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Intracranial Stenting as a Rescue Therapy for Acute Ischemic Stroke After Stentriever Thrombectomy Failure
Original Article
Intracranial Stenting as a Rescue Therapy for Acute Ischemic Stroke After Stentriever Thrombectomy Failure Tengfei Zhou, Tianxiao Li, Liangfu Zhu, Meiyun Wang, Yingkun He, Qiuji Shao, Ziliang Wang, Weixing Bai, Xiaodong Liang
OBJECTIVE: To evaluate the efficacy and safety of intracranial stenting as a rescue therapy for acute ischemic stroke (AIS) after stentriever thrombectomy failure.
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METHODS: Patients who received intracranial stenting as a rescue therapy for AIS after failure of stent retrieval with or without concomitant treatment between January 2014 and December 2016 were retrospectively analyzed. Recanalization results and outcome at 3 months were assessed, and perioperative complications related to the procedure were recorded.
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RESULTS: A total of 193 patients with AIS received stent retriever thrombectomy. Initial successful recanalization with stent retriever was achieved in 125 patients. Among the 68 patients with stent retrieval failure, 47 patients received stent placement as rescue therapy, and successful recanalization was achieved in 38 patients. The rate of successful recanalization, favorable outcome at 90 days, mortality, and symptomatic intracerebral hemorrhage were comparable between the stenting group and nostenting group; however, the time from groin puncture to recanalization was significantly longer in the stenting group (P [ 0.03). Compared with anterior circulation stroke, the rate of stent placement was significantly greater (P [ 0.041) and the intracerebral hemorrhage rate was lower in the patients with posterior circulation stroke who received stent placement.
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Key words Acute ischemic stroke - Intracranial hemorrhage - Large artery occlusion - Stent placement - Stent retriever -
Abbreviations and Acronyms ACS: Anterior circulation stroke AF: Atrial fibrillation AIS: Acute ischemic stroke CT: Computed tomography ICH: Intracerebral hemorrhage ISR: In-stent restenosis IVT: Intravenous thrombolysis MR: Magnetic resonance
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CONCLUSIONS: Intracranial stenting as a rescue therapy for AIS after failure of Solitaire retrieval stent is feasible and safe. AIS of posterior circulation showed greater intracranial stent placement than anterior circulation.
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INTRODUCTION
T
hree major initial randomized control trials—IMS III (Interventional Management of Stroke Trial), MR RESCUE (Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy), and SYNTHESIS (Local vs. Systemic Thrombolysis for Acute Ischemic Stroke)—failed to demonstrate that intra-arterial treatment plus usual care is more effective than usual care alone in patients with acute large arterial occlusion.1-3 Using new-generation stent retrievers, 5 recent trials—MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute. Ischemic Stroke in the Netherlands), EXTEND-IA (Extending the Time for Thrombolysis in Emergency Neurological Deficits - Intra-Arterial), ESCAPE (Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times), SWIFT PRIME (Solitaire FR With the Intention For Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke), and REVASCAT (Randomized Trial of Revascularization with Solitaire FR Device vs. Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting within Eight Hours of Symptom Onset)4-8—demonstrated
PCS: Posterior circulation stroke sICH: Symptomatic intracerebral hemorrhage TICI: Thrombolysis in Cerebral Ischemia Department of Cerebrovascular Center of the Henan Provincial People’s Hospital, Zhengzhou University People’s Hospital, Zhengzhou, China To whom correspondence should be addressed: Tianxiao Li, Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.08.002 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
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INTRACRANIAL STENTING AS A RESCUE THERAPY FOR AIS
the superiority of the intra-arterial approach over intravenous thrombolysis (IVT), and stentriever thrombectomy has been recommended as the first-line method in acute anterior circulation large artery occlusion.9 However, recanalization was not always achieved even with the newest generation of mechanical devices, resulting in about 30% stent retrieval failure. Stent placement has been used to recanalize occluded large vessels and increase blood flow in acute ischemic stroke (AIS).10 However, the potential hemorrhagic complications, life-long antiplatelet therapy, and in-stent restenosis (ISR) are major concerns.11 For patients with mechanical thrombectomy failure, intracranial stenting may be a rescue therapy. This study was conducted at our medical center to evaluate the safety and efficacy of stent placement as a rescue therapy in AIS after stent retriever thrombectomy failure. MATERIALS AND METHODS Patients Stent placement was used as a rescue therapy in patients with AIS after stent retrieval failure. All the included patients received endovascular treatment between January 2014 and December 2016 at our academic medical center. Their data were retrieved from a prospectively maintained database. The inclusion criteria were as follows: 1) aged 18 years; 2) treated within 6 hours from onset of stroke in the anterior circulation and 24 hours in the posterior circulation; 3) hemorrhage excluded by cranial computed tomography (CT) or magnetic resonance (MR) imaging; 4) pre-stroke modified Rankin Scale 1; 5) acute large vessel occlusion confirmed by CT angiography or MR angiography; 6) baseline National Institutes of Health Stroke Scale score 6; 7) patients who underwent stent retriever thrombectomy; and 8) informed consent for thrombectomy obtained from patients or their legally authorized representatives. Pre-Stenting Treatment According to our protocol, patients who were eligible for IVT received IVT (recombinant tissue plasminogen activator 0.9 mg/ kg) before endovascular treatment. With the patient under sedation or general anesthesia, a 6-F guide catheter was placed in the proximity of the target vessel through the femoral artery, and the target vessel was navigated with a 0.014-inch micro-guidewire (Transcend) (Boston Scientific, Marlborough, Massachusetts, USA) through the occlusion. A microcatheter was then advanced over this wire distal to the occlusion. Selective microcatheter angiography was performed to confirm the occlusion site and the distal blood flow. Under optimal working angle, a 0.021-inch Rebar microcatheter (ev3, Irvine, California, USA) was navigated to the distal occlusion over the microwire, and then the microcatheter was exchanged with a stent. The size of the stent was chosen according to the occlusion site and length. The stent distal marker was positioned proximal to the microcatheter. After deployment of the stent, angiography was performed to observe the blood flow. The device was left in place for 3e5 minutes, and then the stent and the microcatheter were gently pulled back. Manual aspiration with a 50-mL syringe was performed during the stent retrieval. When in line with tandem internal carotid and middle cerebral arterial occlusions, the first step
