Neutrophil-Lymphocyte ratio is associated with poor clinical outcome after mechanical thrombectomy in stroke in patients with COVID-19.

BACKGROUND: The neutrophil-lymphocyte ratio (NLR) is emerging as an important biomarker of acute physiologic stress in a myriad of medical conditions, and is a confirmed poor prognostic indicator in COVID-19. OBJECTIVE: We sought to describe the role of NLR in predicting poor outcome in COVID-19 patients undergoing mechanical thrombectomy for acute ischemic stroke. METHODS: We analyzed NLR in COVID-19 patients with large vessel occlusion (LVO) strokes enrolled into an international 12-center retrospective study of laboratory-confirmed COVID-19, consecutively admitted between March 1, 2020 and May 1, 2020. Increased NLR was defined as ≥7.2. Logistic regression models were generated. RESULTS: Incidence of LVO stroke was 38/6698 (.57%). Mean age of patients was 62 years (range 27-87), and mortality rate was 30%. Age, sex, and ethnicity were not predictive of mortality. Elevated NLR and poor vessel recanalization (Thrombolysis in Cerebral Infarction (TICI) score of 1 or 2a) synergistically predicted poor outcome (likelihood ratio 11.65, p = .003). Patients with NLR > 7.2 were 6.8 times more likely to die (OR 6.8, CI95% 1.2-38.6, p = .03) and almost 8 times more likely to require prolonged invasive mechanical ventilation (OR 7.8, CI95% 1.2-52.4, p = .03). In a multivariate analysis, NLR > 7.2 predicted poor outcome even when controlling for the effect of low TICI score on poor outcome (NLR p = .043, TICI p = .070). CONCLUSIONS: We show elevated NLR in LVO patients with COVID-19 portends significantly worse outcomes and increased mortality regardless of recanalization status. Severe neuro-inflammatory stress response related to COVID-19 may negate the potential benefits of successful thrombectomy.

Incidence, Characteristics and Outcomes of Large Vessel Stroke in COVID-19 Cohort: An International Multicenter Study.

BACKGROUND: While there are reports of acute ischemic stroke (AIS) in coronavirus disease 2019 (COVID-19) patients, the overall incidence of AIS and clinical characteristics of large vessel occlusion (LVO) remain unclear. OBJECTIVE: To attempt to establish incidence of AIS in COVID-19 patients in an international cohort. METHODS: A cross-sectional retrospective, multicenter study of consecutive patients admitted with AIS and COVID-19 was undertaken from March 1 to May 1, 2020 at 12 stroke centers from 4 countries. Out of those 12 centers, 9 centers admitted all types of strokes and data from those were used to calculate the incidence rate of AIS. Three centers exclusively transferred LVO stroke (LVOs) patients and were excluded only for the purposes of calculating the incidence of AIS. Detailed data were collected on consecutive LVOs in hospitalized patients who underwent mechanical thrombectomy (MT) across all 12 centers. RESULTS: Out of 6698 COVID-19 patients admitted to 9 stroke centers, the incidence of stroke was found to be 1.3% (interquartile range [IQR] 0.75%-1.7%). The median age of LVOs patients was 51 yr (IQR 50-75 yr), and in the US centers, African Americans comprised 28% of patients. Out of 66 LVOs, 10 patients (16%) were less than 50 yr of age. Among the LVOs eligible for MT, the average time from symptom onset to presentation was 558 min (IQR 82-695 min). A total of 21 (50%) patients were either discharged to home or discharged to acute rehabilitation facilities. CONCLUSION: LVO was predominant in patients with AIS and COVID-19 across 2 continents, occurring at a significantly younger age and affecting African Americans disproportionately in the USA.

Factor v leiden mutation in reocclusion after intra-arterial thrombolysis.

