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Musialek P, Bonati LH, Bulbulia R, Halliday A, Bock B, Capoccia L, Eckstein HH, Grunwald IQ, Lip PL, Monteiro A, Paraskevas KI, Podlasek A, Rantner B, Rosenfield K, Siddiqui AH, Sillesen H, Van Herzeele I, Guzik TJ, Mazzolai L, Aboyans V, Lip GYH. Stroke risk management in carotid atherosclerotic disease: a clinical consensus statement of the ESC Council on Stroke and the ESC Working Group on Aorta and Peripheral Vascular Diseases. Cardiovasc Res 2025; 121:13-43. [PMID: 37632337 DOI: 10.1093/cvr/cvad135] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023] Open
Abstract
Carotid atherosclerotic disease continues to be an important cause of stroke, often disabling or fatal. Such strokes could be largely prevented through optimal medical therapy and carotid revascularization. Advancements in discovery research and imaging along with evidence from recent pharmacology and interventional clinical trials and registries and the progress in acute stroke management have markedly expanded the knowledge base for clinical decisions in carotid stenosis. Nevertheless, there is variability in carotid-related stroke prevention and management strategies across medical specialities. Optimal patient care can be achieved by (i) establishing a unified knowledge foundation and (ii) fostering multi-specialty collaborative guidelines. The emergent Neuro-Vascular Team concept, mirroring the multi-disciplinary Heart Team, embraces diverse specializations, tailors personalized, stratified medicine approaches to individual patient needs, and integrates innovative imaging and risk-assessment biomarkers. Proposed approach integrates collaboration of multiple specialists central to carotid artery stenosis management such as neurology, stroke medicine, cardiology, angiology, ophthalmology, vascular surgery, endovascular interventions, neuroradiology, and neurosurgery. Moreover, patient education regarding current treatment options, their risks and advantages, is pivotal, promoting patient's active role in clinical care decisions. This enables optimization of interventions ranging from lifestyle modification, carotid revascularization by stenting or endarterectomy, as well as pharmacological management including statins, novel lipid-lowering and antithrombotic strategies, and targeting inflammation and vascular dysfunction. This consensus document provides a harmonized multi-specialty approach to multi-morbidity prevention in carotid stenosis patients, based on comprehensive knowledge review, pinpointing research gaps in an evidence-based medicine approach. It aims to be a foundational tool for inter-disciplinary collaboration and prioritized patient-centric decision-making.
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Affiliation(s)
- Piotr Musialek
- Jagiellonian University Department of Cardiac and Vascular Diseases, St. John Paul II Hospital, ul. Pradnicka 80, 31-202 Krakow, Poland
| | | | - Richard Bulbulia
- Medical Research Council Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | - Alison Halliday
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | | | - Laura Capoccia
- Department of Surgery 'Paride Stefanini', Policlinico Umberto I, 'Sapienza' University of Rome, Rome, Italy
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Iris Q Grunwald
- Department of Radiology, Ninewells Hospital, University of Dundee, Dundee, UK
- Tayside Innovation MedTech Ecosystem (TIME), Division of Imaging Science and Technology, University of Dundee, Dundee, UK
| | | | - Andre Monteiro
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | | | - Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), Division of Imaging Science and Technology, University of Dundee, Dundee, UK
- Division of Radiological and Imaging Sciences, University of Nottingham, Nottingham, UK
| | - Barbara Rantner
- Vascular Surgery Department, Ludwig Maximilian University Hospital, Campus Grosshadern, Munich, Germany
| | | | - Adnan H Siddiqui
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, and Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Henrik Sillesen
- Department of Vascular Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Tomasz J Guzik
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Department of Internal Medicine, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Lucia Mazzolai
- Department of Angiology, University Hospital Lausanne, Lausanne, Switzerland
| | - Victor Aboyans
- Department of Cardiology, CHRU Dupuytren Limoges, Limoges, France
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Hu Y, Jiang X, Li Y, Yang C, Ma M, Fang J, He L. Endovascular Treatment With or Without Intravenous Thrombolysis for Acute Ischemic Stroke Due to Tandem Occlusion: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2024; 13:e034829. [PMID: 39206729 PMCID: PMC11646517 DOI: 10.1161/jaha.124.034829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 07/16/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Endovascular treatment (EVT) has been demonstrated to be effective for patients with tandem occlusion. The efficacy and safety of intravenous thrombolysis before EVT in patients with tandem occlusion remain debatable. METHODS AND RESULTS We conducted a systematic review and meta-analysis with PubMed, EMBASE, and the Cochrane Library from inception to September 2023. The primary outcome was functional independence, defined as a modified Rankin Scale score of 0 to 2 at 90 days. The secondary outcomes included the successful recanalization rate, symptomatic intracerebral hemorrhage, and mortality at 90 days. In total, 9 studies with 1838 enrolled participants were identified. Our results showed that, compared with treatment with EVT alone, intravenous thrombolysis before EVT was associated with a greater proportion of functional independence at 90 days (odds ratio [OR], 1.39 [95% CI, 1.14-1.69]; P=0.001), a greater rate of successful recanalization (OR, 1.45 [95% CI, 1.11-1.89]; P=0.007) and decreased mortality (OR, 0.68 [95% CI, 0.50-0.93]; P=0.02). Furthermore, there was no significant difference in symptomatic intracerebral hemorrhage between the intravenous thrombolysis plus EVT group and the EVT alone group (OR, 1.16 [95% CI, 0.79-1.70]; P=0.45). CONCLUSIONS In patients with acute ischemic stroke and tandem occlusion, intravenous thrombolysis before EVT was associated with a greater rate of favorable functional outcomes and successful recanalization and a lower mortality rate without an increased risk of symptomatic intracerebral hemorrhage compared with patients receiving EVT alone.
