Safety and efficacy of balloon-mounted stent in the treatment of symptomatic intracranial atherosclerotic disease: a multicenter experience

Background Randomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications. Objective To study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD. Methods Prospectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up. Results A total of 232 patients were eligible for the analysis (mean age 62.8 years, 34.1% female). The intracranial stenotic lesions were located in the anterior circulation in 135 (58.2%) cases. Recurrent stroke was the qualifying event in 165 (71.1%) while recurrent TIA was identified in 67 (28.9%) cases. The median (IQR) time from the qualifying event to stenting was 5 (2–20.75) days. Strokes were reported in 13 (5.6%) patients within 72 hours of the procedure; 9 (3.9%) ischemic and 4 (1.7%) hemorrhagic, and mortality in 2 (0.9%) cases. Among 189 patients with median follow-up time 6 (3–14.5) months, 12 (6.3%) had TIA and 7 (3.7%) had strokes. Three patients (1.6%) died from causes not related to stroke. Conclusion Our study has shown that BMS may be a safe and effective treatment for medically refractory symptomatic ICAD. Additional prospective randomized clinical trials are warranted

Optical coherence tomography for elucidation of flow-diversion phenomena: The concept of endothelized mural thrombus behind reversible in-stent stenosis in flow-diverters

PURPOSE: Flow-diverters have revolutionized the endovascular treatment of intracranial aneurysms, offering a durable solution to aneurysms with high recurrence rates after conventional stent-assisted coiling. Events that occur after treatment with flow-diversion, such as in-stent stenosis (ISS) are not well understood and require further assessment. After assessing an animal model with Optical Coherence Tomography (OCT), we propose a concept that could explain the mechanism causing reversible ISS after treatment of intracranial aneurysms with flow-diverters. METHODS: Six Pipeline Flex embolization devices (PED-Flex), six PED with Shield technology (PED-Shield), and four Solitaire AB devices were implanted in the carotid arteries (two stents per vessel) of four pigs. Intravascular optical coherence tomography (OCT) and digital subtraction angiography (DSA) images obtained on day 21 were compared to histological specimens. RESULTS: A case of ISS in a PED-Flex device was assessed with OCT imaging. Neointima with asymmetrical topography completely covering the PED struts was observed. Histological preparations of the stenotic area demonstrated thrombus on the surface of device struts, covered by neointima. CONCLUSION: This study provides a plausible concept for reversible ISS in flow-diverters. Based on an observation of a previous experiment, we propose that similar cases of ISS are related to thrombus presence underneath endothelization, but further experiments focused on this phenomenon are needed. Optical Coherence Tomography will be useful tool when available for clinical use

Abstract T P18: Incidence and Management of Intracranial Wire Perforation During Acute Stroke Endovascular Therapy

BACKGROUND: Wire perforation during endovascular thrombectomy for acute stroke is a rare but devastating complication. Understanding the incidence and mechanism of this adverse event may further identify preventive strategies and improvements in management during perforation. METHODS: Retrospective review of a prospectively maintained database of acute stroke interventions at our institute identified 1035 patients. Of these, 46 patients were noted to have contrast extravastion during the procedure concerning for wire perforation (4%). RESULTS: A majority of the cases involved the anterior circulation (76%). Sites of perforation included: ICA (12), MCA (23), ophthalmic (1), anterior choroidal (2), PCA (4), PICA (1), SCA (1) and vertebral artery (2). Successful hemostasis was achieved with onyx embolization (39%), coil embolization (13%), onyx/coil combined embolization (5%), microcatheter occlusion (2%) and balloon inflation (7%). Thirty one percentage of the cases occurred during intracranial stenting or angioplasty. Despite high rates of mortality (72%), rapid recognition of extravasation and hemostasis led to good outcomes in 9% of patient. CONCLUSION: Intra-procedural wire perforation with leakage of contrast is associated with catheterization of small caliber vessels such as distal MCA branches (M3), anterior choroidal artery and diminutive posterior circulation vessels as well as intracranial angioplasty/stenting. Devastating outcomes can potentially be averted with appropriate hemostatic control

Disparities in Stroke: Associating Socioeconomic Status With Long‐Term Functional Outcome After Mechanical Thrombectomy

