Proximal Occlusion Research Articles

Abstract Number ‐ 172: First‐in‐Human Experience: Route 92 Medical 132 cm FreeClimb 88 Catheter for Anterior Circulation LVOs

Introduction Direct aspiration thrombectomy of proximal anterior circulation large vessel occlusions (LVOs) with super‐bore catheters (SBCs, 0.088” ID) may result in improved first pass success, though their consistent delivery to the target occlusion remains challenging. We report the first‐in‐human experience with a novel full‐length 132 cm 0.088” ID FreeClimb ® 88 catheter (Route 92 Medical, San Mateo, CA, currently approved for neurovascular access), and its customized Tenzing ® 8 delivery catheter, for anterior circulation LVO acute stroke patients. Methods We performed a retrospective review of thrombectomy cases for proximal anterior circulation large vessel occlusions performed at three stroke centers from May 2022 through August 2022. All patients were treated using the Route 92 Medical 8F Base Camp® guide catheter, FreeClimb ® 88 catheter and Tenzing ® 8 delivery catheter in an off‐label fashion. Results Ten consecutive acute stroke patients with anterior circulation LVOs were treated. The median age was 71 (45‐91) and 6 were female (60%). The median presenting NIHSS score and ASPECT score were 17 (8‐24) and 9 (6‐10), respectively. LVO locations were as follows: two right carotid termini, three right M1 middle cerebral arteries, and five left M1 middle cerebral arteries. Three patients also had tandem occlusion/near‐occlusion of the respective cervical internal carotid artery. The FC88 catheter was delivered to the target occlusion with 100% success. The median time from groin puncture to catheter delivery to the target occlusion was 14 minutes (7‐35). First pass complete reperfusion (modified Thrombolysis in Cerebral Infarction score, mTICI, of 3) was achieved in 9/10 (90%) patients (self‐adjudicated). Adjunctive therapy for a residual M2 occlusion was utilized in 1/10 patients. There were no adverse events or post‐procedural symptomatic hemorrhages. Conclusions Our first‐in‐human experience with a novel 132 cm full‐length super‐bore catheter (Route 92 FreeClimb ® 88 catheter) and its customized catheter delivery device (Tenzing ® 8) for aspiration thrombectomy of proximal anterior circulation large vessel occlusions demonstrated 100% successful delivery to the target occlusion, with TICI 3 first pass reperfusion achieved in 90% of patients.

From fixed-pressure paediGAV to programmable proGAV/proSA serial valves for pediatric hydrocephalus within the 1st year of life: a technical single-center analysis.

Programmable valves have gained increasing popularity in the complex treatment of pediatric hydrocephalus. Over the last decade, adjustable serial valves have gradually replaced fixed-pressure valves in the authors' department. The present study investigates this development by analyzing shunt- and valve-related outcomes for this vulnerable population. A retrospective analysis of all shunting procedures between January 2009 and January 2021 in children younger than 1 year of age was performed at the authors' single-center institution. Postoperative complications and surgical revisions were set as outcome parameters. Shunt and valve survival rates were evaluated. Statistical analysis compared children who underwent implantation of the Miethke proGAV/proSA programmable serial valves with those who underwent implantation of the fixed-pressure Miethke paediGAV system. Eighty-five procedures were evaluated. The paediGAV system was implanted in 39 cases and the proGAV/proSA in 46 cases. The mean ± SD follow-up was 247.7 ± 140 weeks. In 2009 and 2010, paediGAV valves were used exclusively, but by 2019, the use of proGAV/proSA had evolved into the first-line therapy. The paediGAV system was significantly more often revised (p < 0.05). The main indication for revision was proximal occlusion, with or without impairment to the valve. The valve and shunt survival rates of proGAV/proSA were significantly prolonged (p < 0.05). The surgery-free valve survival of proGAV/proSA was 90% after 1 year and 63% after 6 years. There were no overdrainage-related revisions of proGAV/proSA valves. Favorable shunt and valve survival validates the increasing use of programmable proGAV/proSA serial valves in this delicate population. Potential benefits in postoperative treatment should be addressed in prospective multicenter studies.

Abstract Number ‐ 191: Barriers to Mechanical Thrombectomy in Africa

Introduction The emergence of mechanical thrombectomy (MT) as a standard of care has revolutionized the management of proximal large vessel occlusions (LVOs) in patients with acute ischemic stroke (AIS). Endovascular therapy has already been shown to provide better long‐term outcomes when compared to standard treatment alone. However, despite the significant advances and benefits associated with MT in the treatment of proximal LVOs in developed countries, Africa continues to lag in the use and adaptability of the “gold standard” for proximal LVO stroke treatment. With the prevalence of stroke in Africa approaching the highest rates in the world, this study seeks to highlight the problems threatening endovascular therapy in Africa. This is an important step in advocacy for more radical, effective, and evidence‐based management of patients with proximal LVOs in Africa. Methods For this narrative review, PubMed and Google Scholar were used to search for literature on mechanical thrombectomy and endovascular treatment of LVOs in Africa. Selection criteria were manuscripts published in the last 10 years, written in English language, and addressed challenges with MT. Results 42 papers from 21 African nations were found and reviewed. The major challenges and impediments to MT in Africa were, a lack of government policy on stroke care, a suboptimal health care financing model that makes endovascular treatment nearly impossible to afford, delay in presenting to the hospital after stroke onset coupled with very few emergency services with some countries having none, lack of specialized training, as well as, scarcity of neuroradiological infrastructure. Conclusions Despite these challenges, there is still hope for Africa. With its four domains (surveillance, prevention, acute treatment, and rehabilitation), the stroke quadrangle, adapted by many countries allows for focused initiatives aimed at successfully lowering the burden of stroke in Africa at the community level through prevention and education. There is still an urgent need for increased global support to address these challenges in Africa, even as programs like the MT2020+ by the Society of Vascular and Interventional Neurology (SVIN) have given Africa hope for the future of endovascular therapy by fostering collaboration, training, and policy development.