BACKGROUND AND PURPOSE: Reocclusion of intracranial arteries after successful recanalization is associated with poor clinical outcome. The role of Factor V Leiden mutation in intracranial arterial thrombosis/rethrombosis is unclear. SUMMARY OF REPORT: We report the case of a patient who developed recurrent reocclusions of the middle cerebral artery after intra-arterial thrombolysis for acute ischemic stroke. The patient subsequently underwent transcatheter clot retrieval followed by successful stent-supported angioplasty of the occluded segment. He underwent a detailed workup for thrombophilia. The patient was detected to be heterozygous for Factor V Leiden mutation without any other cause for thrombophilia. CONCLUSIONS: Factor V Leiden mutation could be a contributing etiology for reocclusion after endovascular interventions in stroke. Systematic studies looking for thrombophilic mutations in patients with arterial reocclusion might be warranted.

Albert Wojciech Adamkiewicz (1850-1921): unsung hero behind the eponymic artery.

The artery of Adamkiewicz is an important radiculomedullary artery supplying the spinal cord, especially the lumbar enlargement. Anatomical knowledge of this artery is important for avoiding serious neurological complications during surgery performed in this region--for neurosurgeons and interventional radiologists treating intramedullary tumors and spinal arteriovenous malformations, traumatologists performing spinal fusions, thoracic surgeons treating aortic aneurysms, and urologists and pediatric surgeons conducting retroperitoneal dissections. However, the biography of the talented Polish pathologist Albert Adamkiewicz, after whom the landmark artery is named, has not been described adequately in the existing neurosurgical literature. The authors bring to light the historical perspective of the eponymic artery and provide a recapitulation of other significant contributions made by Adamkiewicz, mostly involving the nervous system. His research papers on the histology of neuronal tissues and neurodegenerative diseases had high scientific merit, but the discovery of the anticancer antitoxin "cancroin" and his postulation of a cancer-causing parasite he named "Coccidium sarcolytus" met with harsh criticism and eventually led to his ill fame. The biography is supplemented with a brief overview of the important surgical implications of the artery of Adamkiewicz.

Modern psychosurgery before Egas Moniz: a tribute to Gottlieb Burckhardt.

The history of modern psychosurgery has been written in several ways, weaving around many pioneers in the field during the 19th century. Often neglected in this history is Gottlieb Burckhardt (1836-1907), who performed the first psychosurgical procedures as early as 1888, several decades before the work of Egas Moniz (1874-1955). The unconventional and original case series of Burckhardt, who claimed success in 50% of patients (3 of 6), had met with overt criticism from his contemporary medical colleagues. The authors describe 2 illustrative cases of cortical extirpation performed by Burckhardt and review his pioneering case series for surgical outcome, despite the ambiguity in postoperative evaluation criteria. Although Burckhardt discontinued the project after publication of his surgical results in 1891, neurosurgeons around the world continued to investigate psychosurgery and revitalized his ideas in 1910; psychosurgery subsequently developed into a full-fledged neurosurgical specialty.

Acute Bilateral Internal Carotid Occlusion from Embolization of Left Atrial Thrombus During Transesophageal Echocardiography: Case Report.

BACKGROUND AND PURPOSE: Transesophageal echocardiography (TEE) is a relatively safe imaging modality used to visualize intracardiac thrombus. SUMMARY OF CASE: We report on a unique, fatal complication during TEE of embolization of a pre-existing "smoking" left atrial thrombus causing acute bilateral internal carotid occlusion, confirmed on angiogram. CONCLUSIONS: Patients with history of lung pathology, such as COPD, who experience retching and cough during transesophageal echocardiography may be more susceptible to embolization of pre-existing thrombi. A need exists to risk stratify such patients.

Mechanical Thrombectomy-Ready Comprehensive Stroke Center Requirements and Endovascular Stroke Systems of Care: Recommendations from the Endovascular Stroke Standards Committee of the Society of Vascular and Interventional Neurology (SVIN).

Five landmark multicenter, prospective, randomized, open-label, blinded end point clinical trials have recently demonstrated significant clinical benefit of endovascular therapy with mechanical thrombectomy in acute ischemic stroke (AIS) patients presenting with proximal intracranial large vessel occlusions. The Society of Vascular and Interventional Neurology (SVIN) appointed an expert writing committee to summarize this new evidence and make recommendations on how these data should guide emergency endovascular therapy for AIS patients.

