Intracranial Stenting as Rescue Therapy After Failure of Mechanical Thrombectomy for Basilar Artery Occlusion: Data From the ANGEL-ACT Registry.

Background and Purpose: Studies on rescue therapy for acute posterior circulation stroke due to basilar artery occlusion (BAO) are limited in the modern era of mechanical thrombectomy (MT). The aim of this study was to evaluate the safety and efficacy of rescue stenting (RS) following MT failure in patients with BAO. Methods: Data were collected from the Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke (ANGEL-ACT) prospective registry in China. Patients who underwent MT for BAO with failure of recanalization were enrolled in this study. The patients were divided into the RS and non-RS groups. Clinical and laboratory findings, procedural details, and clinical outcomes were compared between the two groups. Results: Overall, 93 patients with acute BAO were analyzed. The RS group included 81 (87.1%) patients, and the non-RS group included 12 patients. A modified treatment in cerebral infarction (mTICI) score of 2b/3 was achieved in 75 (92.6%) patients in the RS group. Compared with the non-RS group, the RS group had a significantly higher rate of successful recanalization and favorable clinical outcomes (modified Rankin Scale score at 90 days post-procedure, 0-3: 16.7 vs. 51.9%, respectively; P = 0.023) without an increase in the rate of symptomatic intracranial hemorrhage and a significantly lower mortality rate (58.3 vs. 18.5%, respectively; P = 0.006). Furthermore, the use of a glycoprotein IIb/IIIa inhibitor improved the rate of recanalization of the target artery without increasing the rate of symptomatic intracranial hemorrhage. Conclusions: Permanent stenting appears to be a feasible rescue modality when MT fails and might provide functional benefits in patients with acute ischemic stroke due to BAO.

Thrombolytic Therapy in Acute Ischemic Stroke in Patients Not Fulfilling Conventional Criteria.

INTRODUCTION: There are many exclusion criteria in early randomized control trials for intravenous recombinant tissue plasminogen activator use in acute ischemic stroke, thus, many patients were not eligible for the treatment. OBJECTIVE: This study aimed to compare the safety and short-term treatment outcome between those who fulfilled the criteria and those who did not. METHODS: All acute ischemic stroke patients treated with intravenous thrombolysis from 2004 to 2015 in Tuen Mun hospital were recruited. They were divided into an on-label group if they did not have any of the contraindications and an off-label group if contraindication existed. Primary outcome of symptomatic hemorrhage, and secondary outcome of early neurological change, 3-month mortality and functional outcome were measured. Multivariate analysis with logistic regression with adjustment of baseline characteristics was done. RESULTS: Totally, 323 patients received intravenous thrombolysis and 162 (50.2%) had at least one contraindication. None of the contraindications were associated with symptomatic intracranial hemorrhage. Patients with previous stroke and diabetes mellitus performed similarly in all outcome measures. Patients with minor stroke had less early neurological deterioration and better functional outcome. Old age and high blood pressure were shown to have less early neurological improvement and less good functional outcome. Severe stroke was related to increased mortality and none had a good functional outcome. CONCLUSIONS: This study demonstrated that the off-label group had comparable symptomatic intracranial hemorrhagic risk which gave ground for further study into its safety. However, some subgroups had less favorable outcome, including high blood pressure, severe stroke, and old age. This may be due to underlying comorbidities and limited rehabilitation potential rather than thrombolysis per se.

Asymmetric Acute Motor Axonal Neuropathy With Unilateral Tongue Swelling Mimicking Stroke.

A 60-year-old man presented with acute onset of left hemiparesis and left hypoglossal nerve palsy with ipsilateral tongue swelling. He then progressed to tetraparesis in a few days. Cerebrospinal fluid showed cell protein dissociation. A nerve conduction study showed motor axonal neuropathy with sensory sparing. A subsequent blood test revealed anti-GD1b IgG antibody positivity. He was diagnosed to have acute motor axonal neuropathy (AMAN) and treated with a course of intravenous immunoglobulin with slow improvement. This is probably the first AMAN with asymmetrical presentation mimicking stroke reported in the literature in detail. The anti-GD1b IgG antibody is also not commonly associated with AMAN.