Abstract Number: LBA23 Endovascular treatment of large vessel occlusion stroke caused by infective endocarditis

Introduction Infective endocarditis (IE) often presents as an acute ischemic stroke (AIS) secondary to a thromboembolic event leading to large vessel occlusion (LVO). These patients are at significant risk for intracerebral hemorrhage when given intravenous thrombolytics (IT) and are therefore better candidates for mechanical thrombectomy (MT). Current reports in the literature are divided on the safety of MT in this setting and no randomized control studies exist. With the advent of modern thrombectomy devices, we believe MT might be safe in this patient population. Methods Here we report a patient with IE who presented with LVO stroke (MCA syndrome) and underwent MT leading to first‐pass Thrombolysis inCerebral Infarction (TICI) score of 3 revascularization. In addition to presenting our case, we did a comprehensive review of the current literature on this topic. Results A thirty‐year‐old female with a history of cocaine abuse presented with acute onset left hemiplegia, dysarthria, and rightward gaze deviation. NIHSS was 19 and she presented 90 minutes from her last known well time . Computed Tomography (CT) head and CT perfusion imaging demonstrated a large MCA distribution stroke, an AlbertaStrokeProgram Early CT Score (ASPECTS) of 10, with significant perfusion mismatch of right MCA territory. CT angiography (CTA) confirmed a proximal large vessel occlusion (LVO) at the proximal M1. On initial assessment, the patient was febrile with a temperature of 40 degrees Celsius with a high clinical suspicion for IE; therefore, intravenous thrombolytic was not administered. MT was performed with one pull of stent retrieval under aspiration led to a successful opening of the vessel with TICI score of 3. Positive cocaine on urine toxicology was noted as well as, two sets of gram‐positive blood cultures which later resulted in Staph Aureus, oxacillin susceptible, unremarkable transthoracic echo, but with TEE demonstrating vegetative thickening within atrial aspects of both anterior andposterior mitral valve leaflets(Figure1). On hospital day two, magnetic resonance imaging of the brain shows small acute infarct with no bleed. The patient underwent a mitral valve replacement on hospital day nine. The patient was discharged to rehabilitation facilities with an NIHSS of two for mild left facial droop and mild left arm weakness; her degree of disability was measured as a modified Rankin Scale (mRS) one at 3 months. Conclusions In case IE is suspected, giving IV tPA (tissue‐type plasminogen activator) is contraindicated as it increases the chance of hemorrhagic complications and when LVO is confirmed in the setting of AIS, MT might be safe and effective to be considered .

Abstract Number ‐ 193: Endovascular Thrombectomy for Basilar Artery Occlusion: Systematic Review and Meta‐analysis

Introduction Basilar artery occlusion (BAO), accounting for approximately 1% of all ischemic strokes and 5–10% of all proximal intracranial occlusions, usually causes devastating neurologic sequelae, poor prognosis and even death [1‐2]. Endovascular thrombectomy (EVT) has been recommended for anterior circulation stroke with large vessel occlusion (LVO) [3‐6]. During the past decade, there has been emerging interests in whether EVT could provide similar overwhelming benefits in posterior circulation stroke, especially BAO [7‐8]. The goal of our study is to compare EVT with conservative medical treatment (CMT) about the efficacy and the safety in patients with BAO. Methods All relevant literature comparing the outcomes of EVT versus CMT in patients with BAO were recruited via PubMed, Embase and the Cochrane Library until April 2022. Random‐effects model was adopted to pool estimates regrading favorable/good functional outcome, symptomatic intracranial hemorrhage (sICH) and the mortality. The heterogeneity of outcomes was assessed using the Cochran Q test (reported as a Cochran Q p value) and I2 statistics. Results Of the eight studies, a total of 3733 patients with pure BAO were enrolled. EVT was conducted in 2573 patients, and the others received CMT. Compared with CMT group, EVT group with or without intravenous thrombolytic therapy achieved more favorable functional outcome (OR 1.26, 95% CI 1.03 to 1.55, I2 = 54%, p = 0.05; Figure 1A) in patients with BAO. Similar trend was also noted in the good functional outcome (OR 1.23, 95% CI 0.97 to 1.57, I2 = 63%, p = 0.02; Figure 1B). Even though EVT group tended to provoke more sICH (OR 2.91, 95% CI 1.38 to 6.18, I2 = 22%, p = 0.27; Figure 1C), it reduced the mortality (OR 0.81, 95% CI 0.70 to 0.93, I2 = 31%, p = 0.19; Figure 1D) in patients with BAO, originally a devastating condition. Conclusions Our study worked in concert with the recent climate in the endovascular era [9] that EVT in BAO provides superior functional outcomes and less mortality compared with CMT. Despite the tendency of developing sICH after reperfusion, EVT still brought a dawn to posterior circulation stroke. We are no more at our wits’ end with BAO and its grave prognosis. Furthermore, we still need more future randomized control trials [10] or large‐scale cohorts for conclusive evidence.

