 patients who underwent manual aspiration thrombectomy using the Penumbra 4 MAX Reperfusion Catheter for treatment of an M2 occlusion between January 2013 and November 2014. We evaluated immediate angiographic results and clinical outcomes through review of patient electronic medical records.ResultsThere were slightly more men in this study (M : F=18 : 14) and the median age was 72.5 (age range : 41–90). The rate of successful recanalization (TICI grade ≥2b) was 84% (27/32). NIHSS at discharge and favorable clinical outcomes at 3 months were significantly improved than baseline. Median initial NIHSS score was 10 (range : 4–25) and was 4 (range : 0–14) at discharge. Favorable clinical outcomes (mRS score ≤2 at 3 months) were seen in 25 out of 32 patients (78%). There were no procedure-related symptomatic intracerebral hemorrhages. One patient expired after discharge due to a cardiac problem.ConclusionManual aspiration thrombectomy might be safe and is capable of achieving a high rate of successful recanalization and favorable clinical outcomes in patients with distal cerebral vessel occlusion (M2).

Primary stent retrieval for acute intracranial large artery occlusion due to atherosclerotic disease.

Background and PurposeThe goal of stent retriever–based thrombectomy is removal of embolic clots in patients with intracranial large artery occlusion. However, outcomes of stent retrieval may differ between acute arterial occlusions due to intracranial atherosclerotic disease (IAD) and those due to embolism. This case series describes the outcomes of stent retriever–based thrombectomy and rescue treatments in 9 patients with IAD-related occlusion.MethodsAmong patients who underwent endovascular treatment for acute intracranial large artery occlusion, those in whom stent retrieval was attempted as first-line treatment were included in this review. IAD was defined as significant fixed focal stenosis at the occlusion site, which was evident on final angiographic assessment or observed during endovascular treatment.ResultsMedian number of stent retriever passes was 2 (range, 1-3), and temporary bypass was seen in all patients. Immediate partial recanalization (arterial occlusive lesion grade 2-3) was observed in 7 patients. Immediate modified thrombolysis in cerebral infarction grade 2b-3 was seen in 6 patients, but the lesions often required rescue treatment due to reocclusion or flow insufficiency. In terms of rescue treatments, angioplasty and intra-arterial tirofiban infusion seemed to be effective.ConclusionsOur findings suggest that stent retrieval can effectively remove thrombi from stenotic lesions and achieve partial recanalization despite the tendency toward reocclusion in most patients with IAD-related occlusion. Further research into the use of rescue treatments, such as tirofiban infusion and angioplasty, is warranted.

Choosing a Hyperacute Stroke Imaging Protocol for Proper Patient Selection and Time Efficient Endovascular Treatment: Lessons from Recent Trials.

Recently, several prospective randomized control trials regarding endovascular treatment for patients with intracranial large artery occlusions causing acute ischemic stroke have been successfully reported. Effort to minimize time delays to endovascular treatment, patient selection and the use of retrievable stent were important factors for the success of these trials. The inclusion and exclusion criteria for each of these trials did include differences in imaging protocols. In this review, we focus on the importance of baseline non-invasive angiography prior to deciding endovascular treatment. Then imaging protocols are described for each trial according to measurement of infarct volume and collateral grading.

High Blood Pressure Increases the Risk of Poor Outcome at Discharge and 12-month Follow-up in Patients with Symptomatic Intracranial Large Artery Stenosis and Occlusions: Subgroup analysis of the CICAS Study.