What proportion of stroke is not explained by classic risk factors?

Ischemic stroke is a complex entity with multiple etiologies and variable clinical manifestations. The most frequent cause of stroke is atherosclerosis of cerebral vasculature followed by cardioembolism. Two thirds of strokes are explained by identifiable risk factors. Age, hypertension, and nonvalvular atrial fibrillation are by far the most frequent and well documented ones. Approximately 5% of strokes are caused by conditions other than atherosclerosis or heart disease, i.e., cervical arteries dissections, nonatherosclerotic vasculopathies, infectious or systemic vasculitis, and collagen vascular diseases. In spite of a thorough diagnostic evaluation, 30% of strokes remain cryptogenic, i.e., no specific cause is identified and the classic risk factors are not present. Identification of unknown environmental or genetic risk factors should be the subject of further research.

Catheter-based recanalization techniques for acute ischemic stroke.

Recent advances in endovascular interventional therapies have revolutionized the management of acute ischemic stroke. For patients who present with occluded circle of Willis vessels, timely and successful arterial recanalization is the best predictor of clinical improvement. Diagnostic neuroimaging has advanced noninvasive tools--namely, transcranial Doppler, CT angiography, and MR angiography--to screen individuals with acute neurologic syndromes rapidly for arterial occlusion, and hence to exclude from treatment those who are unlikely to benefit from or could be harmed by arterial recanalization strategies. Intra-arterial thrombolysis has been proven to be of benefit in large clinical trials. Moreover, the US Food and Drug Administration has recently approved the use of a mechanical clot retrieval device for acute embolic stroke, and a number of other similar strategies are under various stages of investigation. This article reviews the diagnostic and interventional approach to the management of large vessel embolic stroke.

Clinical potential of intra-arterial thrombolytic therapy in patients with acute ischaemic stroke.

Acute ischaemic stroke is a leading cause of mortality and morbidity around the world. An arterial occlusive lesion is found in the majority of patients with acute ischaemic stroke, and recanalisation has been shown to result in a better clinical outcome. The only widely approved recanalisation strategy is the use of intravenous alteplase (recombinant tissue-type plasminogen activator; tPA) within 3 hours of stroke onset. However, this therapy has limitations, and alternative or supplemental recanalisation strategies need to be considered in a large number of patients with acute ischaemic stroke. One such promising strategy is intra-arterial thrombolysis. This article reviews the pharmacology of the various drugs used for intra-arterial thrombolysis in the setting of acute ischaemic stroke and the results of the clinical trials that have studied their benefit. Three generations of thrombolytic agents have been available for clinical use so far. The first-generation agents such as streptokinase and urokinase were the first to be studied in acute stroke, and a number of positive case reports and series of their intra-arterial use have been reported from around the world. Second-generation products include alteplase and pro-urokinase. The clinical benefits of intra-arterial pro-urokinase were recently proven in a randomised, placebo-controlled study. Third-generation agents, such as reteplase, lanoteplase and tenecteplase, offer superior recanalisation rates with limited systemic adverse effects and might prove to be the agents of choice for intra-arterial acute stroke thrombolysis in the future. The exact administration regimens as well as the identification of patient sub-populations most likely to benefit from intra-arterial thrombolysis are subjects of current investigations, and hopefully firmer guidelines will be established in the next few years, once the results of the clinical trials are available.

Reocclusion of recanalized arteries during intra-arterial thrombolysis for acute ischemic stroke.

