Oclusión basilar pediátrica tratada mediante trombectomía con stents extractores / A paediatric case of basilar occlusion treated with mechanical thrombectomy using stent retrievers

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Recanalization and mortality rates of thrombectomy with stent-retrievers in octogenarian patients with acute ischemic stroke.

BACKGROUND: Our objective was to evaluate the effect of treatment with stent-retrievers in octogenarians suffering an acute ischemic stroke. METHODS: A total of 150 consecutive patients with acute stroke who were treated with stent-retrievers between April 2010 and June 2012 were retrospectively reviewed. Patients were divided into those <80 years old (n = 116) and those ≥80 (n = 34). Baseline characteristics, procedure data, and endpoints (postprocedural NIHSS, death, and mRS at 3 months) were compared. RESULTS: High blood pressure, atrial fibrillation, and anticoagulation were more frequent in octogenarians (p = 0.01, 0.003, and 0.04 respectively). There were no differences between both groups regarding previous intravenous thrombolysis (32.4 vs. 48.3 %, p = 0.1), preprocedural NIHSS (18.1 vs. 16.8, p = 0.3), procedure time (74.5 (40-114) min vs. 63 (38-92) min, p = 0.2), revascularization time (380.5 (298-526.3) min vs. 350 (296.3-452.8), p = 0.3), TICI ≥ 2B (88.2 vs. 93.9 %, p = 0.1), and symptomatic haemorrhage (5.9 vs. 2.6 %, p = 0.3). Discharge NIHSS was higher in octogenarians (9.7 vs. 6.5, p = 0.03). Death and 3-month mRS ≥3 were more frequent in octogenarians (35.3 vs. 17.2 %, p = 0.02 and 73.5 vs. 37.1 %, p = 0.02). ICA-involvement and prolonged revascularization involved higher mortality (66.7 vs. 27.6 %, p = 0.03) and worse mRS (50 vs. 24.4 %, p = 0.06) in octogenarians. CONCLUSIONS: In our series, treatment with stent-retrievers in octogenarians with acute ischemic stroke achieved good rates of recanalization but with a high mortality rate. ICA involvement and revascularization times beyond 6 hours associated to a worse prognosis. These data might be of value in the design of prospective studies evaluating the clinical efficacy of the endovascular treatments in octogenarians.

Comparison between proximal versus distal protection devices in 287 cases of carotid revascularization using angioplasty and stenting: periprocedure complications, morbidity, and mortality.

BACKGROUND: Embolic protection devices may decrease periprocedural thromboembolic complications during carotid angioplasty and stenting (CAS). When using proximal-protection devices (PPDs), protection starts before crossing the lesion. However, in the medical literature, its use is scarcely reported compared with that of distal-protection filters (DPDs). The objective of this study was to compare periprocedure complications, morbidity, and mortality among 287 consecutive cases of CAS performed with PPDs or DPDs. PATIENTS AND METHODS: This was a retrospective analysis of 287 patients treated with CAS at our hospital between January 2006 and March 2012. Periprocedure complications, morbidity, and mortality at 30 days, including ischemic stroke or transient ischemic attack, reperfusion syndrome, myocardial infarction (MI), and death, were globally registered, and the results in PPD and DPD groups were compared. RESULTS: Two hundred eight patients were treated with DPD and 79 with PPD; 80.8 % were symptomatic. CAS procedures performed with PPD presented a statistically significant greater grade of stenosis than those with DPD (82.5 vs. 74.5 %, p < 0.001). Death rates were 1.9 and 1.3 %; stroke rates were 4.3 and 3.8 %; MI rates were 1.4 and 1.3 %; and total morbidity and mortality rates were 6.2 and 5 % (DPD and PPD groups, respectively); all differences were nonstatistically significant. No statistical difference was found between symptomatic and asymptomatic patients. CONCLUSION: Carotid angioplasty and stenting is a safe procedure to treat carotid disease in our patients. PPDs are not always associated with a greater risk of periprocedure complications, morbidity, and mortality than DPDs despite the greater grade of carotid stenosis in the PPD group. This observation may be of interest in the design of future studies with CAS.

