Vascular Perforation During Coil Embolization of an Intracranial Aneurysm: the Incidence, Mechanism, and Clinical Outcome

PurposeThe occurrence of a vascular perforation during an endovascular procedure is an unexpected and feared complication which can be fatal. However, the incidence, risk or the mechanism of vascular perforation which can occur in the endovascular management of aneurysms remains unclear. The purpose of the present study was to evaluate the incidence of vascular perforation during endovascular coil embolization of a cerebral aneurysm, and to reveal characteristics and clinical outcomes.Materials and MethodsWe reviewed the endovascular coil embolization procedures performed for the treatment of 459 aneurysms. Incidence and clinical, radiological and technical data of patients concerning the vascular perforation were reviewed from medical records and radiological findings.ResultsThe incidence of procedure-related vascular perforation in our patient group was 0.87% (4/459). For all four occurrences, the cause of vascular perforation involved the guidewire or microcatheter. Clinical outcome was poor in 2 cases and favorable in 2 cases.ConclusionAlthough rare, the occurrence of vascular perforation during coil embolization for treatment of an aneurysm may be fatal. Therefore, careful management of the guidewire is suggested for the prevention of vascular rupture during an endovascular procedure

Intra-Arterial Thrombolysis after Full-Dose Intravenous tPA via the "Drip and Ship" Approach in Patients with Acute Ischemic Stroke: Preliminary Report

According to the "drip and ship" concept, patients who are not responsive to intravenous tissue plasminogen activator (IV-tPA) at a community hospital may be candidates for subsequent intra-arterial (IA) thrombolysis at a comprehensive stroke center. We elucidated the efficacy and safety of combined IV/IA thrombolysis via the drip and ship approach. We retrospectively reviewed patients with acute ischemic stroke who underwent combined IV/IA thrombolysis between March 2006 and June 2009. The patients were divided into two groups (inside hospital IV-tPA vs. outside hospital IV-tPA). We compared the short- and long-term clinical outcome, recanalization rate, intracranial hemorrhage after the procedure, and onset to treatment time between the two groups. A total of 23 patients with inside hospital IV-tPA and 10 patients with outside hospital IV-tPA were included. The mean pre-treatment National Institutes of Health Stroke Scale (NIHSS) scores were 15.8 and 17.5, respectively. Baseline characteristics were not significantly different between the two groups. The NIHSS score at 1 week and favorable outcome rate (modified Rankin Scale ≤2) 3 months after the procedure were not significantly different (p=0.730 and p=0.141, respectively). The rate of recanalization and intracranial hemorrhage were not significantly different (p=0.560 and p=0.730, respectively). The onset to IA thrombolysis time was also not significantly different (222.7 vs. 239.3 minutes, p=0.455). Our results suggest that initiation of IV-tPA in a community hospital with rapid transfer to a comprehensive stroke center for subsequent IA thrombolysis can be a safe and feasible therapeutic option in acute stroke management

Ultrasound Enhanced Thrombolysis: Applications in Acute Cerebral Ischemia

Intravenous tissue plasminogen activator (TPA) improves patient chances to recover from stroke by inducing mostly partial recanalization of large intracranial thrombi. TPA activity can be enhanced with ultrasound including 2 MHz transcranial Doppler (TCD). TCD identifies residual blood flow signals around thrombi, and, by delivering mechanical pressure waves, exposes more thrombus surface to circulating TPA. The international multi-center CLOTBUST trial showed that ultrasound enhances thrombolytic activity of a drug in humans thereby confirming multi-disciplinary experimental research conducted worldwide for the past 30 years

Review of the Current Status of Intra-Arterial Thrombolysis for Treating Acute Cerebral Infarction: a Retrospective Analysis of the Data from Multiple Centers in Korea

Objective The purpose of the study was to review the current status of intra-arterial (IA) thrombolysis in Korea by conducting a retrospective analysis of the data from multiple domestic centers. Materials and Methods The radiologists at each participating institution were asked to fill out case report forms on all patients who had undergone IA recanalization due to acute anterior circulation ischemia. These forms included clinical, imaging and procedure-related information. A central reader analyzed the CT/MR and angiographic results. The rates of successful recanalization, hemorrhagic transformation and functional outcome were obtained. The univariate analyses were performed together with the multivariate analysis. Results We analyzed the data from 163 patients, and they had been treated at seven institutes. The initial imaging modalities were CT for 46 patients (28%), MR for 63 (39%), and both for 54 (33%). Various mechanical treatment methods were applied together in 50% of the patients. Radiologically significant hemorrhage was noted in 20/155 patients (13%). We found various factors that influenced the recanalization rate and the occurrence of significant hemorrhagic transformations. The favorable outcome rate, reported as modified Rankin Scale ≤ 2, was 40%, and the mortality rate was 11%. The factors that predicted a poor functional outcome were old age (p = 0.01), initially severe neurological symptoms (p < 0.0001), MR findings of a wide distribution of lesions (p = 0.001), involvement of the basal ganglia (p = 0.01), performance of procedures after working hours (p = 0.01), failure of recanalization (p = 0.003), contrast extravasation after the procedure (p = 0.007) and significant hemorrhagic transformation (p = 0.002). The subsequent multivariate analysis failed to show any statistically significant variable. Conclusion There was a trend toward increased dependency on MR imaging during the initial evaluation and increased usage of combined pharmacologic/mechanical thrombolysis. The imaging and clinical outcome results of this study were comparable to those of the previous major thrombolytic trials.ope

Rescue therapy with local intra-arterial urokinase after poor clinical response with intravenous recombinant tissue plasminogen activator in acute ischaemic stroke

We report a case of combined intravenous and intra-arterial thrombolysis in a patient presenting with acute ischaemic stroke. Progression to intra-arterial thrombolysis in patients who fail to show clinical improvement within 6 h of symptom onset might be a safe treatment option at centres with access to stroke specialist and endovascular services. The purpose of this report is to demonstrate the efficacy and potential benefits of this rescue therapy.L. H. Lee, S. Chryssidis and J. Janne