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Acute Anterior Circulation Stroke: Recanalization Using Clot Angioplasty

Published online by Cambridge University Press:  02 December 2014

Cheemun Lum ,
Peter K. Stys ,
Matthew J. Hogan ,
Thanh B. Nguyen ,
Ashok Srinivasan  and
Mayank Goyal
Cheemun Lum*
Affiliation:
Department of Diagnostic Imaging-Neuroradiology Section, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
Peter K. Stys
Affiliation:
Department of Medicine-Division of Neurology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
Matthew J. Hogan
Affiliation:
Department of Medicine-Division of Neurology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
Thanh B. Nguyen
Affiliation:
Department of Diagnostic Imaging-Neuroradiology Section, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
Ashok Srinivasan
Affiliation:
Department of Diagnostic Imaging-Neuroradiology Section, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
Mayank Goyal
Affiliation:
Department of Diagnostic Imaging-Neuroradiology Section, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
*
Department of Diagnostic Imaging, The Ottawa Hospital-Civic Campus, 1053 Carling Avenue, Ottawa, Ontario, Canada
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Abstract:

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Background and Purpose:

Different strategies have been employed to recanalize acutely occluded middle cerebral and internal carotid arteries (ICA) in the setting of acute stroke including intravenous and intra-arterial tPA. However, pharmaceutical thrombolysis alone, may not be effective in patients with a large amount of clot volume (complete M1, terminal internal carotid artery). We report our initial experience with endovascular clot disruption using a soft silicone balloon in addition to intravenous or intraarterial thrombolysis with tPA.

Methods:

This is a retrospective review of nine patients with symptoms of acute stroke from clot in the middle cerebral or internal carotid territories who were treated with intracranial balloon angioplasty. All patients presented with symptoms of acute anterior circulation stroke less than six hours from onset. Patients in whom computed tomography (CT) angiography confirmed the presence of large vessel clot (terminal ICA, M1 or proximal M2) were included in the study. A CT perfusion was performed providing maps of cerebral blood volume, flow and mean transit time. If the patient presented less than three hours from onset then intravenous tissue plasminogen activator (tPA) was also administered. Intra-arterial tPA was delivered into the clot. If the volume of clot was judged to be significant by the treating neurointerventionist, then a limited trial of tPA was administered intraarterially followed by balloon angioplasty of persistant clot. The time from imaging to vessel recanalization was recorded. Clinical outcomes were assessed using the modified Rankin scale and Barthel Index.

Results:

Diagnostic CT perfusion studies were performed in 7 (78%), all of which showed a significant amount of salvageable tissue as judged by the treating neurointerventionist and neurologist. Recanalization (TIMI 2 or 3) was possible in 8 (89%). There were no cases of symptomatic intracranial hemorrhage and 2 (22%) asymptomatic hemorrhages. The average time from performance of the initial emergency CT to vessel recanalization was 2.1 hours with mean time from symptom onset to vessel recanalization of 4.1 hours. Five (56%) patients had good outcomes, 1 (11%) had mild and 3 (33%) had moderate to severe disability.

Conclusion:

Clot angioplasty can potentially shorten recanalization times in well-selected patients and can be an effective complimentary procedure in patients with tPA resistant clot. Angioplasty can be performed with a very low complication rate using the technique described and may be associated with good outcomes.

Résumé:

RÉSUMÉ:Contexte et objectif:

Différentes stratégies, dont l’administration intraveineuse et intra-artérielle de t-PA, ont été utilisées pour reperméabiliser l’artère cérébrale moyenne (ACM) et la carotide interne (CI) en phase aiguë de l’accident vasculaire cérébral (AVC). Cependant, la thrombolyse pharmacologique seule peut être inefficace chez des patients qui ont des caillots volumineux (CI terminale, M1 complète). Nous rapportons notre expérience initiale de fragmentation du caillot par voie endovasculaire, au moyen d’un ballonnet mou composé de silicone, associée à la thrombolyse intraveineuse ou intra-artérielle par le t-PA.

Méthodes:

Il s’agit d’une revue rétrospective de neuf patients présentant des symptômes d’AVC aigu thrombotique dans le territoire de l’ACM ou de la CI qui ont été traités par angiophastie intracrânienne par ballonnet. Tous les patients ont consulté moins de six heures après le début des symptômes pour un AVC aigu par occlusion de la circulation antérieure. Les patients chez qui l’angiographie de soustraction a confirmé la présence d’un gros caillot (CI terminale, M1 ou M2 proximale) ont été inclus dans l’étude. Le volume, le flot et le temps moyen de transit sanguin cérébral ont été cartographiés par tomodensitométrie avec perfusion. Si moins de trois heures s’étaient écoulées depuis le début des symptômes, le patient recevait également du t-PA intraveineux. Le t-PA intra-artériel était injecté directement dans le caillot. Si le volume du caillot était jugé important par le neurointerventionniste, il procédait à un essai limité de t-PA intra-artériel suivi d’une angioplastie par ballonnet du caillot résiduel. Le temps écoulé entre l’imagerie et la reperméabilisation était noté. L’issue clinique était évaluée au moyen de l’échelle modifiée de Rankin et de l’indice de Barthel.

Résultats:

Une tomodensitométrie avec perfusion a été effectuée chez 7 (78%) des patients qui tous avaient une quantité appréciable de tissu viable selon le neurointerventionniste et le neurologue traitant. La reperméabilisation (TIMI 2 ou 3) a été possible chez 8 patients (89%). Aucun cas d’hémorragie intracrânienne symptomatique n’a été observé et 2 patients (22%) ont subi des hémorragies asymptomatiques. Le temps moyen écoulé depuis la tomodensitométrie d’urgence jusqu’à la reperméabilisation était de 2,1 heures et le temps moyen depuis le début des symptoms jusqu’à la reperméabilisation était de 4,1 heures. Cinq patients (56%) ont eu un bon résultat. L’invalidité était légère chez un patient (11%) et de modérée à sévère chez 3 patients (33%).

Conclusion:

L’angioplastie du caillot peut abréger le temps de reperméabilisation chez des patients bien choisis et peut constituer une intervention complémentaire efficace chez des patients qui présentent des caillots résistants au t-PA. L’angioplastie peut être effectuée par la technique que nous décrivons, avec de bons résultats et peu de complications.

Type
Original Articles
Information
Canadian Journal of Neurological Sciences , Volume 33 , Issue 2 , May 2006 , pp. 217 - 222
Copyright
Copyright © The Canadian Journal of Neurological 2006

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