Manifestaciones neurológicas de los mixomas cardiacos. Experiencia en un centro de referencia / Neurological manifestations of cardiac myxoma: Experience in a referral hospital

Introducción: El mixoma cardiaco es una causa poco frecuente pero importante de infarto cerebral en pacientes jóvenes. Existen pocas series de pacientes que analicen la frecuencia de las manifestaciones neurológicas en pacientes con mixoma y su presentación clínica. Objetivo: Conocer las complicaciones neurológicas del mixoma cardiaco en nuestro hospital durante los últimos 28 años. Pacientes y métodos: Revisión retrospectiva de las manifestaciones neurológicas de 36 pacientes operados de mixoma cardiaco con confirmación patológica en nuestro centro desde diciembre de 1983 hasta marzo del 2012. Resultados: Ocho de los 36 pacientes con mixomas cardiacos (22%) intervenidos en nuestro centro presentaron clínica neurológica. El 50% eran mujeres y la edad media ± desviación estándar de 52,4 ± 11,6 años. El síntoma neurológico más frecuente fue la hemiparesia de aparición brusca (63%). El ictus isquémico establecido fue la manifestación clínica más frecuente (75%), seguido del accidente isquémico transitorio. El territorio más afectado fue el de la arteria cerebral media. En todos los casos se alcanzó el diagnóstico del tumor mediante ecocardiografía. El tamaño medio del mixoma fue de 4,12 cm. La mayoría (63%) presentaba una superficie polipoide. Todos los tumores fueron resecados quirúrgicamente con éxito. No hubo muertes hospitalarias. Conclusiones: Los mixomas cardíacos comienzan frecuentemente con manifestaciones neurológicas, en particular como eventos isquémicos (AIT o ictus establecidos) en pacientes jóvenes y sin factores de riesgo cardiovascular. El territorio anterior, en especial la arteria cerebral media, suele estar más frecuentemente afectado. La ecocardiografía puede facilitar el diagnóstico y permitir un tratamiento precoz de la lesión (AU)

Introduction: Cardiac myxoma is an important but uncommon cause of stroke in younger patients. Few published case series analyse the frequency and clinical presentation of neurological complications in patients with myxoma. Objective: To list all neurological complications from cardiac myxoma recorded in our hospital in the past 28 years. Patients and methods: We retrospectively reviewed the neurological manifestations of cardiac myxoma in patients treated in our hospital between December 1983 and March 2012. Results: Of the 36 patients with cardiac myxoma, 8 (22%) presented neurological manifestations. Half were women and mean age of patients was 52.4 ± 11.6 years. Sudden-onset hemiparesis was the most frequent neurological symptom (63%). Established ischaemic stroke was the most common clinical manifestation (75%), followed by transient ischemic attack. The most commonly affected territory corresponded to the middle cerebral artery. Myxoma was diagnosed by echocardiography in all cases. Mean myxoma size was 4.1 cm and most of the tumours (63%) had a polypoid surface. All tumours were successfully removed by surgery. There were no in-hospital deaths. Conclusions: Cardiac myxomas frequently present with neurological symptoms, especially ischaemic events (established stroke or transient ischaemic attack), in younger patients with no cardiovascular risk factors. The anterior circulation is more frequently affected, especially the middle cerebral artery. Echocardiography can facilitate prompt diagnosis and early treatment of the lesion (AU)

Neurological manifestations of cardiac myxoma: experience in a referral hospital.

INTRODUCTION: Cardiac myxoma is an important but uncommon cause of stroke in younger patients. Few published case series analyse the frequency and clinical presentation of neurological complications in patients with myxoma. OBJECTIVE: To list all neurological complications from cardiac myxoma recorded in our hospital in the past 28 years. PATIENTS AND METHODS: We retrospectively reviewed the neurological manifestations of cardiac myxoma in patients treated in our hospital between December 1983 and March 2012. RESULTS: Of the 36 patients with cardiac myxoma, 8 (22%) presented neurological manifestations. Half were women and mean age of patients was 52.4 ± 11.6 years. Sudden-onset hemiparesis was the most frequent neurological symptom (63%). Established ischaemic stroke was the most common clinical manifestation (75%), followed by transient ischemic attack. The most commonly affected territory corresponded to the middle cerebral artery. Myxoma was diagnosed by echocardiography in all cases. Mean myxoma size was 4.1cm and most of the tumours (63%) had a polypoid surface. All tumours were successfully removed by surgery. There were no in-hospital deaths. CONCLUSIONS: Cardiac myxomas frequently present with neurological symptoms, especially ischaemic events (established stroke or transient ischaemic attack), in younger patients with no cardiovascular risk factors. The anterior circulation is more frequently affected, especially the middle cerebral artery. Echocardiography can facilitate prompt diagnosis and early treatment of the lesion.

