Extracranial-Intracranial Bypass and Risk of Stroke and Death in Patients With Symptomatic Artery Occlusion: The CMOSS Randomized Clinical Trial.

Importance: Prior trials of extracranial-intracranial (EC-IC) bypass surgery showed no benefit for stroke prevention in patients with atherosclerotic occlusion of the internal carotid artery (ICA) or middle cerebral artery (MCA), but there have been subsequent improvements in surgical techniques and patient selection. Objective: To evaluate EC-IC bypass surgery in symptomatic patients with atherosclerotic occlusion of the ICA or MCA, using refined patient and operator selection. Design, Setting, and Participants: This was a randomized, open-label, outcome assessor-blinded trial conducted at 13 centers in China. A total of 324 patients with ICA or MCA occlusion with transient ischemic attack or nondisabling ischemic stroke attributed to hemodynamic insufficiency based on computed tomography perfusion imaging were recruited between June 2013 and March 2018 (final follow-up: March 18, 2020). Interventions: EC-IC bypass surgery plus medical therapy (surgical group; n = 161) or medical therapy alone (medical group; n = 163). Medical therapy included antiplatelet therapy and stroke risk factor control. Main Outcomes and Measures: The primary outcome was a composite of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years after randomization. There were 9 secondary outcomes, including any stroke or death within 2 years and fatal stroke within 2 years. Results: Among 330 patients who were enrolled, 324 patients were confirmed eligible (median age, 52.7 years; 257 men [79.3%]) and 309 (95.4%) completed the trial. For the surgical group vs medical group, no significant difference was found for the composite primary outcome (8.6% [13/151] vs 12.3% [19/155]; incidence difference, -3.6% [95% CI, -10.1% to 2.9%]; hazard ratio [HR], 0.71 [95% CI, 0.33-1.54]; P = .39). The 30-day risk of stroke or death was 6.2% (10/161) in the surgical group and 1.8% (3/163) in the medical group, and the risk of ipsilateral ischemic stroke beyond 30 days through 2 years was 2.0% (3/151) and 10.3% (16/155), respectively. Of the 9 prespecified secondary end points, none showed a significant difference including any stroke or death within 2 years (9.9% [15/152] vs 15.3% [24/157]; incidence difference, -5.4% [95% CI, -12.5% to 1.7%]; HR, 0.69 [95% CI, 0.34-1.39]; P = .30) and fatal stroke within 2 years (2.0% [3/150] vs 0% [0/153]; incidence difference, 1.9% [95% CI, -0.2% to 4.0%]; P = .08). Conclusions and Relevance: Among patients with symptomatic ICA or MCA occlusion and hemodynamic insufficiency, the addition of bypass surgery to medical therapy did not significantly change the risk of the composite outcome of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years. Trial Registration: ClinicalTrials.gov Identifier: NCT01758614.

Giant Fusiform and Dolichoectatic Aneurysms of the Basilar Trunk and Vertebrobasilar Junction-Clinicopathological and Surgical Outcome.

BACKGROUND: Giant fusiform and dolichoectatic aneurysms of the basilar trunk and vertebrobasilar junction (BTVBJ-GFDA) are extremely difficult to treat. OBJECTIVE: To evaluate factors influencing survival and outcome of BTVBJ-GFDA by performing a retrospective multicenter cohort study. METHODS: A total of 32 patients with BTVBJ-GFDA were included in this study. Clinicopathological characteristics, treatment measures, and outcomes were collected from medical records and imaging studies. Autopsy and histological findings of the aneurysm and adjacent brain tissue were also obtained in 9 cases. RESULTS: A total of 11 patients did not undergo surgery, of whom 10 died; 3 from progressive brainstem compression, 4 from subarachnoid hemorrhage, 2 from brainstem infarction, and 1 from associated atherosclerotic disease. The remaining 21 patients underwent a surgical treatment, consisting of immediately proximal parent artery occlusion, remotely proximal parent artery occlusion, clip reconstruction, and distal bypass and achieved significantly longer overall survival compared with those who received conservative therapy (adjusted hazard ratio 1.508, 95% CI 1.058-2.148, P = .02). Histological examination of the aneurysms demonstrated staged clots, open lumen, and intrathrombotic channels with endothelial lining. The patients younger than 45 yr of age showed statistically longer survival than those equal and older than 45 yr (P = .03). CONCLUSION: Surgical intervention achieved greater survival than conservative management in BTVBJ-GFDA. Narrow ideal treatment window of the blood flow within the aneurysm to maintain sufficient but not excess supply should be targeted based on the hemodynamics of both the posterior communicating arteries and perforating vessel collaterals.

