Penumbra System Research Articles

Acute stroke treatment using the Penumbra endovascular mechanical thrombolysis device: a single-centre experience

Ischaemic stroke due to occlusion of large cerebral vessels has a poor prognosis. The clinical outcome is related to efficacy and timing of recanalisation of the occluded arteries. We report our experience with a thrombus aspiration device (Penumbra), and focus on pre- and postprocedural management. We retrospectively reviewed 18 consecutive patients with acute ischaemic stroke due to the occlusion of large cerebral vessels who were treated with mechanical thrombolysis at our centre between September 2009 and July 2010. Preprocedural symptoms were quantified using the National Institutes of Health Stroke Scale (NIHSS). Mechanical thrombolysis was performed with the Penumbra system. Intravenous thrombolysis was done only if <3 h had elapsed since symptom onset. Associated vessel stenoses were treated with stenting. All patients underwent neurological examination and postprocedural magnetic resonance angiography (MRA) at 3 and 6 months. Mechanical thrombolysis using the Penumbra system was performed in all cases. A total of 83% of treated vessels had a value of 2/3 according to the Thrombolysis in Cerebral Infarction (TICI) scale. In seven patients (39%) intravenous thrombolysis was unsuccessful, and salvage mechanical thrombolysis followed. Three patients died after the procedure (16.7%). Five patients (27.8%) required a stenting procedure. All patients reported a significant improvement in symptoms (mean baseline NIHSS 19.6±5.6; mean postprocedural NIHSS, 7.8±5.5 p<0.0001) Our preliminary experience with the Penumbra mechanical thrombolysis system confirms previously reported results showing the efficacy and safety of the device in treating acute stroke caused by the occlusion of large intracranial vessels.

Effectiveness of Mechanical Endovascular Thrombectomy in a Model System of Cerebrovascular Occlusion

A number of thrombectomy devices are currently undergoing clinical evaluation; meanwhile, various novel devices are under investigation. The aims of this study were to quantify flow restoration and the particle size distribution of the effluent pursuant to MET in an in vitro occlusion model. The model system was composed of 3 elements: an ICA/MCA replica, a clot model with mechanical properties similar to those of thrombi found in patients at risk of stroke, and a pulsatile flow loop. Different thrombectomy mechanisms including mechanical retrieval, aspiration, and waveguide induced cavitation were used. The efficacy end points were recanalization rate and amount of flow restoration. The risk of the embolic shower was assessed to evaluate device safety. The recanalization rates were the following: Merci, 67%; Solitaire, 100%; Penumbra, 83%; Enterprise, 17%; and the waveguide, 0%. In experiments in which recanalization was achieved, the amount of flow restoration for the Merci, Solitaire, and Enterprise devices was 100%, 92%, and 86%, respectively. The mean sizes of generated small and large clot fragments were between 23 and 37 and 215 and 285 μm, respectively, depending on the device used. The Merci device generated the fewest number of large fragments compared with the Penumbra system (P < .05) and Solitaire (not significant). The risk of embolic shower was influenced by the mechanism of action for the thrombectomy device. Clinically reported recanalization rates for the Solitaire, Penumbra, and Merci devices were nearly identical in this model system, suggesting that this model may provide a predictive tool for preclinical evaluation of MET.

Outcome of forced-suction thrombectomy in acute intracranial internal carotid occlusion

ObjectivesIschemic stroke from acute intracranial distal internal carotid artery (ICA) occlusion usually carries a poor prognosis. Despite the intra-arterial revascularization therapies, the results are still unsatisfactory. The aim of this...