SummaryAimsThe purpose of this study was to discuss the relationship between blood pressure and prognosis of patients with symptomatic intracranial arterial stenosis.MethodsData on 2426 patients with symptomatic intracranial large artery stenosis and occlusion who participated in the Chinese Intracranial Atherosclerosis (CICAS) study were analyzed. According to the JNC 7 criteria, blood pressure of all patients was classified into one of the four subgroups: normal, prehypertension, hypertension stage I, and hypertension stage II. Poor outcomes were defined as death and functional dependency (mRS 3‐5) at discharge or at 1 year.ResultsFor patients with intracranial stenosis of 70% to 99%, the rate of poor outcome at discharge was 19.3%, 23.5%, 26.8%, and 39.8% (P = 0.001) for each blood pressure subgroup. For patients with intracranial large artery occlusion, the rates were 17.6%, 22.1%, 29.5%, and 49.8%, respectively (P < 0.0001). The rate of poor outcome at 12‐month follow‐up was 12.6%, 15.3%, 28.5%, and 27.9% (P = 0.0038) in patients with stenosis of 70% to 99% for each blood pressure subgroup and 11.6%, 21.5%, 23.9%, 35.1% (P < 0.0001) in patients with occlusion.ConclusionsFor patients with severe intracranial arterial stenosis or occlusion, higher hypertension stages are associated with an increased risk of poor outcome at discharge and 12‐month follow‐up.

Endovascular Mechanical Thrombectomy for Acute Ischemic Stroke: A New Standard of Care.

The treatment of acute ischemic stroke (AIS) in the setting of intracranial large artery occlusion (LAO) with intravenous tissue plasminogen activator (IV-tPA) is associated with low rates of recanalization and high rates of neurological morbidity and functional dependence. Endovascular intervention, particularly mechanical thrombectomy, is a promising therapeutic adjunct to IV-tPA for the treatment of acute LAO. However, until recently, its efficacy has been controversial. In this brief review, we analyze the criticisms of three negative randomized controlled trials (RCT) of endovascular stroke treatment and evaluate the results from seven positive endovascular stroke RCTs that have recently been presented or published. IMS III, MR RESCUE, and SYTHESIS Expansion were three RCTs that failed to show a benefit from endovascular stroke therapy. Major criticisms of these studies included a lack of routine screening for LAO, resulting in the selection of AIS patients without LAO for endovascular intervention, and a low utilization rate of modern endovascular thrombectomy devices, leading to substandard rates of successful recanalization. MR CLEAN was the first phase III RCT to show a significant clinical benefit from endovascular stroke therapy. The dissemination of its findings elicited a cascade of positive results from, to date, six additional endovascular stroke RCTs, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, THERAPY, and THRACE, which were halted prematurely for efficacy. The cumulative evidence from these studies shows an overwhelming benefit from the endovascular treatment of acute LAO, therefore effectively establishing a new standard of care for the management of AIS.

Two in One: Endovascular Treatment of Acute Tandem Occlusions in the Anterior Circulation

Acute major stroke with high-grade stenosis or occlusion of the extracranial internal carotid artery (ICA) and additional intracranial large artery occlusion is increasingly treated with a mechanical endovascular approach by extracranial stenting and intracranial thrombectomy due to poor response to systemic thrombolysis with recombinant tissue plasminogen activator (rtPA). This article presents a single centre cohort of this challenging subtype of stroke, describing the technical procedure and analysing the angiographic and clinical outcome. Clinical and imaging data of all consecutive patients between July 2008 and March 2013 with intracranial artery occlusion in the anterior circulation and additional occlusion or pseudo-occlusion of the cervical ICA were retrospectively analysed with respect to demographical and clinical characteristics. Technical approach, recanalization rate, recanalization time and short-term clinical outcome were determined. A total of 43 patients with tandem occlusion in the anterior circulation met the inclusion criteria. Out of these, 32 (74.4%) occlusions and 11 (25.6%) pseudo-occlusions of the extracranial ICA with additional occlusion of the distal segment of the ICA in 7.0% (3/43), the M1-segment of the middle cerebral artery (MCA) in 81.4% (35/43) or the M2-segment of the MCA in 11.6% (5/43) of cases were treated with combined endovascular approach including extracranial stenting with angioplasty and intracranial mechanical thrombectomy. In 76.7% of cases, an angiographic recanalization result of 2b or 3 using the Thrombolysis in Cerebral Infarction (TICI) score was achieved. Mean time from first angiographic series to recanalization was 103 min. A modified Rankin Scale (mRS) score of ≤ 2 was achieved in 32.6% at the time of discharge. Endovascular therapy of patients with tandem occlusion in the anterior circulation with emergency extracranial stenting and intracranial mechanical thrombectomy appears to be safe and may lead to a satisfactory angiographic result and clinical outcome.