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was to establish endovascular access with balloon dilatation, stent implantation, or forced suction thrombectomy, after which recanalization of the distal occlusion was attempted. Aspiration system, percutaneous balloon angioplasty, or intra-arterial thrombolysis treatment was used, when necessary. Generally, the stent retrieval steps were performed no more than 5 times, and the number of maneuvers was decided at the discretion of the neurointerventionalist. The failure of stent retrieval was defined as Thrombolysis in Cerebral Ischemia (TICI) <2b/3. Finally, stent placement was performed based on the operator’s preference. Before stent placement, intracranial hemorrhage was excluded by cranial CT. Stent Placement During the process of stent placement, a road map was used to guide the passage, the occlusion was crossed with an exchange steerable wire, the stent delivery catheter was navigated over the wire to the distal occlusion or stenosis, the wire was then removed, and a stent was delivered distal to the catheter and deployed at the site of stenosis or occlusion. Before stent placement, the length of the occlusion or stenosis was measured. Balloon angioplasty was performed when necessary during the stent placement. The occlusion etiology, length, and location were considered when selecting the type and size of stent. The stent was required to easily navigate to the site of occlusion, have adequate radial strength, be long enough to cover the lesion, with the diameter >0.5e1 mm that of the vessel. Stents used in the present study were self-expanding and balloon-mounted stents, and various stents were selected according to the diversity of the occlusion lesion based on the operator’s preference. If a balloonmounted stent was used, slow inflation techniques were practiced, using approximately 6 atm pressure. After the stent was deployed, the delivery system was withdrawn and postprocedure angiography was performed to grade angiographic revascularization and ensure that the stent was fully expanded. Perioperative Antithrombotic Therapy The procedure was performed with systemic heparin administration to maintain the activated clotting time at 250e300 seconds. In general, the use of perioperative antithrombotic therapy was highly individualized. The glycoprotein-IIb/IIIa inhibitor tirofiban was used in the following situations: if patients received permanent stent deployment, if patients suffered immediate reocclusion of the target artery, embolization into distal or a different vascular territory, or poor blood flow due to residual stenosis after endovascular therapy. Tirofiban was intravenously or intra-arterially administered. In patients who received stent deployment, tirofiban was intravenously administered with 8.0 g/kg bolus over a period of 3 minutes immediately before stent deployment, followed by a maintenance dose of 0.10 g/kg/min up to 24 hours after procedure. Two hours before the cessation of tirofiban, dual antiplatelet drug therapy with clopidogrel (300 mg) and aspirin (300 mg) was overlapped with one-half the dose of the intravenous infusion, followed by a dosage of 75 mg clopidogrel and 100 mg aspirin daily for 3e6 months. Generally, the dosage of intraarterially administered tirofiban was at the discretion of the neurointerventionalist. Permanent stenting patients with intracerebral
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INTRACRANIAL STENTING AS A RESCUE THERAPY FOR AIS
hemorrhage (ICH) received correspondingly lower volume of antiplatelet agents.
Clinical and Imaging Follow-Up Modified TICI was used to evaluate reperfusion status; successful reperfusion was defined as TICI 2b or 3. Cranial CT or MR imaging was performed in the first 24 hours after intervention to identify any hemorrhage and new infarction. Symptomatic intracerebral hemorrhage (sICH) was defined as any type of intracranial hemorrhage on imaging studies and clinical deterioration with 4point increase on the National Institutes of Health Stroke Scale score. Digital subtraction angiography was performed at the 6month follow-up. ISR was defined as a lesion demonstrating stenosis >50% adjacent to the stent on follow-up angiography. Clinical outcome at 90 days was assessed according to the modified Rankin Scale, and good outcome was defined as 0e2.
Statistical Analysis All data were analyzed by SPSS software (version 22.0; IBM Corp., Armonk, New York, USA). Continuous variables were presented as means standard deviation. Baseline characteristics and clinical outcomes of the 2 groups were compared with Fisher test for categorical variables and Student t test for continuous variables. Reported probability values were 2-sided. P < 0.05 was considered significant.
RESULTS A total of 193 patients with AIS due to large intracranial artery occlusion underwent Solitaire (eV3) stent retriever thrombectomy as initial endovascular treatment. There were 112 patients with anterior circulation stroke (ACS) and 81 with posterior circulation stroke (PCS). Among them, 11 patients also had an aspiration device (Penumbra System, Alameda, California, USA). The baseline characteristics of the patients are summarized in Table 1. The median time from groin puncture to recanalization was 74 (38e 162) minutes, the median number of stent retrieval passes was 2, and initial immediate reperfusion with stent retriever was achieved in 125 (64.77%) patients. Among the 68 patients with failed stent retrieval, aspiration thrombectomy and balloon angioplasty were adopted in 12 patients before stent deployment, and 47 patients received stent placement as rescue therapy for 55 lesions. Among the 55 stents, 24 were Solitaire stents (eV3), 16 were Apollo stents (MicroPort, Shanghai, China), 5 were Enterprise stents (Codman/DePuy Synthes, Raynham, Massachusetts, USA), 6 were Wingspan stents (Boston Scientific), and 4 were Neuroform stents (Boston Scientific). In addition, extracranial internal carotid stent placement was performed in 17 patients to establish endovascular access, including 12 Wallstent stents (Boston Scientific) and 5 Precise stents (Cordis, Fremont, California, USA). Successful reperfusion was achieved in 38 patients (80.85%), and the rate of favorable outcome at 90 days was 57.45% (27/47).
Table 1. Comparison of Clinical Characteristics and Outcomes Between the Stenting and No-Stenting Groups All Patients (n [ 193)
Stenting (n [ 47)
No Stenting (n [ 146)
P Value
Age, years
62.95 12.18
62.24 13.23
63.18 11.79
0.817
Male
118 (61.14%)
34 (72.34%)
84 (57.53%)
0.070
Hypertension
131 (67.88%)
34 (72.34%)
97 (66.44%)
0.451
Diabetes
43 (22.28%)
12 (25.53%)
31 (21.23%)
0.538
Dyslipidemia
102 (52.85%)
27 (57.45%)
75 (51.37%)
0.468
AF
59 (30.57%)
2 (4.26%)
57 (39.04%)
<0.001
Smoking
38 (19.69%)
11 (23.40%)
27 (18.49%)
0.461
Baseline NIHSS
19.48 6.22
20.30 6.92
19.22 5.45
0.525
IV rt-PA
45 (23.32%)
12 (25.53%)
33 (22.60%)
0.909
TICI 2b
163 (84.46%)
38 (80.85%)
125 (85.62%)
0.433
LAA
121 (62.69%)
39 (82.98%)
82 (56.16%)
0.001
GRT, minutes
78.1 27.3
92.3 28.8
73.5 25.9
0.030
ICH
37 (19.17%)
11 (23.40%)
26 (17.81%)
0.397
sICH
15 (7.78%)
4 (8.51%)
11 (7.53%)
0.828
90-day mRS score
115 (59.59%)
27 (57.45%)
88 (60.27%)
0.731
Mortality
48 (24.87%)
11 (23.04%)
37 (25.34%)
0.789
AF, atrial fibrillation; NIHSS, National Institutes of Health Stroke Scale; IV rt-PA, intravenous recombinant tissue plasminogen activator; TICI, Thrombolysis in Cerebral Ischemia; LAA, left atrial appendage; GRT, time from groin puncture to recanalization; ICH, intracerebral hemorrhage; sICH, symptomatic intracerebral hemorrhage; mRS, modified Rankin Scale.