Abstract Number ‐ 90: Bailout Technique for Entangled Stentriever and Carotid Stent during Tandem Large Vessel Occlusion Endovascular Therapy

Introduction Tandem occlusions represent 10–20% of all acute ischemic stroke patients.1 Endovascular Thrombectomy (EVT) for this subset of patients is more challenging given the proximal underlying steno occlusive disease. Emergent carotid artery stenting could achieve a considerably high chance of reperfusion and functional independence.2 Methods This is a case report of a 73‐year‐old woman who presented with left MCA syndrome‐NIHSS 13 found to have left ICA/MCA tandem occlusions. EVT was pursued, initial angiographic run of the left common carotid artery demonstrated severe stenosis at the origin of left cervical ICA which harbors a mid‐cervical ICA loop and proximal left MCA occlusion. Following our retrograde revascularization approach, an intracranial pass using an embotrap 5mm x 37 mm stent retriever (SR) was attempted however given proximal cervical ICA tortuosity and underlying proximal stenosis, the stability of triaxial system prevented optimal placement of the SR and achieving intracranial reperfusion. An antegrade revascularization approach was then pursued with uneventful cervical ICA angioplasty followed by extracranial carotid closed cell Xact stent placement. A stable triaxial system was navigated through the stented cervical ICA. An ideal SR pass was performed. Upon retrieving the clot‐incorporated SR with the intention to fully retrieve the SR into the locally placed aspiration catheter (AC) in the supraclinoid ICA under continuous aspiration, the triaxial system collapsed into the distal CCA, likely due to the mid cervical ICA loop, leading to entanglement of the proximal end of SR and distal ICA stent (Figure1‐A). Large thrombus was recovered from the AC aspirate. Results Numerous attempts to disentangle the SR from the ICA stent including attempts to re‐sheath the SR with different size microcatheters and guide catheters were unsuccessful. The cervical ICA lumen remained patent without evidence of dissection or residual thrombus however, the presence of SR pusher‐wire would preclude safe termination of the procedure. Surgical bailout with emergent carotid endarterectomy and removal of the stent/SR metal mesh was considered.3,4 However, given the high surgical risk with recent intravenous load of antithrombotics for emergent stent placement, this option was deemed as a last resort. We decided to attempt safe separation of the SR from its pusher wire and leave behind the patent ICA stent/SR in place. A gradual pulling pressure was applied to the SR wire while maintaining adjacent microwire access and fully inflated Viatrac 5mm x 30 mm extracranial balloon over the entangled portion to ensure continuous vascular access (Figure1‐B). The SR wire was then separated from the SR and fully retracted outside the body (Figure1‐C). Delayed angiographic runs continued to demonstrate full patency of the ICA lumen (Figure1‐D). No residual dissection, spasm or thrombus noted. Patient was discharged home with NIHSS of 3. Conclusions Exposure to EVT technical complications and bailout techniques are of utmost importance.

Abstract Number: LBA1 Endovascular Thrombectomy vs Best Medical Therapy for Late Presentation Ischaemic Stroke Selected using Non‐Contrast CT

Introduction The efficacy and safety of endovascular thrombectomy (EVT) beyond 6 hours from acute ischaemic stroke (AIS) onset for patients with proximal large vessel occlusion (LVO) selected without CT perfusion or MR imaging is undetermined in routine clinical practice. Methods In this single centre study, we identified consecutive AIS patients with an ICA or M1 MCA segment occlusion who were eligible for EVT based on non‐contrast CT/CT angiography (without CT perfusion or MR imaging) using an Alberta Stroke Program Early CT Score (ASPECTS) of ≥ 6, and an NIHSS score of≥ 6, presenting beyond 6 hours from stroke onset, between January 2018 and March 2022. During the study period, EVT capacity limitations meant EVT‐eligible patients presenting out of regular working hours (between 18.00 and 08.00 on weekdays) or on weekends, consistently received best medical management (BMM). This systemic unavailability of EVT, allows a comparison of EVT and BMM in patients who meet the same inclusion criteria, in which selection based on physician‐related bias is significantly reduced. Functional outcomes (modified Rankin Scale (mRS) at 90 days), symptomatic intracranial haemorrhage (sICH) and mortality at 90 days were compared between patients receiving EVT or BMM following multivariable adjustment for age, sex, baseline stroke severity, ASPECTS, onset‐to‐neuroimaging time, IV thrombolysis, and clot location.Pre‐specified subgroup analyses were performed. Results Among 4802 AIS patients, 150 patients (3.1%) presenting beyond 6‐hours of onset were eligible for EVT: 74 (49%) treated with EVT and 76 (51%) with BMM. Compared to the BMM group, patients treated with EVT had significantly improved functional outcome (mRS) (adjusted common OR = 2.23, 95%CI 1.18‐4.22, p = 0.013), and higher rates of functional independence (mRS≤2; 39.2.% vs 9.2%; aOR = 4.73, 95%CI 1.64‐13.63, p = 0.004). No significant difference was observed between the EVT and BMM groups in the sICH (5.4% vs 2.6%, p = 0.94) or mortality (20.2% vs 47.3%, p = 0.16) rates, respectively. EVT remained effective within the 6–12 hour and &gt;12 hour time window subgroups. No significant treatment interaction was observed in all subgroups. Conclusions In routine clinical practice, of the 3.1% of patients in our AIS population presenting after 6 hours from stroke onset who were deemed eligible for EVT by NCCT/CTA alone, those treated with EVT achieved significantly improved functional outcome, compared to patients treated with BMM only. No significant differences were noted between the two groups with respect to sICH and mortality. While confirmatory randomised trials are awaited, these findings suggest that EVT is effective and safe when performed in AIS patients selected without CTP or MRI beyond 6 hours from stroke onset.