Endovascular Treatment Outcomes in Acute Posterior Circulation Stroke Patients Undergoing Mechanical Thrombolysis with Penumbra System: A Single Center Experience (P05.270)

Objective: To assess outcome of endovascular mechanical thrombolysis with Penumbra system in patients with posterior circulation acute ischemic strokes (AIS). Background Posterior circulation large vessel ischemic strokes are known for poor prognosis. Recent advances in endovascular therapy have shown improved clinical outcome in patients who present with posterior circulation ischemic stroke. Limited data exist regarding use of penumbra system to treat posterior circulation strokes. Design/Methods: Retrospective chart review was performed in 150 consecutive patients who underwent endovascular treatments AIS at our institution between 2008 and 2011. We included those with posterior circulation AIS (n=17) with mean age 63.7±12.3 years, 6 females, 11 males. Of these patients, 52.9% (n=9) underwent Penumbra system intervention along with other endovascular treatment modalities (MERCI and/or Penumbra and/or angioplasty and stenting) and/or chemical thrombolysis (intra-arterial tPA). 11% (n=1) had posterior cerebral artery and 89% (n=8) had basilar artery strokes. Comorbidities include 89% (n=8) hypertension, 33% (n=3) diabetes mellitus, 78% (n=7) dyslipidemia, 67% (n=6) coronary artery disease, and 33% (n=3) with atrial fibrillation. Primary outcome measures were rate of partial to complete recanalization (TIMI 2-3 post-intervention), discharge NIHSS, discharge modified Rankin Scale (mRS), symptomatic intracerebral hemorrhage (SICH) (ECASS criteria), hemicraniectomy, and all cause mortality. Results: Rates of partial to complete recanalization were 88.9% (n=8). Of those with survival, mean discharge NIHSS were 9±9 points. 0% (n=0) patients had SICH, although 11% (n=1) had asymptomatic hemorrhage on CT post-intervention (PH1). 11% (n=1) underwent suboccipital hemicraniectomy. At time of discharge, 11% (n=1) had mRS Conclusions: In patients undergoing endovascular treatment modalities in posterior circulation stroke, those with Penumbra system intervention had good revascularization rates. Additional data with larger sample size is needed to better evaluate outcomes of penumbra system in posterior circulation strokes. Disclosure: Dr. Shams has nothing to disclose. Dr. Sharma has nothing to disclose. Dr. Jung has nothing to disclose. Dr. Blackham has nothing to disclose.

Self-Expandable Stents in the Treatment of Acute Ischemic Stroke Refractory to Current Thrombectomy Devices: Single Center Experience (P06.212)

Objective: This study examines the outcomes of recanalization of large vessel occlusions in acute ischemic stroke. The interventions compared are the Mechanical Embolus Removal in Cerebral Ischemia, the Penumbra System, and self-expandable stents. Background Recanalization of occluded large vessels is a sign of good prognosis in ischemic stroke. With FDA approved thrombectomy devices such as the Concentric Thrombus Retriever (Concentric Medical; Mountain View, CA, USA) and the Penumbra System (Penumbra Inc.; Alameda, CA, USA), recanalization rates have been reported to range between 40-81%. Recent research, however, has shown self-expandable stents (SES) to be a safe option for flow restoration in cases of acute ischemic stroke (AIS), with higher recanalization rates than other treatments at 92-100%. Design/Methods: All cases of self-expandable stent deployment as a acute ischemic stroke (AIS) intervention from August 2008 to the current time at Baptist Cardiac & Vascular Institute are included in this study. Stent intervention was used during AIS according to a National Institute of Health Stroke Scale (NIHSS)≥ 4, due to large vessel occlusion where thrombolysis and mechanical thrombectomy failed to restore flow. A good outcome was defined as a modified Rankin Scale (mRS) ≤2 one month after hospital discharge. This was assessed at follow-up visits or by a structured telephone interview. Recanalization of the vessel was assessed using the Thrombolysis in Myocardial Infarction (TIMI) grading system by a physician not involved with the procedure and blinded from the clinical outcome. Results: Twenty-four stented patients have been included in the study at this point. Forty-one percent of patients had a good outcomes (mRS ≤2) and 95% of patients were reperfused with SES. Symptomatic intracerebral hemorrhage (sICH) occurred in 13% of patients and overall mortality was 21%. Conclusions: SES is a safe and effective alternative when thrombolysis and mechanical thrombectomy fail. Disclosure: Dr. Garland has nothing to disclose. Dr. Linfante has received personal compensation for activities with Micrus Corporation and Codman Neurovascular as a consultant.Dr. Linfante has received research support from Surpass Medical Inc. Dr. Samaniego has nothing to disclose.

