Stenting In Acute Ischemic Stroke Research Articles

Acute intracranial stenting in acute ischemic stroke with underlying atherosclerosis: A two-center retrospective study

Objective In patients with large vessel occlusion, successful reperfusion is a predictor of favorable outcome. However, patients with underlying intracranial atherosclerotic disease (ICAD) show higher rates of immediate reocclusion, frequently requiring rescue stenting. We aimed to investigate the safety, efficacy, and outcome of acute stenting in acute stroke patients with underlying ICAD. Methods Prospective databases from two centers between 2012 and 2021 were reviewed. Adult patients who underwent ICAD-related acute intracranial stenting, after mechanical thrombectomy (MT) were included. Clinical and procedural data, technical success measured by Modified Thrombolysis in Cerebral Infarction score, periprocedural complications, stent restenosis, and follow up mRS at three months were evaluated. Results During a 10-year period, a total of 96 patients with acute stroke and intracranial atherosclerotic steno-occlusive lesions underwent stenting after MT. Mean age was 63 (SD 14) and 54 patients were male (56.3%). Successful reperfusion (TICI ≥ 2b) was achieved in 86 patients (89.6%) following rescue stenting; favorable clinical outcome (mRS < 3) was observed in 32 patients (37.6%). Symptomatic intracranial hemorrhage and mortality were observed in 9.5% and 22.4% of patients, respectively. Multivariate regression yielded older age (OR: 0.477, 95% CI: 0.933–0.999, p=0.046) as an independent negative predictor of favorable functional outcome after acute intracranial stenting. Conclusion Our results suggest that acute intracranial stenting is safe and effective as a rescue treatment after MT in acute stroke patients with underlying ICAD. Younger age was found as an independent predictor of good outcome. Nevertheless, ICAD still carries a high mortality and poor functional clinical outcome.

Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data

BackgroundThe periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis....

Rescue intracranial stenting in acute ischemic stroke: a preliminary Vietnamese study.

In cases of acute ischemic stroke (AIS) caused by intracranial large vessel occlusion, rescue intracranial stenting (RIS) has recently emerged as a treatment option for achieving recanalization when mechanical thrombectomy (MT) fails. However, few studies to date have reported on the beneficial outcomes of RIS. Our goal was to analyze whether RIS use can improve prognosis in patients 3 months post-treatment. A retrospective analysis was performed on a prospective cohort of patients with AIS treated with RIS at Can Tho S.I.S General Hospital. The study inclusion criteria were evidence of intracranial large vessel occlusion, absence of intracranial hemorrhage (ICH), and severe stenosis or reocclusion after MT. Patients with tandem occlusions, failure to follow up after discharge, or severe or fatal illness concomitant with AIS were excluded from the study. The primary outcome was the "non-poor" prognosis status rate at 3 months after RIS and post-procedural symptomatic ICH (sICH). The post-treatment outcomes of 85 eligible patients who received RIS between August 2019 and May 2021 were assessed. Of the 85 included patients, 82 (96.5%) achieved successful recanalization, and 4 (4.7%) experienced sICH. At 3-months post-treatment, 47 (55.3%) patients had "non-poor" outcomes, whereas 35 (41.2%) had good outcomes. The use of dual antiplatelet therapy was associated with new infarcts (relative risk [RR]: 0.1; 95% confidence interval [CI]: 0.01-0.7) and sICH occurrence (RR: 0.1; 95% CI: 0.01-0.9). Our study suggests that despite the occurrence of post-procedural sICH in a small proportion of cases, RIS could serve as a useful alternative or additional treatment in the event of MT failure.

