Aggressive therapy with intravenous abciximab and intra-arterial rtPA and additional PTA/stenting improves clinical outcome in acute vertebrobasilar occlusion: combined local fibrinolysis and intravenous abciximab in acute vertebrobasilar stroke treatment (FAST): results of a multicenter study.

BACKGROUND AND PURPOSE: A combined therapy of local recombinant tissue plasminogen activator (rtPA) fibrinolysis and intravenous Abciximab platelet inhibition with additional percutaneous transluminal angioplasty (PTA)/stenting may improve recanalization and neurological outcome in patients with acute vertebrobasilar occlusion. METHODS: Combined FAST therapy consisted on intravenous bolus of Abciximab (0.25 mg/kg) followed by a 12-hour infusion therapy (0.125 microg/kg per minute) and low-dose intra-arterial rtPA (median dosage: 20 mg, FAST cohort: N=47). The results were compared with a retrospective cohort, treated by intraarterial rtPA monotherapy (median dosage: 40 mg, rtPA cohort, N=41). Additional PTA/stenting was performed in case of severe residual stenosis. Recanalization success was classified according to the Trials in Myocardial Infarction (TIMI) criteria: TIMI0/1, failed recanalization; TIMI2/3, successful recanalization. Bleeding complications were evaluated according to severe extracerebral hemorrhage (ECH), asymptomatic intracerebral hemorrhage (AIH), and symptomatic intracerebral hemorrhage (SIH). RESULTS: Overall bleeding rate was higher under the combined therapy, but the SIH rate did not differ (FAST versus rtPA: ECH, 3% versus 0%; AIH, 32% versus 22%; SIH 13% versus 12%). Additional PTA/stenting was performed in 14 (FAST) versus 5 (rtPA) patients. TIMI2/3 recanalization rate was similar (FAST, 72%; rtPA, 68%), but TIMI3 rate was remarkably higher under combined therapy (FAST, 45%; rtPA, N=22%). Neurologic outcome appeared better under combined therapy (FAST versus rtPA: favorable outcome rate: 34% versus 17%) with a significantly lower mortality rate (FAST versus rtPA: 38% versus 68%; P=0.006). These results were consistent for embolic and atherothrombotic occlusions. CONCLUSIONS: Combined therapy of intravenous Abciximab and half dose intra-arterial rtPA with additional PTA/stenting appears to improve neurologic outcome in acute vertebrobasilar occlusion despite an increase of overall bleeding complications.

Acute basilar artery occlusion treated with combined intravenous Abciximab and intra-arterial tissue plasminogen activator: report of 3 cases.

BACKGROUND: Acute vertebrobasilar occlusion remains a disease with a high mortality even after treatment by local intra-arterial fibrinolysis. Adjunctive treatment with platelet glycoprotein IIb/IIIa receptor inhibitors such as abciximab may facilitate recanalization and improve the neurological outcome. Results after treatment of 3 patients by combined intravenous abciximab and local intra-arterial tissue plasminogen activator (tPA) are reported. CASE DESCRIPTIONS: Treatment was performed within 6 hours of stroke onset. Angiography revealed embolic occlusion of the basilar artery in 2 patients and atherothrombotic occlusion at the vertebrobasilar junction in 1 patient. Therapy consisted of intravenous abciximab bolus administration (0.25 mg/kg) followed by 12-hour infusion therapy (0.125 microg/kg per minute) and local intra-arterial thrombolysis with tPA (10 mg/h). Heparin was only applied for catheter flushing (500 IU/h). The patient with the atherothrombotic occlusion was treated with additional percutaneous transluminal angioplasty and stenting. Complete recanalization of the basilar artery occurred in 2 patients, whose conditions improved clinically to functional independence. In the third patient only partial recanalization was seen, with only slight clinical improvement. This patient died of cardiac failure 2 months later. Besides a subtle subarachnoid hemorrhage (n=1), no intracranial or extracranial bleeding complication was observed. CONCLUSIONS: The combination of glycoprotein IIb/IIIa receptor inhibitor with local intra-arterial tPA might be a promising therapy for patients with acute vertebrobasilar occlusion. Further studies are necessary to define the clinical benefit and the bleeding rate of this new pharmacological approach.

Prediction of malignant middle cerebral artery infarction by early perfusion- and diffusion-weighted magnetic resonance imaging.