Image Guided Patient Selection and Its Impact on Outcome: Results of the Penumbra Imaging Collaborative Study (PICS) (IN2-1.002)

Objective: The PICS registry sought to determine the impact of baseline imaging on patient functional outcome in acute ischemic stroke intervention. Background Several imaging techniques are currently used to triage patients in this setting but it is unclear which imaging modality (IM) is best for mechanical thrombectomy (MT). Design/Methods: Patients treated by the Penumbra System and had noncontrast CT (NCCT), CT perfusion (CT-P), and MRI diffusion weighted imaging (DWI) were enrolled across 35 centers in the US. The modified Rankin Scale (mRS) was used to assess 90-day functional outcome. Results: Among 305 patients enrolled in the PICS registry, 267 qualified for this analysis. Mean age was 66.6 ± 15.9 years; 49.4% were females, median NIHSS score was 17.0 (IQR 12-21). The median time from stroke onset to presentation was 2.3 hrs, and onset to arterial puncture was 4.8 hrs. Post-treatment, 83.5% of patients were successfully recanalized (TIMI 2/3 from 0/1) with 43.5% functionally independent at 90-days (mRS of 0-2). All cause mortality was 19.9% and rate of symptomatic intracranial hemorrhage was 4.5%. IM used for patient triage were NCCT (61.8%), CT-P (27.3%) and DWI (10.9%). There was no significant difference between groups for patient age, baseline NIHSS, and time from onset to presentation. The time from stroke symptom onset to groin puncture was significantly longer in the DWI cohort (median = 6.5 hrs) than for NCCT (4.4 hrs) or CTP (4.8 hrs) (p Conclusions: These data suggest that in the US, there is a wide variability in the types of imaging modality used to guide patient selection for acute stroke intervention by MT. In addition, the imaging approach appears to have little impact on patient functional outcome after treatment. Disclosure: Dr. Zaidat has received personal compensation for activities with Boston Scientific Corporation and Micrus Inc. Dr. Meagher has nothing to disclose. Dr. Brant-Zawadski has received personal compensation for activities with Penumbra Inc. as a consultant. Dr. Farkas has nothing to disclose. Dr. Malek has nothing to disclose. Dr. Crandall has nothing to disclose. Dr. Frei has received personal compensation for activities with Penumbra Inc. as a consultant. Dr. Hui has nothing to disclose. Dr. Alexander has received personal compensation for activities with Penumbra Inc as a consultant. Dr. Chong has nothing to disclose. Dr. Janjua has nothing to disclose. Dr. Shaff has nothing to disclose. Dr. Yavagal has received personal compensation for activities with Boston Scientific Corporation, Micrus Corporation, and Penumbra Inc., Dr. Heck has received personal compensation for activities with Penumbra Inc as a consultant. Dr. Malisch has nothing to disclose. Dr. Turk has received personal compensation for activities with Penumbra Inc as a consultant. Dr. Hayakawa has nothing to disclose. Dr. Miskolczi has nothing to disclose. Dr. Tarr has nothing to disclose. Dr. Ortiz has received personal compensation for activities with Penumbra Inc. as a consultant. Dr. Zauner has nothing to disclose. Dr. Klucznik has nothing to disclose. Dr. Zylak has nothing to disclose. Dr. Yoo has received research support from Penumbra Inc. Dr. Mualem has received personal compensation for activities with Penumbra Inc as an employee. Dr. Mualem holds stock and/or stock options in Penumbra Inc. Dr. Bose has received personal compensation for activities with Penumbra Inc. as an employee. Dr. Bose has received compensation for serving on the board of directors of Penumbra Inc. Dr. Bose holds stock and/or stock options in Penumbra Inc. Dr. Sit has received personal compensation for activities with Penumbra Inc as an employee. Dr. Sit holds stock and/or stock options in Penumbra Inc. Dr. Mualem has received personal compensation for activities with Penumbra Inc as an employee. Dr. Mualem holds stock and/or stock options in Penumbra Inc.