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Figure 1. A 59-year-old female patient presented with left hemispheric syndrome for 3 hours; the admission National Institutes of Health Stroke Scale score was 12. She received intravenous recombinant tissue plasminogen activator at a primary stroke center before arriving at our center. (A) Left internal carotid angiogram showed occlusion of the left middle cerebral artery (MCA) of M2 segment, and (B) the distal MCA was patent. Angiogram obtained after the deployment of (C) Solitaire stent (4 30 mm) revealed complete recanalization of the MCA. (D) However,
Two stents did not fully expand during the procedure of stent placement, and 1 patient received balloon angioplasty to expand the stent. Three patients suffered acute in-stent thrombosis, of whom 2 received intra-arterial tirofiban treatment (Figure 1). One patient suffered artery perforation and received protamine reversal treatment. Two patients suffered remarkable arterial vasospasm, of whom 1 patient received intra-arterial papaverine treatment, and 10 minutes later the stenosis disappeared. Four patients (8.51%) developed symptomatic hemorrhage, and the mortality rate was 23.04% (11/47) at 90-day follow-up. ISR was found in 4 asymptomatic patients (2 Wingspan and 2 Apollo stents) of the 21 patients during angiography follow-up, 3 in the anterior circulation and 1 in the posterior circulation, and balloon angioplasty was adopted in 1 patient. No significant differences were found in baseline characteristics between the stenting group and no-stenting group, except for a significantly greater rate of atrial fibrillation (AF) in the nostenting group (P < 0.001). Trial of Org 10172 in Acute Stroke Treatment (TOAST)12 etiology was more frequently left atrial appendage in the stenting group (P ¼ 0.001), successful reperfusion was achieved in 84.46% of the total patients, and there were no differences between the 2 groups. The time from groin puncture to recanalization was significantly longer in the stenting group (P ¼ 0.03). The rate of favorable outcome at 90 days, mortality, and sICH was comparable between the 2 groups.
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angiogram performed 10 minutes after attempted recanalization with the Solitaire retriever showed persistent M2 occlusion. (E) The stent was deployed again in the occluded site; (F) thrombosis occurred within the stent, and the patient received intra-arterial infusion of glycoprotein IIb/IIIa inhibitor. (G) After 3 stent retrieval passes, the vessel remained occluded, (H) the stent was permanently deployed in the occluded site, and complete reperfusion was achieved. The patient had a modified Rankin scale score of 2 at the 3-month follow-up.
Among the 47 patients who received stent placement as rescue therapy (Table 2), 21 had ACS whereas 26 had were PCS. The baseline characteristics, including age, sex, hypertension, AF, hyperlipidemia, and diabetes mellitus, were not significantly different between ACS and PCS; the rate of successful reperfusion, favorable outcome, and mortality were also comparable, although AF was less frequent in patients with PCS. As compared with ACS, the rate of stent placement was significantly greater in patients with PCS (P ¼ 0.041). Although the PCS group had a trend of lower ICH rate (15.38%) than the ACS group (33.33%), there was no significant difference between them. The sICH rate was comparable among the 2 groups. There were no significant differences between the 2 groups in the rate of successful reperfusion and positive neurologic outcome at 3 months (Figure 2). DISCUSSION The reperfusion rate of initial treatment with retrieval stent in this study was 64.77%, which was lower than previous reports,13,14 and may be due to the large percentage of intracranial atherosclerotic disease etiology in the patients in this study, which is one of the most common causes of ischemic stroke worldwide, and is particularly prevalent among Asian patients.15 Studies have shown that patients with underlying intracranial atherosclerotic stenosis
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Table 2. Clinical Characteristics and Outcomes Between the ACS and PCS Groups All Patients (n [ 47)
Patients with ACS (n [ 21)
Patients with PCS (n [ 26)
Age, years
62.24 13.23
63.26 12.89
61.42 13.76
0.661
Male, n (%)
34 (72.34%)
14 (66.67%)
20 (76.92%)
0.520
P Value
Hypertension, n (%)
34 (72.34%)
15 (71.42%)
19 (73.08%)
1.000
Diabetes, n (%)
12 (25.53%)
5 (23.81%)
7 (26.92%)
1.000
Dyslipidemia, n (%)
27 (57.45%)
12 (57.14%)
15 (57.69%)
1.000
AF, n (%)
2 (4.26%)
2 (9.52%)
0 (0%)
0.194
Smoking, n (%)
11 (23.40%)
4 (19.05)
7 (26.92)
0.731
Baseline NIHSS
20.30 6.92
17.90 6.50
22.23 6.53
0.029
IV-rtPA
12 (25.53%)
6 (28.57%)
6 (23.08%)
0.744
TICI 2b
38 (80.85%)
16 (76.19%)
22 (84.62%)
0.486
Rate of stenting
24.35% (47/193)
18.75% (21/112)
32.10% (26/81)
0.041
ICH
11 (23.40%)
7 (33.33%)
4 (15.38%)
0.181
sICH
4 (8.51%)
2 (9.52%)
2 (7.69%)
1.000
90-day mRS
27 (57.45%)
13 (61.90%)
14 (53.85%)
0.767
Mortality
11 (23.04%)
4 (19.05%)
7 (26.92%)
0.731
ACS, anterior circulation stroke; PCS, posterior circulation stroke; AF, atrial fibrillation; NIHSS, National Institutes of Health Stroke Scale; IV rt-PA, intravenous recombinant tissue plasminogen activator; TICI, Thrombolysis in Cerebral Ischemia; ICH, intracerebral hemorrhage; sICH, symptomatic intracerebral hemorrhage; mRS, modified Rankin Scale.
may have different outcomes than those with cardiogenic embolism when treated with the Solitaire retrieval stent. Also, occlusion caused by atherosclerotic disease may be more difficult to treat since the thrombi are harder than cardiogenic ones.16,17 Yoon et al.18 found that patients with underlying atherosclerotic intracranial artery stenosis had relatively poor response to mechanical thrombectomy; 38 of 40 cases with underlying atherosclerotic intracranial artery stenosis received intracranial angioplasty with or without stenting after stent
Figure 2. A 54-year-old man presented with disturbance of consciousness for 6 hours; the National Institutes of Health Stroke Scale score on admission was 24. Preoperative magnetic resonance angiograms showed an occlusion of upper segment of basilar artery. (A) Left vertebral artery angiogram showed an occlusion at the proximal segment of the basilar
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retrieval failure in their study.18 Among the patients who received stent placement in this study, the majority of them suffered from an intracranial atherosclerotic disease-related large artery occlusion. Moreover, the rate of stent placement as a rescue therapy was significantly greater in the posterior circulation as compared with the anterior circulation. Intracranial stent placement can rapidly recanalize the occluded vessels. Several trials with small sample sizes used stent placement as complementary treatment after other endovascular
artery. (B) Angiogram obtained after stent retrieval revealed severe stenosis at the proximal segment of the basilar artery. (C) Angiogram obtained after intracranial balloon angioplasty showed the persistence of stenosis. (D) The stenosis disappeared after permanent deployment of the stent. The modified Rankin Scale score at 3 months was 0.