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Affiliation(s)
- Yaowen Hu
- Department of NeurologyWest China Hospital, Sichuan UniversityChengduSichuanChina
| | - Xin Jiang
- Department of NeurologyWest China Hospital, Sichuan UniversityChengduSichuanChina
| | - Yanbo Li
- Department of NeurologyWest China Hospital, Sichuan UniversityChengduSichuanChina
| | - Chuang Yang
- Department of NeurologyWest China Hospital, Sichuan UniversityChengduSichuanChina
| | - Mengmeng Ma
- Department of NeurologyWest China Hospital, Sichuan UniversityChengduSichuanChina
| | - Jinghuan Fang
- Department of NeurologyWest China Hospital, Sichuan UniversityChengduSichuanChina
| | - Li He
- Department of NeurologyWest China Hospital, Sichuan UniversityChengduSichuanChina
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Ay H. Classification of Ischemic Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00020-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wang J, Paritala PK, Mendieta JB, Gu Y, Raffel OC, McGahan T, Lloyd T, Li Z. Carotid Bifurcation With Tandem Stenosis-A Patient-Specific Case Study Combined in vivo Imaging, in vitro Histology and in silico Simulation. Front Bioeng Biotechnol 2019; 7:349. [PMID: 31824937 PMCID: PMC6879432 DOI: 10.3389/fbioe.2019.00349] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 11/06/2019] [Indexed: 11/13/2022] Open
Abstract
A patient-specific carotid bifurcation with tandem stenosis found at both internal carotid artery (ICA) and common carotid artery (CCA) was studied. The in vivo pre-carotid endarterectomy (pre-CEA) multi-spectral magnetic resonance imaging (MRI) were performed and in vitro post-CEA carotid plaque tissue sample was collected. MR imaging data and tissue sample staining histology were used to recognize the plaque components. Further, the computational fluid dynamics (CFD) were performed on four MR-based reconstructed 3D carotid bifurcation models (the patient-specific geometry with tandem stenosis and three presumptive geometries by removing the stenosis part). The flow and shear stress behavior affected by the tandem stenosis was analyzed. From the results of MR segmentation and histology analysis, plaque lipid pool and calcification were found at both ICA and CCA. From the result of CFD simulation, the flow shear stress behavior suggested the tandem stenosis as a more “dangerous” situation than a single-stenosis artery. Besides, the CFD results deduced that the stenosis at the CCA location formed initially and led to the subsequent formation of stenosis at ICA. This study suggests that when planning CEA, CFD simulation on the presumptive models could help clinicians to estimate the blood flow behavior after surgery. Particular attention should be paid to the case of tandem stenosis, as the local hemodynamic environment is more complex and treatment of one stenosis may lead to a variation in the hemodynamic loading on the second plaque, which may result in either a higher risk of plaque rupture or restenosis.
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Affiliation(s)
- Jiaqiu Wang
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology, Brisbane, QLD, Australia
| | - Phani Kumari Paritala
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology, Brisbane, QLD, Australia
| | - Jessica Benitez Mendieta
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology, Brisbane, QLD, Australia
| | - Yuantong Gu
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology, Brisbane, QLD, Australia
| | - Owen Christopher Raffel
- Department of Cardiology, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Tim McGahan
- Department of Vascular Surgery, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Thomas Lloyd
- Department of Radiology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Zhiyong Li
- School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology, Brisbane, QLD, Australia.,School of Biological Science & Medical Engineering, Southeast University, Nanjing, China
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Kauw F, Bennink E, de Jong HW, Kappelle LJ, Horsch AD, Velthuis BK, Dankbaar JW. Intracranial Cerebrospinal Fluid Volume as a Predictor of Malignant Middle Cerebral Artery Infarction. Stroke 2019; 50:1437-1443. [PMID: 31092157 PMCID: PMC6553515 DOI: 10.1161/strokeaha.119.024882] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/13/2019] [Accepted: 04/08/2019] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Predicting malignant middle cerebral artery (MCA) infarction can help to identify patients who may benefit from preventive decompressive surgery. We aimed to investigate the association between the ratio of intracranial cerebrospinal fluid (CSF) volume to intracranial volume (ICV) and malignant MCA infarction. Methods- Patients with an occlusion proximal to the M3 segment of the MCA were selected from the DUST (Dutch Acute Stroke Study). Admission imaging included noncontrast computed tomography (CT), CT perfusion, and CT angiography. Patient characteristics and CT findings were collected. The ratio of intracranial CSF volume to ICV (CSF/ICV) was quantified on admission thin-slice noncontrast CT. Malignant MCA infarction was defined as a midline shift of >5 mm on follow-up noncontrast CT, which was performed 3 days after the stroke or in case of clinical deterioration. To test the association between CSF/ICV and malignant MCA infarction, odds ratios and 95% CIs were calculated for 3 multivariable models by using binary logistic regression. Model performances were compared by using the likelihood ratio test. Results- Of the 286 included patients, 35 (12%) developed malignant MCA infarction. CSF/ICV was independently associated with malignant MCA infarction in 3 multivariable models: (1) with age and admission National Institutes of Health Stroke Scale (odds ratio, 3.3; 95% CI, 1.1-11.1), (2) with admission National Institutes of Health Stroke Scale and poor collateral score (odds ratio, 7.0; 95% CI, 2.6-21.3), and (3) with terminal internal carotid artery or proximal M1 occlusion and poor collateral score (odds ratio, 7.7; 95% CI, 2.8-23.9). The performance of model 1 (areas under the receiver operating characteristic curves, 0.795 versus 0.824; P=0.033), model 2 (areas under the receiver operating characteristic curves, 0.813 versus 0.850; P<0.001), and model 3 (areas under the receiver operating characteristic curves, 0.811 versus 0.856; P<0.001) improved significantly after adding CSF/ICV. Conclusions- The CSF/ICV ratio is associated with malignant MCA infarction and has added value to clinical and imaging prediction models in limited numbers of patients.