Combined STA-MCA Bypass and Encephalodurosynangiosis Versus Encephalodurosynangiosis Alone in Adult Hemorrhagic Moyamoya Disease: A 5 -Year Outcome Study.

AIM: The purpose of this study was to compare the 5-year prognosis of combined superficial temporal artery- middle cerebral artery (STA-MCA) bypass and Encephalodurosynangiosis (EDAS) and EDAS alone in hemorrhagic moyamoya disease (MMD). METHODS: This study included 123 adult patients admitted to Beijing Tiantan Hospital with hemorrhagic MMD between 2010 and 2015. The surgical procedures included combined revascularization of STA-MCA anastomosis with EDAS (n = 79) or EDAS alone (n = 44). We recorded basic demographic data as well as several risks factors, and used multivariate regression analysis to evaluate the predictive factor of overall survival and rebleeding-free survival. RESULTS: Of the 123 patients with hemorrhagic MMD, the mean age was 37.97 ± 11.04 years old and the mean follow-up period was 65.9 months (ranging from 12 to 100 months). A total of 21 rebleeding events occurred in 19 patients, yielding an annual incidence of rebleeding of 3.1%. Of the 19 patients with rebleeding, 11 (57.8%) patients died of rebleeding and one patient experience 3 rebleeding events. In the combined revascularization group, 9 (11.3%) patients experienced rebleeding, of which 5 (6.3%) died. This incidence was lower than in the indirect group, where 22.7% of patients experienced rebleeding events and 13.6% died. However, no significant difference was found between these 2 groups. In Kaplan-Meier survival analysis, the combined revascularization group had a better prognosis than the EDAS alone group, and multivariate regression analysis revealed that the combined revascularization procedure was associated with a better outcome. CONCLUSIONS: Both combined revascularization and EDAS alone can reduce the risk of rebleeding in hemorrhagic MMD. Combined revascularization was found to be superior to EDAS alone in terms of preventing rebleeding events.

Thrombolysis in Cerebral Infarction Grade 2C or 3 Represents a Better Outcome than 2B for Endovascular Thrombectomy in Acute Ischemic Stroke: A Network Meta-Analysis.

BACKGROUND: Although Thrombolysis in Cerebral Infarction (TICI) grade 2B or 3 is considered successful after endovascular thrombectomy (EVT) for acute ischemic stroke, TICI 2B was found to be associated with poorer outcomes than was 3. Furthermore, the newly proposed TICI 2C grade seems to be clinically equivalent to TICI 3 rather than to 2B. This network meta-analysis aimed to assess the differences in clinical outcomes between TICI grades and redefine successful reperfusion. METHODS: PubMed, Embase, and Cochrane Central Register were queried. A random-effect model with frequentist framework was applied to evaluate outcomes using odds ratios (ORs) and 95% confidence intervals (CIs). Using surface under the cumulative ranking curve (SUCRA), the hierarchy of TICI grades was indicated. RESULTS: Analysis of 12 studies, with 2084 patients, indicated that TICI 2C (OR, 2.28; 95% CI, 1.65-3.13) and 3 (OR, 2.40; 95% CI, 1.74-3.30) were significantly more associated with favorable 90-day clinical outcomes than were 2B; there was no significant difference between TICI 2C and 3 (OR, 1.05; 95% CI, 0.76-1.46). Based on the SUCRA, TICI 2C and 3 were considered as more effective reperfusion end points than was 2B (TICI 3, 80.8%; 2C, 69.2%; 2B, 0.0%) and showed significant association with lower rates of mortality and symptomatic intracranial hemorrhage. CONCLUSIONS: Patients with TICI 2C grade would be distinguished from those with 2B, because 2C is clinically equivalent to 3 and has a better outcome than 2B. Therefore, achieving 2C or 3 is likely to be closer to the successful aim of endovascular thrombectomy in acute ischemic stroke than achieving 2B.

Cerebral revascularization after the Carotid Occlusion Surgery Study: what candidates remain, and can we do better?