Endovascular aspiration thrombectomy in acute ischemic stroke therapy: the Penumbra system

Approximately half of acute ischemic stroke patients end up with a disability that interferes with independent living, despite treatment with intravenous tissue plasminogen activator (iv. tPA). One of the strongest explanations is the low rates of full and sustained recanalization at the arterial occlusion site with iv. tPA alone. This prompted the search for adjunctive therapies to achieve recanalization when iv. tPA fails. The Penumbra system is one of only two US FDA-approved devices for use in the endovascular therapy of ischemic stroke. Its design allows it to remove thrombi by a combination of suction and extraction. Studies reporting on this device describe recanalization rates in the range of 80–100%. While these rates are very promising, it is yet to be translated into better functional outcome. Until then, research continues to identify patients who are likely to benefit from recanalization and to get them treated as soon as possible.

Techniques and Results—Penumbra Aspiration Catheter

The Penumbra System is an endovascular mechanical thrombectomy device that uses continuous aspiration to perform recanalization of occluded intracranial vessels. The objective of this article was to provide a comprehensive overview of the data on technical and functional outcome so far published for aspiration thrombectomy and resume techniques that can be used to optimize functionality of the Penumbra System. We focus on existing clinical data as well as our institutional experience and techniques.

Thromboaspiration in a Patient With Persisting Intracranial Occlusion After Intravenous Thrombolysis: A Case Report

The last few years have been characterized by a rapid diffusion of endovascular treatments aimed at achieving arterial recanalization in patients with acute ischemic stroke. Clinical trials have shown higher rates of arterial recanalization being achieved by the Penumbra System (PS) as compared to standard treatment, i.e. systemic thrombolysis by recombinant tissue plasminogen activator (rtPA). This case-report enhances the relevance of strict patient monitoring during and after rtPA administration in order to consider urgent mechanical thrombectomy as additional treatment in highly selected cases. A 69-year-old woman presented with sudden onset of left hemiparesis and slurred speech. Systemic rtPA was administered with marked clinical improvement. Ultrasound study performed during rtPA infusion suggested intracranial occlusion. Diffusion-weighted MRI was negative for acute ischemia, perfusion-weighted imaging detected a wide region of hypoperfused tissue in the right middle cerebral artery (MCA) territory, and MR angiography detected right proximal MCA occlusion. After the initial clinical improvement, the patient deteriorated. Clot aspiration by the PS and complete recanalization were achieved in 56 minutes. The patient was discharged with mild left hemiparesis, and she had excellent recovery at 6 months. Acute endovascular treatment by the PS proved successful in this patient experiencing clinical fluctuations due to persisting intracranial artery occlusion after systemic thrombolysis. Strict patient monitoring by MRI and ultrasound studies may allow prompt mobilization of the interventional radiology team thus offering an increased chance of favourable outcome and preventing more invalidating strokes in patients known to benefit poorly by systemic thrombolysis. doi:10.4021/jnr84w

Incidence and outcome of procedural distal emboli using the Penumbra thrombectomy for acute stroke

BackgroundThe Penumbra system is effective for recanalization of the primary arterial occlusion (PAO) in acute stroke. However, clinical outcomes are not as promising. The authors hypothesized that the formation of...

Mechanical embolectomy for treatment of large vessel acute ischemic stroke in children

Background and purposeThe three largest adult stroke trials investigating mechanical embolectomy retrieval devices in acute stroke (the Merci, Multi Merci and Penumbra Pivotal Stroke Trials) excluded children. There is a...

Abstract 3820: Penumbra Imaging Collaborative Study (PICS): Utilization of Imaging for Patient Selection and Its Impact on Outcomes Following Penumbra System ® Treatment