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Affiliation(s)
- Frans Kauw
- From the Department of Radiology (F.K., E.B., H.W.A.M.d.J., A.D.H., B.K.V., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Edwin Bennink
- From the Department of Radiology (F.K., E.B., H.W.A.M.d.J., A.D.H., B.K.V., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands
- Image Sciences Institute (E.B.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Hugo W.A.M. de Jong
- From the Department of Radiology (F.K., E.B., H.W.A.M.d.J., A.D.H., B.K.V., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - L. Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (L.J.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Alexander D. Horsch
- From the Department of Radiology (F.K., E.B., H.W.A.M.d.J., A.D.H., B.K.V., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Birgitta K. Velthuis
- From the Department of Radiology (F.K., E.B., H.W.A.M.d.J., A.D.H., B.K.V., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jan W. Dankbaar
- From the Department of Radiology (F.K., E.B., H.W.A.M.d.J., A.D.H., B.K.V., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands
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Endovascular Therapy for Tandem Occlusion in Acute Ischemic Stroke: Intravenous Thrombolysis Improves Outcomes. J Clin Med 2019; 8:jcm8020228. [PMID: 30744174 PMCID: PMC6407107 DOI: 10.3390/jcm8020228] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/30/2019] [Accepted: 02/07/2019] [Indexed: 11/17/2022] Open
Abstract
Ischemic stroke related to tandem internal carotid and middle cerebral artery (TIM) occlusion is a challenging condition where endovascular treatment (EVT) is an emerging revascularization option. The identification of factors influencing clinical outcomes can assist in creating appropriate therapeutic algorithms for such patients. This study aimed to evaluate prognostic factors in the context of EVT for TIM occlusion. We performed a retrospective study of consecutive patients with TIM occlusion admitted within 6 h from symptom onset to two tertiary stroke centers. We recorded the etiology of stroke, clinical deficits at stroke onset and discharge, details of EVT, final infarct volume (FIV), in-hospital mortality, and outcome at three months. Among 73 patients with TIM occlusion, 53 were treated with EVT. The median age was 75.9 years (interquartile range (IQR) 64.6–82.6), with the most common etiology of cardioembolism (51.9%). Intravenous thrombolysis with tissue-plasminogen activator (t-PA) was performed in the majority (69.8%) of cases. EVT achieved successful recanalization with a thrombolysis in cerebral infarction (TICI) grade of 2b or 3 in 67.9%. A good outcome (modified Rankin score of 0–2 at three months) was observed in 37.7%. After adjustment for age, the National Institutes of Health Stroke Scale (NIHSS) at admission, and success of recanalization, smaller final infarct volume (odds ratio (OR) 0.021 for FIV above 25th percentile (95% CI 0.001–0.332, p = 0.005)) and administration of intravenous t-PA (OR 12.04 (95% CI 1.004–144.392, p = 0.049)) were associated with a good outcome at three months. Our study demonstrates that bridging with t-PA is associated with improved outcomes in the setting of tandem ICA and MCA occlusions treated with EVT and should therefore not be withheld in eligible patients.
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Li W, Yin Q, Xu G, Liu X. Treatment Strategies for Acute Ischemic Stroke Caused by Carotid Artery Occlusion. INTERVENTIONAL NEUROLOGY 2016; 5:148-156. [PMID: 27781043 DOI: 10.1159/000445304] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Acute ischemic stroke caused by internal carotid artery (ICA) occlusion usually has a poor prognosis, especially the T occlusion cases without functional collaterals. The efficacy of intravenous (IV) or intra-arterial (IA) thrombolysis with recombinant tissue plasminogen activator (rt-PA) remains ambiguous in these patients. Eendovascular recanalization of the occluded carotid has been attempted in recent years as a potential strategy. However, the different etiologies of ICA occlusion pose a significant challenge to neurointerventionists. Recently, several endovascular evolvements have been reported in treating carotid occlusion-related stroke. This review summarizes the current status of treatment for acute ICA occlusion.
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Affiliation(s)
- Wei Li
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Qin Yin
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Gelin Xu
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Xinfeng Liu
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, China
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Nogueira RC, Bor-Seng-Shu E, Saeed NP, Teixeira MJ, Panerai RB, Robinson TG. Meta-analysis of Vascular Imaging Features to Predict Outcome Following Intravenous rtPA for Acute Ischemic Stroke. Front Neurol 2016; 7:77. [PMID: 27242660 PMCID: PMC4870283 DOI: 10.3389/fneur.2016.00077] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 05/02/2016] [Indexed: 12/17/2022] Open
Abstract
Background The present review investigated which findings in vascular imaging techniques can be used to predict clinical outcome and the risk of symptomatic intracerebral hemorrhage (sICH) in patients who underwent intravenous thrombolytic treatment. Methods Publications were searched, and the inclusion criteria were as follows: (1) published manuscripts, (2) patients with acute ischemic stroke managed with intravenous recombinant tissue plasminogen activator (rtPA), and (3) availability of imaging assessment to determine vessel patency or the regulation of cerebral blood flow prior to, during, and/or after thrombolytic treatment. Clinical outcomes were divided into neurological outcome [National Institutes of Health Stroke Scale (NIHSS) within 7 days] and functional outcome (modified Rankin score in 2–3 months). sICH was defined as rtPA-related intracerebral bleeding associated with any worsening of NIHSS. Results Thirty-nine articles were selected. Recanalization was associated with improved neurological and functional outcomes (OR = 7.83; 95% CI, 3.71–16.53; p < 0.001 and OR = 11.12; 95% CI, 5.85–21.14; p < 0.001, respectively). Both tandem internal carotid artery/middle cerebral artery (ICA/MCA) occlusions and isolated ICA occlusion had worse functional outcome than isolated MCA occlusion (OR = 0.26, 95% CI, 0.12–0.52; p < 0.001 and OR = 0.24, 95% CI, 0.07–0.77; p = 0.016, respectively). Reocclusion was associated with neurological deterioration (OR = 6.48, 95% CI, 3.64–11.56; p < 0.001), and early recanalization was associated with lower odds of sICH (OR = 0.36, 95% CI, 0.18–0.70; p = 0.003). Conclusion Brain circulation data before, during, and after thrombolysis may be useful for predicting the clinical outcome. Cerebral arterial recanalization, presence and site of occlusion, and reocclusion are all important in predicting the clinical outcome.