Abstract Number ‐ 269: Brainstem Stroke Secondary to Lyme Neuroborreliosis Vasculitis

Introduction Clinical presentations of Lyme disease are variable. A rash is often the first symptom, subsequently evolving into late complications including arthritic, cardiac, and neurological manifestations. CNS pathologies of Borrelia burgdorferi are diverse and usually include meningitis, encephalitis, strokes, intracranial hemorrhages, and central and peripheral cranial neuropathies. Stroke secondary to Lyme vasculitis is a rare entity as such there are few cases reported in the literature. The presumed mechanism of cerebral ischemia is perivascular and vascular lymphocytic infiltration causing inflammation and vasculitis, resulting in a stroke. Methods We present a case of neuroborreliosis from our stroke service in a patient who presented with sudden onset of right‐sided facial droop, dizziness, and difficulty walking. Results A 53‐year‐old male tobacco smoker (his only known risk factor for stroke) presented to the emergency department with acute onset right‐sided facial paresis, difficulty walking, double vision, and trouble managing his oropharyngeal secretions. CT Head showed no acute intracranial pathology and angiography was negative for proximal large vessel occlusion. He was eligible for and received intravenous alteplase due to concerns for acute ischemic stroke. Notably, he disclosed a history of a tick bite (roughly two and half years prior) and daily headaches (for the past 1.5 months). His exam revealed bidirectional nystagmus, negative head impulse, right LMN facial nerve palsy, left‐sided face and arm numbness, and left‐sided tongue weakness. MRI brain revealed acute infract in the right medulla, leptomeningeal and bilateral cranial (3rd, 5th, and 7th) nerves enhancement. Serum Lyme IgG and IgM antibodies were positive. Lumbar puncture revealed an elevated protein with lymphocytic predominance. CSF Lyme antibody revealed 3 bands of IgG and 1 band of IgM, consistent with Lyme meningitis. Intravenous Ceftriaxone was started and his difficulty walking and cranial neuropathies improved during the hospital course. The patient required g‐tube placement and was discharged to sub‐acute rehab. A four‐month follow MRI brain showed decreased cranial nerve enhancement without new evidence of ischemia. He eventually regained the ability to swallow, and his exam had otherwise returned to baseline. Conclusions The proposed mechanism of ischemic stroke due to Lyme Neuroborreliosis is secondary to localized inflammatory vasculitis. Lyme vasculitis can present with hemorrhagic or ischemic strokes, the latter being more common and usually affecting posterior circulation, as seen in this case. Negative CTA or transcranial Doppler studies do not exclude the diagnosis of arteriopathy as stenosis primarily involves small vessels and is usually segmental. Parenchymal brain imaging often reveals multiple territory strokes, leptomeningeal, and multiple cranial nerves enhancement in contrast studies. A thorough history of tick exposure or symptoms consistent with Erythema Migrans should be obtained in suspicious cases. Notably, patients will often complain of meningitic symptoms (including headache, neck stiffness, and malaise) usually weeks to months before any stroke‐like symptoms or deficits. Our case of Lyme Neuroborreliosis presenting as stroke illustrates the importance of considering rare etiologies in younger patients without any significant cerebrovascular risk factors, especially those residing in or traveling to endemic areas.

Abstract Number ‐ 240: Association of intravenous thrombolysis and pre‐interventional reperfusion: a post‐hoc analysis of the SWIFT DIRECT trial

Introduction One potential benefit of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) is pre‐interventional reperfusion. Currently, there is a paucity of data regarding the occurrence of pre‐interventional reperfusion in patients randomized to IVT or no‐IVT before MT. Methods SWIFT DIRECT was a randomized controlled trial including acute ischemic stroke IVT‐eligible patients being directly admitted to a comprehensive stroke center, with allocation to either MT alone or IVT + MT. Primary endpoint of this analysis was the occurrence of pre‐interventional reperfusion defined as pre‐interventional expanded Thrombolysis in Cerebral Infarction score ≥ 2a. The effect of IVT and potential treatment effect heterogeneity were analyzed using logistic regression analyses. Results Out of the 396 patients analyzed, pre‐interventional reperfusion occurred in 20 (10.0%) of patients randomized to IVT+MT, and 7 (3.6%) of patients randomized to MT alone. Receiving IVT favored the occurrence of pre‐interventional reperfusion (aOR 2.91 [95% CI 1.23 – 6.87]). There was no IVT treatment effect heterogeneity on the occurrence of pre‐interventional reperfusion with different strata of Randomization‐to‐Groin‐Puncture (p for interaction = 0.33), although the effect tended to be stronger in patients with Randomization‐to‐Groin‐Puncture &gt;28 minutes (aOR 4.65 [95% CI 1.16 – 18.68]). There were no significant difference in rates of functional outcomes between patients with and without pre‐interventional reperfusion. Conclusions Even for patients with proximal large vessel occlusions and direct access to MT, IVT leads towards an absolute increase of 6.9% (95% CI 1.7‐12.2%) in the rates of pre‐interventional reperfusion. The effect of IVT tended to be more pronounced when Randomization‐to‐Groin‐Puncture intervals were longer, but this heterogeneity did not reach statistical significance.

Contraintuitive fallacy in a big-risk-no-gain stroke scenario? Please verify!

Contraintuitive fallacy in a big-risk-no-gain stroke scenario? Please verify!

Intravenous thrombolysis + endovascular thrombectomy versus thrombolysis alone in large vessel occlusion mild stroke: a propensity score matched analysis.