Purpose: Various imaging approaches are utilized for evaluating acute stroke patients. Despite numerous studies, there is no clear evidence that one approach is superior to another for identifying which patients will benefit from mechanical thrombectomy (MT). The PICS registry was established to determine the imaging modalities being employed to triage acute stroke patients for MT and to assess their impact on patient functional outcome. Methods: Patients were enrolled across 35 centers. For each patient, the baseline imaging modality was recorded to determine the utilization rates of noncontrast CT (NCCT), CT perfusion (CT-P), and MRI diffusion weighted imaging (DWI). All patients subsequently treated by the Penumbra System per standard of care were followed for 3 months after the procedure to assess functional outcome using the modified Rankin Scale (mRS). Results: A total of 305 patients were enrolled in this registry, of which 267 had the requisite imaging modalities used for this analysis. Of these, 49.4% were females. Mean age was 66.6 ± 15.9 years; median NIHSS score was 17.0 (IQR 12-21). The median time from stroke onset to presentation was 2.3 hours, from stroke symptom onset to arterial puncture was 4.8 hours, and from arterial puncture to end of thromboaspiration was 73.0 minutes. Post-treatment evaluation revealed that 83.5% of patients were successfully recanalized to TIMI 2/3 (from TIMI 0/1) with 43.5% achieving a 90-day mRS of 0-2. All cause mortality was 19.9% with symptomatic intracranial hemorrhage reported in 4.5% of the patients. The principal imaging modalities used for patient triage were NCCT in 61.8%, CT-P in 27.3% and DWI in 10.9% of the study population. Of the patients selected for NCCT, 42.5% were functionally independent at 90 days, whereas for CT-P and DWI, the rates were 45.9% and 42.9%, respectively. There was no significant difference between groups for patient age, baseline NIHSS, time from onset to presentation, time from arterial puncture to end of thromboaspiration. The time from stroke symptom onset to groin puncture was significantly different in the DWI cohort (p&lt;0.0001) with a median of 4.4 hrs for NCCT, 4.8 hrs for CTP, and 6.5 hrs for DWI. There was a significant difference in % of female patients with CTP 37.0%, DWI 48.3%, and NCCT 55.2% (p=0.034). Conclusion: The type of imaging modality utilized to triage acute ischemic stroke patients for MT varies widely across the US. Based on the present findings, the imaging approach appears to have little impact on patient functional outcome after MT.

Abstract 3232: Distal Embolization Predicts Infarct Growth and Futile Recanalization after Endovascular Stroke Therapy

OBJECTIVE With the growing use of intra-arterial devices in acute stroke therapy, distal embolization (DE) is increasingly encountered. Reports described the incidence of these emboli but none so far linked them to the futile recanalization phenomenon. We report DE impact on clinical and radiographic outcomes in relation to futile recanalization. METHODS This is a retrospective longitudinal cohort including all anterior circulation stroke patients treated using intra-arterial therapy in our center between 2005 and 2011. Patients enrolled in randomized trials were excluded. Baseline and follow-up CT scans were scored by a stroke neurologist and a neuro-radiologist blinded to the clinical and angiographic data. Angiograms were reviewed by an experienced interventional neuro-radiologist blinded to the clinical and radiographic outcome. DE is defined as any luminal filling defect in the arterial tree distal to the thrombus or any new luminal filling defect in a different arterial territory evaluated at final cerebral angiogram. Infarct growth was defined as a drop of two points in ASPECTS on noncontrast CT follow up scan compared to baseline. RESULTS Eighty two patients (mean age 68 [13.8] years, median NIHSS 17[IQR 7], median ASPECTS 8[2]) were studied. Intravenous tPA was used in 63%. The median onset-to-puncture time was 209 (119) minutes. The occlusion site was the L/T-type carotid occlusion in 22%, proximal MCA in 53.7%, and M2-MCA in 24.3%. The Merci device was used in 28%, Penumbra system in 31.7%, angioplasty balloon in 18.3%, and retrievable stents in 11%. Intra-arterial tPA was also used in 59% of cases. Successful recanalization (TICI 2b/3) was achieved in 43%. Distal emboli occurred in 45.1% of cases, 10% of which were in the ACA territory. Despite successful recanalization, infarct growth occurred in 28.6% of patients. DE occurred in 80% (8/10) of those with infarct growth and recanalized vs. 60% (15/25) in those who had no infarct growth and recanalized. Good clinical outcome (mRS 0-2) at discharge was noted in 58.3% of patients with successful recanalization and no DE, 30.4% in those with successful recanalization and DE, and 17% in those who did not recanalize (TICI 0-2a) (p=0.015). CONCLUSIONS DE is common in the setting of endovascular stroke therapy and is associated with infarct growth and worse outcomes despite successful recanalization. DE may be one factor contributing to the futile recanalization phenomenon. This retrospective, single center experience needs to be validated in endovascular clinical trials.