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Affiliation(s)
- Ricardo C Nogueira
- Department of Neurology, Hospital das Clínicas, University of São Paulo School of Medicine , São Paulo , Brazil
| | - Edson Bor-Seng-Shu
- Department of Neurosurgery, Hospital das Clínicas, University of São Paulo School of Medicine , São Paulo , Brazil
| | - Nazia P Saeed
- Department of Cardiovascular Sciences, University of Leicester , Leicester , England
| | - Manoel J Teixeira
- Department of Neurosurgery, Hospital das Clínicas, University of São Paulo School of Medicine , São Paulo , Brazil
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, England; Biomedical Research Unit in Cardiovascular Science, Glenfield Hospital, Leicester, England
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, England; Biomedical Research Unit in Cardiovascular Science, Glenfield Hospital, Leicester, England
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Horsch AD, Dankbaar JW, Stemerdink TA, Bennink E, van Seeters T, Kappelle LJ, Hofmeijer J, de Jong HW, van der Graaf Y, Velthuis BK. Imaging Findings Associated with Space-Occupying Edema in Patients with Large Middle Cerebral Artery Infarcts. AJNR Am J Neuroradiol 2016; 37:831-7. [PMID: 26797136 DOI: 10.3174/ajnr.a4637] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 10/30/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Prominent space-occupying cerebral edema is a devastating complication occurring in some but not all patients with large MCA infarcts. It is unclear why differences in the extent of edema exist. Better knowledge of factors related to prominent edema formation could aid treatment strategies. This study aimed to identify variables associated with the development of prominent edema in patients with large MCA infarcts. MATERIALS AND METHODS From the Dutch Acute Stroke Study (DUST), 137 patients were selected with large MCA infarcts on follow-up NCCT (3 ± 2 days after stroke onset), defined as ASPECTS ≤4. Prominent edema was defined as a midline shift of ≥5 mm on follow-up. Admission patient and treatment characteristics were collected. Admission CT parameters used were ASPECTS on NCCT and CBV and MTT maps, and occlusion site, clot burden, and collaterals on CTA. Permeability on admission CTP, and day 3 recanalization and reperfusion statuses were obtained if available. Unadjusted and adjusted (age and NIHSS) odds ratios were calculated for all variables in relation to prominent edema. RESULTS Prominent edema developed in 51 patients (37%). Adjusted odds ratios for prominent edema were higher with lower ASPECTS on NCCT (adjusted odds ratio, 1.32; 95% CI, 1.13-1.55) and CBV (adjusted odds ratio, 1.26; 95% CI, 1.07-1.49), higher permeability (adjusted odds ratio, 2.35; 95% CI, 1.30-4.24), more proximal thrombus location (adjusted odds ratio, 3.40; 95% CI, 1.57-7.37), higher clot burden (adjusted odds ratio, 2.88; 95% CI, 1.11-7.45), and poor collaterals (adjusted odds ratio, 3.93; 95% CI, 1.78-8.69). CONCLUSIONS Extensive proximal occlusion, poor collaterals, and larger ischemic deficits with higher permeability play a role in the development of prominent edema in large MCA infarcts.
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Affiliation(s)
- A D Horsch
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - J W Dankbaar
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - T A Stemerdink
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - E Bennink
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - T van Seeters
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - L J Kappelle
- Neurology (L.J.K.), Utrecht Stroke Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J Hofmeijer
- Department of Neurology (J.H.), Rijnstate Hospital, Arnhem, the Netherlands
| | - H W de Jong
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
| | - Y van der Graaf
- Julius Center for Health Sciences and Primary Care (Y.v.d.G.), Utrecht, the Netherlands
| | - B K Velthuis
- From the Departments of Radiology (A.D.H., J.W.D., T.A.S., E.B., T.v.S., H.W.d.J., B.K.V.)
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Abstract
PURPOSE OF REVIEW A major advantage of transcranial Doppler (TCD) ultrasound is its ability to measure cerebral hemodynamics noninvasively at the patient's bedside. This article summarizes the basic physics and variables used during TCD, recent pediatric data published on the use of TCD in stroke and cerebrovascular disorders and how it may impact diagnosis and management, and some issues to be resolved so that TCD can be put into clinical practice. RECENT FINDINGS In sickle cell disease in children, TCD is the gold standard stroke prediction tool. Recent data suggest that TCD may provide important information in ischemic stroke because of other childhood arteriopathies such as moyamoya syndrome, transient or focal cerebral arteriopathy, and genetic/syndromic causes. TCD may also detect cerebral emboli and diagnose right-to-left atrial cardiac shunts in children with cryptogenic stroke and transient ischemic attack. SUMMARY There are many potential clinical applications for TCD in pediatric stroke and cerebrovascular disorders. Additional research in children is needed to determine whether TCD can identify markers of increased stroke risk, elucidate underlying stroke mechanisms, influence the choice of additional testing and treatment, and ultimately impact patient outcomes.
