Manual aspiration thrombectomy through balloon-tipped guide catheter for rapid clot burden reduction in endovascular therapy for ICA L/T occlusion.

INTRODUCTION: Timely recanalization during endovascular procedures for acute ischemic stroke can be challenging in cases with large clot burden, such as those encountered in the terminal internal carotid T- or L-type occlusion. METHODS: A novel but simple technique to achieve fast reduction in clot burden in stroke patients with occlusion of the internal carotid artery termination is described where manual suction using a 60-ml syringe applied through an 8-F balloon guide catheter positioned in the cervical carotid vasculature with proximal flow arrest allows subsequent revascularization of the residual middle cerebral artery clot. RESULTS: The use of manual suction through a balloon-tipped guide catheter in internal carotid artery L- or T-type occlusion is illustrated. This resulted in a significant reduction of the clot burden and facilitated further interventions leading to full recanalization. CONCLUSION: Manual suction using a 60-ml syringe through a balloon guide catheter is a useful and feasible technique that facilitates thrombectomy of large burden cerebral clots.

Accuracy of serial National Institutes of Health Stroke Scale scores to identify artery status in acute ischemic stroke.

BACKGROUND: Early recovery after intravenous thrombolysis can be observed in stroke; however, the utility of measuring clinical improvement to assess artery status has not been established. We sought to determine the accuracy of serial National Institutes of Health Stroke Scale (NIHSS) scores to detect complete early recanalization of the middle cerebral artery. METHODS AND RESULTS: Data from the CLOTBUST trial (Combined Lysis of Thrombus in Brain Ischemia Using Transcranial Ultrasound and Systemic tPA) were used to determine the most sensitive and specific NIHSS-derived parameter to identify complete recanalization. Then, reproducibility was tested against a separate patient population (Barcelona data set). NIHSS scores were determined before tissue plasminogen activator bolus and at 60 and 120 minutes in both data sets. Receiver operating characteristic curves were used to compare test performance. The accuracy of individual cutoffs was demonstrated by sensitivity, specificity, and positive and negative predictive values. A total of 122 patients in the CLOTBUST data set and 98 in the Barcelona data set received 0.9 mg/kg intravenous tissue plasminogen activator [mean age 69+/-12 versus 72+/-12 years, 57% male versus 51% male, median NIHSS 16 versus 17 points, mean time from onset to treatment 140+/-32 versus 177+/-59 minutes, and complete recanalization of the middle cerebral artery in 19% versus 17%). For identification of recanalization, an NIHSS score reduction of > or = 40% offered the best tradeoff, with sensitivity, specificity, positive predictive value, and negative predictive value of 65%, 85%, 50%, and 91% at 60 minutes and 74%, 80%, 58%, and 89% at 120 minutes, respectively. Test performance was equal in the Barcelona data set. CONCLUSIONS: Relative changes in serial NIHSS scores can serve as a simple clinical indicator of arterial status after intravenous thrombolysis. Accuracy parameters are affected by the process of recanalization and its varying clinical significance.

Detection of carotid artery stenosis by in vivo duplex ultrasound: correlation with planimetric measurements of the corresponding postmortem specimens.

BACKGROUND AND PURPOSE: The correct detection and quantification of carotid artery disease are of decisive impact on patient prognosis and adequate treatment. In this study, we evaluated the ability of ultrasonography to detect and to grade carotid artery stenosis through a comparison of the in vivo ultrasound findings with the planimetric analysis of the corresponding postmortem specimens. METHODS: Shortly before their death, 59 critically ill neurological patients (mean age, 70 years) were prospectively examined by extracranial and intracranial Doppler sonography and color-coded duplex ultrasound. Carotid stenosis was classified by hemodynamic and morphological ultrasound criteria. Carotid specimens were removed in toto during autopsy. Under standardized conditions, specimens were redistended, sectioned, and histologically processed. Computerized planimetric measurements of the arteries were carried out and compared with the ultrasound findings. Correlation of the ultrasound and postmortem planimetric findings was available in 93 carotid bifurcations. RESULTS: Through both techniques, 46 carotid arteries were found to be normal. Steno-occlusive carotid lesions ranged from 8.5% to 100% lumen reduction. Overall, r=0.96 and adjusted R(2)=0.90. For the steno-occlusive carotid lesions, r=0.91. CONCLUSIONS: Extracranial and intracranial Doppler and color-coded duplex ultrasound permits reliable detection and quantification of carotid artery stenoses and occlusions even under difficult examination conditions in critically ill patients.

Response to intra-arterial and combined intravenous and intra-arterial thrombolytic therapy in patients with distal internal carotid artery occlusion.