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methods had failed and achieved a high rate of recanalization with favorable prognosis.19-21 Sauvageau et al.20 used stent placement as a rescue therapy after unsuccessful recanalization with the Merci retriever and achieved 90% recanalization rate. Baek et al.21 found a more favorable outcome in the stenting group than in the no-stenting group for stentriever-failed occlusion, without an increase in the rate of sICH and mortality. Vasospasm usually results from manipulations with catheter and microwire during thrombectomy. It is a rare but potentially devastating complication of endovascular treatment of AIS and may lead to recurrence of cerebral ischemia. Vasospasm was observed after the endovascular treatment of AIS with retrieverstent device in recent studies. Procedure-related vessel vasospasm occurred in 4 patients (3.9%) in REVASCAT,6 whereas Behme et al.22 reported vasospasm of access vessels in 5 of 176 patients (3%). The management of arterial vasospasm was quite different from failure of thrombectomy, in most cases, vasospasm will diminish within minutes without further treatment. The operation should be suspended once the arterial vasospasm occurred. If vasospasm persists, antispasmodic drugs such as papaverine and nimodipine can be used to prevent arterial vasospasm, and balloon angioplasty also can be considered when necessary. In 1 patient who experienced arterial vasospasm of our study, he received intra-arterial papaverine treatment, and 10 minutes later the stenosis disappeared. Permanent stenting might increase the rate of ICH, which is the most serious complication for patients who received endovascular reperfusion therapy. Additional antiplatelet therapy during stent deployment may increase the risk of ICH.23 Furthermore, the increase in onset-to-reperfusion time due to additional operation procedures and vessel injury also may be related to ICH.24 However, the rate of sICH was 8.51% in this study, which is comparable with previous studies. The rate of ICH was considerably lower in PCS in the present study, similar to a
REFERENCES 1. Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med. 2013;368:893-903. 2. Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368: 904-913. 3. Kidwell CS, Jahan R, Gornbein J, Alger JR, Nenov V, Ajani Z, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013;368:914-923. 4. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372: 11-20. 5. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009-1018.
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previous study.25 However, the reason for the lower rate of ICH in PCS remains unknown. AF was less frequently present in PCS, which may be potentially related to the greater rate of ICH in ACS. Another concern of stent placement is stenting-related ischemic complications. Moreover, the “snow-plow effect” resulting from stent squeezing and debris displacement might lead to perforator stroke. Previous studies showed a high ISR rate of intracranial stents (up to 32%).26 Anterior circulation, diabetes, tobacco use, and the length and diameter of stent are associated with a high rate of ISR after stenting.27,28 Long-term use of antiplatelet drugs can prevent the occurrence of ISR. As compared with the aspiration system, the initial treatment method of stent retrieval before stenting causes more damage to vessel walls, which is also associated with ISR. ISR is an important long-term complication after stent placement that may lead to stroke recurrence. Therefore, long-term angiography follow-up is critical after intracranial stent placement, and retreatment measures need to be adopted when necessary for patients with ISR. This study had several limitations, including its retrospective design, single center, and small sample size. Additional therapies such as IVT and aspiration thrombectomy before stent placement may affect its evaluation.
CONCLUSIONS The present study showed that stent placement is a feasible and safe rescue technique in patients with large artery occlusion refractory to stent retriever thrombectomy. The study also demonstrated the limitation of stent retriever in revascularization of large artery occlusion with atherosclerotic intracranial artery stenosis. Large sample size, randomized controlled clinical trials are needed to confirm these findings.
6. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296-2306. 7. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372:2285-2295. 8. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019-1030. 9. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49:e46-e110. 10. Levy EI, Siddiqui AH, Crumlish A, Snyder KV, Hauck EF, Fiorella DJ, et al. First Food and Drug Administration-approved prospective trial of primary intracranial stenting for acute stroke: SARIS (stent-assisted recanalization in acute ischemic stroke). Stroke. 2009;40:3552-3556.
11. Dorado L, Castano C, Millan M, Aleu A, de la Ossa NP, Gomis M, et al. Hemorrhagic risk of emergent endovascular treatment plus stenting in patients with acute ischemic stroke. J Stroke Cerebrovasc Dis. 2013;22:1326-1331. 12. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24: 35-41. 13. Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 2012; 380:1241-1249. 14. Singer OC, Haring HP, Trenkler J, Nolte CH, Bohner G, Reich A, et al. Age dependency of successful recanalization in anterior circulation stroke: the ENDOSTROKE study. Cerebrovasc Dis. 2013;36:437-445. 15. Kim JS, Bonovich D. Research on intracranial atherosclerosis from the East and West: why are the results different? J Stroke. 2014;16:105-113.
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16. Kim TK, Rhim JK, Lee CJ, Oh SH, Chung BS. The limitations of thrombectomy with Solitaire AB as first-line treatment in acute ischemic stroke: a single center experience. J Cerebrovasc Endovasc Neurosurg. 2012;14:203-209. 17. Lee JS, Hong JM, Lee KS, Suh HI, Choi JW, Kim SY. Primary stent retrieval for acute intracranial large artery occlusion due to atherosclerotic disease. J Stroke. 2016;18:96-101. 18. Yoon W, Kim SK, Park MS, Kim BC, Kang HK. Endovascular treatment and the outcomes of atherosclerotic intracranial stenosis in patients with hyperacute stroke. Neurosurgery. 2015;76: 680-686 [discussion: 686].
INTRACRANIAL STENTING AS A RESCUE THERAPY FOR AIS
of mechanical thrombectomy for anterior circulation large artery occlusion. Stroke. 2016;47: 2360-2363. 22. Behme D, Gondecki L, Fiethen S, Kowoll A, Mpotsaris A, Weber W. Complications of mechanical thrombectomy for acute ischemic strokea retrospective single-center study of 176 consecutive cases. Neuroradiology. 2014;56:467-476. 23. Kellert L, Hametner C, Rohde S, Bendszus M, Hacke W, Ringleb P, et al. Endovascular stroke therapy: tirofiban is associated with risk of fatal intracerebral hemorrhage and poor outcome. Stroke. 2013;44:1453-1455.
