1.Alternative Transcarotid Approach for Endovascular Treatment of Acute Ischemic Stroke Patients: A Case Series
Hanna STYCZEN ; Daniel BEHME ; Amelie Carolina HESSE ; Marios Nikos PSYCHOGIOS
Neurointervention 2019;14(2):131-136
PURPOSE: Mechanical thrombectomy has become the standard of care for acute stroke caused by large vessel occlusion. As more patients are treated endovascularly, the number of older patients with tortuous vessels has risen. In these patients, catheterizing the internal carotid artery via a transfemoral approach can be very difficult or even impossible. Therefore, in selected patients, alternative strategies to the transfemoral approach have to be applied. MATERIALS AND METHODS: We report a case series of six patients undergoing mechanical thrombectomy via a combined transfemoral and transcarotid approach. Puncture of the carotid artery was conducted using roadmap guidance after an unsuccessful transfemoral attempt. Technical aspects and outcomes with this alternative approach were analyzed. RESULTS: Direct puncture of the carotid artery was achieved in five out of six patients (83%). In three out of six patients (50%), revascularization (modified Thrombolysis in Cerebral Infarction score ≥2b) was restored. No complications related to endovascular therapy were documented. One patient showed good neurological outcome (modified Rankin Scale [mRS] 5 at admission, mRS 1 at discharge). CONCLUSION: A combined transfemoral/transcarotid approach can be an alternative vascular access in patients with problematic vessel anatomy.
Carotid Arteries
;
Carotid Artery, Internal
;
Catheters
;
Cerebral Infarction
;
Humans
;
Punctures
;
Standard of Care
;
Stroke
;
Thrombectomy
2.Safety and Angiographic Efficacy of Intra-Arterial Fibrinolytics as Adjunct to Mechanical Thrombectomy: Results from the INFINITY Registry
Johannes KAESMACHER ; Nuran ABDULLAYEV ; Basel MAAMARI ; Tomas DOBROCKY ; Jan VYNCKIER ; Eike I. PIECHOWIAK ; Raoul POP ; Daniel BEHME ; Peter B. SPORNS ; Hanna STYCZEN ; Pekka VIRTANEN ; Lukas MEYER ; Thomas R. MEINEL ; Daniel CANTRÉ ; Christoph KABBASCH ; Volker MAUS ; Johanna PEKKOLA ; Sebastian FISCHER ; Anca HASIU ; Alexander SCHWARZ ; Moritz WILDGRUBER ; David J. SEIFFGE ; Sönke LANGNER ; Nicolas MARTINEZ-MAJANDER ; Alexander RADBRUCH ; Marc SCHLAMANN ; Dan MIHOC ; Rémy BEAUJEUX ; Daniel STRBIAN ; Jens FIEHLER ; Pasquale MORDASINI ; Jan GRALLA ; Urs FISCHER
Journal of Stroke 2021;23(1):91-102
Background:
and Purpose Data on safety and efficacy of intra-arterial (IA) fibrinolytics as adjunct to mechanical thrombectomy (MT) are sparse.
Methods:
INtra-arterial FIbriNolytics In ThrombectomY (INFINITY) is a retrospective multi-center observational registry of consecutive patients with anterior circulation large-vessel occlusion ischemic stroke treated with MT and adjunctive administration of IA fibrinolytics (alteplase [tissue plasminogen activator, tPA] or urokinase [UK]) at 10 European centers. Primary outcome was the occurrence of symptomatic intracranial hemorrhage (sICH) according to the European Cooperative Acute Stroke Study II definition. Secondary outcomes were mortality and modified Rankin Scale (mRS) scores at 3 months.
Results:
Of 5,612 patients screened, 311 (median age, 74 years; 44.1% female) received additional IA after or during MT (194 MT+IA tPA, 117 MT+IA UK). IA fibrinolytics were mostly administered for rescue of thrombolysis in cerebral infarction (TICI) 0-2b after MT (80.4%, 250/311). sICH occurred in 27 of 308 patients (8.8%), with an increased risk in patients with initial TICI0/1 (adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.1 to 5.0 per TICI grade decrease) or in those with intracranial internal carotid artery occlusions (aOR, 3.7; 95% CI, 1.2 to 12.5). In patients with attempted rescue of TICI0-2b and available angiographic follow-up, 116 of 228 patients (50.9%) showed any angiographic reperfusion improvement after IA fibrinolytics, which was associated with mRS ≤2 (aOR, 3.1; 95% CI, 1.4 to 6.9).
Conclusions
Administration of IA fibrinolytics as adjunct to MT is performed rarely, but can improve reperfusion, which is associated with better outcomes. Despite a selection bias, an increased risk of sICH seems possible, which underlines the importance of careful patient selection.