Abstract
Background
Mechanical thrombectomy devices have recently been developed and approved for recanalization of intracranial arterial occlusion. Here, we investigated the feasibility of combined stent-assisted and clot aspiration mechanical thrombectomy for effective recanalization of acute carotid terminus occlusion (CTO).
Methods
Ten consecutive patients with acute ischemic stroke secondary to CTO who underwent intra-arterial (IA) treatment with both stent retrieval and negative-pressured clot aspiration systems were enrolled. Periprocedural and radiologic findings and clinical outcomes were evaluated.
Results
The median age was 69 years (range, 47–86 years), and the median initial NIHSS score was 17.5 (range, 12–33). Mechanical thrombectomy was performed using a combination of the Solitaire stents and Penumbra system. Thrombolysis in cerebral ischemia [TICI] grade II–III was achieved in eight patients (80.0 %); complete recanalization of the CTO (TICI III) was achieved in three of those patients. Any type of intracranial hemorrhages occurred in four patients (40.0 %), but parenchymal hematoma type 2 was not observed. Four patients died within 3 months (40.0 %).
Conclusions
Combined mechanical thrombectomy treatment was effective for recanalization of acute CTO. The combination of Solitaire and Penumbra devices can be considered as a treatment option for CTO.
Similar content being viewed by others
References
Arnold M (2003) Intra-arterial thrombolysis in 24 consecutive patients with internal carotid artery T occlusions. J Neurol Neurosurg Psychiatry 74:739–742
Bose A, Henkes H, Alfke K, Reith W, Mayer TE, Berlis A, Branca V, Sit SP, Penumbra Phase 1 Stroke Trial Investigators (2008) The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism. AJNR Am J Neuroradiol 29:1409–1413
Castano C, Dorado L, Guerrero C, Millan M, Gomis M, Perez de la Ossa N, Castellanos M, Garcia MR, Domenech S, Davalos A (2010) Mechanical thrombectomy with the Solitaire AB device in large artery occlusions of the anterior circulation: a pilot study. Stroke 41:1836–1840
Costalat V, Machi P, Lobotesis K, Maldonado I, Vendrell JF, Riquelme C, Mourand I, Milhaud D, Heroum C, Perrigault PF, Arquizan C, Bonafe A (2011) Rescue, combined, and stand-alone thrombectomy in the management of large vessel occlusion stroke using the solitaire device: a prospective 50-patient single-center study: timing, safety, and efficacy. Stroke 42:1929–1935
Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, Pessin M, Ahuja A, Callahan F, Clark WM, Silver F, Rivera F (1999) Intra-arterial prourokinase for acute ischemic stroke. The PROACT II Study: a randomized controlled trial. Prolyse in acute cerebral thromboembolism. JAMA 282:2003–2011
Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R, Boysen G, Bluhmki E, Hoxter G, Mahagne MH, Hennerici M (1995) Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA 274:1017–1025
Higashida RT, Furlan AJ, Roberts H, Tomsick T, Connors B, Barr J, Dillon W, Warach S, Broderick J, Tilley B, Sacks D (2003) Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke 34:e109–e137
IMS II Trial Investigators (2007) The Interventional Management of Stroke (IMS) II Study. Stroke 38:2127–2135
IMS Study Investigators (2004) Combined intravenous and intra-arterial recanalization for acute ischemic stroke: the Interventional Management of Stroke Study. Stroke 35:904–911
Jansen O, von Kummer R, Forsting M, Hacke W, Sartor K (1995) Thrombolytic therapy in acute occlusion of the intracranial internal carotid artery bifurcation. AJNR Am J Neuroradiol 16:1977–1986
Kang DH, Hwang YH, Kim YS, Park J, Kwon O, Jung C (2011) Direct thrombus retrieval using the reperfusion catheter of the Penumbra system: forced-suction thrombectomy in acute ischemic stroke. AJNR Am J Neuroradiol 32:283–287
Kulcsar Z, Bonvin C, Pereira VM, Altrichter S, Yilmaz H, Lovblad KO, Sztajzel R, Rufenacht DA (2010) Penumbra system: a novel mechanical thrombectomy device for large-vessel occlusions in acute stroke. AJNR Am J Neuroradiol 31:628–633
Lee JS, Hong JM, Kim EJ, Shin DH, Joo IS, Lim YC, Suh SH, Kim SY (2012) Comparison of the incidence of parenchymal hematoma and poor outcome in patients with carotid terminus occlusion treated with intra-arterial urokinase alone or with combined IV rtPA and intra-arterial urokinase. AJNR Am J Neuroradiol 33:175–179
Lee KY, Kim DI, Kim SH, Lee SI, Chung HW, Shim YW, Kim SM, Heo JH (2004) Sequential combination of intravenous recombinant tissue plasminogen activator and intra-arterial urokinase in acute ischemic stroke. AJNR Am J Neuroradiol 25:1470–1475
Lewandowski CA, Frankel M, Tomsick TA, Broderick J, Frey J, Clark W, Starkman S, Grotta J, Spilker J, Khoury J, Brott T (1999) Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke: Emergency Management of Stroke (EMS) Bridging Trial. Stroke 30:2598–2605
Menon BK, Hill MD, Eesa M, Modi J, Bhatia R, Wong J, Hudon ME, Morrish W, Demchuk AM, Goyal M (2011) Initial experience with the Penumbra Stroke System for recanalization of large vessel occlusions in acute ischemic stroke. Neuroradiology 53:261–266
Miteff F, Faulder KC, Goh AC, Steinfort BS, Sue C, Harrington TJ (2011) Mechanical thrombectomy with a self-expanding retrievable intracranial stent (Solitaire AB): experience in 26 patients with acute cerebral artery occlusion. AJNR Am J Neuroradiol 32:1078–1081
Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, Liebeskind DS, Smith WS (2012) Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 380:1231–1240
Park H, Hwang GJ, Jin SC, Jung CK, Bang JS, Han MK, Bae HJ, Choe GY, Oh CW, Kwon OK (2011) A retrieval thrombectomy technique with the Solitaire stent in a large cerebral artery occlusion. Acta Neurochir 153:1625–1631
Penumbra Pivotal Stroke Trial Investigators (2009) The Penumbra pivotal stroke trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke 40:2761–2768
Pexman JH, Barber PA, Hill MD, Sevick RJ, Demchuk AM, Hudon ME, Hu WY, Buchan AM (2001) Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol 22:1534–1542
Rha JH, Saver JL (2007) The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 38:967–973
Roth C, Papanagiotou P, Behnke S, Walter S, Haass A, Becker C, Fassbender K, Politi M, Korner H, Romann MS, Reith W (2010) Stent-assisted mechanical recanalization for treatment of acute intracerebral artery occlusions. Stroke 41:2559–2567
Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, Clark W, Budzik R, Zaidat OO (2012) Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 380:1241–1249
Tomsick T, Broderick J, Carrozella J, Khatri P, Hill M, Palesch Y, Khoury J (2008) Revascularization results in the Interventional Management of Stroke II trial. AJNR Am J Neuroradiol 29:582–587
Urbach H, Ries F, Ostertun B, Solymosi L (1997) Local intra-arterial fibrinolysis in thromboembolic “T” occlusions of the internal carotid artery. Neuroradiology 39:105–110
Wolpert SM, Bruckmann H, Greenlee R, Wechsler L, Pessin MS, del Zoppo GJ (1993) Neuroradiologic evaluation of patients with acute stroke treated with recombinant tissue plasminogen activator. The rt-PA Acute Stroke Study Group. AJNR Am J Neuroradiol 14:3–13
Zaidat OO, Suarez JI, Santillan C, Sunshine JL, Tarr RW, Paras VH, Selman WR, Landis DM (2002) Response to intra-arterial and combined intravenous and intra-arterial thrombolytic therapy in patients with distal internal carotid artery occlusion. Stroke 33:1821–1826
Conflicts of interest
None.
Author information
Authors and Affiliations
Corresponding author
Additional information
Comment
In this article by Dr. Jin Soo Lee et al., two groups of patients treated for CTO were compared: a group treated with IA fibrinolytic alone and a group that had mechanical thrombectomy. The stand-alone and combined use of two different mechanical thrombectomy systems (Penumbra aspiration and Solitaire stent-retriever) was applied to the treatment of this challenging clinical entity.
Excluding IA fibrinolytic treatment from CTO treated with mechanical thrombectomy was key to allowing the effects of the mechanical thrombectomy devices alone to be measured and outcomes reported.
Large emboli likely require multi-modality thrombectomy treatment as previous reports have indicated that these occlusions have been refractory to IV and IA fibrinolytic therapy as well as the combination of IV and IA fibrinolytic therapy (Jansen et al. 1995 AJNR 16:1977–1986 and Urbach et al. 1997 Neuroradiology 39: 105–110 and Zaidat et al. 2002 Stroke 33:1821–1826).
Recanalization rates achieved with mechanical thrombectomy for CTO were superior to IV, IA, and combination IV + IA fibrinolytic therapy.
It is interesting to note the inverse proportional relationship between reperfusion and ICH especially because the onset to decision interval was less for the fibrinolytic group.
Additionally, the clinical impact of the hemorrhages that were observed in this study were less detrimental to patients than when compared to previous reports of CTO treated with fibrinolytic therapy alone (i.e., type 2 IPH was not observed).
These devices can and should be used in tandem when advantages for one or the other can be exploited in a deserving clinical situation (e.g., when the length of the clot surpasses the length of the Solitaire, the Penumbra system can be used to remove small portions of the clot to facilitate deployment of a stent retriever). These techniques and systems, both in isolation and in combination, should be kept in the neuroendovascular practitioner’s armamentarium.
CTO proves to be a great challenge when considering clinical outcome. The mRS of the patients with the best outcomes were rated at 3. Decreasing symptom onset to needle time and swift, efficacious thrombectomy devices are possible factors that may impact outcome.
The current study, despite its acknowledged limitations, serves as an important collection of consecutive patients with a rarer, intractable, acute stroke that adds to the data that can facilitate a large-scale randomized study that may more fully elucidate the efficacy of neuroendovascular treatments.
John Braca MD
Christopher M. Loftus MD
Maywood, IL, USA
Rights and permissions
About this article
Cite this article
Lee, J.S., Hong, J.M., Lee, SJ. et al. The combined use of mechanical thrombectomy devices is feasible for treating acute carotid terminus occlusion. Acta Neurochir 155, 635–641 (2013). https://doi.org/10.1007/s00701-013-1649-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00701-013-1649-5