Citations

Background and Purpose— Mechanical thrombectomy has been shown to improve clinical outcomes in patients with acute ischemic stroke. However, the impact of balloon guide catheter (BGC) use is not well established. Methods— STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter study of patients with large vessel occlusion treated with the Solitaire stent retriever as first-line therapy. In this study, an independent core laboratory, blinded to the clinical outcomes, reviewed all procedures and angiographic data to classify procedural technique, target clot location, recanalization after each pass, and determine the number of stent retriever passes. The primary clinical end point was functional independence (modified Rankin Scale, 0–2) at 3 months as determined on-site, and the angiographic end point was first-pass effect (FPE) success rate from a single device attempt (modified Thrombolysis in Cerebral Infarction, ≥2c) as determined by a core laboratory. Achieving modified FPE (modified Thrombolysis in Cerebral Infarction, ≥2b) was also assessed. Comparisons of clinical outcomes were made between groups and adjusted for baseline and procedural characteristics. All participating centers received institutional review board approval from their respective institutions. Results— Adjunctive technique groups included BGC (n=445), distal access catheter (n=238), and conventional guide catheter (n=62). The BGC group had a higher rate of FPE following first pass (212/443 [48%]) versus conventional guide catheter (16/62 [26%]; P =0.001) and distal access catheter (83/235 [35%]; P =0.002). Similarly, the BGC group had a higher rate of modified FPE (294/443 [66%]) versus conventional guide catheter (26/62 [42%]; P <0.001) and distal access catheter (129/234 [55%]; P =0.003). The BGC group achieved the highest rate of functional independence (253/415 [61%]) versus conventional guide catheter (23/55 [42%]; P =0.007) and distal access catheter (113/218 [52%]; P =0.027). Final revascularization and mortality rates did not differ across the groups. Conclusions— BGC use was an independent predictor of FPE, modified FPE, and functional independence, suggesting that its routine use may improve the rates of early revascularization success and good clinical outcomes. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT02239640.

Objective: The overall risk of ischemic stroke from a chronically occluded internal carotid artery (COICA) is around 5%-7% per year despite receiving the best medical therapy. We propose a radiographic classification of COICA that can be used as a guide to determine the technical success and safety of endovascular recanalization for symptomatic COICA. Methods: The radiographic images of 100 consecutive subjects with COICA were analyzed. A new classification of COICA was proposed based on the morphology, location of occlusion, and presence or absence of reconstitution of the distal ICA. The classification was used to predict successful revascularization in 32 symptomatic COICAs in 31 patients. Patients were included in the study if they had a COICA with ischemic symptoms refractory to medical therapy. Results: Four types (A-D) of radiographic COICA were identified. Types A and B were more amenable to safe revascularization than types C and D. Recanalization was successful at a rate of 68.75% (22/32 COICAs; type A: 8/8; type B: 8/8; type C: 4/8; type D: 2/8). The perioperative complication rate was 18.75% (6/32; type A: 0/8 [0%]; type B: 1/8 [12.50%]; type C: 3/8 [37.50%], type D: 2/8 [25.00%]). None of these complications led to permanent morbidity or death. Twenty (64.52%) of 31 subjects had improvement in their symptoms at the 2-6 months' follow-up. A statistically significant decrease in systolic blood pressure (SBP) was noted in 17/21 (80.95%) patients who had successful revascularization, which persisted on follow-up (p = 0.0001). The remaining 10 subjects in whom revascularization failed had no significant changes in SBP (p = 0.73). Conclusions: The pilot study suggested that our proposed classification of COICA may be useful as an adjunctive guide to determine the technical feasibility and safety of revascularization for symptomatic COICA using endovascular techniques. Additionally, successful revascularization may lead to a significant decrease in SBP postprocedure. A Phase 2b trial in larger cohorts to assess the efficacy of endovascular revascularization using our COICA classification is warranted.