BACKGROUND AND PURPOSE: Early reocclusion of recanalized arteries has been observed after thrombolysis for acute coronary occlusion and has been attributed to platelet activation after exposure to thrombolytic agents. We conducted a retrospective study to determine the rate of reocclusion during intra-arterial thrombolysis for acute ischemic stroke and the effect of reocclusion on functional outcome. METHODS: Patients treated for acute ischemic stroke at our center between September 2000 and May 2002 received a maximum total dose of 4 U of reteplase intra-arterially in 1-U increments via superselective catheterization. Pharmacologic thrombolysis was supplemented by mechanical thrombolysis with balloon angioplasty or snare manipulation at the occlusion site. Angiography was performed after each unit of reteplase or mechanical maneuver, and the images were interpreted by a blinded reviewer. Reocclusion was defined as partial or complete initial recanalization with occlusion recurring at the same site as documented by angiography during the endovascular treatment. Reocclusions were treated by further pharmacologic and/or mechanical thrombolysis according to the discretion of the treating physician. Clinical evaluations were performed before and 24 hr, 7 to 10 days, and 1 to 3 months after treatment. RESULTS: Forty-six consecutive patients underwent intra-arterial thrombolysis. Reocclusion was observed in eight (17%). Among these patients, initial sites of occlusion were in the following arteries: intracranial internal carotid artery (n = 2), M1 segment of the middle cerebral artery (n = 3), M1 and M2 segments of the middle cerebral artery (n = 2), and basilar artery (n = 1). The mean initial National Institutes of Health Scale score for these eight patients was 23.3 +/- 6.2; mean time from symptom onset to treatment was 4.4 +/- 1.2 hr. The reocclusions were treated by using additional doses of reteplase alone (n = 1), reteplase with snare maneuver and/or angioplasty (n = 5), reteplase with angioplasty or snare and then stent placement (n = 1), and angioplasty with stent placement (n = 1). The reocclusions resolved in six of eight patients after further treatment. Six patients died and two survived but were severely disabled at 1 month (modified Rankin Scale scores of 4 and 5, respectively). Independent functional outcome scores (modified Rankin Scale scores of 0-2) were significantly lower among patients with angiographically shown reocclusion than in those without (0 of 8 versus 17 of 38, P =.02). CONCLUSION: Reocclusion occurs relatively frequently during intra-arterial thrombolysis for ischemic stroke and seems to be associated with poor clinical outcomes.

Safety of high-dose intravenous eptifibatide as an adjunct to internal carotid artery angioplasty and stent placement: a prospective registry.

OBJECTIVE: Eptifibatide, a competitive platelet glycoprotein IIb-IIIa receptor inhibitor with high selectivity for platelet glycoprotein IIb-IIIa receptors and a short half-life, has been shown to reduce the risk of ischemic events associated with coronary interventions, particularly when used in high doses. However, its role in conjunction with neurointerventional procedures needs to be determined. We report the results of an open-label prospective registry to evaluate the safety (in terms of avoiding hemorrhagic complications) and effectiveness (in terms of preventing ischemic complications such as stroke) of administering high-dose eptifibatide during internal carotid artery angioplasty and stent placement (CAS) for extracranial carotid artery stenosis. METHODS: After femoral artery access was established and intravenous heparin (30 U/kg bolus) was administered, each patient was administered intravenous eptifibatide (two 180-microg/kg single-dose boluses before CAS, then a 2.0-microg/kg/min infusion for 20-24 hours thereafter). The primary end point was the 30-day composite occurrence of death, cerebral infarction, and unplanned or urgent endovascular or surgical intervention. The primary safety end point was bleeding, for which complications were classified according to the Thrombolysis in Myocardial Infarction scheme as major (hemoglobin decrease of more than 5 g/dl), minor (hemoglobin decrease of 3-5 g/dl), or insignificant. Platelet aggregation was measured in 13 consecutive patients with a rapid platelet-function analyzer. RESULTS: Twenty-six patients (mean age, 68.1 +/- 9.4 yr; 16 men) underwent treatment. The infusion and the CAS procedure were discontinued in one patient who developed angioneurotic edema after being administered intravenous heparin and the first bolus dose of eptifibatide. Among the 25 patients who underwent the procedure, no intracerebral hemorrhages and one minor ischemic stroke occurred during the 1-month follow-up period. The minor stroke was observed on postprocedure Day 7 in a patient for whom antiplatelet therapy was discontinued before a coronary artery bypass graft operation was performed. Another patient was discharged after an uncomplicated hospitalization but died as a result of urinary sepsis 12 days after CAS. One episode of major bleeding from the femoral insertion site required surgical repair and blood transfusions. Minor bleeding occurred in one patient. Platelet aggregation measurements obtained in 13 patients revealed a high degree (mean, 96%; range, 86-100%) of platelet inhibition after the administration of the second bolus dose of intravenous eptifibatide. CONCLUSION: High-dose eptifibatide administered as an adjunct to CAS seems to be safe. Further studies are required to analyze its effectiveness and role in neurointerventional procedures.