Outcomes After Intracranial Rescue Stenting for Acute Ischemic Stroke

Background In cases of failed recanalization despite modern mechanical thrombectomy (MT) techniques, intracranial rescue stenting (RS) may be beneficial. However, outcomes and complications of RS relative to the natural history of ongoing emergent large vessel occlusion are unknown. To evaluate whether RS for ongoing emergent large vessel occlusion after failed MT achieves superior outcomes to the natural history of persistent emergent large vessel occlusion. Methods Patients from the Stroke Thrombectomy and Aneurysm Registry who underwent RS after failed MT from 2014 to 2019 were analyzed. For outcome comparisons, patients were screened for inclusion/exclusion criteria of 3 major randomized, controlled MT trials. Results Over 5 years, 2827 patients underwent thrombectomy, of which 120 required RS for failed revascularization. RS resulted in reperfusion (Thrombolysis in Cerebral Infarction≥2B) in 85.8%. Good 90‐day clinical outcomes (modified Rankin scale 0–2) were achieved in 33.9% of patients. Inclusion/exclusion criteria was met in 50 patients for MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), 64 patients for ESCAPE (Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke), and 45 patients for DAWN (DWI or CTP Assessment With Clinical Mismatch in the Triage of Wake‐Up and Late Presenting Strokes Undergoing Neurointervention). Of patients meeting trial criteria, 40.8% of the RS cohort achieved modified Rankin scale 0–2 versus 19% in the MR CLEAN medical arm ( P <0.001) and 27% versus 13% in the RS versus DAWN medical arm ( P =0.04). There was no difference in RS versus the ESCAPE medical arm ( P =0.15). Symptomatic intracranial hemorrhage was not significantly increased after RS compared with MR CLEAN ( P =0.06), but was increased compared with DAWN. Conclusion This large retrospective registry of RS for failed MT suggests that RS in trial‐eligible patients yields significantly improved outcomes over failed revascularization, with no significant increase in hemorrhagic events in early thrombectomy windows and comparable outcomes to successful thrombectomy at early and intermediate timeframes.

Abstract 1122‐000185: Rescue Intracranial Stenting in Acute Ischemic Stroke

This meeting abstract was removed due to the OA licensing requirements of this journal. The full abstract is listed here : https://www.svin.org/files/SVIN_2021_Abstracts_for_Web.pdf

Cangrelor and Stenting in Acute Ischemic Stroke : Monocentric Case Series.

Cangrelor is an intravenous P2Y12 receptor inhibitor with arapid onset/offset of action and ashort half-life (3-6 min). The objective was to present apreliminary experience regarding the safety and effectiveness using cangrelor, in combination with aspirin, in acute ischemic stroke patients requiring acute stenting. Retrospective analysis for patients who underwent stenting (intracranial and/or extracranial) in the setting of acute ischemic stroke with cangrelor and aspirin as antiplatelet therapy. Cangrelor was used in 12patients, 4 (33%) with extracranial stenting, 6 (50%) with intracranial stenting and 2 (17%) with combined extracranial and intracranial stenting. The mean age was 67years (44-88) and 9patients (75%) were female. The median National Institutes of Health Stroke Score at admission was15 (IQR: 8-22). Of the patients, six (50%) received intravenous thrombolysis. All patients (100%) obtained modified thrombolysis in cerebral infarction score ≥2b. Good clinical outcome, defined as modified Rankin scale score ≤2 at 3‑months follow-up, was observed in 7 patients (58%). None of the patients experienced intraprocedural thromboembolic complications. Postprocedural stent thrombosis after cessation of cangrelor infusion due to emergency craniotomy surgery to manage malignant cerebral infarction occurred in one patient (8%). Of the patients, two (17%) experienced asymptomatic intracranial hemorrhage (ICH), one patient (8%) experienced symptomatic ICH and one (8%) retroperitoneal hematoma was observed, which was managed conservatively. Cangrelor might be asafe and effective antiplatelet medication owing to its on/off activity for acute stenting in the setting of acute ischemic stroke. Further investigations through randomized studies with larger samples are necessary.

Overview of Evidence on Emergency Carotid Stenting in Acute Ischemic Stroke due to Tandem Occlusions: A Systematic Review and Meta-Analysis

Introduction - The combination of cervical internal carotid artery (ICA) occlusion with synchronous intracranial thrombus represents 10-20% of all acute ischemic strokes (AIS), and such tandem occlusions are strongly associated with poor outcome.

Functional Outcome and Safety of Intracranial Thrombectomy After Emergent Extracranial Stenting in Acute Ischemic Stroke Due to Tandem Occlusions.

