Rescue Strategies in Anterior Circulation Stroke with Failed Mechanical Thrombectomy-A Retrospective Observational Study (RAFT).

Context: Recanalization failure rate in mechanical thrombectomy (MT) for large vessel occlusions is up to 30%. Outcome greatly depends on recanalization success and, thus, there is an urgent need to adopt new strategies to improve recanalization. Aims: To report on the feasibility, safety, and outcome of rescue strategies (stenting and/or angioplasty) in cases of failed MT for acute ischemic stroke (AIS) in anterior circulation. Materials and Methods: It was a retrospective observational study where patients undergoing MT were divided into two groups. The first group (MT-only) was of patients who had undergone only MT with the standard tools (stentriever and/or aspiration). The second group (MT-plus) consisted of patients who underwent a rescue procedure after failure of the standard MT. The two groups were compared based on the demographics, risk factors, stroke severity, and the extent of infarct on imaging. The angiographic findings, procedural details, periprocedural care, and angiographic and clinical outcome were also compared. Results: Out of 181 cases, 142 were in MT-only while 39 were included in MT-plus group. The two groups had comparable baseline stroke severity, extent of infarct on imaging and door to puncture time. The MT-plus patients had significantly longer time of onset and puncture to recanalization time. The clinical outcome was favorable in both groups with 57.7% and 59% patients achieving mRS 0-2 in MT-only and MT-plus groups, respectively. Successful recanalization was achieved in 80.3% and 89.7% in MT-only and MT-plus groups, respectively. There was no significant increase in symptomatic intracranial hemorrhage and mortality after rescue procedures. Conclusions: Rescue stenting and/or angioplasty after failed MT is a safe and effective recanalization method for AIS in anterior circulation without increasing mortality or morbidity.

Ticagrelor Use in Indian Patients Undergoing Neuroendovascular Procedures: A Single Center Experience.

PURPOSE: A safe and efficacious antiplatelet drug is needed for patients with clopidogrel resistance who undergo neuroendovascular procedures. Ticagrelor is a new reversibly binding, oral, direct-acting P2Y receptor antagonist with no known resistance. We describe our clinical experience using ticagrelor for neuroendovascular procedures in Indian patients with clopidogrel resistance at the NH Institute of Neurosciences, Narayana Health City, Bangalore. MATERIALS AND METHODS: We retrospectively reviewed our endovascular procedure database for all patients with predefined clopidogrel resistance. Clopidogrel resistance was defined as P2Y12 inhibition <40%. Patients were administered ticagrelor along with aspirin prior to the procedure. RESULTS: Of 127 patients, 32 (25%) were non-responders to clopidogrel (22 [69%] males, 10 [31%] females; median age, 54 years [range, 20-75]). All patients were treated with a 180-mg loading dose of ticagrelor, followed by 90 mg twice daily. Twenty patients (63%) underwent endovascular intervention for intracranial aneurysm, two (6%) for dissecting aneurysms, nine (28%) for stenotic lesions, and one (3%) for carotico-cavernous fistula. No patient experienced any adverse effects related to the use of Ticagrelor in the postoperative period. CONCLUSION: Ticagrelor is an effective alternative to clopidogrel for use in conjunction with aspirin in patients with clopidogrel resistance. None of our patients had adverse effects from ticagrelor. Drug cost, twice-daily dosing, and risk of faster platelet aggregation activation after discontinuation should be taken into consideration prior to its use in such patients.

Mechanical Thrombectomy Using Retrievable Stents in Pediatric Acute Ischemic Stroke.