Abstract T P15: Could Intra-Arterial Thrombolysis Safely Enhance Efficacy of Mechanical Thrombectomy for Acute Ischemic Stroke?

Background: Occlusion of large intracranial arteries is associated with disability and death. In this study we assess whether intra-arterial thrombolysis(IAT) safely enhances efficacy of mechanical thrombectomy. Method: We studied consecutive patients with acute large vessel occlusion. We compared 2 groups:(1) thrombectomy plus IAT and(2) thrombectomy alone (non-IAT). Recanalization was defined by TIMI ≥ 2. Results: Between 12/2007 and 10/2012, 87 patients(age 67±16years) received 88 thrombectomy procedures. The median admission NIHSS was18. Forty six cases were treated IAT. Overall recanalization was 60%. Recanalization was seen more frequently in cases using IAT (72%) compared to non-IAT(48%)( p=0.02 ). IAT tended to associate with fewer numbers of arterial attempts than non-IAT (2.37±1.76 vs. 3.07± 1.98) (p=0.08) but longer procedure duration(119± 53 minutes vs. 90± 55 minutes)( p=0.02 ). The rate of symptomatic hemorrhagic transformation, in-hospital and 3 month mortality rates were not significantly different between IAT and non-IAT(p=0.90, p=0.99 and p=0.72), respectively. Conclusions: During mechanical thrombectomy, IAT is associated with increased recanalization rate and longer procedure duration. Mechanical thrombectomy with concomitant IAT appeared relatively safe.

Prevalence and Outcomes of Symptomatic Intracranial Large Artery Stenoses and Occlusions in China

We aimed to establish the prevalence, characteristics, and outcomes of intracranial atherosclerosis (ICAS) in China by a large, prospective, multicenter study. We evaluated 2864 consecutive patients who experienced an acute cerebral ischemia<7 days after symptom onset in 22 Chinese hospitals. All patients underwent magnetic resonance angiography, with measurement of diameter of the main intracranial arteries. ICAS was defined as ≥50% diameter reduction on magnetic resonance angiography. The prevalence of ICAS was 46.6% (1335 patients, including 261 patients with coexisting extracranial carotid stenosis). Patients with ICAS had more severe stroke at admission and stayed longer in hospitals compared with those without intracranial stenosis (median National Institutes of Health Stroke Scale score, 3 versus 5; median length of stay, 14 versus 16 days; both P<0.0001). After 12 months, recurrent stroke occurred in 3.27% of patients with no stenosis, in 3.82% for those with 50% to 69% stenosis, in 5.16% for those with 70% to 99% stenosis, and in 7.27% for those with total occlusion. Cox proportional hazards regression analyses showed that the degree of arterial stenosis, age, family history of stroke, history of cerebral ischemia or heart disease, complete circle of Willis, and National Institutes of Health Stroke Scale score at admission were independent predictors for recurrent stroke at 1 year. The highest rate of recurrence was observed in patients with occlusion with the presence of ≥3 additional risk factors. ICAS is the most common vascular lesion in patients with cerebrovascular disease in China. Recurrent stroke rate in our study was lower compared with those of previous clinical trials but remains unacceptably high in a subgroup of patients with severe stenosis.