Abstract We present a case of a patient with pseudotumor cerebri (PC) and transverse/sigmoid junction sinus (TSJS) stenosis treated with stenting venoplasty. A 54-yr-old man with a history of hypertension, hyperlipidemia, and chronic obstructive pulmonary disease presented with subacute onset of progressive headaches, blurred vision, and papilledema. He was clinically diagnosed with PC. Left TSJS stenosis was suspected on magnetic resonance venography and confirmed with digital subtraction angiography and venography. During angiography, venous pressures were measured along the intracranial venous system revealing a significant drop compared with pressures obtained from the superior sagittal and sigmoid sinuses. For 7 d prior to venous sinus stenting, he was prescribed antiplatelet therapy with aspirin (350 mg/d) and clopidogrel (75 mg/d). Patient consent was obtained prior to performing the procedure; institutional board approval is not required for the report of a single case. Under conscious sedation and systemic heparinization, the patient underwent endovascular stenting of the left TSJS with an open-cell carotid stent (Precise 7 × 40 mm; Cordis, Milpitas, California). Successful left TSJS reconstruction transpired with no procedure-related complications. The patient was discharged home 1 d postprocedure. After 2 mo of dual antiplatelet therapy, clopidogrel was discontinued. At the 1-yr follow-up, he had resolution of papilledema and notably less intense headaches. Venous sinus stenting is an effective endovascular treatment for symptomatic patients with PC and sinus stenosis. Venous pressure measurement is imperative for patient selection. Adequate venous access with a 6-French guide catheter into the sigmoid sinus and an intermediate catheter into the transverse sinus is crucial to navigate a stent through the acute angles of the TSJS and jugular vein.

Abstract Mechanical thrombectomy has become the standard of care for management of most acute large-vessel occlusion (LVO) strokes. Most intracranial occlusions are located in the middle cerebral and internal carotid arteries. We present a unique case of acute occlusion of an azygous anterior cerebral artery (ACA). A 59-yr-old man with known hypertension and alcoholism presented with right hemiparesis, right facial palsy, aphasia, and dysarthria. His initial National Institutes of Health Stroke Scale (NIHSS) score was 20. Computed tomographic angiography and perfusion imaging demonstrated acute bilateral ACA occlusion with viable penumbra and preserved cerebral blood volume. The patient was not a candidate for intravenous tissue plasminogen activator because he presented with a wake-up stroke. After consent was obtained from his family, the patient was taken urgently for endovascular recanalization. Digital subtraction angiography confirmed acute azygous ACA occlusion. Under conscious sedation, the patient underwent mechanical thrombectomy with a stent retriever and a large-bore aspiration catheter. Successful revascularization (thrombolysis in cerebral infarction [TICI] grade 3) of the azygous ACA and both A2 arteries was obtained after 2 attempts and the use of a different stent retriever (first a 3 × 30 mm Trevo [Stryker Neurovascular, Kalamazoo, Michigan] and then a 4 × 40 mm Solitaire Platinum [Medtronic, Dublin, Ireland]). A reperfusion catheter was used during both attempts. No procedure-related complications occurred. The patient was discharged to a rehabilitation facility 3 d after the procedure with an NIHSS score of 2. In this video, we present the operative nuances of an uncommon location of LVO and its endovascular management.

Abstract We present a case of tandem stenosis of the great vessels (cervical internal carotid artery [ICA] and brachiocephalic trunk ostium [BTO]) treated with stenting and balloon angioplasty of both lesions under flow arrest. A 70-yr-old woman with a history of hypertension, hyperlipidemia, coronary artery disease, and previous strokes presented with recurrent transient ischemic attacks of the left upper and lower extremities over the last 6 mo. She underwent right cervical endarterectomy (CEA) 16 yr prior. Neurological examination was unremarkable. Carotid Doppler ultrasonography revealed severely increased velocities of the right ICA. Cervical magnetic resonance angiography demonstrated 80% right ICA stenosis and 50% BTO stenosis. Digital subtraction cerebral angiography showed 80% right ICA stenosis and 70% BTO stenosis. The patient was not a candidate for standard carotid artery stenting because the BTO precluded endovascular access or for CEA because of the previous CEA; therefore, direct carotid access and flow reversal was an alternative. Under general anesthesia and systemic heparinization, the patient underwent right carotid artery surgical exposure. Under flow reversal using the Enroute System (Silk Road Medical, Sunnyvale, California), anterograde right ICA stenting angioplasty and retrograde BTO stenting and angioplasty were performed. Successful revascularization of the right ICA and BTO was obtained. No procedure-related complications occurred. The patient was discharged home 2 d postprocedure, neurologically intact. Direct carotid access with flow reversal is a safe and effective therapeutic alternative for patients with ICA (or common carotid artery) stenosis who cannot undergo CEA or when endovascular access from the aortic arch is not possible. Patient consent was obtained prior to performing the procedure. Institutional board approval is not required for the report of a single case.