Background and Purpose: Various endovascular approaches to treat acute ischemic stroke caused by extra- intracranial tandem occlusions (TO) exist: percutaneous transluminal angioplasty with or without emergent extracranial carotid stenting (ECS) due to high-grade stenosis preceded or followed by intracranial mechanical and/or aspiration thrombectomy (MT). Which treatment strategy to use is still a matter of debate.Methods: From our ongoing prospective stroke registry we retrospectively analyzed 1,071 patients with anterior circulation stroke getting endovascular treatment within 6 h of symptom onset. ECS prior to intracranial MT for TO (n = 222) was compared to MT as standard of care (control group; acute intracranial vessel occlusion without concomitant ipsilateral ICA-occlusion or high-grade stenosis [C; n = 849]). Good functional outcome (mRS ≤ 2 at 3 months), mortality rates, frequencies of symptomatic intracranial hemorrhage (sICH) and successful recanalization (Thrombolysis in Cerebral Infarction Score [TICI] 2b or 3) were assessed. In subgroup analyses we tried to detect possible influences of stroke etiology, dual inhibition of platelet aggregation (IPA; clopidogrel [CLO]: n = 83; ticagrelor [TIC]: n = 137; in combination with Aspirin) and intravenous thrombolysis (IVT).Results: Functional outcome was superior in TO (mRS 0–2: 44.6%) when compared with controls (36.0%; OR [95% CI]: 3.49 [1.59–7.67]; p = 0.002). There was no difference in all-cause mortality at 3 months (TO: 21.6%; C: 27.7%; 0.78 [0.47–1.29]; p = 0.324), in-hospital mortality (0.76 [0.45–1.30]; p = 0.324), sICH (TO: 3.2%; C: 5.0%; 0.70 [0.30–1.59]; p = 0.389), and TICI 2b/3 (TO: 89.1%; C: 88.3%; p = 0.813). In subgroup-analysis, TIC and CLO did not differ in functional outcome (TIC: 45.3%; CLO: 44.6%; 1.04 [0.51–2.09]; p = 0.920) and mortality rates (all-cause mortality: TIC: 23.4%; CLO: 16.9%; 0.75 [0.27–2.13]; p = 0.594). sICH was more frequent in TIC (n = 7 [5.1%]) vs. CLO (n = 0; p = 0.048).Conclusion: In our pre-selected cohort, ECS prior to intracranial MT in TO allowed for a good functional outcome that was superior compared to a control population. Mortality rates did not differ. Despite a dual IPA in TO, there was no increase in sICH. CLO and TIC for dual IPA did not differ in terms out outcome and mortality rates. A significant increase in sICH was observed after initial loading with TIC.

Hyperacute Carotid Stenting for Acute Ischemic Stroke After Systemic Thrombolysis with IV rt-PA (P1.282)

Hyperacute Carotid Stenting for Acute Ischemic Stroke After Systemic Thrombolysis with IV rt-PA (P1.282)

Emergency Carotid Artery Stenting in Acute Ischemic Stroke

Emergency Carotid Artery Stenting in Acute Ischemic Stroke

Advances in interventional neuroradiology: novel use of mechanical thrombectomy in acute ischemic stroke.

Dr Sanjeev Nayak speaks to Sean Fitzpatrick, Commissioning Editor: Dr Sanjeev Nayak is a Consultant Neuroradiologist with special interest in Interventional Neuroradiology at the University Hospital of North Midlands, Stoke on Trent. He was responsible for the development of Interventional Stroke Service which he did immediately following his appointment in 2009 and was the lead neuroradiologist from 2010 to 2013. Dr Nayak and his team have pioneered in the field of mechanical thrombectomy and stenting in acute ischemic stroke and treated the largest number of such cases in the UK. His team has produced one of the best clinical outcomes for such patients with the lowest mortality rates in the UK. This work has been nominated for numerous national awards in various categories of BMJ, Patient Safety and Care integration awards. Dr Nayak was the finalist at the HSJ awards under the category of 'Clinical Leader of the Year 2012' and NHS Leadership awards 'NHS Inspirational Leader of the Year 2013. Dr Nayak is also involved in patents and designs involving new stroke interventional devices and is actively involved in stroke research which has led to numerous publications in peer reviewed journals. Dr Nayak has organized national conferences and lectured at various national and international conferences in his field of interest.

E-074 Emergency Carotid Artery Stenting in Acute Ischemic Stroke

Introduction/purposeRecanalization of occluded arteries is crucial for good functional outcome of acute stroke patients with large vessel occlusion. Endovascular treatment, particularly mechanical thrombectomy, plays an increasing role to achieve rapid...

O-034 Carotid Artery Angioplasty versus Stenting in Acute Ischemic Stroke

IntroductionAcute ischemic stroke secondary to cervical carotid artery occlusion can lead to significant morbidity and mortality. Acute carotid occlusion may be managed by carotid angioplasty, stenting, or both. The use...

Primary stenting for acute ischemic stroke using the Enterprise vascular reconstruction device: early results

ObjectivePrimary stenting for acute ischemic stroke (AIS) using the Wingspan stent delivery system has been reported. Major technical limitations in that study were difficulties in delivering the device and a...