Background Socioeconomic status is regarded as a significant predictor of poor outcomes after ischemic stroke. However, there is sparse evidence of its effect in patients undergoing mechanical thrombectomy. This study aimed to explore the effect of socioeconomic status on long‐term functional outcomes after mechanical thrombectomy. Methods A retrospective, self‐adjudicated, single‐center study comparing favorable and unfavorable functional outcomes through risk factors, demographic factors, and neighborhood socioeconomic status was performed. Functional outcome was defined by modified Rankin scale scores evaluated at 90 days after thrombectomy. Results Factors that were independently associated with favorable functional outcome included age (odds ratio [OR], 0.97; 95% CI, 0.96–0.98 [P<0.001]), baseline National Institutes of Health Stroke Scale scores (OR, 0.94; 95% CI, 0.92–0.97 [P<0.001]), baseline modified Rankin scale scores (OR, 3.02; 95%CI, 1.46–6.25 [P=0.003]), ischemic core size at presentation (OR, 0.47; 95% CI, 0.26–0.84 [P=0.011]), symptomatic intracranial hemorrhage (OR, 0.3; 95% CI, 0.14–0.66 [P=0.003]), puncture‐to‐recanalization time (OR, 0.99; 95% CI, 0.98–1.00 [P=0.007]), median income based on zip code (OR, 1.01; 95% CI, 1.00–1.02 [P=0.016]), and final modified thrombolysis in cerebral infarction (OR, 6.05; 95% CI, 2.23–16.08 [P<0.001]). Conclusions Patients from zip codes with higher median income who achieved successful reperfusion during mechanical thrombectomy were more likely to achieve a long‐term favorable functional outcome

Venous sinus stenting shortens the duration of medical therapy for increased intracranial pressure secondary to venous sinus stenosis

INTRODUCTION: Medical treatment, cerebrospinal fluid (CSF) shunting, and optic nerve sheath fenestration are standard treatments for increased intracranial pressure (ICP) in patients with idiopathic intracranial hypertension (IIH). Venous sinus stenting provides a novel alternative surgical treatment in cases of venous sinus stenosis with elevated ICP. METHODS: 12 consecutive subjects with papilledema, increased ICP, and radiological signs of dural sinus stenosis underwent cerebral venography and manometry. All subjects had papilledema and demonstrated radiological evidence of dural venous sinus stenosis. RESULTS: Six subjects chose venous stenting (Group A) and six declined and were managed conservatively with oral acetazolamide (Group B). The relative pressure gradient across the venous narrowing was 29±16.3 mm Hg in Group A and 17.6±9.3 mm Hg in Group B (p=0.09). The mean lumbar puncture opening pressure was 40.4±7.6 cm HO in Group A and 35.6±10.6 cm HO in Group B (p=0.4). Spectral domain optical coherence tomography (SD-OCT) showed mean average retinal nerve fiber layer (RNFL) thickness of 210±44.8 µm in Group A and 235±124.7 µm in Group B. However, the mean average RNFL thickness at 6 months was 85±9 µm in Group A and 95±24 µm in Group B (p=0.6). The total duration of acetazolamide treatment was 188±209 days in Group A compared with 571±544 days in Group B (p=0.07). CONCLUSIONS: In subjects with venous sinuses stenosis, endovascular stenting offers an effective treatment option for intracranial hypertension which may shorten the duration of medical therapy

Stent Retriever-Mediated Manual Aspiration Thrombectomy for Acute Ischemic Stroke

BACKGROUND AND PURPOSE: Stent retriever thrombectomy and manual aspiration thrombectomy (MAT) have each been shown to lead to high rates of recanalization as single-modality endovascular stroke therapy. We sought to describe the safety and efficacy of a multimodal approach combining these two techniques termed \u27stent retriever-mediated manual aspiration thrombectomy\u27 (SMAT) and compared them to MAT alone. METHODS: Retrospective review of a prospectively acquired acute endovascular stroke database. RESULTS: 195 consecutive patients with large-vessel occlusion were identified between July 2013 and April 2015. Occlusion distribution was as follows: 52% middle cerebral artery segment 1 (M1), 6% M2, 29% internal carotid artery, and 13% vertebrobasilar. Median onset to treatment time was 278 min. Intravenous rtPA was administered in 33% of cases, whereas 34% of cases had symptom onset beyond 8 h. Effective recanalization (TICI 2b/3) was achieved in 91% of patients and in 49% of patients, only a single pass was necessary. Median groin puncture to recanalization time was 40 min. Symptomatic intracerebral hemorrhage occurred in 5% of patients. Favorable outcomes defined as a modified Rankin Scale score of 0-2 were noted in 42% of patients. Compared with MAT alone, SMAT achieved a similar rate of effective recanalization (91 vs. 88%, p = n.s.) but was associated with faster access to reperfusion times (49 vs. 77 min, p \u3c 0.00001). CONCLUSIONS: SMAT is a safe and efficacious method to achieve rapid revascularization that leads to faster recanalization compared to manual aspiration alone. Future prospective comparisons are necessary to establish the most clinically effective therapy for acute thrombectomy

Duration of Ischemia Impacts Postreperfusion Clinical Outcomes Independent of Follow‐Up Infarct Volume