The best reperfusion treatment for patients with mild acute ischaemic stroke harbouring proximal anterior circulation large vessel occlusion (LVO) is unknown. The aim was to compare the safety and efficacy of intravenous thrombolysis (IVT) plus endovascular thrombectomy (EVT) versus IVT alone in LVO patients with mild symptoms. From the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis and Thrombectomy Register (SITS-ISTR), were included: (i) consecutive acute ischaemic stroke patients, (ii) treated within 4.5h from symptoms onset, (iii) baseline National Institutes of Health Stroke Scale (NIHSS) score ≤5 and (iv) intracranial internal carotid artery [ICA], M1 or T occlusion [defined as occlusion of ICA terminal bifurcation]. After propensity score matching, 3-month functional outcomes (modified Rankin Scale [mRS] 0-1 and 0-2) and safety outcomes (symptomatic intracerebral haemorrhage and death) were compared (via univariable and multivariable logistic [and ordinal] regression analyses) in patients treated with IVT + EVT versus IVT alone. In all, 1037 patients were included. After propensity score matching (n= 312 per group), IVT + EVT was independently associated with poor functional outcomes (adjusted odds ratio [aOR] 0.46 for mRS 0-1, 95% confidence interval [CI] 0.30-0.72, p= 0.001; aOR 0.52 for mRS 0-2, 95% CI 0.32-0.84, p= 0.007; aOR 1.61 for 1-point shift in mRS score, 95% CI 1.12-2.32, p= 0.011), with no significant differences in safety outcomes compared to IVT alone, despite numerically higher rates of symptomatic intracerebral haemorrhage (3.3% vs. 1.1%; p= 0.082), a higher rate of any haemorrhagic transformation (17.6% vs. 7.3%; p< 0.001) and subarachnoid haemorrhage (7.9% vs. 1.5%; p= 0.002) in the IVT + EVT group. In anterior circulation LVO patients presenting with NIHSS score ≤5, IVT + EVT (vs. IVT alone) was associated with poorer 3-month functional outcome. Randomized controlled trials are needed to elucidate the best treatments in mild LVO patients.

A challenging case of recurrent and progressive fusiform anterior circulation intracranial aneurysms: illustrative case.

Intracranial fusiform aneurysms are circumferential dilations of cerebral arteries that can lead to complications including ischemic stroke due to vessel occlusion, subarachnoid hemorrhage, or intracerebral hemorrhage. Treatment options for fusiform aneurysms have expanded significantly in recent years. Microsurgical treatment options include proximal and distal surgical occlusion and microsurgical trapping of the aneurysm, usually in association with high-flow bypass procedures. Endovascular treatment options include the placement of coils and/or flow diverters. Here the authors report a case of aggressive surveillance and treatment of a man with multiple progressive, recurrent, and de novo fusiform aneurysms of the left anterior cerebral circulation over 16 years. Because the long-term course of his treatment coincided with the recent expansion of endovascular treatment options, he underwent every type of treatment listed above. This case demonstrates the wide range of therapeutic options for fusiform aneurysms and how the treatment model for these lesions has evolved.