Hyperacute Stenting for Acute Ischemic Stroke Is Associated with a High Rate of Symptomatic Intracranial Hemorrhage (P02.200)

Objective: To report the safety of acute stent placement in patients with acute ischemic stroke. Background Patients with large vessel occlusions often fail to recanalize with intravenous rt-PA or standard endovascular techniques. Small series have reported excellent recanalization rates with acute stenting. However, its safety is not well known. Design/Methods: We retrospectively reviewed charts of twenty-four consecutive patients treated with stents for large artery occlusions. All eligible patients received intravenous rt-PA before proceeding to endovascular treatment. If there was contraindication to its usage or no neurological improvement occurred after its infusion, the patient underwent immediate angiographic evaluation and treatment. Outcomes were based upon disposition and in-hospital mortality. Results: Twenty-four patients had twenty-seven stents deployed in three scenarios: 1. initial therapy (n=3), 2. after the usage of intra-arterial rt-PA and/or angioplasty (n=19) or 3. as a salvage therapy (n=4). Fourteen patients (58%) received IV rt-PA. The arterial occlusion sites included 11 (44%) proximal M1 middle cerebral artery, 10 (40%) internal carotid artery (8 intracranial, 2 extracranial and 3 involving both), 3 (16%) basilar artery and 1 (4%) vertebral artery. Stents were successfully deployed in 24 out of 27 cases (89%) Poor discharge outcomes were defined as death (n=7), hospice (n=2) or skilled nursing facility (n=5) and occurred in 58% of patients. Good outcomes included home discharge (n=1), inpatient rehabilitation (n=7) or long term acute care facility (n=2) for a total of 42%. The causes attributed to poor outcomes were secondary to either symptomatic intracerebral hemorrhage (sICH) or stroke progression. Five (21%) patients had sICH where any ICH was seen in 14 (58%) total patients. Conclusions: Our results indicate that the usage of acute stentings in ischemic stroke is associated with a high rate of sICH and its routine use is not recommended. Prospective studies regarding the utility and benefits of stents are warranted. Disclosure: Dr. Fong has nothing to disclose. Dr. Bershad has nothing to disclose. Dr. Morsi has nothing to disclose. Dr. Shaltoni has nothing to disclose. Dr. Mawad has nothing to disclose. Dr. Georgiadis has nothing to disclose. Dr. Suarez has received personal compensation for activities with Bristol-Myers Squibb/Sanofi and Boehringer Ingelheim as a speaker. Dr. Suarez has received research support from the Haas Trust and NINDS. Dr. Venkatasubba Rao has nothing to disclose.

Mechanical Thrombolysis and Stenting in Acute Ischemic Stroke

Acute ischemic stroke is one of the major sources of morbidity and mortality in the industrialized countries. The lifetime risk of stroke is estimated to be 1 in 5 for middle-aged women and 1 in 6 for men according to the Framingham Study.1 Outcome depends on the length of time between onset of symptoms and revascularization, the recanalization rate, and on whether or not intracranial hemorrhage occurs.2 A meta-analysis of 52 studies on thrombolysis outcome in 2066 patients showed that the chance of an independent life after stroke increases 4.4 times for patients with successful recanalization compared with patients without recanalization; mortality rate decreases 4-fold.2 Intravenously administered tissue plasminogen activator (IV tPA) and local intra-arterial thrombolysis (IAT) have both been shown to improve patient outcome. However, the time window for treatment and the recanalization rate of both approaches are limited,3–5 and the application of thrombolytic drugs increases the risk of symptomatic intracranial hemorrhage (sICH).6 The success of recanalization, furthermore, depends on the occlusion site; proximal occlusions of large vessels such as the internal carotid artery have a poor recanalization rate after either IV tPA or IAT.4,5 Recent studies have examined whether mechanical recanalization techniques can accelerate the process of recanalization, increase the recanalization rate, and even expand the window of opportunity. This article describes the evolution of the different mechanical thrombolysis and stenting techniques and their working principles for endovascular vessel recanalization and reviews the data on the outcome after acute stroke treatment. The various techniques and approaches for mechanical thrombolysis (MT) can be divided into 3 categories: thrombus disruption, immediate flow restoration with self-expandable stents, and thrombectomy. According to Pro-Urokinase for Acute Cerebral Thromboembolism-2 (PROACT II), IAT consists of local application of the fibrinolytic drug at the proximal surface …

Delayed Catastrophic Intracerebral Hemorrhage Preceded by Progressive Recovery after Carotid Stenting for Acute Ischemic Stroke

Hemorrhagic transformation (HT) is a feared complication of reperfusion therapy for treatment of acute ischemic stroke. Generally, HT occurs within 24-36 hours after thrombolysis. We present a case of a fatal symptomatic HT of an infarction that occurred 7 days after acute ischemic stroke which was preceded by a remarkable recovery following a combination of acute revascularization therapies. Fatal symptomatic HT is a rare potential complication that can occur after several days of treatment of acute ischemic stroke.

