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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Emergency cervical internal carotid artery stenting in combination with intracranial thrombectomy in acute stroke
S Stampfl1, P A Ringleb, M Möhlenbruch
1From the Departments of Neuroradiology (S.S., M.M., C. Herweh, M.P., S.H., M.B., S.R.).
Insights
Emergency carotid artery stent placement combined with intracranial thrombectomy is feasible for acute stroke patients with tandem occlusions. While achieving successful recanalization, this combined approach presents an acceptable outcome but carries a high risk of symptomatic intracranial hemorrhage.
Area of Science:
- Interventional Neuroradiology
- Cerebrovascular Diseases
- Endovascular Therapy
Background:
- Thrombectomy is standard for acute intracranial occlusions.
- 10-20% of patients have concurrent cervical internal carotid artery lesions.
- Need for combined treatment strategies is evident.
Purpose of the Study:
- Evaluate feasibility of emergency carotid artery stent placement.
- Assess clinical outcomes of combined stent placement and thrombectomy.
- Analyze safety and efficacy in acute stroke patients.
Main Methods:
- Retrospective analysis of 24 patients (Nov 2009 - Jul 2012).
- Combined emergency cervical internal carotid artery stent placement and intracranial thrombectomy.
- Recanalization assessed by Thrombolysis in Cerebral Infarction (TICI) score.
- Clinical outcomes evaluated by National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS).
Main Results:
- Stent implantation was technically feasible in all patients.
- Successful recanalization (TICI ≥ 2b) achieved in 62.5% of patients.
- Median mRS score was 3.0 at 90 days; 29.2% had good outcomes (mRS 0-2).
- Symptomatic intracranial hemorrhage occurred in 16.6% of patients.
Conclusions:
- Emergency internal carotid artery stent placement is technically feasible.
- High rates of intracranial recanalization were achieved.
- Clinical outcomes and mortality are acceptable for severe stroke, but hemorrhage risk is significant.
Background And Purpose:
In past years, thrombectomy has become a widely used procedure in interventional neuroradiology for the treatment of acute intracranial occlusions. However, in 10-20% of patients, there are additional occlusions or stenotic lesions of the ipsilateral cervical internal carotid artery. The purpose of this study was to evaluate the feasibility of emergency carotid artery stent placement in combination with intracranial thrombectomy and the clinical outcome of the treated patients.
Materials And Methods:
We analyzed clinical and angiographic data of patients who underwent emergency cervical ICA stent placement and intracranial thrombectomy with stent-retriever devices in our institution between November 2009 and July 2012. Recanalization was assessed according to the Thrombolysis in Cerebral-Infarction score. Clinical outcome was evaluated at discharge (NIHSS) and after 3 months (mRS).
Results:
Overall, 24 patients were treated. The mean age was 67.2 years; mean occlusion time, 230.2 minutes. On admission, the median NIHSS score was 18. In all patients, the Thrombolysis in Cerebral Infarction score was zero before the procedure. Stent implantation was feasible in all cases. In 15 patients (62.5%), a Thrombolysis in Cerebral Infarction score ≥ 2b could be achieved. Six patients (25%) improved ≥10 NIHSS points between admission and discharge. After 90 days, the median mRS score was 3.0. Seven patients (29.2%) had a good clinical outcome (mRS 0-2), and 4 patients (16.6%) died, 1 due to fatal intracranial hemorrhage. Overall, symptomatic intracranial hemorrhage occurred in 4 patients (16.6%).
Conclusions:
Emergency ICA stent implantation was technically feasible in all patients, and the intracranial recanalization Thrombolysis in Cerebral Infarction score of ≥2b was reached in a high number of patients. Clinical outcome and mortality seem to be acceptable for a cohort with severe stroke. However, a high rate of symptomatic intracranial hemorrhage occurred in our study.
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