Frequency and relevance of anterior cerebral artery embolism caused by mechanical thrombectomy of middle cerebral artery occlusion.

BACKGROUND AND PURPOSE: Spread of thrombus material in previously unaffected vessels is a potential hazard of mechanical thrombectomy, but it has not yet been investigated in detail, to our knowledge. Our purpose was to evaluate the frequency and relevance of these events in mTE of M1 occlusions. MATERIALS AND METHODS: We retrospectively reviewed all patients treated for isolated M1 occlusion between January 2008 and July 2012. Angiographic images were analyzed to assess emboli in anterior cerebral artery branches induced by mTE and associated devices. Recanalization attempts in the ACA were reported as well as technical success and adverse events of rescue therapies. ACA infarcts on follow-up imaging served as a surrogate for clinical relevance. ACA infarcts were quantified volumetrically and assessed visually for involvement of motor or supplementary motor areas. RESULTS: New ACA emboli occurred in 12 of 105 (11.4%) M1 recanalization procedures and were caused by a stent-retriever in 11 intances. Attempts to recanalize the ACA were made in 6 patients and were deemed technically successful in 5 with no adverse events. We detected 6 (5.7%) new infarcts on follow-up imaging with an average volume of 26.9 cm(3). Involvement of motor or supplementary motor areas was seen in 4 (3.8%) cases. Three patients developed ACA infarcts despite successful endovascular ACA recanalization. CONCLUSIONS: The frequency of ACA emboli in mTE of M1 occlusions is relevant, causing ACA infarcts in 5.7% of patients; 3.8% of emboli were likely to hamper motor-function recovery. Endovascular recanalization of major ACA branches reduced the incidence of infarcts with no adverse events.

[The persistence of pathogens and its immunepathological consequences]. / Die Persistenz pathogener Erreger und ihre immunpathologischen Folgen.

In principle the persistence of pathogens is favored by disturbances of the interplay between specific humoral and cellular defence mechanisms in the particular individual characteristic. Clinical secondary reactions in persistence of infection are in many cases not characterized by the infection as such but more decisively by the "terrain" which a particular organism encounters. This terrain is characterized by immunopathological secondary reactions which now become in turn the basis of the clinical secondary disease. In the individual case the manifestations are due to: acquired disturbances of immunotolerance; formation of neoantigens or induced autoimmune reactions; frequent immune complex reactions due to infectious or secondary antigens with corresponding antibody formation and complement activation.

[Inflammatory diseases of the vessels. Clinical aspects, immunopathology, characteristic features of therapy (author's transl)]. / Entzündliche Gefässerkrankungen. Klinik, Immunpathologie, Grundzüge der Therapie.

Arterial obstructive diseases become manifest principally in the great peripheral vessels, visceral symptoms are rare. In the overwhelming majority of inflammatory vascular processes changes in the small arteries are impressive, visceral symptoms are common, in many cases the rule, peripheral occlusive syndromes are exceptions, although possible, and then prognostically especially serious in the individual case. The diagnosis of such vascular processes can be extraordinarily difficult if there is systemic spread because of the great variety of symptoms, and in the individual case may be almost impossible. Principles of classification should contribute to the facilitation of necessary clinical differentiation and lead to the proper therapeutic indication of the fundamental process. But they should also serve for the understanding of those inflammatory vascular diseases whose special position is based on the new scientific knowledge of immunopathology.