BACKGROUND AND PURPOSE: We tested the hypothesis that early diffusion- and perfusion-weighted MRI (DWI and PWI, respectively) allows the prediction of malignant middle cerebral artery (MCA) infarction (MMI). METHODS: Thirty-seven patients with acute MCA infarction and proximal vessel occlusion (carotid-T, MCA main stem) were studied by DWI, PWI, and MR angiography within 6 hours of symptom onset. Eleven patients developed MMI, defined by decline of consciousness and radiological signs of space-occupying brain edema. Lesion volumes were retrospectively defined as apparent diffusion coefficient <80% (ADC<80%) and time to peak >+4 seconds (TTP>+4s) compared with the unaffected hemisphere. ADC decrease within the infarct core (ADCcore) and relative ADC within the ADC<80% lesion (rADClesion) were measured. Neurological deficit at admission was assessed with the National Institutes of Health Stroke Scale (NIHSS). RESULTS: Patients with MMI showed larger ADC<80% (median, 157 versus 22 mL; P<0.001) and TTP>+4s (208 versus 125 mL; P<0.001) lesion volumes, smaller TTP/ADC mismatch ratio (1.5 versus 5.5; P<0.001), lower ADCcore values (290 versus 411 mm2/s; P<0.001), lower rADClesion (0.60 versus 0.66; P=0.001), higher frequency of carotid-T occlusion (64% versus 15%; P=0.006), and higher NIHSS score at admission (20 versus 15; P=0.001). Predictors of MMI were as follows for sensitivity and specificity, respectively: ADC<80% >82 mL, 87%, 91%; TTP>+4s >162 mL, 83%, 75%; TTP/ADC mismatch ratio <2.4, 80%, 79%; ADCcore <300 mm2/s, 83%, 85%; rADClesion <0.62, 79%, 74%; and NIHSS score at admission > or =19, 96%, 72%. CONCLUSIONS: Quantitative analysis of early DWI and PWI parameters allows the prediction of MMI and can help in the selection of patients for aggressive tissue-protective therapy.

Screening for cerebellopontine angle tumors: is a CISS sufficient?

This study attempted to evaluate the reliability of ultra-thin T2-weighted imaging with a constructive interference in steady state (CISS) sequence as a screening method for tumors in the cerebellopontine angle. A retrospective study of 200 CISS examinations was made by five investigators. The examinations were inspected on plain film supported by clinical information. The interobserver agreement in the detection of lesions was analyzed. Fourteen cases (50% of the contrast-enhancing lesions) were rated pathological by all five readers. One case of subarachnoid lymphoma infiltration was overlooked by all five readers. Overall, six pathological lesions (median = 6, range 1-9) were not identified. The interobserver agreement for all pathological lesions was moderate (kappa=0.53; 95% CI, 0.43-0.62). The mean sensitivity was 77.8% (range 72.0-96.3%), and the mean specificity was 97.6% (range 94.8-100%). The median sensitivity for pathological lesions concerning only patients with acute sensorineural hearing loss (n=148, patients with 20 contrast-enhancing cases) was 86.6% (range 80-100%), and median specificity was 95.2% (range 84.4-96.9%) with a moderate interobserver agreement (kappa=0.55; 95% CI, 0.44-0.66). In our opinion the CISS sequence is a valuable addition to the examination of the cerebellopontine angle but lacks sufficient reliability for the detection of tumors of small size or of tumors adjacent to brain parenchyma or the temporal bone.

Endovascular treatment of internal carotid artery stenosis: effect of primary stent application on debris particle release in human cadaveric specimens.

PURPOSE: To compare debris release with primary stent application (self-expanding stent application at stenosis and then balloon dilation through the opened stent) and that with secondary stent application (balloon angioplasty of stenosis and afterward additional stent application) for high-grade internal carotid artery stenosis in human cadaveric specimens. MATERIALS AND METHODS: Fresh human cadaveric internal carotid artery specimens were attached to a tube system. High-grade stenoses (>66%) were selected, randomized for primary or secondary stent application, and then treated, with fluoroscopic guidance, while the system was rinsed in a pulsating flow. Fluid was collected and filtered, and debris particles were examined with a light microscope. Particles were analyzed according to those consecutively caught by 100 x 100-microm and 11 x 11-microm mesh filters. Results were evaluated in relation to stent application. For statistical analyses of group differences, the exact Mann-Whitney U test was used. RESULTS: Thirteen high-grade human cadaveric internal carotid artery stenoses were analyzed. Five specimens were randomly assigned to secondary stent application, and eight were assigned to primary stent application. No significant difference could be demonstrated for debris release with primary or secondary stent application. P values ranged from.051 to.754. CONCLUSION: The reported superiority of primary stent application may not be related to debris reduction.