Abstract
Introduction
The use of coronary balloons in the cerebral vasculature is limited due to their poor trackability and increased risk of vessel injury. We report our experience using more compliant elastomer balloons for thrombus resistant to intraarterial (IA) pharmacological and mechanical thrombolysis in acute stroke.
Methods
We retrospectively analyzed 12 consecutive patients with an occluded intracranial artery treated with angioplasty using a low-pressure elastomer balloon. Angiograms were graded according to the Thrombolysis in Cerebral Infarction (TICI) and Qureshi grading systems. Outcomes were categorized as independent (modified Rankin scale, mRS, score ≤2), dependent (mRS score 3–5), or dead (mRS score 6).
Results
Included in the study were 12 patients (mean age 66±17 years, range 31–88 years; mean baseline National Institutes of Health stroke scale score 17±3, range 12–23). The occlusion sites were: internal carotid artery (ICA) terminus (five patients, including two concomitant cervical ICA occlusions), M1 segment (two patients), and basilar artery (two patients). Pharmacological treatment included intravenous (IV) t-PA only (two patients), IA urokinase only (nine patients), both IV t-PA and IA urokinase (one patient), and IV and/or IA eptifibatide (eight patients). Mean time to treatment was 5.9±3.9 h (anterior circulation) and 11.0±7.2 h (posterior circulation). Overall recanalization rate (TICI grade 2/3) was 91.6%. Procedure-related morbidity occurred in one patient (distal posterior inferior cerebellar artery embolus). There were no symptomatic hemorrhages. Outcomes at 90 days were independent (five patients), dependent (three patients) and dead (four patients, all due to progression of stroke with withdrawal of care).
Conclusion
Angioplasty of acutely occluded intracranial arteries with low-pressure elastomer balloons results in high recanalization rates with an acceptable degree of safety. Prior use of thrombolytics may increase the chances of recanalization, and glycoprotein IIb-IIIa inhibitors may be helpful in preventing reocclusion and in increasing patency rates.
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References
Marks MP, Wojak JC, Al-Ali F et al (2006) Angioplasty for symptomatic intracranial stenosis: clinical outcome. Stroke 37:1016–1020
Schwamm LH, Rosenthal ES, Swap CJ et al (2005) Hypoattenuation on CT angiographic source images predicts risk of intracerebral hemorrhage and outcome after intra-arterial reperfusion therapy. AJNR Am J Neuroradiol 26:1798–1803
Schaefer PW, Roccatagliata L, Ledezma C et al (2006) First-pass quantitative CT perfusion identifies thresholds for salvageable penumbra in acute stroke patients treated with intra-arterial therapy. AJNR Am J Neuroradiol 27:20–25
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333:1581–1587
Higashida RT, Furlan AJ, Roberts H et al (2003) Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke 34:e109–e137
Qureshi AI (2002) New grading system for angiographic evaluation of arterial occlusions and recanalization response to intra-arterial thrombolysis in acute ischemic stroke. Neurosurgery 50:1405–1414; discussion 1415–1415
Furlan A, Higashida R, Wechsler L et al (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
The NINDS t-PA Stroke Study Group (1997) Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. Stroke 28:2109–2118
Berger C, Fiorelli M, Steiner T et al (2001) Hemorrhagic transformation of ischemic brain tissue: asymptomatic or symptomatic? Stroke 32:1330–1335
Hunter GJ, Silvennoinen HM, Hamberg LM et al (2003) Whole-brain CT perfusion measurement of perfused cerebral blood volume in acute ischemic stroke: probability curve for regional infarction. Radiology 227:725–730
Hacke W, Albers G, Al-Rawi Y et al (2005) The Desmoteplase in Acute Ischemic Stroke Trial (DIAS): a phase II MRI-based 9-hour window acute stroke thrombolysis trial with intravenous desmoteplase. Stroke 36:66–73
Molina CA, Alvarez-Sabin J, Montaner J et al (2002) Thrombolysis-related hemorrhagic infarction: a marker of early reperfusion, reduced infarct size, and improved outcome in patients with proximal middle cerebral artery occlusion. Stroke 33:1551–1556
Smith WS, Sung G, Starkman S et al (2005) Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 36:1432–1438
Smith WS (2006) Safety of mechanical thrombectomy and intravenous tissue plasminogen activator in acute ischemic stroke. Results of the multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI) trial, part I. AJNR Am J Neuroradiol 27:1177–1182
Lisboa RC, Jovanovic BD, Alberts MJ (2002) Analysis of the safety and efficacy of intra-arterial thrombolytic therapy in ischemic stroke. Stroke 33:2866–2871
Ueda T, Sakaki S, Nochide I et al (1998) Angioplasty after intra-arterial thrombolysis for acute occlusion of intracranial arteries. Stroke 29:2568–2574
Ringer AJ, Qureshi AI, Fessler RD et al (2001) Angioplasty of intracranial occlusion resistant to thrombolysis in acute ischemic stroke. Neurosurgery 48:1282–1288; discussion 1288–1290
Nakano S, Iseda T, Yoneyama T et al (2002) Direct percutaneous transluminal angioplasty for acute middle cerebral artery trunk occlusion: an alternative option to intra-arterial thrombolysis. Stroke 33:2872–2876
Ramee SR, Subramanian R, Felberg RA et al (2004) Catheter-based treatment for patients with acute ischemic stroke ineligible for intravenous thrombolysis. Stroke 35:e109–e111
Noser EA, Shaltoni HM, Hall CE et al (2005) Aggressive mechanical clot disruption: a safe adjunct to thrombolytic therapy in acute stroke? Stroke 36:292–296
Abou-Chebl A, Bajzer CT, Krieger DW et al (2005) Multimodal therapy for the treatment of severe ischemic stroke combining GPIIb/IIIa antagonists and angioplasty after failure of thrombolysis. Stroke 36:2286–2288
Mangiafico S, Cellerini M, Nencini P et al (2005) Intravenous glycoprotein IIb/IIIa inhibitor (tirofiban) followed by intra-arterial urokinase and mechanical thrombolysis in stroke. AJNR Am J Neuroradiol 26:2595–2601
Lum C, Stys PK, Hogan MJ et al (2006) Acute anterior circulation stroke: recanalization using clot angioplasty. Can J Neurol Sci 33:217–222
Levy EI, Ecker RD, Horowitz MB et al (2006) Stent-assisted intracranial recanalization for acute stroke: early results. Neurosurgery 58:458–463; discussion 458–463
Conflict of interest statement
R.G. Nogueira is a consultant for Concentric Medical, ev3, and Coaxia; L.H. Schwamm is a consultant for Coaxia; and J.C. Pryor is a consultant for ev3. The other authors declare that they have no conflict of interest.
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Nogueira, R.G., Schwamm, L.H., Buonanno, F.S. et al. Low-pressure balloon angioplasty with adjuvant pharmacological therapy in patients with acute ischemic stroke caused by intracranial arterial occlusions. Neuroradiology 50, 331–340 (2008). https://doi.org/10.1007/s00234-007-0340-z
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DOI: https://doi.org/10.1007/s00234-007-0340-z