Outcome following intracerebral hemorrhage and subarachnoid hemorrhage.

Intracerebral hemorrhage and subarachnoid hemorrhage account for almost 20% of all stroke cases. Both forms of stroke are associated with a high morbidity and mortality rate. The incidence of intracerebral hemorrhage increases with the age and certain ethnical groups are more affected. Subarachnoid hemorrhage tends to occur in a much younger population than other types of strokes. Outcome predictors for intracerebral and subarachnoid hemorrhage have been extensively discussed in the literature. Based on the current literature, we review the morbidity and mortality rates and predictors of outcome for these two life-threatening diseases. Initial Glasgow Coma Scale (GCS) score, hematoma volume, and presence of ventricular blood are the most prominent predictors of outcome following intracerebral hemorrhage. Age and initial severity of neurologic deficits on presentation, measured by GCS, Hunt and Hess Scale or the World Federation of Neurological Surgeons Scale, are the most important predictors of outcome following subarachnoid hemorrhage.

Qureshi grading scheme for angiographic occlusions strongly correlates with the initial severity and in-hospital outcome of acute ischemic stroke.

BACKGROUND: The thrombolysis in myocardial infarction (TIMI) grading scheme and other classification systems have limitations in evaluating patients with ischemic stroke because they do not account for occlusion location or collateral circulation. The Qureshi grading scheme has been recently proposed to evaluate the severity of arterial occlusion in acute ischemic stroke because of limitations in existing grading systems. METHODS: The Qureshi grading scheme assigns a score from 0 to 5 on the basis of occlusion site and collateral supply. The authors determined the relationship between initial severity of stroke and outcome at discharge measured by the National Institutes of Health Stroke Scale (NIHSS) and the Qureshi grading scale assessed from initial angiography (by a neuroradiologist blinded to the clinical examination) in 57 patients who underwent intra-arterial therapy for acute ischemic stroke within 6 hours of symptom onset. RESULTS: A strong association was observed between the initial severity of neurological deficits and Qureshi scheme on angiography (F ratio = 2.6, P =.03). The initial NIHSS for grade 1 was 11 +/- 4 and progressively increased to 23 +/- 6 for grade 5. In the multivariate analysis, initial NIHSS was significantly associated with Qureshi scheme on angiography (R2 = 358, P =.03). The mean discharge NIHSS was 12 +/- 10 (range, 0-40). There was also a direct relationship between the Qureshi scheme and discharge NIHSS (F ratio = 2.8, P =.02). CONCLUSION: The Qureshi grading scheme can be effectively used to determine the severity of ischemic stroke (brain at risk) from the initial angiography.

Characteristics and predictors of aortic plaques in patients with transient ischemic attacks and strokes.