OBJECTIVECerebral revascularization for carotid occlusion was previously a mainstay procedure for the cerebrovascular neurosurgeon. However, the 1985 extracranial-intracranial bypass trial and subsequently the Carotid Occlusion Surgery Study (COSS) provided level 1 evidence via randomized controlled trials against bypass for symptomatic atherosclerotic carotid occlusion disease. However, in a small number of patients optimal medical therapy fails, and some patients with flow-limiting stenosis develop a perfusion-dependent neurological examination. Therefore it is necessary to further stratify patients by risk to determine who may most benefit from this intervention as well as to determine perioperative morbidity in this high-risk patient population.METHODSA retrospective review was performed of all revascularization procedures done for symptomatic atherosclerotic cerebrovascular steno-occlusive disease. All patients undergoing revascularization after the publication of the COSS in 2011 were included. Perioperative morbidity and mortality were assessed as the primary outcome to determine safety of revascularization in this high-risk population. All patients had documented hypoperfusion on hemodynamic imaging.RESULTSAt total of 35 revascularization procedures were included in this review. The most common indication was for patients with recurrent strokes, who were receiving optimal medical therapy and who suffered from cerebrovascular steno-occlusion. At 30 days only 3 perioperative ischemic events were observed, 2 of which led to no long-term neurological deficit. Immediate graft patency was good, at 94%. Long term, no further strokes or ischemic events were observed, and graft patency remained high at 95%. There were no factors associated with perioperative ischemic events in the variables that were recorded.CONCLUSIONSCerebral revascularization may be done safely at high-volume cerebrovascular centers in high-risk patients in whom optimal medical therapy has failed. Further research must be done to develop an improved methodology of risk stratification for patients with symptomatic atherosclerotic cerebrovascular steno-occlusive disease to determine which patients may benefit from intervention. Given the high risk of recurrent stroke in certain patients, and the fact that patients fail medical therapy, surgical revascularization may provide the best method to ensure good long-term outcomes with manageable up-front risks.

Comparison of Therapeutic Efficacy Between Isolated Encephaloduroarteriosynangiosis and Medical Treatment in Patients with Atherosclerotic Middle Cerebral Artery Occlusion.

BACKGROUND: Encephaloduroarteriosynangiosis (EDAS) as a form of indirect revascularization has been recently proposed as a potentially promising alternative for patients with intracranial atherosclerotic disease (ICAD). The object of this study was to compare the prognostic roles between isolated EDAS and medical therapy in patients with atherosclerotic middle cerebral artery occlusion (MCAO). METHODS: From January 2014 to June 2017, 125 patients with atherosclerotic MCAO were enrolled in this prospective nonrandomized controlled cohort study. Patients who underwent EDAS (n = 60) were compared with those treated medically (n = 65). Early and late adverse events and functional outcomes including memory ability were compared between groups. RESULTS: During 23.7 months of mean follow-up, rates of adverse events, including ischemic events in the territory of the qualifying middle cerebral artery, and death from any causes, were not significantly different in patients treated with EDAS and with medical therapy (6.7% vs. 12.3%; P = 0.285). Landmark analyses showed that at initial 6-month follow-up, there was no significant difference for adverse event rates, whereas the opposite finding was shown for the subsequent period (EDAS 1/57 [1.7%] vs. medical management 7/64 [10.9%]; P = 0.024). The P value for the interaction between time (first 6 months vs. subsequent period) was 0.044. No significant differences were found with respect to neural function status and cognitive ability. CONCLUSIONS: In the long-term, isolated EDAS can be considered effective and safe for patients with atherosclerotic MCAO, whereas it may need additional medical therapy support in the short-term.

Low Morbidity after Extracranial-Intracranial Bypass Operation. The Danish Extracranial-Intracranial Bypass Study: A Nationwide Survey.

BACKGROUND: Patients with symptomatic atherosclerotic carotid artery occlusion (SACAO) have a high risk of a recurrent stroke. Extracranial-intracranial bypass (EC-IC bypass) has been shown not to improve outcome compared with medical treatment alone because long-term prevention of recurrent stroke in operated patients was offset by high perioperative stroke rates. We report our experience with EC-IC bypass operated at an experienced high-volume centre. METHODS: We conducted a nationwide observational study of EC-IC bypass patients operated in the years 2007-2016 due to SACAO with ongoing clinical symptoms or progression on MRI and severe haemodynamic failure (SHF). Perioperative stroke and death within 30 days after the operation, ipsilateral stroke, bypass patency, transient ischaemic attack, and all-stroke events and deaths during long-term follow-up were registered prospectively. RESULTS: EC-IC bypass was performed in 48 patients with SHF and SACAO. The mean age was 64 (45-83) years. The mean follow-up was 3.6 years. The stroke rate after 30 days was 4.2%. No further ipsilateral strokes occurred during follow-up. Clinical symptoms arrested in all patients. Bypass patency rate was 94%. CONCLUSIONS: The perioperative stroke rate in EC-IC bypass operation, performed at a highly experienced centre, was low. During long-term follow-up, no ipsilateral stroke occurred. Consequently, EC-IC-bypass should still be considered for selected patients with SACAO, if operation can be carried out in experienced centres with low perioperative morbidity.

Impact of Hospital Caseload and Elective Admission on Outcomes After Extracranial-Intracranial Bypass Surgery.