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Horsch AD, Dankbaar JW, Niesten JM, van Seeters T, van der Schaaf IC, van der Graaf Y, Mali WPTM, Velthuis BK. Predictors of reperfusion in patients with acute ischemic stroke. AJNR Am J Neuroradiol 2015; 36:1056-62. [PMID: 25907522 DOI: 10.3174/ajnr.a4283] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/11/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke studies emphasize a difference between reperfusion and recanalization, but predictors of reperfusion have not been elucidated. The aim of this study was to evaluate the relationship between reperfusion and recanalization and identify predictors of reperfusion. MATERIALS AND METHODS From the Dutch Acute Stroke Study, 178 patients were selected with an MCA territory deficit on admission CTP and day 3 follow-up CTP and CTA. Reperfusion was evaluated on CTP, and recanalization on CTA, follow-up imaging. Reperfusion percentages were calculated in patients with and without recanalization. Patient admission and treatment characteristics and admission CT imaging parameters were collected. Their association with complete reperfusion was analyzed by using univariate and multivariate logistic regression. RESULTS Sixty percent of patients with complete recanalization showed complete reperfusion (relative risk, 2.60; 95% CI, 1.63-4.13). Approximately one-third of patients showed some discrepancy between recanalization and reperfusion status. Lower NIHSS score (OR, 1.06; 95% CI, 1.01-1.11), smaller infarct core size (OR, 3.11; 95% CI, 1.46-6.66; and OR, 2.40; 95% CI, 1.14-5.02), smaller total ischemic area (OR, 4.20; 95% CI, 1.91-9.22; and OR, 2.35; 95% CI, 1.12-4.91), lower clot burden (OR, 1.35; 95% CI, 1.14-1.58), distal thrombus location (OR, 3.02; 95% CI, 1.76-5.20), and good collateral score (OR, 2.84; 95% CI, 1.34-6.02) significantly increased the odds of complete reperfusion. In multivariate analysis, only total ischemic area (OR, 6.12; 95% CI, 2.69-13.93; and OR, 1.91; 95% CI, 0.91-4.02) was an independent predictor of complete reperfusion. CONCLUSIONS Recanalization and reperfusion are strongly associated but not always equivalent in ischemic stroke. A smaller total ischemic area is the only independent predictor of complete reperfusion.
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Affiliation(s)
- A D Horsch
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands Department of Radiology (A.D.H.), Rijnstate Hospital, Arnhem, the Netherlands
| | - J W Dankbaar
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - J M Niesten
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - T van Seeters
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - I C van der Schaaf
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - Y van der Graaf
- Julius Center for Health Sciences and Primary Care (Y.v.d.G.), Utrecht, the Netherlands
| | - W P Th M Mali
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - B K Velthuis
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
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13
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Abstract
Intravenous thrombolysis is the only approved treatment for acute ischemic stroke when administered within the first 3 h of stroke onset. Response to systemic thrombolysis depends on several factors including the location of arterial occlusion, clot characteristics and, ultimately, the embolic source. In the last few years, tremendous progress has been made, resulting in the widespread implementation of noninvasive neurovascular techniques. These imaging modalities are being increasingly performed in the acute stroke setting, without substantial delay, in a large number of centers worldwide. Transcranial Doppler ultrasound provides a unique opportunity to assess several aspects of clot dissolution by means of continuous monitoring of recanalization during and after tissue plasminogen activator administration. This approach allows for the evaluation of patients at the bedside and in real time due to the commencement, timing, speed and degree of artery reopening in addition to allowing the documentation of reocclusion after successful recanalization. Gradient refocused echo susceptibility vessel sign (GRE SVS) magnetic resonance imaging may be particularly useful for the identification of an intravascular thrombus during the acute phase of ischemic stroke; GRE SVS may represent a surrogate of clot composition and differential response to thrombolysis. The increasing availability of advanced neurovascular techniques may, in the near future, improve the design of stroke trials. The capability of these techniques to assess not only tissue viability but also key aspects regarding susceptibility to thrombolysis such as location, amount, composition, and age of the offending clot may improve the safety and efficacy profile of thrombolytic therapy for acute ischemic stroke.
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Affiliation(s)
- Carlos A Molina
- Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-12908035, Barcelona, Spain.
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14
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Bulsara KR, Ediriwickrema A, Pepper J, Robertson F, Aruny J, Schindler J. Tissue plasminogen activator via cross-collateralization for tandem internal carotid and middle cerebral artery occlusion. World J Clin Cases 2013; 1:290-294. [PMID: 24364024 PMCID: PMC3868713 DOI: 10.12998/wjcc.v1.i9.290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 10/28/2013] [Accepted: 12/11/2013] [Indexed: 02/05/2023] Open
Abstract
Tandem internal carotid and middle cerebral artery occlusion after carotid dissection predicts poor outcome after systemic thrombolysis. Current treatments include the use of endovascular carotid stenting, which carries with it a high risk of propagating further embolic events and worsening the dissection. New strategies for avoiding the aforementioned side-effects include recanalization using cross-collaterals for delivery of intra-lesional tissue plasminogen activator (tPA). We present two cases that provide further support for this novel approach. Both patients presented with a National Institute of Health Stroke Scale of 20, received intra-arterial tPA via cross-collateralization, and made full recoveries without the need for stenting.