19. Brekenfeld C, Schroth G, Mattle HP, Do DD, Remonda L, Mordasini P, et al. Stent placement in acute cerebral artery occlusion: use of a selfexpandable intracranial stent for acute stroke treatment. Stroke. 2009;40:847-852.
24. Mazighi M, Chaudhry SA, Ribo M, Khatri P, Skoloudik D, Mokin M, et al. Impact of onset-toreperfusion time on stroke mortality: a collaborative pooled analysis. Circulation. 2013;127: 1980-1985.
20. Sauvageau E, Samuelson RM, Levy EI, Jeziorski AM, Mehta RA, Hopkins LN. Middle cerebral artery stenting for acute ischemic stroke after unsuccessful Merci retrieval. Neurosurgery. 2007;60:701-706 [discussion: 706].
25. Dornak T, Kral M, Hazlinger M, Herzig R, Veverka T, Burval S, et al. Posterior vs. anterior circulation infarction: demography, outcomes, and frequency of hemorrhage after thrombolysis. Int J Stroke. 2015;10:1224-1228.
21. Baek JH, Kim BM, Kim DJ, Heo JH, Nam HS, Yoo J. Stenting as a rescue treatment after failure
26. SSYLVIA Study Investigators. Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or
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Intracranial Arteries (SSYLVIA): study results. Stroke. 2004;35:1388-1392. 27. Zhu SG, Zhang RL, Liu WH, Yin Q, Zhou ZM, Zhu WS, et al. Predictive factors for in-stent restenosis after balloon-mounted stent placement for symptomatic intracranial atherosclerosis. Eur J Vasc Endovasc Surg. 2010;40:499-506. 28. Ma MM, Yin Q, Xu GL, Zhang RL, Zhu SG, Fan XY, et al. Predictors of Wingspan in-stent restenosis for the treatment of symptomatic intracranial arterial stenosis. Zhonghua Yi Xue Za Zhi. 2011;91:1303-1307 [in Chinese]. Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 25 March 2018; accepted 2 August 2018 Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.08.002 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
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Intracranial Stenting as a Rescue Therapy for Acute Ischemic Stroke After Stentriever Thrombectomy Failure Tengfei Zhou, Tianxiao Li, Liangfu Zhu, Meiyun Wang, Yingkun He, Qiuji Shao, Ziliang Wang, Weixing Bai, Xiaodong Liang
OBJECTIVE: To evaluate the efficacy and safety of intracranial stenting as a rescue therapy for acute ischemic stroke (AIS) after stentriever thrombectomy failure.
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METHODS: Patients who received intracranial stenting as a rescue therapy for AIS after failure of stent retrieval with or without concomitant treatment between January 2014 and December 2016 were retrospectively analyzed. Recanalization results and outcome at 3 months were assessed, and perioperative complications related to the procedure were recorded.
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RESULTS: A total of 193 patients with AIS received stent retriever thrombectomy. Initial successful recanalization with stent retriever was achieved in 125 patients. Among the 68 patients with stent retrieval failure, 47 patients received stent placement as rescue therapy, and successful recanalization was achieved in 38 patients. The rate of successful recanalization, favorable outcome at 90 days, mortality, and symptomatic intracerebral hemorrhage were comparable between the stenting group and nostenting group; however, the time from groin puncture to recanalization was significantly longer in the stenting group (P [ 0.03). Compared with anterior circulation stroke, the rate of stent placement was significantly greater (P [ 0.041) and the intracerebral hemorrhage rate was lower in the patients with posterior circulation stroke who received stent placement.
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Key words Acute ischemic stroke - Intracranial hemorrhage - Large artery occlusion - Stent placement - Stent retriever -
Abbreviations and Acronyms ACS: Anterior circulation stroke AF: Atrial fibrillation AIS: Acute ischemic stroke CT: Computed tomography ICH: Intracerebral hemorrhage ISR: In-stent restenosis IVT: Intravenous thrombolysis MR: Magnetic resonance
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CONCLUSIONS: Intracranial stenting as a rescue therapy for AIS after failure of Solitaire retrieval stent is feasible and safe. AIS of posterior circulation showed greater intracranial stent placement than anterior circulation.
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INTRODUCTION
T
hree major initial randomized control trials—IMS III (Interventional Management of Stroke Trial), MR RESCUE (Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy), and SYNTHESIS (Local vs. Systemic Thrombolysis for Acute Ischemic Stroke)—failed to demonstrate that intra-arterial treatment plus usual care is more effective than usual care alone in patients with acute large arterial occlusion.1-3 Using new-generation stent retrievers, 5 recent trials—MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute. Ischemic Stroke in the Netherlands), EXTEND-IA (Extending the Time for Thrombolysis in Emergency Neurological Deficits - Intra-Arterial), ESCAPE (Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times), SWIFT PRIME (Solitaire FR With the Intention For Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke), and REVASCAT (Randomized Trial of Revascularization with Solitaire FR Device vs. Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting within Eight Hours of Symptom Onset)4-8—demonstrated
PCS: Posterior circulation stroke sICH: Symptomatic intracerebral hemorrhage TICI: Thrombolysis in Cerebral Ischemia Department of Cerebrovascular Center of the Henan Provincial People’s Hospital, Zhengzhou University People’s Hospital, Zhengzhou, China To whom correspondence should be addressed: Tianxiao Li, Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.08.002 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
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INTRACRANIAL STENTING AS A RESCUE THERAPY FOR AIS
the superiority of the intra-arterial approach over intravenous thrombolysis (IVT), and stentriever thrombectomy has been recommended as the first-line method in acute anterior circulation large artery occlusion.9 However, recanalization was not always achieved even with the newest generation of mechanical devices, resulting in about 30% stent retrieval failure. Stent placement has been used to recanalize occluded large vessels and increase blood flow in acute ischemic stroke (AIS).10 However, the potential hemorrhagic complications, life-long antiplatelet therapy, and in-stent restenosis (ISR) are major concerns.11 For patients with mechanical thrombectomy failure, intracranial stenting may be a rescue therapy. This study was conducted at our medical center to evaluate the safety and efficacy of stent placement as a rescue therapy in AIS after stent retriever thrombectomy failure. MATERIALS AND METHODS Patients Stent placement was used as a rescue therapy in patients with AIS after stent retrieval failure. All the included patients received endovascular treatment between January 2014 and December 2016 at our academic medical center. Their data were retrieved from a prospectively maintained database. The inclusion criteria were as follows: 1) aged 18 years; 2) treated within 6 hours from onset of stroke in the anterior circulation and 24 hours in the posterior circulation; 3) hemorrhage excluded by cranial computed tomography (CT) or magnetic resonance (MR) imaging; 4) pre-stroke modified Rankin Scale 1; 5) acute large vessel occlusion confirmed by CT angiography or MR angiography; 6) baseline National Institutes of Health Stroke Scale score 6; 7) patients who underwent stent retriever thrombectomy; and 8) informed consent for thrombectomy obtained from patients or their legally authorized