OBJECTIVE: To report efficacy and outcome of mechanical thrombectomy for treatment of pediatric acute ischemic stroke with large vessel occlusion using stent retrievers. METHODS: Retrospective record review of institutional database for patients <18 years of age. RESULTS: Five boys aged between 6 to 17 years received reperfusion therapy using mechanical thrombectomy for acute ischemic stroke with large vessel occlusion (2 basilar, 2 middle cerebral and 1 internal carotid artery). Pediatric National Institute of Health Stroke Scale (PedNIHSS) at onset ranged from 12 to 21. Complete recanalization as defined by the modified Treatment In Cerebral Infarction scale (mTICI 3 or 2b) was achieved in all, using stent retreivers. Favorable outcome as per the modified Rankin scale (mRS 0-1) was achieved in all with no peri-procedural complications. CONCLUSION: Mechanical thrombectomy using retrievable stents is a safe and effective therapy for pediatric ischemic stroke due to large vessel occlusion, and may be offered in carefully selected patients.

Symptomatic Extracranial Carotid Artery Thrombus: An Indian Experience.

INTRODUCTION: Symptomatic intraluminal carotid artery thrombus (ICT) is an uncommon finding, whose incidence increases with the percentage of stenosis. The optimal treatment modality to address carotid artery thrombus is not well established. We present our data of medical management of carotid artery thrombus with antiplatelet and anticoagulation. METHODS: We reviewed our data from January 1, 2016 to December 31, 2017. Patients with extracranial carotid artery thrombus underwent a catheter digital subtraction angiogram to confirm the presence of thrombus. Medical management was done with dual antiplatelets along with low-molecular-weight heparin, and a check angiogram was done after 14 days. Factors contributing to the persistence of thrombus were analyzed. RESULTS: A total of 21 patients diagnosed with acute ischemic stroke and extracranial carotid artery thrombus. Three patients opted for endarterectomy. Eighteen patients underwent medical management. Nine (50%) had a resolution of thrombus. Those with persistent thrombus were significantly older (average age 64 vs. 43 years, P = 0.008). They also had significantly higher proportions of hypertension (100% vs. 44%, P = 0.029), diabetes mellitus (89% vs. 11%, P = 0.003), and underlying carotid stenosis (100% vs. 33%, P = 0.009). CONCLUSION: Our regimen of dual antiplatelets plus short-term anticoagulation is safe and effective in the management of ICT. Large-scale studies are warranted to determine the optimal regimen and duration of medical treatment.

Rapid Processing of Perfusion and Diffusion for Ischemic Strokes in the Extended Time Window: An Indian Experience.

BACKGROUND: Endovascular treatment of acute ischemic stroke with large-vessel occlusion is the standard of care now. Initially restricted to 6 h after onset, the treatment can now be offered to selected patients up to 24 h based on clinical and imaging criteria. OBJECTIVE: Perfusion imaging can help in identifying patients who may benefit from endovascular treatment in the extended time window. Manual analysis of perfusion images is time and skill intensive. Rapid processing of perfusion and diffusion (RAPID) is an automated image analysis system that analyzes perfusion maps. We report our initial experience of using this system in selection of patients for endovascular stroke treatment. METHODS: All patients who presented with acute stroke underwent baseline imaging with computed tomography (CT) and CT angiogram or magnetic resonance imaging (MRI) and MR angiogram. Patients presenting between 6 and 24 h after onset underwent perfusion imaging, which was analyzed by RAPID. The results were used to select the patients who then underwent mechanical thrombectomy. RESULTS: RAPID results identifying ischemic core and hypoperfused tissue were available within 5 min in each of the three cases. At 3 months, all patients showed improvement in the modified Rankin Scale. CONCLUSION: In extended time windows, RAPID provides a fast and reliable estimate of salvageable brain tissue to help select patients for endovascular treatment.

Supra-recommendation Treatment of Super-refractory Status Epilepticus.

A 28-year old female was admitted with recurrent seizures following 2 days of febrile illness, after which she developed status epilepticus. Midazolam and later thiopentone infusions were started after failure of regular intravenous antiepileptics. Burst suppression was achieved at doses of 3 mg/kg/hr for midazolam and 6 mg/kg/hr of thiopentone. Adjunctive medications included methylprednisolone, intravenous immunoglobulin and acyclovir. Imaging and biochemical parameters were normal. She required 3 cycles of midazolam and 2 cycles of thiopentone for complete cessation of seizures. She recovered with mild attentional and recent memory deficits on follow up. Treatment of super-refractory status epilepticus requires individualized regimens and may need doses beyond conventional limits. To the best of our knowledge, there is no such reported case from India.