Mechanische Thrombektomie beim akuten Schlaganfall

The therapy of acute ischemic stroke aims at fast recanalization of the occluded brain vessel. In contrast to intravenous thrombolysis (IVT), endovascular approaches yield higher recanalization rates especially in large vessel occlusions. Mechanical thrombectomy with the Merci Retriever received FDA approval in 2004 as an adjunct to IVT or in the case of failed recanalization after IVT. The time window for treatment is 8 h from stroke onset. However, the recanalization rate was 55 %, still leaving space for further improvement. In addition to the Merci Retriever, the Penumbra System received FDA approval in 2008. The newest endovascular approach comprising retrievable intracranial stents results in an increased recanalization rate exceeding 90 % and has markedly reduced the time to recanalization. On the other hand, the complication rate has not increased yet. These promising results suggest a combined therapy for acute ischemic stroke. In a first step IVT can be started independently of the size of the treating hospital and in a next step the patient is transferred to a neuroradiological center. If vessel occlusion persists, additional endovascular recanalization is performed (bridging concept). Patients who don't qualify for IVT are candidates for mechanical thrombectomy up to 8 h after stroke onset.

Stand alone mechanical thrombectomy (with penumbra system) for acute ischemic stroke based on MR imaging: Single center experience

There is dismal rate of recanalization following intravenous thrombolysis of large vessel occlusive ischemic stroke. Trials on use of mechanical clot retrievers in acute ischemic stroke have used time from onset and clinical deficit at presentation as the main indications for intervention. Retrospective analysis of case records of acute stroke seen between May 2009 and October 2011 was done. It revealed 23 patients with acute ischemic stroke treated by mechanical thrombectomy using Penumbra system (PS). We used magnetic resonance (MR) imaging in correlation with clinical presentation to determine patients likely to benefit from recanalization and accordingly offered or at times deferred revascularization. A comparison of approach and outcomes was done with other relevant trials/reports. Recanalization was achieved in all but one patient. Median modified Rankin Scale (mRS) score at 90 days was 2. Good clinical outcome (mRS ≤ 2) was achieved in 56.5% compared with 25% in Penumbra pivotal trial and 36% in multi Mechanical Embolus Removal in Cerebral Ischemia (multi MERCI) trial. All cause mortality was 13.04%. Symptomatic intracerebral hemorrhage (ICH) occurred in two patients (8.6%). Analysis of our results suggests that PS is safe and effective (91.3%) in recanalizing cerebral vessels without concomitant thrombolytics.

Thromboaspiration in a Patient With Persisting Intracranial Occlusion After Intravenous Thrombolysis: A Case Report

The last few years have been characterized by a rapid diffusion of endovascular treatments aimed at achieving arterial recanalization in patients with acute ischemic stroke. Clinical trials have shown higher rates of arterial recanalization being achieved by the Penumbra System (PS) as compared to standard treatment, i.e. systemic thrombolysis by recombinant tissue plasminogen activator (rtPA). This case-report enhances the relevance of strict patient monitoring during and after rtPA administration in order to consider urgent mechanical thrombectomy as additional treatment in highly selected cases. A 69-year-old woman presented with sudden onset of left hemiparesis and slurred speech. Systemic rtPA was administered with marked clinical improvement. Ultrasound study performed during rtPA infusion suggested intracranial occlusion. Diffusion-weighted MRI was negative for acute ischemia, perfusion-weighted imaging detected a wide region of hypoperfused tissue in the right middle cerebral artery (MCA) territory, and MR angiography detected right proximal MCA occlusion. After the initial clinical improvement, the patient deteriorated. Clot aspiration by the PS and complete recanalization were achieved in 56 minutes. The patient was discharged with mild left hemiparesis, and she had excellent recovery at 6 months. Acute endovascular treatment by the PS proved successful in this patient experiencing clinical fluctuations due to persisting intracranial artery occlusion after systemic thrombolysis. Strict patient monitoring by MRI and ultrasound studies may allow prompt mobilization of the interventional radiology team thus offering an increased chance of favourable outcome and preventing more invalidating strokes in patients known to benefit poorly by systemic thrombolysis. J Neurol Res. 2012;2(1):33-35 doi: https://doi.org/10.4021/jnr84w