BACKGROUND: Limited information exists evaluating the impact of hospital caseload and elective admission on outcomes after patients have undergone extracranial-intracranial (ECIC) bypass surgery. Using the Nationwide Inpatient Sample (NIS) for 2001-2014, we evaluated the impact of hospital caseload and elective admission on outcomes after bypass. METHODS: In an observational cohort study, weighted estimates were used to investigate the association of hospital caseload and elective admission on short-term outcomes after bypass surgery using multivariable regression techniques. RESULTS: Overall, 10,679 patients (mean age, 43.39 ± 19.63 years; 59% female) underwent bypass across 495 nonfederal U.S. hospitals. In multivariable models, patients undergoing bypass at high-volume centers were associated with decreased probability of mortality (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.22-0.70; P < 0.001), length of stay (OR, 0.86; 95% CI, 0.82-0.90; P < 0.001), postbypass neurologic complications (OR, 0.66; 95% CI, 0.49-0.89; P = 0.007), venous thromboembolism (OR, 0.69; 95% CI, 0.49-0.97; P = 0.033), and acute renal failure (OR, 0.45; 95% CI, 0.26-0.80; P = 0.007), and higher hospitalization cost (26.3% higher) compared with low-volume centers. Likewise, patients undergoing elective bypass were associated with decreased likelihood of mortality (OR, 0.38; 95% CI, 0.25-0.59; P < 0.001), unfavorable discharge (OR, 0.57; 95% CI, 0.43-0.76; P < 0.001), length of stay (OR, 0.62; 95% CI, 0.59-0.64; P < 0.001), venous thromboembolism (OR, 0.61; 95% CI, 0.49-0.77; P < 0.001), acute renal failure (OR, 0.64; 95% CI, 0.43-0.94; P = 0.022), wound complications (OR, 0.71; 95% CI, 0.53-0.96; P = 0.028), and lower hospitalization cost (34.5% lower) compared with nonelective admissions. CONCLUSIONS: Our findings serve as a framework for strengthening referral networks for complex cases to centers performing high volumes of cerebral bypass. Also, our study supports improved outcomes in select patients undergoing elective bypass procedures.

Anesthesia-Related Outcomes for Endovascular Stroke Revascularization: A Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: There is currently controversy on the ideal anesthesia strategy during mechanical thrombectomy for acute ischemic stroke. We performed a systematic review and meta-analysis of studies comparing clinical and angiographic outcomes of patients undergoing general anesthesia (GA group) and those receiving either local anesthesia or conscious sedation (non-GA group). METHODS: A literature search on anesthesia and endovascular treatment of acute ischemic stroke was performed. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome at 90 days (modified Rankin Score≤2), symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, and time to groin puncture. RESULTS: Twenty-two studies (3 randomized controlled trials and 19 observational studies), including 4716 patients (1819 GA and 2897 non-GA) were included. In the nonadjusted analysis, patients in the GA group had higher odds of death (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.66-2.45) and respiratory complications (OR, 1.70; 95% CI, 1.22-2.37) and lower odds of good functional outcome (OR, 0.58; 95% CI, 0.48-0.64) compared with the non-GA group. There was no difference in procedure time between the 2 primary comparison groups. When adjusting for baseline National Institutes of Health Stroke Scale, GA was still associated with lower odds of good functional outcome (OR, 0.59; 95% CI, 0.29-0.94). When considering studies performed in the stent-retriever/aspiration era, there was no significant difference in good neurological outcome rates (OR, 0.84; 95% CI, 0.67-1.06). CONCLUSIONS: Acute ischemic stroke patients undergoing intra-arterial therapy may have worse outcomes when treated with GA as compared with conscious sedation/local anesthesia. However, major limitations of current evidence (ie, retrospective studies and selection bias) indicate a need for adequately powered, multicenter randomized controlled trials to answer this question.

Safety and Efficacy of Surgical and Endovascular Treatment for Distal Anterior Cerebral Artery Aneurysms: A Systematic Review and Meta-Analysis.