representatives. Pre-Stenting Treatment According to our protocol, patients who were eligible for IVT received IVT (recombinant tissue plasminogen activator 0.9 mg/ kg) before endovascular treatment. With the patient under sedation or general anesthesia, a 6-F guide catheter was placed in the proximity of the target vessel through the femoral artery, and the target vessel was navigated with a 0.014-inch micro-guidewire (Transcend) (Boston Scientific, Marlborough, Massachusetts, USA) through the occlusion. A microcatheter was then advanced over this wire distal to the occlusion. Selective microcatheter angiography was performed to confirm the occlusion site and the distal blood flow. Under optimal working angle, a 0.021-inch Rebar microcatheter (ev3, Irvine, California, USA) was navigated to the distal occlusion over the microwire, and then the microcatheter was exchanged with a stent. The size of the stent was chosen according to the occlusion site and length. The stent distal marker was positioned proximal to the microcatheter. After deployment of the stent, angiography was performed to observe the blood flow. The device was left in place for 3e5 minutes, and then the stent and the microcatheter were gently pulled back. Manual aspiration with a 50-mL syringe was performed during the stent retrieval. When in line with tandem internal carotid and middle cerebral arterial occlusions, the first step
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was to establish endovascular access with balloon dilatation, stent implantation, or forced suction thrombectomy, after which recanalization of the distal occlusion was attempted. Aspiration system, percutaneous balloon angioplasty, or intra-arterial thrombolysis treatment was used, when necessary. Generally, the stent retrieval steps were performed no more than 5 times, and the number of maneuvers was decided at the discretion of the neurointerventionalist. The failure of stent retrieval was defined as Thrombolysis in Cerebral Ischemia (TICI) <2b/3. Finally, stent placement was performed based on the operator’s preference. Before stent placement, intracranial hemorrhage was excluded by cranial CT. Stent Placement During the process of stent placement, a road map was used to guide the passage, the occlusion was crossed with an exchange steerable wire, the stent delivery catheter was navigated over the wire to the distal occlusion or stenosis, the wire was then removed, and a stent was delivered distal to the catheter and deployed at the site of stenosis or occlusion. Before stent placement, the length of the occlusion or stenosis was measured. Balloon angioplasty was performed when necessary during the stent placement. The occlusion etiology, length, and location were considered when selecting the type and size of stent. The stent was required to easily navigate to the site of occlusion, have adequate radial strength, be long enough to cover the lesion, with the diameter >0.5e1 mm that of the vessel. Stents used in the present study were self-expanding and balloon-mounted stents, and various stents were selected according to the diversity of the occlusion lesion based on the operator’s preference. If a balloonmounted stent was used, slow inflation techniques were practiced, using approximately 6 atm pressure. After the stent was deployed, the delivery system was withdrawn and postprocedure angiography was performed to grade angiographic revascularization and ensure that the stent was fully expanded. Perioperative Antithrombotic Therapy The procedure was performed with systemic heparin administration to maintain the activated clotting time at 250e300 seconds. In general, the use of perioperative antithrombotic therapy was highly individualized. The glycoprotein-IIb/IIIa inhibitor tirofiban was used in the following situations: if patients received permanent stent deployment, if patients suffered immediate reocclusion of the target artery, embolization into distal or a different vascular territory, or poor blood flow due to residual stenosis after endovascular therapy. Tirofiban was intravenously or intra-arterially administered. In patients who received stent deployment, tirofiban was intravenously administered with 8.0 g/kg bolus over a period of 3 minutes immediately before stent deployment, followed by a maintenance dose of 0.10 g/kg/min up to 24 hours after procedure. Two hours before the cessation of tirofiban, dual antiplatelet drug therapy with clopidogrel (300 mg) and aspirin (300 mg) was overlapped with one-half the dose of the intravenous infusion, followed by a dosage of 75 mg clopidogrel and 100 mg aspirin daily for 3e6 months. Generally, the dosage of intraarterially administered tirofiban was at the discretion of the neurointerventionalist. Permanent stenting patients with intracerebral
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INTRACRANIAL STENTING AS A RESCUE THERAPY FOR AIS
hemorrhage (ICH) received correspondingly lower volume of antiplatelet agents.
Clinical and Imaging Follow-Up Modified TICI was used to evaluate reperfusion status; successful reperfusion was defined as TICI 2b or 3. Cranial CT or MR imaging was performed in the first 24 hours after intervention to identify any hemorrhage and new infarction. Symptomatic intracerebral hemorrhage (sICH) was defined as any type of intracranial hemorrhage on imaging studies and clinical deterioration with 4point increase on the National Institutes of Health Stroke Scale score. Digital subtraction angiography was performed at the 6month follow-up. ISR was defined as a lesion demonstrating stenosis >50% adjacent to the stent on follow-up angiography. Clinical outcome at 90 days was assessed according to the modified Rankin Scale, and good outcome was defined as 0e2.
Statistical Analysis All data were analyzed by SPSS software (version 22.0; IBM Corp., Armonk, New York, USA). Continuous variables were presented as means standard deviation. Baseline characteristics and clinical outcomes of the 2 groups were compared with Fisher test for categorical variables and Student t test for continuous variables. Reported probability values were 2-sided. P < 0.05 was considered significant.
RESULTS A total of 193 patients with AIS due to large intracranial artery occlusion underwent Solitaire (eV3) stent retriever thrombectomy as initial endovascular treatment. There were 112 patients with anterior circulation stroke (ACS) and 81 with posterior circulation stroke (PCS). Among them, 11 patients also had an aspiration device (Penumbra System, Alameda, California, USA). The baseline characteristics of the patients are summarized in Table 1. The median time from groin puncture to recanalization was 74 (38e 162) minutes, the median number of stent retrieval passes was 2, and initial immediate reperfusion with stent retriever was achieved in 125 (64.77%) patients. Among the 68 patients with failed stent retrieval, aspiration thrombectomy and balloon angioplasty were adopted in 12 patients before stent deployment, and 47 patients received stent placement as rescue therapy for 55 lesions. Among the 55 stents, 24 were Solitaire stents (eV3), 16 were Apollo stents (MicroPort, Shanghai, China), 5 were Enterprise stents (Codman/DePuy Synthes, Raynham, Massachusetts, USA), 6 were Wingspan stents (Boston Scientific), and 4 were Neuroform stents (Boston Scientific). In addition, extracranial internal carotid stent placement was performed in 17 patients to establish endovascular access, including 12 Wallstent stents (Boston Scientific) and 5 Precise stents (Cordis, Fremont, California, USA). Successful reperfusion was achieved in 38 patients (80.85%), and the rate of favorable outcome at 90 days was 57.45% (27/47).
