Outcome of mechanical thrombectomy in the very elderly for the treatment of acute ischemic stroke: the real world experience.

BACKGROUND: Although initial studies of neuroendovascular intervention did not review benefit over intravenous thrombolytics (iv r-tPA), recent studies have suggested otherwise. Elderly patients (age ≥80 years) are typically excluded from clinical trials. PURPOSE: To examine the utility of mechanical thrombectomy based on patient outcomes. MATERIAL AND METHODS: All stroke-alert activations at our health system from January 2011 to June 2014 were examined. All patients aged ≥80 years who had undergone mechanical thrombectomy were identified. Clinical characteristics included physiologic imaging findings, use of intravenous thrombolytics, baseline and postoperative National Institute of Health Stroke Scale (NIHSS), thrombolysis in cerebral infarction scores (TICI), and discharge destination. RESULTS: Mean NIHSS on presentation was 18.2 (range, 6-31), and 13.3 (range, 3-30) post thrombectomy. Three (16.6%) patients received iv r-tPA, two (11.1%) had symptomatic intracranial hemorrhage. Eight (44.4%) died, eight (44.4%) were discharged to nursing homes, and two (11.7%) were discharged to inpatient rehab and subsequently home. Favorable outcome was achieved in five (27.7%) patients. Fourteen (77.7%) patients had physiologic imaging prior to intervention. Three (75%) of four patients who did not have physiologic imaging prior to thrombectomy died. Thirteen (66.6%) patients had TICI 3 recanalization. CONCLUSION: Our study showed that although there remains a role of mechanical thrombectomy in the treatment of acute ischemic stroke in very elderly patients, it is associated with significant higher morbidity and mortality compared to younger patients, but should remain a very viable treatment option when quality of life is the most important consideration.

Intractable Hiccups Due to Posterior Inferior Cerebellar Artery Aneurysm.

This is the third reported case of a posterior inferior cerebellar artery (PICA) aneurysm presenting as intractable hiccups (IH). A previously healthy 29-year-old woman was admitted with a 2-week history of hiccups occurring >100 times per minute. Symptoms persisted despite numerous noninvasive therapies. Magnetic resonance imaging and magnetic resonance angiogram of the brain showed a left PICA aneurysm that was confirmed by catheter angiography. Symptoms resolved following suboccipital craniotomy and resection. Although rare, PICA aneurysm is a potentially curable cause of IH.

Intravenous thrombolysis in acute ischemic stroke patients with negative CT perfusion: a case series.

BACKGROUND: Computed tomography perfusion (CTP) is a commonly used modality of neurophysiologic imaging to aid the selection of acute ischemic stroke patients for neuroendovascular intervention by identifying the presence of penumbra versus infarcted brain tissue. However many patients present with evidence of cerebral ischemia with normal CTP, and in that case, should intravenous thrombolytics be given? PURPOSE: To demonstrate if tissue-type plasminogen activator (tPA)-eligible stroke patients without perfusion defects demonstrated on CTP would benefit from administration of intravenous thrombolytics. MATERIAL AND METHODS: We retrospectively identified patients presenting with acute ischemic symptoms who received intravenous tPA (IV-tPA) from January to June 2012 without a perfusion defect on CTP. Clinical and radiographic findings including the NIHSS at presentation, 24 h, and at discharge, symptomatic and asymptomatic hemorrhagic transformation, and the modified Rankin score at 30 days were collected. A reduction of NIHSS of greater than 4 points or resolution of symptoms was considered significant. RESULTS: Seventeen patients were identified with a mean NIHSS of 8.2 prior to administration of intravenous thrombolytics, 3.5 after 24 h, and 2.5 at discharge. Among them, 13 patients had significant improvement of NIHSS with a mean reduction of 6.15 points at 24 h. One patient initially improved but had delayed hemorrhagic transformation and died. Two patients had improvement in NIHSS but were not significant and two patients had increased in NIHSS at 24 h, although one eventually improved at discharge. There was no asymptomatic hemorrhagic transformation. Mean mRS at 3 months is 1.76. CONCLUSION: The failure to identify a perfusion deficit by CTP should not be used as a contraindication for intravenous thrombolytics. Criteria for administration of intravenous thrombolytics should still be based on time from symptom onset as previously published by NINDS.

Endovascular intervention for delayed stenosis of extracranial-intracranial bypass saphenous vein grafts.

PURPOSE: Bypass graft stenosis is an uncommon but significant issue which can be encountered following extracranial-intracranial (EC-IC) bypass surgery and carries significant potential for morbidity and mortality. Angioplasty for graft stenosis (with or without stenting) has been extensively discussed in the cardiothoracic literature but its application for neurosurgical purposes has not been well documented. METHODS: Cases of EC-IC bypass undergoing endovascular intervention for graft stenosis were retrospectively reviewed; a literature search was performed. Diagnosis, pathology and indications for intervention were reviewed. RESULTS: Three patients underwent 13 endovascular interventions for EC-IC saphenous vein graft stenosis. The indication for the initial bypass was an unsecured intracranial aneurysm in all cases, using an interposition saphenous vein graft. The initial endovascular procedure was needed 9-23 weeks after the bypass surgery, a timeframe suggestive of intimal hyperplasia as the underlying etiology of stenosis. There were nine cases of angioplasty alone, three with stent placement and one case in which vasodilators were infused. Non-invasive phase contrast quantitative MR angiography was effective in predicting graft stenosis. Despite intervention, two grafts ultimately occluded and a third has remained patent only after multiple angioplasties and placement of a drug eluting coronary stent. CONCLUSION: Although rare, bypass graft stenosis can occur in the subacute period, and likely represents a flow related venopathy. Given the challenges of re-do bypass surgery, endovascular intervention is an attractive treatment option. However, although repeated interventions with diligent follow-up may allow graft salvage, failure of endovascular intervention can also ultimately result in graft occlusion.

Safety of early endovascular catheterization and intervention through extracranial-intracranial bypass grafts.

OBJECT: The goal of this study was to demonstrate feasibility and evaluate technical aspects of early endovascular access through extracranial-intracranial (EC-IC) bypass grafts. METHODS: Patients undergoing endovascular interventions through the graft in the acute postoperative period following EC-IC bypass are presented. Results, complications, and technical nuances are reviewed. RESULTS: Fourteen endovascular procedures were performed in 5 patients after EC-IC bypass for ruptured aneurysms in 4 patients and posterior circulation ischemia in 1 patient. In 2 patients, a saphenous vein graft (SVG) was used to bypass the common carotid artery (CCA) to the middle cerebral artery (MCA). One patient underwent a superficial temporal artery (STA)-MCA bypass, and in 2 other patients the STA stump was connected to the intracranial circulation via an interposition SVG. The interval from surgery to endovascular intervention spanned 2-18 days; the indication was intracranial vasospasm in all patients. One case involved angioplasty of the proximal anastomosis on postoperative Day 14. All other interventions entailed proximal access through the bypass conduit for intraarterial infusion of vasodilators. Significant vasospasm of the STA itself was encountered in 2 patients during endovascular manipulation, and it was treated with intraarterial nitroglycerin. There were no cases of anastomotic disruption. CONCLUSIONS: Endovascular catheterization and intervention involving a recent EC-IC bypass is feasible. The main limitation in this series was catheter-induced vasospasm involving the STA. A vein graft may be the more appropriate option in patients with subarachnoid hemorrhage who may require subsequent endovascular intervention for vasospasm.