BACKGROUND: Aneurysms of the distal anterior cerebral artery (DACA) are rare, representing between 1% and 9% of all intracranial aneurysms. The best treatment strategy for these aneurysms continues to be debated. OBJECTIVE: We conducted a systematic review of the literature to evaluate the safety and efficacy of treatment strategies of DACA aneurysms. METHODS: A systematic search of Medline, Embase, Scopus, and Web of Science was performed for studies published from January 2000 to August 2015. We included studies describing treatment of DACA aneurysms with ≥10 patients. Random effects meta-analysis was used to pool the following outcomes: complete occlusion, technical success, periprocedural morbidity/mortality and stroke rates, aneurysm recurrence/rebleed, and long-term neurologic morbidity/mortality. RESULTS: Thirty studies with 1329 DACA aneurysms were included. Complete occlusion was 95% (95% confidence interval [CI], 91.0%-97.0%) in the surgical group and 68% (95% CI, 56.0%-78.0%) in the endovascular group (P < 0.0001). Aneurysm recurrence occurred in 3% (95% CI, 2.0%-4.0%) after surgery and in 19.1% (95% CI, 12.0%-27.0%) after endovascular treatment (P < 0.0001). Overall neurologic morbidity and mortality were 15% (95% CI, 11.0%-21.0%) and 9% (95% CI, 7.0%-11.0%) after surgery and 14% (95% CI, 10.0%-19.0%) (P = 0.725) and 7% (95% CI, 5.0%-10.0%) (P = 0.422) after endovascular treatment, respectively. Overall long-term favorable neurologic outcome was 80% and it was equal in both groups (80%; 95% CI, 73.0%-85.0% in the surgical group and 80%; 95% CI, 72.0%-87.0% in the endovascular group) (P = 0.892). CONCLUSIONS: Our meta-analysis showed that both treatment modalities are technically feasible and effective with sufficient long-term aneurysm occlusion and acceptable recurrence/rebleed rates. Surgical treatment is associated with superior angiographic outcomes. There were no substantial differences in procedure-related morbidity and mortality. These findings are important because they suggest that therapy of DACA aneurysms should be performed on a selective, case-by-case basis to maximize patient benefits.

Intracranial Carotid Artery Calcification Relates to Recanalization and Clinical Outcome After Mechanical Thrombectomy.

BACKGROUND AND PURPOSE: Intracranial carotid artery calcification (ICAC) is a surrogate marker of intracranial arteriosclerosis, which may impact the revascularization and clinical outcome of acute stroke patients who undergo mechanical thrombectomy. METHODS: We included 194 patients admitted to our Stroke Unit between January 2009 and September 2015 who underwent mechanical thrombectomy for an anterior circulation occlusion. ICAC was quantified in both intracranial carotid arteries on the nonenhanced computed tomographic scan that was acquired before thrombectomy. Complete arterial revascularization was defined as a Thrombolysis in Cerebral Infarction ≥2b on the final angiographic examination. Poor functional outcome was defined as a modified Rankin Scale score of >2 at 90 days. We assessed the independent effect of ICAC volume on complete arterial revascularization, functional outcome, and mortality using logistic regression models adjusted for relevant confounders. RESULTS: ICAC was present in 164 (84.5%) patients, with a median volume of 87.1 mm3 (25th-75th quartile: 18.9-254.6 mm3). We found that larger ICAC volumes were associated with incomplete arterial revascularization (adjusted odds ratio per unit increase in ln-transformed ICAC volume 0.73 [95% confidence interval, 0.57-0.93]) and with poorer functional outcome (adjusted odds ratio per unit increase in ln-transformed ICAC volume 1.31 [95% confidence interval, 1.04-1.66]). CONCLUSIONS: A larger amount of ICAC before mechanical thrombectomy in acute stroke patients is an indicator of worse postprocedural arterial revascularization and poorer functional outcome.

The Carotid and Middle cerebral artery Occlusion Surgery Study (CMOSS): a study protocol for a randomised controlled trial.

BACKGROUND: Patients with symptomatic internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion with haemodynamic insufficiency are at high risk for recurrent stroke when treated medically. METHODS: The Carotid or Middle cerebral artery Occlusion Surgery Study (CMOSS) trial is an ongoing, government-funded, prospective, multicentre, randomised controlled trial. The CMOSS will recruit 330 patients with symptomatic ICA or MCA occlusion (parallel design, 1:1 allocation ratio) and haemodynamic insufficiency. Participants will be allocated to best medical treatment alone or best medicine plus extracranial-intracranial (EC-IC) bypass surgery. The primary outcome events are all strokes or deaths occurring between randomisation and 30 days post operation or post randomisation and ipsilateral ischaemic stroke within 2 years. Recruitment will be finished by December 2016. All the patients will be followed for at least 2 years. The trial is scheduled to complete in 2019. DISCUSSION: The CMOSS will test the hypothesis that EC-IC bypass surgery plus best medical therapy reduces subsequent ipsilateral ischaemic stroke in patients with symptomatic ICA or MCA occlusion and haemodynamic cerebral ischaemia. This manuscript outlines the rationale and the design of the study. CMOSS will allow for more critical reappraisal of the EC-IC bypass for selected patients in China. TRIAL REGISTRATION: NCT01758614 with ClinicalTrials.gov. Registered on 24 December 2012.

Is Carotid Revascularization Safe for Patients with Concomitant Carotid Stenosis and Intracranial Aneurysms?