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15
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Ratanaprasatporn L, Grossberg JA, Spader HS, Jayaraman MV. Endovascular treatment of acute carotid occlusion. Clin Neurol Neurosurg 2013; 115:2521-3. [PMID: 24239517 DOI: 10.1016/j.clineuro.2013.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 10/09/2013] [Accepted: 10/14/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Acute cervical carotid occlusion is one of the most challenging scenarios encountered in endovascular stroke treatment. PATIENTS AND METHODS A retrospective analysis of 11 consecutive non-dissection stroke patients with concomitant cervical carotid and intracranial occlusion treated with intraarterial (IA) mechanical thrombectomy and/or pharmacologic thrombolysis over five years at two academic hospitals was performed. Data was analyzed using Fisher's exact test. RESULTS Patients included 3 females and 8 males. Average age was 64.7 years (range 30-94 years). All patients had both cervical carotid and intracranial occlusions. Intracranial occlusion involved the internal carotid artery in 7 patients and the middle cerebral artery in 4 patients. All of the patients received intracranial IA Tissue Plasminogen Activator (tPA). Six patients received carotid stents for cervical occlusion as part of their treatment. Five patients received only IA tPA via collateral circulation. Of the patients receiving stents, 5 of 6 (83.3%) had successful recanalization (Thrombolysis in Cerebral Ischemia 2b or 3 flow). Only 1 of 5 (20%) patients who did not receive stents prior to intracranial treatment had successful recanalization. The difference in recanalization rates approached statistical significance (p=.08). There were 4 total in-hospital mortalities: 2 in the group that received stents prior to thrombolysis and 2 in the non-stent group. There were 2 clinically significant hemorrhages in the study, both in the stent group. CONCLUSIONS Revascularization of the cervical carotid occlusion prior to treatment of the intracranial occlusion led to increased rates of recanalization in patients with tandem extracranial and intracranial occlusions. Whether a clinical benefit can be consistently derived likely relies on other factors, including the evaluation of cerebral perfusion.
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Affiliation(s)
- L Ratanaprasatporn
- Departments of Radiology and Neurosurgery, Brown University, Rhode Island Hospital, 593 Eddy Street, APC 6, Providence, USA
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16
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Fargen KM, Hoh BL. Angioplasty alone versus angioplasty and stenting for acute cervical carotid occlusions: technical and antiplatelet considerations. World Neurosurg 2012; 79:66-8. [PMID: 23103275 DOI: 10.1016/j.wneu.2012.10.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 10/23/2012] [Indexed: 11/24/2022]
Affiliation(s)
- Kyle M Fargen
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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17
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Dababneh H, Guerrero WR, Khanna A, Hoh BL, Mocco J. Management of tandem occlusion stroke with endovascular therapy. Neurosurg Focus 2012; 32:E16. [PMID: 22537125 DOI: 10.3171/2012.1.focus11350] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Approximately 25% of patients with middle cerebral artery (MCA) occlusion will have a concomitant internal carotid artery (ICA) occlusion, and 50% of patients with an ICA occlusion will have a proximal MCA occlusion. Cervical ICA occlusion with MCA embolic occlusion is associated with a low rate of recanalization and poor outcome after intravenous thrombolysis. The authors report their experience with acute ischemic stroke patients who suffered tandem ICA/MCA (TIM) occlusions and underwent intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial MCA mechanical thrombectomy. METHODS In a retrospective analysis of their stroke database (2008-2011), the authors identified 2 patients with TIM occlusion treated with intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial mechanical thrombectomy. They examined early neurological improvement defined by a greater than 10-point reduction of National Institutes of Health Stroke Scale (NIHSS) score and an improved modified Rankin Scale (mRS) score at 60 days. Successful recanalization based on thrombolysis in cerebral infarction (TICI) score of 2 or 3 was also evaluated. RESULTS In both patients a TICI score of 2b or 3 was achieved, signifying successful recanalization. In addition, both patients had a reduction in the NIHSS score by greater than 10 points and an mRS score of 0 at 60 days. CONCLUSIONS Tandem occlusions of the cervical ICA and MCA may be successfully treated using the multimodality approach of intravenous thrombolysis followed by extracranial ICA angioplasty and intracranial mechanical thrombectomy.
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Affiliation(s)
- Haitham Dababneh
- Department of Neurology, University of Florida, Gainesville, Florida 32610-0236, USA.
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18
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Classification of Ischemic Stroke. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10020-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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19
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Tai ML, Sharma V. Floating thrombus in the common carotid artery. J Ultrasound 2010; 13:202-3. [PMID: 23397464 PMCID: PMC3552661 DOI: 10.1016/j.jus.2010.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
| | - V.K. Sharma
- Division of Neurology, National University Hospital System, Singapore
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20
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21
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Ozdemir O, Bussière M, Leung A, Gulka I, Lee D, Chan R, Spence JD, Pelz D. Intra-arterial thrombolysis of occluded middle cerebral artery by use of collateral pathways in patients with tandem cervical carotid artery/middle cerebral artery occlusion. AJNR Am J Neuroradiol 2008; 29:1596-600. [PMID: 18524975 DOI: 10.3174/ajnr.a1163] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Cervical internal carotid artery (ICA) occlusion with middle cerebral artery (MCA) embolic occlusion is associated with a low rate of recanalization and poor outcome after intravenous thrombolysis. Prompt revascularization is required to prevent disabling stroke. We report our experience on acute ischemic stroke patients with tandem ICA or MCA occlusions treated with microcathether navigation and intra-arterial thrombolysis by use of collateral pathways including the posterior or anterior communicating arteries, or both pathways. MATERIALS AND METHODS We retrospectively identified 8 patients with proximal ICA occlusion associated with MCA embolic occlusions treated with intra-arterial thrombolysis (IA rtPA). Access to the occluded MCA was obtained via catheter navigation through intact collateral pathways, including posterior communicating (PcomA) or anterior communicating (AcomA) arteries, without passing a microcathether through the acutely occluded ICA. We assessed clinical outcomes using modified Rankin scale (mRS) and National Institutes of Health Stroke Scale (NIHSS). RESULTS Eight patients with a mean age of 57 +/- 4 years and median NIHSS of 14 were identified. Mean time from stroke onset to intra-arterial thrombolysis was 292 +/- 44 minutes. The MCA was revascularized completely in 5 of the 8 patients via collateral intra-arterial rtPA administration. All of the patients had a favorable outcome defined as a mRS of < or =2 or more at 1 and 3 months' follow-up after thrombolytic therapy. One patient had an asymptomatic petechial hemorrhage. CONCLUSION In this small number of patients with tandem occlusions of the ICA and MCA, intra-arterial thrombolysis and recanalization of the MCA by use of collateral pathways to bypass the occluded ICA is a safe and efficacious therapeutic option.