Once in a Blue Moon: Iatrogenic Coronary Dissection in Anomalous Coronary Artery

Coronary anomalies present as a rare phenomenon. One of the most observed coronary anomalies is the single coronary artery (SCA) originating from one coronary ostium and dividing into the coronary arteries in various configurations1Angelini P. Coronary artery anomalies: an entity in search of an identity.Circulation. 2007; 115: 1296-1305Crossref PubMed Scopus (532) Google Scholar, classified by Lipton’s Classification.2Lipton M.J. Barry W.H. Obrez I. Silverman J.F. Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance.Radiology. 1979; 130: 39-47Crossref PubMed Scopus (414) Google Scholar A 38-year-old male patient was admitted to a community hospital with typical signs of non-ST-elevation myocardial infarction (NSTEMI) but without any known comorbidities. Urgent coronary angiography revealed a rare anomaly (incidence of 0.008%3Yamanaka O. Hobbs R.E. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography.Cathet Cardiovasc Diagn. 1990; 21: 28-40Crossref PubMed Google Scholar,4Mohanty A. Chandra S. A rare case of 'superdominant' single coronary artery.Indian Heart J. 2015; 67: 389-391Abstract Full Text Full Text PDF Google Scholar) of an SCA with the left coronary system originating from the right coronary periphery, posterior to the great vessels (Lipton’s Classification R-IP, table 1) and occlusion of the circumflex artery (CX) (figure 1a-b, video 1). A culprit-lesion percutaneous coronary intervention was attempted. However, despite the use of various flexible guidewires and angled microcatheters (90°) CX passage through the left main artery equivalent (LMA) was not achieved (video 2) and resulted in ST elevation. A prompt control demonstrated a dissection of the LMA (figure 1c, video 3). Further interventional approaches were waived and the patient was transferred for surgical revascularization.Table 1Lipton’s Single Coronary Artery Classification2Lipton M.J. Barry W.H. Obrez I. Silverman J.F. Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance.Radiology. 1979; 130: 39-47Crossref PubMed Scopus (414) Google ScholarCodeDescriptionOstial LocationRRight Sinus of ValsalvaLLeft Sinus of ValsalvaAnatomical DistributionIThe solitary domain vessel follows the course of either a normal right or left coronary arteryIIOne coronary artery arises from the proximal part of the normally located other coronary arteryIIILAD and CX arise separately from a common trunk originating from the right sinus of ValsalvaCourse of the Transverse TrunkAAnterior to the great vesselsBBetween the aorta and the pulmonary arteriesPPosterior to the great vesselsSSeptal Type: A part of the route passes through the interventricular septumCCombined Type: Combination of diverse routes Open table in a new tab Intraoperatively, coronary dissection could be confirmed, whereas the left anterior descending artery (LAD) and CX were identified in the typical locations. Coronary revascularization was performed by anastomosis of the left internal mammary artery to the LAD, and a saphenous vein graft to the CX in perfusion-assisted beating heart technique. The postoperative course remained uneventful and the patient was discharged on the 10th postoperative day. The main issue in SCA persists in the dependency on one system with fatal results in proximal occlusion. Since the overall incidence of coronary anomalies is very low3Yamanaka O. Hobbs R.E. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography.Cathet Cardiovasc Diagn. 1990; 21: 28-40Crossref PubMed Google Scholar, the treatment strategy for acute coronary syndromes in patients with anomalous coronary anatomy remains questionable. In particular, an interventional approach in complex coronary anatomy can result in coronary injury. Since in cases of myocardial infarction time matters most, a deep – even inter-hospital – heart team approach is crucial to maintain in-time life-saving treatments. •Lipton’s Classification R-IP is the rarest form of single coronary artery configuration with the left coronary system originating from the right coronary periphery.•Percutaneous coronary intervention of the left coronary system may be very challenging in Lipton’s Classification R-IP•Surgical revascularization is a reasonable strategy in particular when the coronary periphery location is in typical location.•A deep heart team approach is crucial to maintain in-time life-saving treatments in such critical and complex cases. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI1ZWIwZTk5NTRiZWEzMDA2MGVlNzI5MmM4OTZjNDlmYyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc2MjA3NTg4fQ.My1bJvayG27S7R8PKVtQsWVd9XLKhwldpsEWqzuMHIzYxOz_VIFRiJulyjzbngC4CyNUqZMU_qmU-_r_3QPgVbNU2xkwNmcDVsxgXDGD3oSMx3rmyXQK-bNXjlY-qh_YzCrTQ4UEB8jH1qiVcNVpHyrGc-MtRjc7v89p3xEBD1aa_Ns-xk1OOfXUrdGlF9O7EQX7iWrHtaVkLbdCUhgxc55eQP4YI97gKqxSTzFKe4nOdxPc5K41oBsMkajdNYt83O5oDph59QzDCmbWJJDlinjzvGQqRFcavZjX7emVYeuqr5DOGxgmXTA36j331owW-wzHpdKn7wy_SAu2l1u30g Download .mp4 (3.49 MB) Help with .mp4 files eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzYjhkMDgxYzg2OTRiYTM0MDZmYTgyZDcyYzcxMmI1NyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc2MjA3NTg4fQ.gH37xsv4GXLcsKMdb-SAuac7Xh_CpCm5C0UOpTzC6x5WB68zYxcjtSgpUhdMHve6TUbPHbeu4gyaKxxZOZFAyXhaMk3R4CzuIFQGSdNyQ3UbqN2MXekQOyGM0i6FNEiLMnWIlxCoQlwOvXWyQ1sI5cKCz5qIkr0f6r_5o2C3gv15nrn3mBIX3vPynprGA_1gHGfLtCQXAvMvVUwYfg-Ba-GOjt1NTSJ0ccCjlQefWR_6jSDTk7NX3BfZ5jU-ybtSzeAxEfALNpfSP2YHm960AaPVaXDNtI0CYb5bkGWLepuD3vzkGAahQrf2K23VUEfho5FELp_CpUVjx4EUMLZ3gA Download .mp4 (1.48 MB) Help with .mp4 files eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI2MTc2OTE5MTY2ZDM1OTQ1NTUzYTQ3MzcwOTc1OWJlNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc2MjA3NTg4fQ.G5pvhhPUt-Kl_kxjdKfL-lOu-rH4hRhKzFlVwwANSrmNUjBoRc_thtwNvFupLmPpm1meakrWBTvBZ-JrBLOAlq6fW3AXl46Qy5drW5RxsehHs52zYd8GMPUQ9Trimxz6LG5NH50cVzlCWKi_iaZKUGpRueErVe1WFrp0YqXxkauvv-qmuoIW2pTQS1IpP-6E3u_z8OpKdj53TlaNfpGQJq3z28Uqw5FsY44sS9OP0k_A6uhflBqSRFLKU22pDTS3TPOUSqoxJAATd7yxU-H9QckIiu6lEHsAS2AKowXlAZiXHJnAcRaOBWAFkXx7eJ-MkLy7Eqms1glQNP6hxmoK4Q Download .mp4 (0.95 MB) Help with .mp4 files

The diagnostic performance of artificial intelligence algorithms for identifying M2 segment middle cerebral artery occlusions: A systematic review and meta-analysis

BackgroundArtificial intelligence (AI)-based algorithms have been developed to facilitate rapid and accurate computed tomography angiography (CTA) assessment in proximal large vessel occlusion (LVO) acute ischemic stroke, including internal carotid artery and M1 occlusions. In clinical practice, however, the detection of medium vessel occlusion (MeVO) represents an ongoing diagnostic challenge in which the added value of AI remains unclear. PurposeTo assess the diagnostic performance of AI platforms for detecting M2 occlusions. MethodsStudies that report the diagnostic performance of AI-based detection of M2 occlusions were screened, and sensitivity and specificity data were extracted using the semi-automated AutoLit software (Nested Knowledge, MN) platform. STATA (version 16 IC; Stata Corporation, College Station, Texas, USA) was used to conduct all analyses. ResultsEight studies with a low risk of bias and significant heterogeneity were included in the quantitative and qualitative synthesis. The pooled estimates of sensitivity and specificity of AI platforms for M2 occlusion detection were 64% (95% CI, 53 to 74%) and 97% (95% CI, 84 to 100%), respectively. The area under the curve (AUC) in the SROC curve was 0.79 (95% CI, 0.74 to 0.83). ConclusionThe current performance of the AI-based algorithm makes it more suitable as an adjunctive confirmatory tool rather than as an independent one for M2 occlusions. With the rapid development of such algorithms, it is anticipated that newer generations will likely perform much better.