Primary Intracranial Stenting in Acute Ischemic Stroke

Acute intracranial stroke is a major source of morbidity and mortality in the United States. Recent studies have shown improved clinical outcomes for patients who achieve timely arterial recanalization. Multimodal therapies have evolved to meet this end point and include intravenous and/or intra-arterial thrombolysis and mechanical thrombolysis. Modifications to existing balloon-mounted stents commonly used in cardiology have yielded more easily navigable and safer self-expanding intracranial stents that provide rapid arterial recanalization. We review the evolution of acute stroke therapy over the past few decades and the recent results of mechanical thrombolysis, focusing on intracranial stenting in the setting of acute stroke.

First Food and Drug Administration-Approved Prospective Trial of Primary Intracranial Stenting for Acute Stroke

Acute revascularization is associated with improved outcomes in ischemic stroke patients. However, it is unclear which method of intraarterial intervention, if any, is ideal. Numerous case series and cardiac literature parallels suggest that acute stenting may yield high revascularization levels with low associated morbidity. We therefore conducted a Food and Drug Administration-approved prospective pilot trial to evaluate the safety of intracranial stenting for acute ischemic stroke. Eligibility criteria included presentation <or=8 hours after stroke onset, age 18 years or older, National Institutes of Health Stroke Scale score >or=8, angiographic demonstration of focal intracerebral artery occlusion <or=14 mm, and either contraindication to intravenous tissue plasminogen activator or failure to improve 1 hour after intravenous tissue plasminogen activator administration. Exclusion criteria included known hemorrhagic diathesis or coagulopathy, platelet count <100 000, intracranial hemorrhage, blood glucose level of <51 mg/100 mL, or CT perfusion imaging demonstrating more than one-third at-risk territory with nonsalvageable brain (low cerebral blood volume). Data are presented as mean+/-SD. Twenty patients were enrolled (mean age, 63+/-18 years;14 women). Mean presenting National Institutes of Health Stroke Scale was 14+/-3.8 (median 13). Presenting thrombolysis in myocardial infarction score was 0 (85% of patients) or 1 (15%). Recanalization to thrombolysis in myocardial infarction score of 3 (60% of patients) or 2 (40% of patients; P<0.0001) was achieved. One (5%) symptomatic and 2 (10%) asymptomatic intracranial hemorrhages occurred. At 1-month follow-up, a modified Rankin scale score of <or=3 was achieved in 12 of 20(60%) patients and a modified Rankin scale score of <or=1 was achieved in 9 of 20 (45%) patients. This Food and Drug Administration-approved prospective study suggests primary intracranial stenting for acute stroke may be a valuable addition to the stroke treatment armamentarium.

Acute M2 Bifurcation Stenting for Cerebral Infarction: Lessons Learned from the Heart:Technical Case Report

Acute ischemic stroke is the third leading cause of death in the United States. For patients with NIHSS scores >10 and evaluated within 6 hours, intra-arterial thrombolysis is the treatment of choice. The Merci retriever (Concentric Medical Inc., Mountain View, CA) and IV TPA are currently the only FDA-approved treatments for acute ischemic stroke. For patients who do not meet the criteria for TPA administration and/or in whom the Merci device fails, options are limited. Intracranial stenting for acute ischemic stroke after failed thrombolysis is now possible because of improved delivery systems and appropriately sized stents. A 26-year-old woman presented with an NIHSS score of 11 (right-sided hemiparesis and mixed aphasia) 4 hours from the time of symptom onset. CT perfusion demonstrated increased time to peak in the entire left hemisphere; conventional angiography demonstrated a left M1 occlusion. After crossing the occlusion with a microcatheter, reteplase (2 units) was administered into the clot. Mechanical thrombolysis was then attempted, without restoration of flow. Two 3 x 12-mm coronary stents were placed from the M1 into the superior and inferior divisions, respectively, with complete restoration of flow (TIMI 3). Within 72 hours, the patient had an NIHSS score of 1, with a small infarction in the external capsule. Novel stroke interventions need to be developed for patients with acute ischemic stroke in whom traditional interventions fail. We present (to our knowledge) the first case of successful revascularization of an acute M1 occlusion accomplished with placement of two coronary stents.