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Affiliation(s)
- O Ozdemir
- Department of Clinical Neurological Sciences, University of Western Ontario, London Health Sciences, University Campus, London, Ontario, Canada. ozcan_99@yahoo
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22
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Molina CA, Alexandrov AV. Transcranial ultrasound in acute stroke: from diagnosis to therapy. Cerebrovasc Dis 2007; 24 Suppl 1:1-6. [PMID: 17971633 DOI: 10.1159/000107373] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In the last few years, several studies have improved our knowledge and understanding of the dynamic nature of the recanalization process during stroke thrombolysis. Transcranial Doppler ultrasound provides a unique opportunity to assess several aspects of clot dissolution by means of continuous monitoring of recanalization during and after administration of tissue plasminogen activator. This approach allows us to evaluate at the patient's bedside and in real time the beginning, timing, speed and degree of artery reopening, as well as to document reocclusion after successful recanalization. Moreover, the simultaneous clinical assessment during transcranial Doppler monitoring allows correlation of the hemodynamic changes with the clinical course and outcome. Experimental studies have shown that ultrasound (US)-accelerated thrombolysis may be further enhanced by administration of microbubbles (MBs). Low-frequency US with high power has been demonstrated to produce cavitation and fluid motion in the thrombus. The MBs, by acting as cavitation nuclei, lower the amount of energy needed for cavitation. Application of high-acoustic-pressure US has been shown to induce nonlinear oscillations of MBs, leading to a continuous absorption of energy until the bubbles explode, releasing the absorbed energy. A multicenter randomized phase II trial of MB-enhanced thrombolysis in acute stroke is under way.
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Affiliation(s)
- Carlos A Molina
- Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain.
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23
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Malferrari G, Bertolino C, Casoni F, Zini A, Sarra VM, Sanguigni S, Pratesi M, Lochner P, Coppo L, Brusa G, Guidetti D, Cavuto S, Marcello N. The Eligible study: ultrasound assessment in acute ischemic stroke within 3 hours. Cerebrovasc Dis 2007; 24:469-76. [PMID: 17895622 DOI: 10.1159/000108922] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2006] [Accepted: 06/04/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AIMS OF THE STUDY to identify with echo color Doppler ultrasound of the supra-aortic vessels and transcranial color-coded duplex sonography (TCCD) various patterns of vessel occlusion within 3 h from stroke onset, to compare each group defined at the admission with clinical findings and outcome, and to study the recanalization process, independent of therapy. METHODS We enrolled 89 consecutive patients (mean age 68.9 years). Ultrasound evaluation was done within 3 h from stroke onset, and was repeated at 3-6 and 24-36 h, at day 5, and at 3 months. At admission, patients were divided into the following groups: internal carotid artery occlusions and stenoses (<50%, 50-69%, > or =70%, near occlusion), middle cerebral artery stenoses and occlusions, tandem occlusions and T occlusions. Vascular recanalization in each group was evaluated. Subgroups were compared for NIH Stroke Scale (NIHSS) and the outcome measures mortality, Barthel index (BI) and modified Rankin scale (mRS). Favorable outcome was defined as mRS < or =2 and BI > or =90. RESULTS Each subgroup differed significantly for baseline NIHSS (p < 0.0001), 3-month mortality (p = 0.0235), BI at day 5 (p = 0.0458) and mRS at 3 months (p = 0.0028), even after adjustment for treatment. T and tandem occlusions were the subgroups with the highest NIHSS scores and the poorest outcomes, and the same subgroups had the worst recanalization rates. CONCLUSIONS TCCD in the acute setting of stroke patients allows identification of the presence and site of clots, prediction of outcome and study of the dynamic process of vessel recanalization, in both the acute phase and follow-up.
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MESH Headings
- Acute Disease
- Adult
- Aged
- Aged, 80 and over
- Brain Ischemia/complications
- Brain Ischemia/diagnostic imaging
- Brain Ischemia/etiology
- Brain Ischemia/physiopathology
- Carotid Artery, Internal/diagnostic imaging
- Carotid Artery, Internal/physiopathology
- Carotid Stenosis/complications
- Carotid Stenosis/diagnostic imaging
- Carotid Stenosis/physiopathology
- Female
- Follow-Up Studies
- Humans
- Infarction, Middle Cerebral Artery/complications
- Infarction, Middle Cerebral Artery/diagnostic imaging
- Infarction, Middle Cerebral Artery/physiopathology
- Italy
- Male
- Middle Aged
- Predictive Value of Tests
- Prognosis
- Recovery of Function
- Severity of Illness Index
- Stroke/diagnostic imaging
- Stroke/etiology
- Stroke/physiopathology
- Time Factors
- Ultrasonography, Doppler, Color
- Ultrasonography, Doppler, Transcranial
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24
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Sharma VK, Tsivgoulis G, Lao AY, Flaster M, Frey JL, Malkoff MD, Alexandrov AV. Thrombotic occlusion of the common carotid artery (CCA) in acute ischemic stroke treated with intravenous tissue plasminogen activator (TPA). Eur J Neurol 2007; 14:237-40. [PMID: 17250737 DOI: 10.1111/j.1468-1331.2006.01654.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Although common carotid artery (CCA) occlusions are rare, acute clinical presentations vary from mild to devastating strokes primarily due to tandem occlusions in the intracranial arteries. Three patients with acute CCA occlusions were treated with systemic tissue plasminogen activator (TPA). Blood pressures were kept at the upper limits allowed with TPA therapy with fluid balance and the 'head-down' position. Recanalization occurred in intracranial vessels only. Marked early neurological improvement occurred in two of three patients. CCA occlusions should not be considered contra-indication to systemic thrombolysis.