Computed Tomography Perfusion Imaging in Acute Ischemic Stroke: Accurate Interpretation Matters.

Computed Tomography Perfusion Imaging in Acute Ischemic Stroke: Accurate Interpretation Matters.

Abstract TP41: Assessing The Relationship Between The Los Angeles Motor Scale And Computed Tomography Perfusion Parameters In Acute Ischemic Stroke Secondary To Large Vessel Occlusion

The Los Angeles Motor Scale (LAMS) is a rapid pre-hospital scale used to predict stroke severity. LAMS has also been shown to accurately predict large vessel occlusions (LVOs), however, to date there is no study exploring whether LAMS correlates with CT perfusion (CTP) parameters used to decide mechanical thrombectomy (MT) candidacy. The aim of this study is to elucidate the potential relationship between LAMS and these CTP parameters. We retrospectively reviewed patients with LVO between September 2019 and October 2021. Patients were included if they had available CTP data and neurologic exam on admission. LAMS was documented based on EMS exam or scored retrospectively based on admission neurologic exam. CTP data was processed by RAPID (IschemaView, Menlo Park, CA) with ischemic core volume (rCBF &lt; 30%), Tmax volume (Tmax &gt; 6 second delay), hypoperfusion index (HI), and CBV index. Spearman’s correlations were performed between LAMS and the aforementioned CTP parameters. Eighty-five patients were included, of which 11 had intracranial internal carotid artery (ICA) occlusions, 52 had M1 occlusions, and 22 had proximal M2 occlusions. Of all patients, 26 had LAMS of 0-3, and 59 had LAMS of 4-5. In all cases, LAMS was positively correlated with CBF &lt;30% (Correlation Coefficient (CC): 0.32, p &lt; 0.01), Tmax &gt; 6 s (CC:0.23, p&lt; 0.04), HI (CC:0.27, p &lt; 0.01), and negatively correlated with CBV index (CC:-0.24, p &lt; 0.05). These relationships between LAMS and CBF &lt; 30% and HI were more pronounced in M1 occlusions (CC:0.42, p&lt; 0.01; 0.34, p&lt; 0.01 respectively) and proximal M2 occlusions (CC:0.53, p&lt;0.01; 0.48, p&lt; 0.03 respectively). LAMS also correlated with Tmax &gt; 6 s in M1 occlusions (CC:0.42, p&lt; 0.01), and negatively correlated with CBV index in M2 occlusions (CC:-0.69, p&lt; 0.01). There was no significant correlation between LAMS and CTP parameters in intracranial ICA occlusions. Our results indicate that LAMS is positively correlated with estimated ischemic core, perfusion deficit, and HI, and negatively correlated with CBV index in patients with LVO. Vessel based analyses reveal stronger correlations with M1 and M2 occlusions. This is the first study showing that the LAMS may be correlated with estimated ischemic core and collateral status parameters in patients with LVO.

Abstract 92: Tenecteplase Treatment And Thrombus Characteristics Associated With Early Reperfusion - An EXTEND-IA TNK Trials Analysis

Background: Intracranial occlusion site, contrast permeability, and clot burden are thrombus characteristics that influence alteplase-associated reperfusion. In this study, we assessed the reperfusion efficacy of tenecteplase and alteplase in subgroups based on these characteristics in a pooled analysis of the EXTEND-IA TNK trials. Methods: Patients with large vessel occlusion (LVO) were randomized to treatment with tenecteplase (0.25mg/kg or 0.4mg/kg) or alteplase (0.9mg/kg) prior to thrombectomy. The primary outcome, early reperfusion, was defined as the absence of retrievable thrombus or &gt;50% reperfusion on initial angiographic assessment. We compared the treatment effect of tenecteplase versus alteplase overall, and in subgroups based on intracranial occlusion site, the presence of contrast permeability (measured via residual flow grades), and clot burden (measured via clot burden scores), whilst adjusting for relevant covariates using mixed effects logistic regression models. Results: Among the 465 patients in the primary analysis, early reperfusion occurred in 18% (84/465). Tenecteplase was associated with a higher odds of early reperfusion (tenecteplase: 75/369 [20%] vs. alteplase: 9/96 [9%], aOR: 2.18 [95%CI: 1.03-4.63]). The difference between thrombolytics was most notable in distal M1 or M2 occlusions (tenecteplase: 53/176 [30%] vs. alteplase: 4/42 [10%], aOR: 3.73 [95%CI: 1.25-11.11]), thrombi with contrast permeability (tenecteplase: 38/160 [24%] vs. alteplase: 5/48 [10%], aOR: 2.83 [95%CI: 1.00-8.05]), and in low clot burden occlusions (tenecteplase: 66/261 [25%] vs. alteplase: 5/67 [7%], aOR: 3.93 [95%CI: 1.50-10.33]). Both thrombolytics had limited early reperfusion efficacy in proximal occlusions (ICA: tenecteplase 1/73 [1%] vs. alteplase 1/19 [5%]) and in high clot burden occlusions (tenecteplase: 9/108 [8%] vs. alteplase: 4/29 [14%], aOR: 0.58 [95%CI: 0.16-2.06]). Conclusions: Tenecteplase demonstrates superior early reperfusion versus alteplase in distal LVO, in contrast-permeable thrombi, and in lesions with low clot burden. Reperfusion efficacy remains limited in ICA occlusions and lesions with high clot burden. Further improvements in intravenous thrombolytics are required.

Direct high-frequency intravascular ultrasound visualization of drug delivery after paclitaxel urea eluting balloon angioplasty.