OBJECTIVE: The safety of carotid revascularization in patients with concomitant extracranial carotid stenosis and cerebral aneurysm is rarely reported. We examine the risk of subarachnoid hemorrhage, aneurysm growth, ipsilateral transient ischemic attack, or stroke after revascularization in patients with both carotid stenosis and cerebral aneurysms. METHODS: A retrospective cohort study of patients with concomitant diagnosis of aneurysm and carotid stenosis evaluated in the neurosurgical department at our institution from 1990 to 2013 was carried out. Patients with both revascularized and nonrevascularized carotid stenosis were included. Demographic and angiographic characteristics, medical history, and treatment outcomes were collected. Comparison was made between the following 2 groups: revascularized carotid stenosis with stent or carotid endarterectomy versus nonrevascularized carotid stenosis. RESULTS: The study cohort consisted of 39 patients with 48 stenotic cervical internal carotid arteries and 51 cerebral aneurysms. Twenty patients (51.3%) underwent carotid endarterectomy/stenting, and 19 (48.7%) were managed medically. Patient characteristics were similar across the 2 groups except for increased severity of carotid stenosis (P < 0.001) and more posterior circulation aneurysms (P = 0.045) in the revascularized group. Ipsilateral stenosis and aneurysm was observed in 9 cases (40.9%) in the revascularized group and in 11 cases (42.3%) in the nonrevascularized group. During average follow-up of 1.62 years, no aneurysm rupture was observed. One ipsilateral stroke occurred in the revascularized group during follow-up, corresponding to an annual risk of 2.0%. One aneurysm enlargement occurred per group, with both located in the posterior circulation. CONCLUSIONS: Our study suggests that revascularization procedures for carotid stenosis should be considered safe and effective in patients with concomitant extracranial carotid occlusive disease and cerebral aneurysms.

Alberta Stroke Program Early CT Score applied to CT angiography source images is a strong predictor of futile recanalization in acute ischemic stroke.

INTRODUCTION: Reliable predictors of poor clinical outcome despite successful revascularization might help select patients with acute ischemic stroke for thrombectomy. We sought to determine whether baseline Alberta Stroke Program Early CT Score (ASPECTS) applied to CT angiography source images (CTA-SI) is useful in predicting futile recanalization. METHODS: Data are from the FUN-TPA study registry (ClinicalTrials.gov; NCT02164357) including patients with acute ischemic stroke due to proximal arterial occlusion in anterior circulation, undergoing reperfusion therapies. Baseline non-contrast CT and CTA-SI-ASPECTS, time-lapse to image acquisition, occurrence, and timing of recanalization were recorded. Outcome measures were NIHSS at 24 h, symptomatic intracranial hemorrhage, modified Rankin scale score, and mortality at 90 days. Futile recanalization was defined when successful recanalization was associated with poor functional outcome (death or disability). RESULTS: Included were 110 patients, baseline NIHSS 17 (IQR 12; 20), treated with intravenous thrombolysis (IVT; 45 %), primary mechanical thrombectomy (MT; 16 %), or combined IVT + MT (39 %). Recanalization rate was 71 %, median delay of 287 min (225; 357). Recanalization was futile in 28 % of cases. In an adjusted model, baseline CTA-SI-ASPECTS was inversely related to the odds of futile recanalization (OR 0.5; 95 % CI 0.3-0.7), whereas NCCT-ASPECTS was not (OR 0.8; 95 % CI 0.5-1.2). A score ≤5 in CTA-SI-ASPECTS was the best cut-off to predict futile recanalization (sensitivity 35 %; specificity 97 %; positive predictive value 86 %; negative predictive value 77 %). CONCLUSIONS: CTA-SI-ASPECTS strongly predicts futile recanalization and could be a valuable tool for treatment decisions regarding the indication of revascularization therapies.

Flow-diverter devices in the treatment of intracranial aneurysms: A meta-analysis and systematic review.