Table 1. Comparison of Clinical Characteristics and Outcomes Between the Stenting and No-Stenting Groups All Patients (n [ 193)
Stenting (n [ 47)
No Stenting (n [ 146)
P Value
Age, years
62.95 12.18
62.24 13.23
63.18 11.79
0.817
Male
118 (61.14%)
34 (72.34%)
84 (57.53%)
0.070
Hypertension
131 (67.88%)
34 (72.34%)
97 (66.44%)
0.451
Diabetes
43 (22.28%)
12 (25.53%)
31 (21.23%)
0.538
Dyslipidemia
102 (52.85%)
27 (57.45%)
75 (51.37%)
0.468
AF
59 (30.57%)
2 (4.26%)
57 (39.04%)
<0.001
Smoking
38 (19.69%)
11 (23.40%)
27 (18.49%)
0.461
Baseline NIHSS
19.48 6.22
20.30 6.92
19.22 5.45
0.525
IV rt-PA
45 (23.32%)
12 (25.53%)
33 (22.60%)
0.909
TICI 2b
163 (84.46%)
38 (80.85%)
125 (85.62%)
0.433
LAA
121 (62.69%)
39 (82.98%)
82 (56.16%)
0.001
GRT, minutes
78.1 27.3
92.3 28.8
73.5 25.9
0.030
ICH
37 (19.17%)
11 (23.40%)
26 (17.81%)
0.397
sICH
15 (7.78%)
4 (8.51%)
11 (7.53%)
0.828
90-day mRS score
115 (59.59%)
27 (57.45%)
88 (60.27%)
0.731
Mortality
48 (24.87%)
11 (23.04%)
37 (25.34%)
0.789
AF, atrial fibrillation; NIHSS, National Institutes of Health Stroke Scale; IV rt-PA, intravenous recombinant tissue plasminogen activator; TICI, Thrombolysis in Cerebral Ischemia; LAA, left atrial appendage; GRT, time from groin puncture to recanalization; ICH, intracerebral hemorrhage; sICH, symptomatic intracerebral hemorrhage; mRS, modified Rankin Scale.
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Figure 1. A 59-year-old female patient presented with left hemispheric syndrome for 3 hours; the admission National Institutes of Health Stroke Scale score was 12. She received intravenous recombinant tissue plasminogen activator at a primary stroke center before arriving at our center. (A) Left internal carotid angiogram showed occlusion of the left middle cerebral artery (MCA) of M2 segment, and (B) the distal MCA was patent. Angiogram obtained after the deployment of (C) Solitaire stent (4 30 mm) revealed complete recanalization of the MCA. (D) However,
Two stents did not fully expand during the procedure of stent placement, and 1 patient received balloon angioplasty to expand the stent. Three patients suffered acute in-stent thrombosis, of whom 2 received intra-arterial tirofiban treatment (Figure 1). One patient suffered artery perforation and received protamine reversal treatment. Two patients suffered remarkable arterial vasospasm, of whom 1 patient received intra-arterial papaverine treatment, and 10 minutes later the stenosis disappeared. Four patients (8.51%) developed symptomatic hemorrhage, and the mortality rate was 23.04% (11/47) at 90-day follow-up. ISR was found in 4 asymptomatic patients (2 Wingspan and 2 Apollo stents) of the 21 patients during angiography follow-up, 3 in the anterior circulation and 1 in the posterior circulation, and balloon angioplasty was adopted in 1 patient. No significant differences were found in baseline characteristics between the stenting group and no-stenting group, except for a significantly greater rate of atrial fibrillation (AF) in the nostenting group (P < 0.001). Trial of Org 10172 in Acute Stroke Treatment (TOAST)12 etiology was more frequently left atrial appendage in the stenting group (P ¼ 0.001), successful reperfusion was achieved in 84.46% of the total patients, and there were no differences between the 2 groups. The time from groin puncture to recanalization was significantly longer in the stenting group (P ¼ 0.03). The rate of favorable outcome at 90 days, mortality, and sICH was comparable between the 2 groups.
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angiogram performed 10 minutes after attempted recanalization with the Solitaire retriever showed persistent M2 occlusion. (E) The stent was deployed again in the occluded site; (F) thrombosis occurred within the stent, and the patient received intra-arterial infusion of glycoprotein IIb/IIIa inhibitor. (G) After 3 stent retrieval passes, the vessel remained occluded, (H) the stent was permanently deployed in the occluded site, and complete reperfusion was achieved. The patient had a modified Rankin scale score of 2 at the 3-month follow-up.
