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Stent-Assisted Endovascular Thrombolysis Versus Intravenous Thrombolysis in Internal Carotid Artery Dissection With Tandem Internal Carotid and Middle Cerebral Artery Occlusion

Stent-Assisted Endovascular Thrombolysis Versus Intravenous Thrombolysis in Internal Carotid Artery Dissection With Tandem Internal Carotid and Middle

Stent-Assisted Endovascular Thrombolysis Versus Intravenous Thrombolysis in Internal Carotid Artery Dissection With Tandem Internal Carotid and Middle Cerebral Artery Occlusion   (Citations: 9)
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Background and Purpose—Tandem internal carotid and middle cerebral artery occlusion independently predicts poor outcome after intravenous thrombolysis. Recanalization of internal carotid artery dissection by stent-assisted angioplasty has recently been proposed when anticoagulation fails to prevent a new ischemic event. We recently reported a case of tandem internal carotid and middle cerebral artery occlusion with dissection of the internal carotid artery successfully treated with endovascular stent-assisted thrombolysis. Methods—We compared clinical outcomes in consecutive patients presenting with tandem internal carotid and middle cerebral artery occlusion with internal carotid artery dissection within 3 hours of symptom onset who were eligible for intravenous thrombolysis, treated by either endovascular stent-assisted thrombolysis or intravenous recombinant tissue-type plasminogen activator (rtPA) when an endovascular therapist was unavailable. National Institutes of Health Stroke Scale scores were obtained at baseline and after 24 hours. The modified Rankin Scale score was used to assess outcomes at 3 months. Arterial recanalization was assessed by magnetic resonance imaging. Results—Of 10 patients screened, 6 were treated with endovascular therapy and 4 with intravenous rtPA. Before treatment, mean National Institutes of Health Stroke Scale scores were high and comparable in the 2 groups (17 and 16, respectively). In the endovascular group, all patients achieved middle cerebral artery recanalization with subsequent dramatic improvement versus only 1 patient with middle cerebral artery recanalization in the intravenous rtPA group. At 3 months, 4 patients in the endovascular group had a favorable outcome (modified Rankin Scale score0). In the intravenous rtPA group, 3 patients had a poor outcome (modified Rankin Scale score3). Conclusions—Endovascular stent-assisted thrombolysis is a promising treatment in tandem internal carotid and middle cerebral artery occlusion due to internal carotid artery dissection and compares favorably with intravenous rtPA. (Stroke. 2007;38:2270-2274.)
Published in 2010.
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    • ...Internal carotid artery (ICA) dissection with tandem internal carotid and middle cerebral artery (MCA) occlusion may be responsible for large cerebral infarction that may carry a poor prognosis even if intravenous recombinant-tissular plasminogen activator (rt-PA) is administered [...

    Alain Lekoubouet al. Combined Intravenous Recombinant-Tissular Plasminogen Activator and En...

    • ...However, if the MCA is treated first, the subsequent treatment of the ICA occlusion may result in embolism potentially putting previously normal territories (such as the posterior communicating artery (PCOM)/posterior cerebral artery (PCA) or ACA in cases of MCA occlusions) at risk. Other authors have documented proximal treatment first, citing potential benefits of increased proximal flow in autolysis of the distal occlusion and preservation of parenchyma (at risk by increasing perfusion pressure....

    Ferdinand K Huiet al. Embolic protection devices and the Penumbra 054 catheter: utility in t...

    • ...A value of 2 or 3 was regarded as being recanalized. Brain CT scan or magnetic resonance imaging was performed within 24 h of thrombolysis. Symptomatic intracranial hemorrhage was defined as any increase in the National Institute of Health Stroke Scale (NIHSS) score attributable to hemorrhage on CT or MR scans. Clinical assessments included the NIHSS and modified Rankin scores. A modified Rankin score of =2 at 3 months was considered as a good long-term outcome. Institutional review board approval was obtained with waiver of informed consent.ResultsDemographic CharacteristicsFrom May 2004 to June 2007, 147 patients were treated with IAT for hyperacute ischemic stroke. Among these, 13 (11.4%) revealed tandem occlusion as the cause of stroke. The initial median NIHSS score was 13 (range: 7–27). Of the 13 patients 8 were men and 5 women (mean age: 59.5 years, range: 31–80). Six patients received combined IAT after a nonresponsive IV tissue plasminogen activator treatment (table 2). The median time to initiation of urokinase infusion was 360 min (range: 174–560). The median dose of urokinase infused was 720,000 IU (range: 140,000–1,200,000).2Table 2. Summary of casesT02
      IAT of the DILThe tandem DIL-PEL sites were the proximal middle-cerebral-artery (MCA)/ICA (n = 11) and the basilar-artery/VA orifices (n = 2), respectively. Transoccluded ICA/VA (n = 8) or trans-Acom (n = 1) navigation of the microcatheter and microwire to the DIL was successful in 9 out of 13 cases (69%; table 3). Recanalization of the DIL was achieved in all but 1 patient with successful navigation (89%). The overall recanalization rate among all patients with tandem occlusion was 62% (8 out of 13 patients). Neither transoccluded ICA/VA nor trans-Acom/Pcom navigation was successful or feasible in 3 cases (patients 3, 5, 10). IAT was not attempted in a case with good collaterals and symptom improvement (patient 8).3Table 3. IAT of the tandem occlusion casesT03
      Fate and Treatment of PELThe PEL remained occluded immediately after thrombolysis in 5 cases. Narrow reopening of the PEL was seen in 3 patients after thrombolysis, 1 of which showed complete lysis upon follow-up (case 7). The PELs of 2 cases with narrow reopening, moderate collaterals and no clot burden were recanalized by staged stent-assisted angioplasty (patients 2, 12). Emergent angioplasty of the PEL at the VA orifice was attempted in a case with insufficient collateral flow and no clot burden; however, the procedure failed due to severe proximal vessel tortuosity (case 4).Clinical OutcomesNone of the participants died. Symptomatic hemorrhage developed in 1 case. The median NIHSS score at discharge was 8. Five out of 9 patients (56%) with successful navigation showed good functional outcome (mRS =2) at 3 months, and overall good outcome was noted in 6 out of 13 subjects (46%).
      DiscussionWhen tandem artery occlusion is encountered during IAT, the therapeutic options become limited. Complete recanalization by use of thrombolytic agents is usually not possible because of a large thrombus volume throughout the long segment. Although the use of mechanical devices is an option for removal of the clot before access to the DIL, it takes time and is available only in a limited number of hospitals or countries. The findings of our series show that IAT localized to the DIL may be an effective method of treatment in tandem occlusion cases. Rapid redistribution of the blood flow to the brain via pre-existing collateral pathways was possible without therapeutic recanalization of the proximally occluded artery.Tandem occlusions may be caused by atherosclerosis or dissection of the PEL and fragmented dislodgement of thrombi at the DIL [,...

    Dong Joon Kimet al. Intra-Arterial Thrombolytic Therapy for Hyperacute Ischemic Stroke Cau...

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