OBJECTIVE: To identify the prevalence and characteristics of aortic atherosclerotic plaque disease and its association with cerebrovascular risk factors in patients with cerebral ischemic events. BACKGROUND: Aortic atheroma is associated with ischemic stroke. Its characteristics, including morphology and distribution among different stroke subtypes, are not well described. METHOD: From July 2000 to August 2001, all patients evaluated by transesophageal echocardiography (TEE) with diagnoses of transient ischemic attacks (TIAs) and strokes were prospectively studied. Demographics, including age, gender, ethnicity, cerebrovascular risk factors, and stroke subtypes, were collected. RESULTS: Thoracic aortic atheromas (TAAs) were present in 141 of 237 patients (59%) (mean age = 59 +/- 14, 119 [50%] male). Mild plaque (< 2 mm) was present in 13 of 237 (5%), moderate plaque (2-4 mm) in 49 (21%), severe plaque (> or = 4 mm) in 79 (33%), and complex plaque in 64 (27%). Patients' ages (odds ratio [OR] = 1.05, confidence interval [CI] 1.03-1.08, P < .001), coronary artery disease (OR = 2.2, CI 1.02-4.8, P < .042), and patent foramen ovale (PFO) (OR = 0.39, CI 0.22-0.70, P < .002) were associated with the severity and complexity of aortic plaque. In multivariate analysis, age (OR = 1.06, CI 1.03-1.08, P < .001) and the presence of PFO (OR = 0.35, CI 0.18-0.65, P < .001) continued to be significant to the severity and complexity of aortic atheroma. Gender, history of stroke, hypertension, diabetes mellitus, hyperlipidemia, and history of smoking were not associated with TAA. CONCLUSION: One third of TAA plaques are severe and complex in nature and more frequently present in the descending aorta and the arch of the aorta than in the ascending aorta. TEE should be considered for the early detection and treatment of TAA in patients without identified causes of stroke.

Neurophysiological monitoring with brainstem evoked potentials can be a valuable tool for patients undergoing vertebrobasilar stenting and angioplasty-initial experience.

INTRODUCTION: Brainstem auditory evoked potentials (BAEPs) are routinely used during a variety of intracranial surgeries involving the posterior fossa and endovascular procedures including coiling of cerebral aneurysms. However, use of BAEPs has not been reported in vertebrobasilar stenting. METHODS: Six patients underwent stenting and angioplasty of the basilar artery (four) or the dominant vertebral artery (two) for symptomatic stenosis. All the patients received stenting and angioplasty with Wingspan stent and Gateway balloon, respectively. Continuous real time BAEPs were recorded in all patients, and somatosensory evoked potentials in five patients. RESULTS: All the patients had successful stenting and angioplasty in their target vessels. All the procedures were done under general anesthesia. In five patients, there were no significant changes in the BAEP responses during the predilation, stenting, and postdilation. There were no postprocedural neurological deficits in these patients. In one patient, there was a 1-ms increase of latency of wave V at the time of predilation angioplasty. No changes in the amplitude of wave V were noted. This patient had immediate postprocedure left hemiplegia, which improved to power of 3/5 in both upper and lower limbs at the time of discharge and to 4/5 at 3-month follow-up. Computed tomography scan did not show any evidence of hemorrhage. CONCLUSIONS: Brainstem auditory evoked potentials may be a valuable monitoring tool in patients undergoing stenting and angioplasty of vertebrobasilar system. Early signs of brainstem dysfunction can be identified to modify the procedure and reduce neurological deficits. Large studies are needed to validate the use of BAEP during this procedure.

Angioplasty and stenting for mechanical thrombectomy in acute ischemic stroke.

A large number of patients presenting with acute ischemic stroke have large artery intracranial occlusions, and timely recanalization of these occlusions often leads to improved neurologic outcome. Starting with the widespread use of IV tissue plasminogen activator, a wide variety of pharmacologic and mechanical methods have been introduced to improve vessel recanalization and clinical outcome of patients with acute ischemic stroke, which include endovascular therapies such as intra-arterial thrombolytics and mechanical thrombectomy devices. One of the potential therapies is angioplasty and stenting, and this has been evaluated in multiple case reports and small series published by various centers regarding its use in this setting. In this article, we review the current literature on stenting with and without angioplasty, used alone or as a part of multimodal therapy for recanalization for acute cerebrovascular occlusions.

The safety and efficacy of coiling multiple aneurysms in the same session.