Association of E-selectin Gene Polymorphism (S128R) with Ischemic Stroke and Stroke Subtypes

E-selectin is an important inflammatory cytokine involved in the pathogenesis of various diseases such as atherosclerosis and stroke. We investigated the association of E-selectin gene polymorphism (S128R) with ischemic stroke and its subtypes. We studied 610 patients with ischemic stroke and 610 age- and sex-matched healthy controls. The ischemic stroke was classified according to Trial of Org10172 in Acute Stroke Treatment (TOAST). E-selectin gene polymorphism (S128R) was determined by polymerase chain reaction-restriction fragment length polymorphism technique. We found statistically significant difference in the genotypic distribution between patients and controls (for AC vs. AA, χ(2) = 49.5; p < 0.001, odds ratio = 5.47(95 % CI, 3.25-9.21). A significant difference was observed in the frequency of C and A alleles in patients and controls (for C vs. A, χ(2) = 47.4; p < 0.001, odds ratio = 5.13 (95 % CI, 3.06-8.57). Multiple logistic regression analysis revealed that the most predictive risk factor for stroke was AC genotype (adjusted odds ratio = 1.450 (95 % CI, 1.23-2.75) and p = 0.001), hypertension, smoking, and diabetes (p = 0.001 in each case). We also found a significant association of AC genotype with intracranial large artery atherosclerosis (p < 0.01, odds ratio = 9.37, (95 % CI, 5.31-16.5) and small artery occlusion (p < 0.0001, odds ratio = 9.81 (95 % CI, 4.94-19.4). Our results indicate that the individuals bearing AC genotype of E-selectin gene polymorphism (S128R) are more prone to stroke than AA genotype.

Endovascular Treatment in Two Cases of Bilateral Ischemic Stroke

Acute bilateral intracranial large artery occlusion is a rare occurrence that can lead to bihemispheric ischemia and potentially devastating functional consequences. We discuss two cases that initially presented with unilateral symptoms and did not show signs of bilateral arterial occlusions on the initial MRI imaging. This became evident while performing the angiographic study at the beginning of the endovascular procedure. Both patients were successfully treated with bilateral mechanical thrombectomy as a complement to intravenous thrombolysis. We describe our method of simultaneous sequential bilateral thrombectomy. To our knowledge, this is the first report of successful endovascular therapy in bilateral ischemic stroke.

Prevalence of intracranial large artery stenosis and occlusion in patients with acute ischaemic stroke or TIA

Intracranial large artery stenosis and occlusion disease has been considered to be the cause of 8–10 % of ischaemic strokes in North America, and 30–50 % of strokes and more than 50 % of transient ischaemic attacks in Chinese population. So far we do not know the real prevalence of intracranial disease (ID) and the distribution of its risk factors in European population. We aimed to determine the prevalence and risk factors of ID in a European stroke population with computed tomography angiography (CTA). A retrospective study of consecutive ischaemic patients at the Stroke Unit of Utrecht, The Netherlands, from September 2006 to August 2008 was conducted. We assessed the presence of occlusion and/or stenosis of intracranial Internal Carotid Artery (ICA) and Middle Cerebral Artery on post-contrast 30-mm reconstruction axial CTA images. We analyzed the proportion of patients with ID, and the association of ID with risk factors and stroke subtype. In 220 patients (187 with stroke, 33 with TIA; mean age was 65 years, 57.3 % were male), intracranial stenosis was found in 6.4 % (95 % CI 3.9–10.4), intracranial occlusion in 34.5 % (95 % CI 28.6–41.0), and both occlusion and stenosis in 2.3 % (95 % CI 1.0–5.2). Multivariate analysis showed that the variables independently associated with ID were: extracranial ICA atherosclerosis (OR, 24.64; 95 % CI 6.30–96.38) and stroke subtypes TACS–PACS (OR, 7.61; 95 % CI 3.31–17.49). In conclusion, prevalence of intracranial stenosis in our study may well be consistent with previous observations in European and non-European population. ID may have been an underestimated condition in ischaemic Caucasian population.