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Affiliation(s)
- V K Sharma
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ 85013, USA.
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25
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Thomassen L, Waje-Andreassen U, Naess H, Aarseth J, Russell D. Combined Carotid and Transcranial Ultrasound Findings Compared with Clinical Classification and Stroke Severity in Acute Ischemic Stroke. Cerebrovasc Dis 2006; 21:86-90. [PMID: 16330869 DOI: 10.1159/000090008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Accepted: 09/08/2005] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The aim of this study was to assess the association between cerebral hemodynamics and the clinical picture as defined by the Oxfordshire Community Stroke Project (OCSP) classification, as well as the clinical severity as defined by the National Institute of Health Stroke Scale (NIHSS) within the first 6 h of an acute middle cerebral artery (MCA) stroke onset. METHODS 70 unselected patients were grouped according to the OCSP classification and NIHSS. All patients immediately had extracranial and transcranial Doppler (TCD) ultrasound examinations. RESULTS In the study population as a whole, there was a significant association between intracranial vascular pathology and the OCSP classification (p<0.001) as well as the NIHSS score (p<0.001). In patients with severe stroke, however, TCD demonstrated the hypothesized proximal MCA(1) occlusion in only 34% of patients with an OCSP-defined total anterior circulation syndrome and in 42% of patients with an NIHSS score of >or=15. In moderate stroke, the OCSP classification was misleading in almost half of the patients with a partial anterior circulation syndrome, i.e. a hypothesized distal MCA(2) occlusion suitable for thrombolysis. CONCLUSIONS Neither the OCSP classification nor the NIHSS grading provided reliable information about the site or presence of intracranial arterial occlusion in acute stroke within the first 6 h after stroke onset in the individual patient. The results of this study strongly suggest that selection of acute ischemic stroke patients for thrombolysis should also include an assessment of cerebral hemodynamics.
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Affiliation(s)
- Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.
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26
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Treger I, Streifler JY, Ring H. The relationship between mean flow velocity and functional and neurologic parameters of ischemic stroke patients undergoing rehabilitation. Arch Phys Med Rehabil 2005; 86:427-30. [PMID: 15759223 DOI: 10.1016/j.apmr.2004.09.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To investigate the correlation between mean flow velocity (MFV) as measured by transcranial Doppler ultrasonography (TCD) and functional and neurologic impairment during inpatient rehabilitation after acute stroke. DESIGN Prospective study comparing results of rehabilitation in patients with different TCD findings. SETTING Acute neurologic rehabilitation department. PARTICIPANTS Twenty-four consecutive patients admitted to a rehabilitation center with a diagnosis of a first ischemic stroke in the middle cerebral artery (MCA) territory. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Impairment as measured with the National Institutes of Health Stroke Scale (NIHSS) and disability as assessed with the FIM instrument. RESULTS Normative or high blood-flow velocity in the MCA of the damaged hemisphere was associated on admission with higher FIM and lower NIHSS scores during 2 months of hospitalization. Absent or low flow velocity correlated with much worse functional and neurologic outcome, especially after 1 and 2 months of inpatient rehabilitation. Statistical correlation was found between MFV in the MCA of the damaged hemisphere, measured by admission TCD, and FIM score on admission and 1 month later. NIHSS scores during hospitalization also correlated with MFV in the MCA of the damaged hemisphere on admission and after 1 month. MFV in the MCA of the undamaged hemisphere 1 month after admission correlated negatively with FIM scores during inpatient rehabilitation. CONCLUSIONS Our data showed a correlation between blood-flow velocity in the MCA of both hemispheres and the parameters of functional and neurologic status at different stages of acute inpatient rehabilitation after first ischemic stroke in MCA territory. Cerebral blood flow as measured by TCD can be an additional tool for monitoring the rehabilitation process after stroke.
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Affiliation(s)
- Iuly Treger
- Loewenstein Rehabilitation Hospital, Ra'anana, Israel
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27
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Classification of Ischemic Stroke. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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28
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Baumgartner RW. Transcranial color duplex sonography in cerebrovascular disease: a systematic review. Cerebrovasc Dis 2003; 16:4-13. [PMID: 12766355 DOI: 10.1159/000070108] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2002] [Accepted: 08/27/2002] [Indexed: 11/19/2022] Open
Abstract
Transcranial color-coded duplex sonography (TCCS) enables the reliable assessment of intracranial stenoses (sensitivity 94-100%, specificity 99-100%), occlusions (middle cerebral artery: sensitivity 93-100%, specificity 98-100%) and cross-flow through the anterior (sensitivity 98%, specificity 100%) and posterior (sensitivity 84%, specificity 94%) communicating arteries without using potentially dangerous compression tests, as well as the midline shift in hemispheric infarcts. Ultrasound contrast agents (UCAs) increase the number of conclusive TCCS studies and allow the definite evaluation of intracranial arteries in most patients. TCCS is also useful for diagnosis and monitoring of vasospasm and detection of supratentorial hematomas (sensitivity 94%, specificity 95%) and aneurysms (sensitivity per patient 40-78%, specificity 90-91%), and may identify arteriovenous malformations. New developments are (1) UCAs that may increase the number of conclusive TCCS studies, (2) cerebral perfusion assessment, (3) measurement of arteriovenous cerebral transit time, which might enable the detection of small-vessel disease, and (4) site-targeted UCAs that may improve diagnosis and local drug delivery.
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