BACKGROUND AND PURPOSE: The objective of this study was to determine the clinical features, angiographic findings, and response to treatment with thrombolytic therapy in patients with ischemic stroke caused by acute occlusion of the distal internal carotid artery. METHODS: This is a retrospective case series from a prospectively collected stroke database for patients with acute internal carotid occlusion presenting within 6 hours of stroke onset to evaluate safety, feasibility, and response to thrombolytic therapy. The University Hospital-based brain attack database was reviewed over a 5-year period. Demographics, clinical features, stroke mechanisms, severity, imaging findings, type of thrombolysis, treatment responses, mortality, and long-term outcome using modified Rankin Scale and Barthel Index were determined. The short-term outcome was assessed using the National Institutes of Health Stroke Scale (NIHSS). Acute thrombolytic therapy was administered using recombinant tissue plasminogen activator or urokinase given intra-arterially or in combination with intravenous (IV) routes. RESULTS: Two hundred seven patients treated with thrombolysis between 1995 and 2000 were reviewed, and of these, 101 were studied with cerebral angiography. Eighteen patients were identified with acute ischemic stroke and ipsilateral occlusion of the distal internal carotid artery. Time to treatment was the most powerful predictor of response to thrombolytic therapy (P<0.001). The response to therapy also correlated well with the severity of the initial clinical deficit as judged by the NIHSS (P<0.001). There was no difference in recanalization rate, symptomatic hemorrhage, and NIHSS for IV/intra-arterial (IA) versus IA alone (P=NS). Complete angiographic recanalization was accomplished in 80% of those who received combined IV/IA thrombolysis and in 62% of those who received IA therapy (P=NS). Those with distal occlusions extending to the middle and anterior cerebral arteries were the least likely to respond to thrombolysis. Symptomatic intracerebral hemorrhage occurred in 20% of the patients receiving IV/IA therapy, and in 15% of the IA only (P=NS). At 24 hours, the NIHSS dropped by 3 points in the IA group and 4 points in the IV/IA group (P=NS). Mild disability with independence was found in 77% of the survivors at 3-month follow-up. The mortality rate was 50% in this group despite thrombolysis. CONCLUSIONS: Thrombolytic therapy using a combination of IV and IA routes and using the IA-only route may be effective in improving outcome for the patients suffering from occlusion of the distal internal carotid artery. Shorter intervals between onset and treatment seem to be correlated with higher rate of recanalization and improved outcome.

Duplex carotídeo: correlación angiográfica / Ultrasonic duplex scanning for carotid artery

En la actualidad el Duplex es el equipo más utilizado por el diagnóstico de la enfermedad vascular en el territorio carotídeo. En todo el mundo, este método mostró un alto índice de sensibilidad y especificidad con un número aceptable de resultados predictivos negativos y positivos. En el trabajo aquí presentado encontramos buena correlación en los casos con lesiones severas comparándolos con la angiografía

Duplex carotídeo: correlación angiográfica / Ultrasonic duplex scanning for carotid artery

En la actualidad el Duplex es el equipo más utilizado por el diagnóstico de la enfermedad vascular en el territorio carotídeo. En todo el mundo, este método mostró un alto índice de sensibilidad y especificidad con un número aceptable de resultados predictivos negativos y positivos. En el trabajo aquí presentado encontramos buena correlación en los casos con lesiones severas comparándolos con la angiografía

Surgical decisions on the basis of magnetic resonance angiography of the carotid arteries.

The recent demonstration of the efficacy of carotid endarterectomy in certain patients emphasizes the advantages of having a noninvasive, accurate means of evaluating the carotid arteries. Advances in magnetic resonance (MR) angiography now allow accurate depiction of the carotid arteries that may be adequate for surgical planning in many cases. This report examines the accuracy of MR angiography compared with that of conventional angiography in symptomatic patients undergoing carotid endarterectomy and compares them with surgical findings. Twenty-one carotid arteries in 20 patients were treated surgically for severe stenosis or occlusion. Preoperatively, all patients had both MR and conventional angiograms, which were interpreted on a five-grade scale by two independent neuroradiologists who were unaware of the patient's clinical history. The two studies were highly correlated, particularly in the case of severe stenosis and occlusion. There were no false-negative MR studies that missed surgically significant lesions. In two cases, MR angiography overestimated the stenosis by one grade. On MR angiography, surgically significant stenosis appears as focal areas of signal intensity loss at the level of stenosis with reappearance of the signal distally. If the distal signal intensity does not reappear, the artery is likely to be occluded. In symptomatic patients, MR angiograms that demonstrate a flow-void gap with distal reappearance at a site consistent with the symptoms may be adequate as the sole preoperative study. Three patients who underwent carotid endarterectomy on this basis are presented. The factors that contribute to artifactual and overestimated stenosis are reviewed.

[Cerebrovascular disorders--clinical aspects and follow-up]. / Zerebrale Durchblutungsstörungen--Klinik und Verlauf.

The observation of the spontaneous course of the extracranial vascular process as a characteristic cause of cerebral ischemia has shown that vascular changes occur largely independently from the appearance of cerebral functional disturbances in the associated vascular territory. Hemodynamic factors play a minor role; while with the present standard methods available, embolic mechanisms can be insufficiently analyzed. The prospective developmental observations of morphologic and fluid-dynamic aspects and supplemental cell biology and metabolic analysis provide new criteria for an individual risk evaluation of the various mechanisms causing pathologically different cerebral function disturbances, and their analysis has crucial significance for a therapy plan.