Endovascular mechanical thrombectomy for the treatment of acute ischemic stroke due to arterial dissection.

Arterial dissections account for 2% of strokes in all age groups, and up to 25% in patients aged 45 years or younger. The safety of endovascular intervention in this patient population is not well characterized. We identified all patients in the Merci registry - a prospective, multi-center post-market database enrolling patients treated with the Merci Retriever thrombectomy device - with arterial dissection as the most likely stroke etiology. Stroke presentation and procedural details were obtained prospectively; data regarding procedural complications, intracerebral hemorrhage (ICH), and the use of stenting of the dissected artery were obtained retrospectively. Of 980 patients in the registry, ten were identified with arterial dissection (8/10 ICA; 2/10 vertebrobasilar). The median age was 48 years with a baseline NIH stroke scale score of 16 and median time to treatment of 4.9 h. The procedure resulted in thrombolysis in cerebral ischemia (TICI) scores of 2a or better in eight out of ten and TICI 2b or better in six out of ten patients. Stenting of the dissection was performed in four of nine (44%). The single complication (1/9; 11%) - extension of a dissected carotid artery - was treated effectively with stenting. No symptomatic ICH or stroke in a previously unaffected territory occurred. A favorable functional outcome was observed in eight out of ten patients. Despite severe strokes on presentation, high rates of recanalization (8/10) and favorable functional outcomes (8/10) were observed. These results suggest that mechanical thrombectomy in patients with acute stroke resulting from arterial dissection is feasible, safe, and may be associated with favorable functional outcomes.

The Merci Retrieval System for acute stroke: the Southeast Regional Stroke Center experience.

INTRODUCTION: The Merci Retrieval System was cleared for use in patients with stroke in August 2004. However, there are few published results of "real world experience" with the device. METHODS: We captured single-center data on 25 consecutive patients with acute ischemic stroke treated with the Merci Retrieval System according to the MERCI trial except that we treated some patients with tandem proximal carotid and intracranial lesions with carotid angioplasty and stenting and some patients were treated within the 3-hour window. RESULTS: Median patient age was 63 years and median initial National Institute of Health Stroke Scale (NIHSS) score was 18. Isolated M1 or M2 middle cerebral artery lesions occurred in 52%, "carotid T" lesions in 8%, and vertebrobasilar lesions in 8%. Tandem lesions involving proximal carotid and proximal intracranial vessel occurred in 32%, necessitating emergent multilevel treatment including carotid stenting. Median duration from symptom onset to Merci device utilization was 5.2 hours. Successful reperfusion (> or = thrombolysis in myocardial infarction [TIMI] 2 flow) in the target vessel was obtained in 56% of cases. Statistical analysis revealed a strong correlation between ability to achieve greater than or equal to TIMI 2 flow and good clinical outcome as measured by 3-month NIHSS score, modified Rankin Scale (mRS), and mortality (nine out of the 12 without successful reperfusion died compared to none of the 13 with > or =TIMI 2 flow, p < 0.001). Younger age and lower NIHSS score on presentation were also predictors of good clinical outcome at 3 months. CONCLUSION: These "real world data" demonstrate that the results of the previous MERCI trial can be "independently replicated" at a regional stroke center. Although the results of placebo-controlled trials are still pending, mechanical revascularization has become a critical component of our acute stroke protocol, particularly for severe strokes. Issues still remain regarding recalcitrant lesions and operator experience, which necessitate further clinical testing and device optimization.

Cooling for Acute Ischemic Brain Damage (COOL AID): a feasibility trial of endovascular cooling.

OBJECTIVE: To report results of a randomized pilot clinical feasibility trial of endovascular cooling in patients with ischemic stroke. METHODS: Forty patients with ischemic stroke presenting within 12 hours of symptom onset were enrolled in the study. An endovascular cooling device was inserted into the inferior vena cava of those randomized to hypothermia. A core body temperature of 33 degrees C was targeted for 24 hours. All patients underwent clinical assessment and MRI initially, at days 3 to 5 and days 30 to 37. RESULTS: Eighteen patients were randomized to hypothermia and 22 to receive standard medical management. Thirteen patients reached target temperature in a mean of 77 +/- 44 minutes. Most tolerated hypothermia well. Clinical outcomes were similar in both groups. Mean diffusion-weighted imaging (DWI) lesion growth in the hypothermia group (n = 12) was 90.0 +/- 83.5% compared with 108.4 +/- 142.4% in the control group (n = 11) (NS). Mean DWI lesion growth in patients who cooled well (n = 8) was 72.9 +/- 95.2% (NS). CONCLUSIONS: Induced moderate hypothermia is feasible using an endovascular cooling device in most patients with acute ischemic stroke. Further studies are needed to determine if hypothermia improves outcome.

Possible short-term amelioration of basilar plaque by high-dose atorvastatin: use of reductase inhibitors for intracranial plaque stabilization.

Regression of symptomatic intracranial atherostenosis is not known to be a common occurrence. In this case, delay of basilar reconstruction by endovascular means permitted serial angiographic assessment of plaque change. The use of high-dose atorvastatin over a 2-week period was associated with marked angiographic improvement. Medical programs of plaque stabilization may provide adjunctive benefit in patients with symptomatic intracranial disease.