Carotid Artery Stenting in Acute Stroke

The purpose of this study is to demonstrate the technical success of carotid artery stenting in acute extracranial internal carotid artery (ICA) occlusion as well as the benefit in clinical outcome. Stroke caused by acute occlusion of the ICA is associated with a significant level of morbidity and mortality. For this type of lesion, treatment with standard intravenous thrombolysis alone leads to a good clinical outcome in only 17% of the cases, with a death rate as high as 55%. Recanalization of the occluded ICA can lead to an improvement in acute symptoms of stroke, prevent possible deterioration, and reduce long-term stroke risk. At present, there is no consensus treatment for patients with acute ischemic stroke presenting with severe clinical symptoms due to atherosclerotic occlusion of the extracranial ICA. Carotid artery stenting was performed in 22 patients with acute atherosclerotic extracranial ICA occlusion within 6 h of stroke symptom onset. In 18 patients, there was an additional intracranial occlusion at the level of the terminal segment of the ICA (n = 4) and at the level of the middle cerebral artery (n = 14). Intracranial occlusions were either treated with the Penumbra system or the Solitaire stent-based recanalization system, or a combination of mechanical recanalization and intra-arterial thrombolysis. Recanalization results were assessed by angiography immediately after the procedure. The neurologic status was evaluated before and after the treatment with a follow-up as long as 90 days using the National Institutes of Health Stroke Scale and the modified Rankin Scale. Successful revascularization of extracranial ICA with acute stent implantation was achieved in 21 patients (95%). There was no acute stent thrombosis. After successful recanalization of the origin of the ICA, the intracranial recanalization with Thrombolysis In Myocardial Infarction flow grade 2/3 was achieved in 11 of the 18 patients (61%). The overall recanalization rate (extracranial and intracranial) was 14 of 22 patients (63%). Nine patients (41%) had a modified Rankin Scale score of ≤2 at 90 days. The mortality rate was 13.6% at 90 days. Carotid artery stenting in acute atherosclerotic extracranial ICA occlusion with severe stroke symptoms is feasible, safe, and useful within the first 6 h after symptom onset.

CT perfusion-guided patient selection for endovascular treatment of acute ischemic stroke is safe and effective

BackgroundTraditional treatment in acute ischemic stroke is based on time criteria when administering intravenous and intra-arterial therapies. However, recent evidence suggests that image-based criteria may be useful for selecting patients...

P-010 A Study of the novel 054 Penumbra aspiration device in the ICA and MCA

PurposeThe 054 reperfusion catheter is a newly introduced component of the Penumbra System specifically designed to enhance aspiration efficiency by increasing the catheter diameter. The goal of this study was...

Rescue forced-suction thrombectomy using the reperfusion catheter of the Penumbra System for thromboembolism during coil embolization of ruptured cerebral aneurysms.

No definite conclusive management has been established in the treatment of thromboembolism during coil embolization of cerebral aneurysms. To date, intravenous heparin, intra-arterial fibrinolytic agent, and intravenous or intra-arterial glycoprotein IIb-IIIa inhibitors have been the mainstay of treatment. However, in practice, 2 major concerns may arise; first, recanalization is not always possible despite every effort of management; second, rehemorrhagic risk is increased if the event occurred during coiling of ruptured cerebral aneurysms. We introduce a new endovascular mechanical thrombectomy technique to overcome the aforementioned concerns. In 4 refractory cases involving conventional pharmaceutical treatment of thromboembolism during coiling, we practiced rescue suction thrombectomy using the reperfusion catheter of the Penumbra System. All 4 of the patients to whom this technique was applied were successfully recanalized; 2 were Thrombolysis In Cerebral Infarction scale of 2b and the other 2 were a scale of 3. Recanalization was confirmed at the follow-up angiography at least 12 hours after the procedure. No complication associated with this technique occurred. Forced-suction thrombectomy is a simple modification of the Penumbra System. Based on our preliminary data, this technique can play a role as an adjuvant management or as a last resort combined with injection of glycoprotein IIb-IIIa inhibitors in thromboembolic events that occur in coil embolization of a ruptured cerebral aneurysm.