Drug-coated balloons (DCBs) offer an attractive therapeutic option to avoid long stent implantation in diffuse disease, especially for small vessels. We report this first observation with high-frequency intravascular ultrasound (HF-IVUS) of effective delivery of paclitaxel together with urea excipient. A 76-year-old hypertensive and diabetic gentleman with exertional angina underwent coronary computed tomography angiography (Panel 1) showing total occlusion of the mid-segment of the left anterior descending artery, shorter than the occluded segment at selective coronary angiography, performed three months later (Panel 2, Supplemental Video 1). We antegradely crossed the lesion with a Fielder XT-R guidewire supported by a Corsair Pro XS microcatheter (both Asahi Intecc, Japan). After balloon pre-dilatation (Panel 3), HF-IVUS (Opticross™HD 60 MHz, Boston Scientific, USA) showed a subocclusive lesion with positive remodelling in the proximal occluded segment and diffuse subcritical disease in the distal occluded segment (Panel 3A–D, Supplemental Video 3). We elected to limit stent implantation to a 3.0 × 15 mm sirolimus-eluting stent in the proximal occlusion and treat the distal disease with prolonged inflation (up to 5 min) of three paclitaxel urea DCB (Prevail, Medtronic, USA), 3.0 × 30 mm, 2.75 × 25 mm and 2.5 × 20 mm, respectively (Panel 4, Supplemental Video 2). The final HF-IVUS (Panel 4A–D, Supplemental Video 4) documented a continuous intimal hyperechoic layer throughout the entire segment treated with DCB (arrows, Panel 4B–C), with similar echogenicity to the stent struts (arrowheads, Panel 4A) and not present before DCB deployment or distally (Panel 4D). We believe that this phenomenon is the result of the intimal deposition of the DCB coating. Further IVUS studies will reveal how long this pattern persists and whether its visualization is associated with better drug response and lower risk of restenosis over time.

Abstract 23: Effect Of Intravenous Tirofiban Vs Placebo On First-pass Effect In Endovascular Stroke Thrombectomy: Insights From The Rescue Bt Randomized Clinical Trial

Background: First-pass effect (FPE) defined as a complete or near-complete reperfusion achieved after a single thrombectomy pass is predictive of favorable outcome in acute ischemic stroke (AIS) patients with large vessel occlusion. It remains uncertain whether intravenous tirofiban is effective to improve the rate of FPE in anterior circulation strokes. Methods: RESCUE-BT (A randomized controlled trial of intravenous tirofiban or placebo prior to endovascular thrombectomy for large vessel occlusion stroke) enrolled 948 patients with proximal intracranial large vessel occlusion presenting within 24 hours of time last known well to receive intravenous either tirofiban or placebo before endovascular thrombectomy. Patients who did not treated with endovascular thrombectomy were excluded from this cohort. The endpoint was FPE, which defined by extended thrombolysis in cerebral infarction (eTICI) scale 2b, 2c or 3 after the first pass. A modified Poisson regression analysis was performed to assess the association between intravenous tirofiban treatment and FPE. Results: Twenty-two patients were excluded for not treating with endovascular thrombectomy. The remaining 926 patients were included (mean age, 66 years; 380 [41.0%] women), with 450 in the tirofiban and 476 in the placebo group, respectively. Among them, an FPE was achieved in 141 patients (31.3%) of the tirofiban group vs 114 patients (23.9%) of the placebo group. The adjusted risk ratio for FPE with tirofiban vs placebo was 1.24 (95%CI, 1.02-1.52). Conclusions: Treatment with intravenous tirofiban before endovascular thrombectomy significantly increased the incidence of FPE in acute ischemic stroke patients with large vessel occlusion presenting within 24 hours of time last known well.

Abstract 49: Association Of Intravenous Thrombolysis And Pre-interventional Reperfusion: A Post-hoc Analysis Of The Swift Direct Trial

Background: One potential benefit of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) is pre-interventional reperfusion. Currently, there is a paucity of data regarding the occurrence of pre-interventional reperfusion in patients randomized to IVT or no-IVT before MT. Methods: SWIFT DIRECT was a randomized controlled trial including acute ischemic stroke IVT-eligible patients being directly admitted to a comprehensive stroke center, with allocation to either MT alone or IVT + MT. Primary endpoint of this analysis was the occurrence of pre-interventional reperfusion defined as pre-interventional expanded Thrombolysis in Cerebral Infarction score ≥2a. The effect of IVT and potential treatment effect heterogeneity were analyzed using logistic regression analyses. Results: Out of the 396 patients analyzed, pre-interventional reperfusion occurred in 20 (10.0%) of patients randomized to IVT+MT, and 7 (3.6%) of patients randomized to MT alone. Receiving IVT favored the occurrence of pre-interventional reperfusion (aOR 2.91 [95% CI 1.23 - 6.87]). There was no IVT treatment effect heterogeneity on the occurrence of pre-interventional reperfusion with different strata of Randomization-to-Groin-Puncture (p for interaction=0.33), although the effect tended to be stronger in patients with Randomization-to-Groin-Puncture &gt;28 minutes (aOR 4.65 [95% CI 1.16 - 18.68]). There were no significant difference in rates of functional outcomes between patients with and without pre-interventional reperfusion. Conclusion: Even for patients with proximal large vessel occlusions and direct access to MT, IVT leads towards an absolute increase of 6.9% (95% CI 1.7-12.2%) in the rates of pre-interventional reperfusion. The effect of IVT tended to be more pronounced when Randomization-to-Groin-Puncture intervals were longer, but this heterogeneity did not reach statistical significance.