Background Time to reperfusion is believed to influence clinical outcomes following thrombectomy mainly through reduction of infarct growth. In this study, we aim to understand whether clinical outcomes can be influenced by ischemia duration (penumbral time) independent of postintervention infarct volume by comparing outcomes following thrombectomy in patients with similar (and small) follow‐up infarct volumes. Methods We performed a retrospective analysis of a prospectively maintained large‐vessel occlusion stroke thrombectomy database across 3 US centers. Demographic, clinical, radiological, and outcomes data of patients with anterior circulation large‐vessel occlusion (internal carotid or middle cerebral artery M1) stroke who had a witnessed‐onset stroke, had substantial penumbral volumes, achieved successful reperfusion (modified thrombolysis in cerebral infarction 2b‐3), and had a follow‐up infarct volume of <20 mL were analyzed. Results A total of 233 patients (center A, 25; center B, 33; center C, 175) were included. Mean age was 71±16 years, and median National Institutes of Health Stroke Scale was 15 (10–20). Median penumbral time was 4.7 (2.9–10) hours, and median follow‐up infarct volume was 4.7 (0.2–9.4) mL. Despite comparable baseline characteristics and 24‐hour infarct volumes, patients reperfused in the 0‐ to 6‐hour time window had significantly higher rates of modified Rankin scale 0 to 2 (61% versus 40%; P=0.002) and numerically lower rates of mortality (11% versus 17%; P=0.16) at 90 days when compared with patients reperfused in the 6‐ to 24‐hour time window. Duration of ischemia is an independent predictor of modified Rankin scale 0 to 2 (odds ratio, 0.91 [0.80–0.99]; P=0.012). In multivariable analysis accounting for age and baseline National Institutes of Health Stroke Scale score, the association between penumbral time and modified Rankin scale 0 to 2 remained significant (absolute risk difference, −1.2% [(95% CI, −1.9 to −0.4)]/h delay). Conclusion Longer penumbral duration is associated with a lower likelihood of functional independence among large‐vessel occlusion strokes with small and comparable 24‐hour follow‐up infarct volume. Our findings indicate that delays in time to reperfusion affect clinical outcomes through mechanisms mediated by factors not solely limited to infarct reduction

Safety and Efficacy of Stent-assisted Coiling in the Treatment of Unruptured Wide-necked Intracranial Aneurysms: A Single-center Experience

Introduction: Wide-necked intracranial aneurysms (IAs) are complex lesions that may require different microsurgical or endovascular strategies, and stent-assisted coiling (SAC) has emerged as a feasible alternative to treat this subset of aneurysms. Methods: The objective was to assess the rate of complications of unruptured wide-necked IAs treated with SAC. We retrospectively identified patients with unruptured wide-necked IAs treated with SAC. Medical charts, procedure reports, and imaging studies were analyzed. Results: One hundred twenty patients harboring 124 unruptured wide-necked IAs were included. Ninety-two aneurysms (74.2%) were located in the anterior circulation. The median aneurysm size was 7 mm (IQR = 5-10). The immediate complete aneurysm occlusion rate was 29% (36/124). The rate of procedural complications was 3.3 % (4/120), which included 2 intraprocedural aneurysm ruptures, 1 immediate postprocedure aneurysm rupture, and 1 vessel occlusion rescued with an open-cell stent. The median follow-up time was 21 months (IQR = 10.3-40.9). Kaplan-Meier analysis estimated a median time of complete aneurysm occlusion of 6.3 months (95%CI = 3.8-7.8). At 30-day follow-up, 80.7% of patients had a Glasgow Outcome Score (GOS) of 5 and at the latest follow-up 83.9%. Imaging follow-up was available for 102 patients. The rate of complete aneurysm occlusion was 73.5% (75/102), severe in-stent stenosis (>50%) was found in 1% (1/102), the recanalization rate was 6.6% (5/75), and the retreatment rate was 7.8% (8/102). Conclusion: SAC remains a safe and effective technique to treat wide-necked IAs, providing low rate of complications and recanalization with excellent long-term aneurysm occlusion rates.Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Endovascular Treatment of Tandem Common Carotid Artery Origin and Distal Intracranial Occlusion in Acute Ischemic Stroke

BACKGROUND: Tandem occlusion resulting in acute ischemic stroke is associated with high morbidity and mortality and a poor response to thrombolytic therapy. The use of endovascular strategies for tandem stroke cases results in an improved outcome for this subgroup of patients. We present 2 cases with a pattern of tandem occlusion consisting of proximal obstruction at the origin of the common carotid artery (CCA) with concomitant intracranial occlusion treated by endovascular techniques. METHODS: The 2 patients presented each with occlusion at the left CCA origin and ipsilateral intracranial vessel (left middle cerebral artery and carotid terminus, respectively). A transfemoral anterograde approach was used to deliver a balloon-mounted stent across the proximal CCA origin occlusion to gain access to the distal cerebral vasculature. Subsequently, a stent retriever assisted mechanical aspiration thrombectomy was used to revascularize the intracranial occlusion. RESULTS: Complete revascularization with Thrombolysis in Cerebral Infarction scores of 2b and improvement in neurologic deficits occurred in both cases. Good clinical outcome was achieved for both patients at 3-month follow-up. CONCLUSIONS: An anterograde transfemoral approach should be considered in cases of tandem occlusion of the proximal CCA and middle cerebral artery