Endovascular treatment of acute ischemic stroke: an Indian experience from a tertiary care center.

BACKGROUND: In India, late presentation due to poor awareness about stroke precludes intravenous thrombolysis (IVT). Endovascular therapy can be used in these circumstances. We present our experience of endovascular treatment of acute ischemic stroke in a tertiary care center. AIM: Endovascular treatment of acute ischemic stroke in a tertiary care center in India. SETTINGS, DESIGN, MATERIALS, AND METHODS: The study period was from 2009 till 2013. Consecutive patients with acute ischemic stroke, who either had contraindications to IVT or had failed IVT, underwent endovascular treatment. Before the publication of interventional management of stroke 3 results, we took a few patients, with large vessel occlusions, directly for endovascular treatment. After imaging, patients were considered for endovascular treatment, using either intra-arterial thrombolysis or mechanical thrombectomy, if there was a documented large vessel occlusion. Outcome was assessed at 3 months using the modified Rankin Scale. STATISTICAL ANALYSIS: Statistical analysis was done using the Statistical Package for the Social Sciences 17.0 software. RESULTS: A total of 45 patients underwent endovascular treatment. The mean age at presentation was 49 years, median National Institutes of Health Stroke Scale (NIHSS) was 19 and the most common site was the middle cerebral artery (23 patients). Solitaire™ stentriever was used in 33 patients. The median pre-procedure Thrombolysis In Myocardial Infarction (TIMI) score was 0 and the median post-procedure TIMI score was 3. Nine patients underwent decompressive craniectomy. On follow-up at 3 months, the median Modified Rankin Scale (mRS) was 0. Eight patients died during 3 months following stroke. CONCLUSION: Endovascular treatment of acute ischemic stroke is a viable treatment option in patients who either have contraindications to IVT or who fail IVT.

Stent-assisted coiling of wide-necked intracranial aneurysms using the Solitaire AB stent.

CONTEXT: Stent-assisted coiling of wide-necked and complex intracranial aneurysms is an effective and feasible treatment option. The self-expanding, fully retrievable Solitaire AB (eV3, Irvine, CA, USA) stent is the latest neurovascular remodeling device available. To the best of our knowledge, there are no studies of Solitaire AB-assisted coiling of wide-necked intracranial aneurysms from India. AIM: Solitaire AB-assisted coiling of wide-necked intracranial aneurysms. MATERIALS AND METHODS: The study was conducted in a tertiary care center with a dedicated Interventional Neurology division from 2009 to 2013. Consecutive patients with wide-necked aneurysms who underwent coiling assisted by the Solitaire AB stent were enrolled in the study. Axium 3D and Helix (eV3, Irvine, CA, USA) platinum coils were used to densely pack the aneurysm sac after deploying the stent across the neck. All patients were pretreated with antiplatelets according to protocol. Subsequently, dual antiplatelets were given for 6 months followed by continued aspirin. Outcome was assessed at 3 months using the modified Rankin Scale. STATISTICAL ANALYSIS USED: Statistical analysis was done using the SPSS 17.0 software. RESULTS: A total of 16 patients underwent stent-assisted coiling. The most common site was the internal carotid artery (nine patients), median aneurysm size was 7 mm and median neck diameter was 5 mm. Thirteen patients presented with ruptured aneurysms. We achieved complete occlusion in all patients with no major complications. Thirteen patients were followed up, all have an mRS score of zero or one. CONCLUSION: We conclude that for wide-necked aneurysms, stent-assisted coiling using the Solitaire AB is a safe and effective treatment option.