Treatment of acute vertebrobasilar occlusion using thrombectomy with stent retrievers: initial experience with 18 patients.

BACKGROUND AND PURPOSE: Acute vertebrobasilar occlusion is an ominous disease with few proved effective treatments. Experience with stent retrievers is scarce and limited to combined therapies (stent retrievers associated with previous intravenous fibrinolysis, intra-arterial thrombolysis, or other mechanical devices). We present our experience with 18 patients treated with direct thrombectomy by using stent retrievers. MATERIALS AND METHODS: Eighteen patients with vertebrobasilar occlusion were treated with direct thrombectomy by using stent retrievers at our hospital. The mean age was 67.5 years. Clinical presentation was sudden deterioration in consciousness level in 61.2% and progressive or fluctuating brain stem symptoms in 38.8%. Stroke subtype (TOAST) was atherothrombotic (33.3%), undetermined (33.3%), cardioembolic (27.7%), and of unusual etiology (5.5%). RESULTS: The occlusion site was the vertebral artery in 1 case, proximal basilar artery in 4, middle basilar artery in 6, distal basilar artery in 5, and unilateral posterior cerebral artery in 2 cases. SRs included the Solitaire AB in 8 cases, Solitaire FR in 5 cases, and Trevo Pro in 5 cases. An 8F Merci balloon guide catheter was used in 15 patients, and a Neuron 6F, in 3 patients. Post-clot retrieval definitive intracranial stents were used in 5 patients (27.7%). Postprocedural TICI ≥ 2b was achieved in 17 patients (94.4%). Clinically, 72.2% of patients experienced an improved NIHSS score at discharge, 22.2% died, and in 5.5% the NIHSS scores did not change. The mRS score at 3 months was 0-2 in 9 patients (50%) and 3-5 in 5 patients (27.7%). CONCLUSIONS: Thrombectomy with stent retrievers is feasible in the treatment of vertebrobasilar occlusion. These initial results must be confirmed by further prospective studies with a larger number of cases.

Hemorrhage/contrast staining areas after mechanical intra-arterial thrombectomy in acute ischemic stroke: imaging findings and clinical significance.

BACKGROUND AND PURPOSE: The aim of this study was to report the CT evolution and clinical significance of HCA after intra-arterial mechanical thrombectomy (revascularization by using retrievers and/or other mechanical devices without concomitant delivery of intra-arterial thrombolytics) in our patients. These lesions are common after intra-arterial thrombolysis, being considered a negative prognostic sign. Their significance after pure mechanical thrombectomy remains unknown. MATERIALS AND METHODS: Forty-eight patients were treated with mechanical thrombectomy by using retrievable stents between April 2010 and February 2011. All patients underwent initial (first 24 hours) and follow-up (48-72 hours) nonenhanced CT. We retrospectively analyzed the clinical and radiologic data of the patients with HCA and compared them with controls. RESULTS: Fifteen of 48 patients presented with HCA. The site of occlusion was the MCA in 7 patients, both the extra- and intracranial segments of the ICA in 6, and the intracranial ICA in 2. In 7 patients, previous intravenous thrombolysis was administered. Complete recanalization (TICI 3) was achieved in 12 patients, and incomplete recanalization (TICI 2b), in 3. The location of HCA was the subarachnoid space in 6 patients, the brain parenchyma in 4 patients, and both in 5 patients. The HCA were asymptomatic in all patients. There was no statistical difference in final NIHSS score reduction (NIHSS pretreatment-NIHSS at discharge) between patients and controls. CONCLUSIONS: In our series, HCA are common after mechanical thrombectomy but do not carry an increased risk of symptomatic hemorrhage or negative prognosis. These data might be related to the high rate of recanalization and the absence of intra-arterial thrombolytics.