Among the 47 patients who received stent placement as rescue therapy (Table 2), 21 had ACS whereas 26 had were PCS. The baseline characteristics, including age, sex, hypertension, AF, hyperlipidemia, and diabetes mellitus, were not significantly different between ACS and PCS; the rate of successful reperfusion, favorable outcome, and mortality were also comparable, although AF was less frequent in patients with PCS. As compared with ACS, the rate of stent placement was significantly greater in patients with PCS (P ¼ 0.041). Although the PCS group had a trend of lower ICH rate (15.38%) than the ACS group (33.33%), there was no significant difference between them. The sICH rate was comparable among the 2 groups. There were no significant differences between the 2 groups in the rate of successful reperfusion and positive neurologic outcome at 3 months (Figure 2). DISCUSSION The reperfusion rate of initial treatment with retrieval stent in this study was 64.77%, which was lower than previous reports,13,14 and may be due to the large percentage of intracranial atherosclerotic disease etiology in the patients in this study, which is one of the most common causes of ischemic stroke worldwide, and is particularly prevalent among Asian patients.15 Studies have shown that patients with underlying intracranial atherosclerotic stenosis
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INTRACRANIAL STENTING AS A RESCUE THERAPY FOR AIS
Table 2. Clinical Characteristics and Outcomes Between the ACS and PCS Groups All Patients (n [ 47)
Patients with ACS (n [ 21)
Patients with PCS (n [ 26)
Age, years
62.24 13.23
63.26 12.89
61.42 13.76
0.661
Male, n (%)
34 (72.34%)
14 (66.67%)
20 (76.92%)
0.520
P Value
Hypertension, n (%)
34 (72.34%)
15 (71.42%)
19 (73.08%)
1.000
Diabetes, n (%)
12 (25.53%)
5 (23.81%)
7 (26.92%)
1.000
Dyslipidemia, n (%)
27 (57.45%)
12 (57.14%)
15 (57.69%)
1.000
AF, n (%)
2 (4.26%)
2 (9.52%)
0 (0%)
0.194
Smoking, n (%)
11 (23.40%)
4 (19.05)
7 (26.92)
0.731
Baseline NIHSS
20.30 6.92
17.90 6.50
22.23 6.53
0.029
IV-rtPA
12 (25.53%)
6 (28.57%)
6 (23.08%)
0.744
TICI 2b
38 (80.85%)
16 (76.19%)
22 (84.62%)
0.486
Rate of stenting
24.35% (47/193)
18.75% (21/112)
32.10% (26/81)
0.041
ICH
11 (23.40%)
7 (33.33%)
4 (15.38%)
0.181
sICH
4 (8.51%)
2 (9.52%)
2 (7.69%)
1.000
90-day mRS
27 (57.45%)
13 (61.90%)
14 (53.85%)
0.767
Mortality
11 (23.04%)
4 (19.05%)
7 (26.92%)
0.731
ACS, anterior circulation stroke; PCS, posterior circulation stroke; AF, atrial fibrillation; NIHSS, National Institutes of Health Stroke Scale; IV rt-PA, intravenous recombinant tissue plasminogen activator; TICI, Thrombolysis in Cerebral Ischemia; ICH, intracerebral hemorrhage; sICH, symptomatic intracerebral hemorrhage; mRS, modified Rankin Scale.
may have different outcomes than those with cardiogenic embolism when treated with the Solitaire retrieval stent. Also, occlusion caused by atherosclerotic disease may be more difficult to treat since the thrombi are harder than cardiogenic ones.16,17 Yoon et al.18 found that patients with underlying atherosclerotic intracranial artery stenosis had relatively poor response to mechanical thrombectomy; 38 of 40 cases with underlying atherosclerotic intracranial artery stenosis received intracranial angioplasty with or without stenting after stent
Figure 2. A 54-year-old man presented with disturbance of consciousness for 6 hours; the National Institutes of Health Stroke Scale score on admission was 24. Preoperative magnetic resonance angiograms showed an occlusion of upper segment of basilar artery. (A) Left vertebral artery angiogram showed an occlusion at the proximal segment of the basilar
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retrieval failure in their study.18 Among the patients who received stent placement in this study, the majority of them suffered from an intracranial atherosclerotic disease-related large artery occlusion. Moreover, the rate of stent placement as a rescue therapy was significantly greater in the posterior circulation as compared with the anterior circulation. Intracranial stent placement can rapidly recanalize the occluded vessels. Several trials with small sample sizes used stent placement as complementary treatment after other endovascular
artery. (B) Angiogram obtained after stent retrieval revealed severe stenosis at the proximal segment of the basilar artery. (C) Angiogram obtained after intracranial balloon angioplasty showed the persistence of stenosis. (D) The stenosis disappeared after permanent deployment of the stent. The modified Rankin Scale score at 3 months was 0.
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methods had failed and achieved a high rate of recanalization with favorable prognosis.19-21 Sauvageau et al.20 used stent placement as a rescue therapy after unsuccessful recanalization with the Merci retriever and achieved 90% recanalization rate. Baek et al.21 found a more favorable outcome in the stenting group than in the no-stenting group for stentriever-failed occlusion, without an increase in the rate of sICH and mortality. Vasospasm usually results from manipulations with catheter and microwire during thrombectomy. It is a rare but potentially devastating complication of endovascular treatment of AIS and may lead to recurrence of cerebral ischemia. Vasospasm was observed after the endovascular treatment of AIS with retrieverstent device in recent studies. Procedure-related vessel vasospasm occurred in 4 patients (3.9%) in REVASCAT,6 whereas Behme et al.22 reported vasospasm of access vessels in 5 of 176 patients (3%). The management of arterial vasospasm was quite different from failure of thrombectomy, in most cases, vasospasm will diminish within minutes without further treatment. The operation should be suspended once the arterial vasospasm occurred. If vasospasm persists, antispasmodic drugs such as papaverine and nimodipine can be used to prevent arterial vasospasm, and balloon angioplasty also can be considered when necessary. In 1 patient who experienced arterial vasospasm of our study, he received intra-arterial papaverine treatment, and 10 minutes later the stenosis disappeared. Permanent stenting might increase the rate of ICH, which is the most serious complication for patients who received endovascular reperfusion therapy. Additional antiplatelet therapy during stent deployment may increase the risk of ICH.23 Furthermore, the increase in onset-to-reperfusion time due to additional operation procedures and vessel injury also may be related to ICH.24 However, the rate of sICH was 8.51% in this study, which is comparable with previous studies. The rate of ICH was considerably lower in PCS in the present study, similar to a
REFERENCES 1. Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med. 2013;368:893-903. 2. Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368: 904-913. 3. Kidwell CS, Jahan R, Gornbein J, Alger JR, Nenov V, Ajani Z, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013;368:914-923. 4. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372: 11-20. 5. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009-1018.
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previous study.25 However, the reason for the lower rate of ICH in PCS remains unknown. AF was less frequently present in PCS, which may be potentially related to the greater rate of ICH in ACS. Another concern of stent placement is stenting-related ischemic complications. Moreover, the “snow-plow effect” resulting from stent squeezing and debris displacement might lead to perforator stroke. Previous studies showed a high ISR rate of intracranial stents (up to 32%).26 Anterior circulation, diabetes, tobacco use, and the length and diameter of stent are associated with a high rate of ISR after stenting.27,28 Long-term use of antiplatelet drugs can prevent the occurrence of ISR. As compared with the aspiration system, the initial treatment method of stent retrieval before stenting causes more damage to vessel walls, which is also associated with ISR. ISR is an important long-term complication after stent placement that may lead to stroke recurrence. Therefore, long-term angiography follow-up is critical after intracranial stent placement, and retreatment measures need to be adopted when necessary for patients with ISR. This study had several limitations, including its retrospective design, single center, and small sample size. Additional therapies such as IVT and aspiration thrombectomy before stent placement may affect its evaluation.
CONCLUSIONS The present study showed that stent placement is a feasible and safe rescue technique in patients with large artery occlusion refractory to stent retriever thrombectomy. The study also demonstrated the limitation of stent retriever in revascularization of large artery occlusion with atherosclerotic intracranial artery stenosis. Large sample size, randomized controlled clinical trials are needed to confirm these findings.
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