OBJECTIVE: The purpose of this report was to discuss the overall limitations, safety and efficacy of flow-diverter stenting for intracranial aneurysms. METHODS: The authors performed a meta-analysis from January 2009 to September 2014 using the terms "flow diverter" and "intracranial aneurysms." Additional studies were identified through references in each reviewed article. Data extraction, performed independently by the authors, included demographic data, technical and clinical complications, morbidity and mortality, aneurismal occlusion rates related to flow-diverter devices. The analysis was performed using a fixed effect. RESULTS: Twenty-nine studies with 1524 patients and three to 62 months of follow-up were identified for analysis. The overall technical failure and complication rate was 9.3% (95% CI 6%-12.6%). The rate of procedure-related complication was 14% (95% CI 10.2%-17.9%) and 6.6% (95% CI 4%-9.1%) for morbidity and mortality. Fusiform, dissecting and circumferential aneurysm (OR 3.10, 95% CI 0.93-10.37) were significant risk factors for technical failure and complication. Posterior circulation location (OR 4.03, 95% CI 2.45-6.61), peripheral location (OR 2.74, 95% CI 1.52-4.94) and fusiform, dissecting and circumferential aneurysm (OR 1.95, 95% CI 1.15-3.30) were statistically significant risk factors for procedure-related complications. Posterior circulation location (OR 4.39, 95% CI 2.44-7.90) and peripheral location (OR 3.64, 95% CI 1.74-7.62) were statistically significant risk factors for morbidity and mortality. CONCLUSIONS: Fusiform, dissecting and circumferential aneurysm, posterior circulation and peripheral locations have greater procedure-related complications.

Direct Microsurgical Embolectomy for Acute Occlusion of the Internal Carotid Artery and Middle Cerebral Artery.

BACKGROUND: Surgical embolectomy is the most promising therapy for physically removing emboli from major cerebral arteries. However, it requires an experienced surgical team, time-consuming steps, and is not incorporated into acute stroke therapy. METHODS: We established seamless collaboration between services, refined surgical techniques, and conducted a prospective trial of emergency surgical embolectomy. Surgical indications included the presence of acute hemispheric symptoms, absence of low-density area on computed tomography, evidence of internal carotid artery terminus or proximal middle cerebral artery occlusion, and availability of resources to start surgery within 3 hours of symptom onset. The indications were confirmed by an interdisciplinary team. We assessed revascularization rates, time from admission to surgery and from surgery to recanalization, procedural complications, and clinical outcomes. RESULTS: Between 2005 and 2014, 14 consecutive patients with acute proximal middle cerebral artery or internal carotid artery terminus occlusion underwent emergency surgical embolectomy. All patients showed complete recanalization. Twelve patients survived and 7 had fair functional outcome (Rankin Scale score, ≤3). No significant procedural adverse events occurred. The mean times from admission to start of surgery, from surgery to recanalization, and from onset to recanalization were 14 minutes, 79 minutes, and 223 minutes, respectively. CONCLUSIONS: Our results suggest that microsurgical embolectomy can rapidly, safely, and effectively retrieve clots and deserves reappraisal, although the choice largely depends on local institutional expertise.

Predictors of Mortality in Acute Ischemic Stroke Intervention: Analysis of the North American Solitaire Acute Stroke Registry.

BACKGROUND AND PURPOSE: Failure to recanalize predicts mortality in acute ischemic stroke. In the North American Solitaire Acute Stroke registry, we investigated parameters associated with mortality in successfully recanalized patients. METHODS: Logistic regression was used to evaluate baseline characteristics and recanalization parameters for association with 90-day mortality. A multivariable model was developed based on backward selection with retention criteria of P<0.05 from factors with at least marginal significance (P≤0.10), then refit to minimize the number of excluded cases (missing data). RESULTS: Successfully recanalized patients had lower mortality (25.2% [59/234] versus 46.9% [38/81] P<0.001). There was no difference in symptomatic intracranial hemorrhage between patients with successful versus failed recanalization (9% [21/234] versus 14% [11/79]; P=0.205). However, mortality was significantly higher in patients with symptomatic intracranial hemorrhage (72% [23/32] versus 26% [73/281]; P<0.001). Proximal occlusion (internal carotid artery or vertebrobasilar), initial National Institutes of Health Stroke Scale≥18, use of rescue therapy (P<0.05), and 3+ passes (P<0.10) were associated with mortality in recanalized patients. In the multivariate model with good predictive power (c index=0.72), proximal occlusion, initial National Institutes of Health Stroke Scale≥18, and use of rescue therapy remained significant independent predictors of 90-day mortality. CONCLUSIONS: Failure to recanalize and presence of symptomatic intracranial hemorrhage resulted in increased mortality. Despite successful recanalization, proximal occlusion, high National Institutes of Health Stroke Scale, and need for rescue therapy were predictors of mortality.