OBJECTIVE The overall risk of ischemic stroke from a chronically occluded internal carotid artery (COICA) is around 5%–7% per year despite receiving the best available medical therapy. Here, authors propose a radiographic classification of COICA that can be used as a guide to determine the technical success and safety of endovascular recanalization for symptomatic COICA and to assess the changes in systemic blood pressure following successful revascularization. METHODS The radiographic images of 100 consecutive subjects with COICA were analyzed. A new classification of COICA was proposed based on the morphology, location of occlusion, and presence or absence of reconstitution of the distal ICA. The classification was used to predict successful revascularization in 32 symptomatic COICAs in 31 patients, five of whom were female (5/31 [16.13%]). Patients were included in the study if they had a COICA with ischemic symptoms refractory to medical therapy. Carotid artery occlusion was defined as 100% cross-sectional occlusion of the vessel lumen as documented on CTA or MRA and confirmed by digital subtraction angiography. RESULTS Four types (A–D) of radiographic COICA were identified. Types A and B were more amenable to safe revascularization than types C and D. Recanalization was successful at a rate of 68.75% (22/32 COICAs; type A: 8/8; type B: 8/8; type C: 4/8; type D: 2/8). The perioperative complication rate was 18.75% (6/32; type A: 0/8 [0%]; type B: 1/8 [12.50%]; type C: 3/8 [37.50%], type D: 2/8 [25.00%]). None of these complications led to permanent morbidity or death. Twenty (64.52%) of 31 subjects had improvement in their symptoms at the 2–6 months’ follow-up. A statistically significant decrease in systolic blood pressure (SBP) was noted in 17/21 (80.95%) patients who had successful revascularization, which persisted on follow-up (p = 0.0001). The remaining 10 subjects in whom revascularization failed had no significant changes in SBP (p = 0.73). CONCLUSIONS The pilot study suggested that our proposed classification of COICA may be useful as an adjunctive guide to determine the technical feasibility and safety of revascularization for symptomatic COICA using endovascular techniques. Additionally, successful revascularization may lead to a significant decrease in SBP postprocedure. A Phase 2b trial in larger cohorts to assess the efficacy of endovascular revascularization using our COICA classification is warranted.

Abstract BACKGROUND Neck remnants are not uncommon after endovascular treatment of cerebral aneurysms. Critics of endovascular treatments for cerebral aneurysms cite neck remnants as evidence in favor of microsurgical clipping. However, studies have failed to evaluate the true clinical significance of aneurysm neck remnants following endovascular therapies. OBJECTIVE To assess the clinical significance of residual aneurysm necks and to determine the rate of subsequent rupture following coiling or stent-assisted coiling of cerebral aneurysms. METHODS We retrospectively reviewed the records of 1292 aneurysm cases that underwent endovascular treatment at 4 institutions. Aneurysms treated by primary coiling or stent-assisted coiling were included in the study; those treated by flow diversion were excluded Aneurysms with residual filling (i.e., Raymond–Roy Occlusion Classification II, neck remnant; or III, residual aneurysm filling) were assessed for their risk of subsequent rupture. RESULTS A total of 626 aneurysms were identified as having residual filling immediately posttreatment. Of these, 13 aneurysms (2.1%) ruptured during the follow-up period (mean 7.3 mo; range 1-84 mo). Eleven of the 13 (84.6%) were ruptured at presentation. Rupture at presentation, the size of the aneurysm, and the increasing age of the patient were predictive of posttreatment rupture. CONCLUSION We found that unruptured aneurysms with residual necks following endovascular treatment posed a very low risk of rupture (0.6%). However, patients presenting with ruptured aneurysms had a higher risk of rerupture from a neck remnant (3.4%). These results highlight the importance of achieving complete angiographic occlusion of ruptured aneurysms.