OBJECTIVE: Multiple intracranial aneurysms are common. While sequential clipping of multiple aneurysms during a single open surgical procedure has been reported, the same is not true for endovascular coiling. We present our experience describing the safe coiling of multiple aneurysms in the same setting. METHODS: Retrospective review of our coiling log between 2006 and 2009 showed six cases in which multiple aneurysms were coiled in the same session. RESULTS: All patients were coiled using the same microcatheter. Distal aneurysms were coiled first. Good occlusion rates were achieved in all cases. There were no thromboembolic events or procedure-related rupture or mortality. CONCLUSION: In addition to safety and efficacy, cost savings are expected when coiling multiple aneurysms in the same procedure.

Stenting of acute and subacute intracranial vertebrobasilar arterial occlusive lesions.

BACKGROUND AND OBJECTIVE: The outcome of failed recanalization in patients with acutely symptomatic intracranial vertebrobasilar (VB) artery occlusive disease is poor. This paper reports the recanalization rate and safety of VB artery stenting in acutely symptomatic patients presenting >8 h after onset of symptoms. METHODS: A retrospective review of a prospectively maintained database of stent-supported endovascular treatment of intracranial circulation was carried out to identify patients with VB artery occlusive disease who were acutely revascularized >8 h after symptom onset. RESULTS: Of 12 patients (mean age 61 years), nine had acute stroke and three had recurrent transient ischemic attacks. The median time to intervention was 59 h (range 8-80). The median National Institute of Health Stroke Scale score was 11.5 (range 1-40). Angiography showed thrombolysis in myocardial infarction (TIMI) 0 flow in six patients and TIMI 1 flow in the other six. Stents were placed in the basilar artery in six and at the VB junction in the other six. Mechanical and/or intra-arterial thrombolysis was used in three patients before stenting. Nine patients had self-expanding stents and three had balloon-expandable stents. The recanalization rate was 100%. Procedure-related and 3-month mortality was zero. Two patients had asymptomatic intracranial hemorrhage. At 3-month follow-up a favorable outcome with a modified Rankin score ≤2 was achieved in eight. A follow-up angiogram in eight patients showed mild re-stenosis in three. CONCLUSION: Stent-supported VB artery revascularization can be a viable option with an acceptable safety profile in acute VB occlusion or unstable intracranial atherosclerotic arterial disease (ICAD) in carefully selected patients.

Safety and efficacy of intracranial stenting for acute ischemic stroke beyond 8 h of symptom onset.

OBJECTIVE: To report our experience with stent supported intracranial recanalization for acute ischemic stroke beyond 8 h of symptoms onset. Background Acute ischemic stroke (AIS) therapy is often limited to an 8 h window using mechanical means. However, recent reports have shown delayed recanalization beyond 8 h might be a viable option in a subset of patients. METHODS: A retrospective review was performed of our AIS database for patients who underwent stent supported intracranial recanalization beyond 8 h of symptom onset. Clinical and angiographic data were reviewed. Outcome was measured using modified Rankin Scale (mRS) scores at 30 and 90 days. RESULTS: 12 patients (11 men and one woman) underwent delayed stenting for AIS. Mean age was 49 years (range 37-73) and mean National Institutes of Health Stroke Scale was 17 (range 8-29, median 15). Mean time from stroke onset to intervention was 66.1 h (range 10-168 h, median 46 h). 10 patients presented with a Thrombolysis in Myocardial Infarction (TIMI) score of 0 and the remaining two had a TIMI of 1. Recanalized vessels included: left middle cerebral artery (n=6), basilar trunk (n=2), vertebrobasilar junction (n=3) and internal carotid artery (ICA)-T (n=1). Four patients had prior attempts of embolectomy/thrombolysis using mechanical and chemical means. Stents used included: six balloon mounted stents, five Wingspan and one Enterprise self-expanding intracranial stent. Recanalization, defined as a TIMI score of 2 or more, was achieved in 11 patients. Two patients (17%) had intracranial hemorrhage. Thirty day mRS of ≤3 was achieved in six patients (50%). Seven patients (58%) had a 90 day mRS of ≤2. CONCLUSION: Stent supported intracranial recanalization is a safe and feasible approach in a selective group of patients presenting with acute ischemic stroke beyond 8 h of symptom onset.