Functional outcomes and recanalization rates of stent retrievers in acute ischaemic stroke: A systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Intra-arterial therapy for acute ischaemic stroke has evolved rapidly in the last few years. Stent retrievers have now replaced 'first-generation' devices, which have been the principle devices tested in stroke trials.Our aims were to determine the rates of successful recanalization and functional independence in acute stroke patients treated with stent retrievers. We also sought to assess the safety outcomes of stent retrievers by assessing the rates of mortality and intra-cranial haemorrhage. MATERIALS AND METHODS: We conducted a systematic review and meta-analysis of studies which utilized stent retrievers as sole treatment or as part of a multi-modal approach in acute ischaemic stroke. RESULTS: We identified 20 eligible studies: 17 on Solitaire (ev3/Covidien, Irvine, California, USA) (n = 762) and three on Trevo (Stryker, Kalamazoo, Michigan, USA) (n = 210). The mean age of participants was 66.8 (range 62.1-73.0) years and the M:F ratio was 1.1:1. The average stroke severity score (National Institutes of Health Stroke Scale (NIHSS)) at presentation was 17.2. The weighted mean symptom onset to arterial puncture and procedural duration were 265.4 minutes and 54.8 minutes, respectively.Successful recanalization was achieved in 84.5% of patients with a weighted mean of 2.0 stent retriever passes. Independent functional outcome was achieved in 51.2% and the mortality rate was 16.8%. CONCLUSION: Stent retrievers have the potential to achieve a high rate of recanalization and functional independence whilst being relatively safe. They should be assessed in well-designed randomized controlled trials to determine their efficacy and assess whether they compare favourably with 'standard treatment' in stroke.

Indications and results of direct cerebral revascularization in the modern era.

BACKGROUND: There has been a progressive decrease in the indications for cerebral revascularization during the past 30 years, particularly with the advance of endovascular techniques. Our objective was to define indications for and evaluate outcomes of patients treated with bypass surgery in the modern endovascular era. METHODS: We retrospectively reviewed the charts of all patients who underwent direct cerebral revascularization procedures between January 2006 and March 2013. RESULTS: In total, 121 patients underwent 131 direct microsurgical revascularization procedures. The indications for bypass surgery were moyamoya angiopathy (40 patients, 47 bypasses), complex aneurysms (54 patients, 56 bypasses), and occlusive vascular disease (27 patients, 28 bypasses). Revascularization resulted in improvement of symptoms in 77.5% of patients with moyamoya angiopathy (mean clinical follow-up 18.8 months) and 55.5% of patients with occlusive vascular disease (mean clinical follow-up 10.4 months). Among the aneurysm patients treated with revascularization, 81.5% had a favorable outcome (Glasgow Outcome Scale score 4-5) at long-term follow-up (mean clinical followup 18.5 months). CONCLUSIONS: Although microvascular cerebral revascularization is no longer performed as commonly as in the past, it remains an essential part of the skill set required to treat select vascular pathologies. Complex aneurysms are the single largest indication for direct bypass procedures. Moyamoya disease is by far the largest indication if indirect bypass procedures are included in the analysis. In experienced hands, the morbidity and mortality of patients undergoing cerebral revascularization procedures are low and long-term outcomes generally excellent.

Influence of age on clinical and revascularization outcomes in the North American Solitaire Stent-Retriever Acute Stroke Registry.

BACKGROUND AND PURPOSE: The Solitaire With the Intention for Thrombectomy (SWIFT) and thrombectomy revascularization of large vessel occlusions in acute ischemic stroke (TREVO 2) trial results demonstrated improved recanalization rates with mechanical thrombectomy; however, outcomes in the elderly population remain poorly understood. Here, we report the effect of age on clinical and angiographic outcome within the North American Solitaire-FR Stent-Retriever Acute Stroke (NASA) Registry. METHODS: The NASA Registry recruited sites to submit data on consecutive patients treated with Solitaire-FR. Influence of age on clinical and angiographic outcomes was assessed by dichotomizing the cohort into ≤80 and >80 years of age. RESULTS: Three hundred fifty-four patients underwent treatment in 24 centers; 276 patients were ≤80 years and 78 were >80 years of age. Mean age in the ≤80 and >80 cohorts was 62.2±13.2 and 85.2±3.8 years, respectively. Of patients >80 years, 27.3% had a 90-day modified Rankin Score ≤2 versus 45.4% ≤80 years (P=0.02). Mortality was 43.9% and 27.3% in the >80 and ≤80 years cohorts, respectively (P=0.01). There was no significant difference in time to revascularization, revascularization success, or symptomatic intracranial hemorrhage between the groups. Multivariate analysis showed age >80 years as an independent predictor of poor clinical outcome and mortality. Within the >80 cohort, National Institutes of Health Stroke Scale (NIHSS), revascularization rate, rescue therapy use, and symptomatic intracranial hemorrhage were independent predictors of mortality. CONCLUSION: Greater than 80 years of age is predictive of poor clinical outcome and increased mortality compared with younger patients in the NASA registry. However, intravenous tissue-type plasminogen activator use, lower NIHSS, and shorter revascularization time are associated with better outcomes. Further studies are needed to understand the endovascular therapy role in this cohort compared with medical therapy.