Introduction : Patients with Cerebral Venous Sinus Thrombosis (CVT) are candidates for Endovascular Mechanical Thrombectomy (EMT) in cases of coma on presentation or clinical deterioration despite anticoagulation. We present two cases of CVT successfully treated with mechanical thrombectomy using Medtronic’s Solitaire Stent retriever. Methods : A retrospective review at a single center university hospital was performed for all cerebral venous sinus thrombosis case log from December 2018 to November 2020. Cases resistant to conventional medical therapy that underwent intrasinus stent retriever endovascular thrombectomy were noted. Results : Case 1: 26 year‐old male with a history of hypertension presented with 2 weeks of headaches, left sided numbness and blurriness of vision. Imaging revealed superior sagittal (SSS) and bilateral transverse sinus thrombosis. Patient was treated with heparin infusion and discharged home on oral apixaban. The following day he presented with new onset expressive aphasia. Imaging was unchanged. Due to worsening symptoms despite anticoagulation, Patient underwent mechanical thrombectomy using a stent retriever. Solitaire 6 × 40 mm stent was advanced and deployed through the microcatheter and retracted in the upper segment of posterior one third of SSS followed by alteplase infusion at 1 mg/hr (25 ml/hr) via Berenstein catheter for the next 36 hours. Intravenous heparin infusion was also started with aPTT goal 60–80. Cerebral angiogram was repeated two days later revealing successful recanalization of previously thrombosed SSS and bilateral transverse sinuses with significantly improved cerebral venous drainage. Patient was transitioned again to oral apixaban. Repeat CTA in 3 months showed significantly improved patency and recanalization. Case 2: A 42 year‐old male with history of ulcerative colitis presented with sudden onset right‐sided hemiparesis and hemisensory loss along with one month of headaches. Presenting NIHSS 14. Imaging revealed SSS thrombosis with thrombosis of the left transverse sinus complicated by left frontal intraparenchymal hemorrhage and subarachnoid hemorrhage. Patient underwent mechanical thrombectomy of SSS using Solitaire 6 × 40mm stent retriever with distal aspiration resulting in improved flow. Clinical course was complicated by seizures and acute respiratory distress syndrome requiring intubation followed by tracheostomy and G‐tube placement which were eventually removed during recovery. Patient was treated with high intensity heparin during his hospitalization and eventually transitioned to apixaban. Work up revealed protein S deficiency. Serial CT angiograms at 6 and 11 months revealed resolution of CVT. NIHSS improved to 1 with mRS of 2. Conclusions : These cases imply that intra‐cerebrovenous sinus mechanical thrombectomy with stent retrievers may be considered in patients with continuing worsening despite optimal medical management.
Background: Emergent treatment with intravenous thrombolysis and mechanical thrombectomy improved outcomes in patients with acute ischemic stroke. We aim to identify differences in acute stroke treatment trends between strokes occurring in the anterior versus posterior circulation. Methods: The IAC (Initiation of Anticoagulation after Cardioembolic stroke) study represents pooled data registry of 8 comprehensive stroke centers across the United States and included patients with cardioembolic stroke in the setting of AFib. In a post hoc analysis, we identified and separated patients into posterior circulation stroke (PCS) and anterior circulation stroke (ACS) groups based on imaging. Patients without infarct locations or those with multi-circulation infarcts were excluded. We compared baseline characteristics, stroke severity and the treatment trends with alteplase (tPA) and mechanical thrombectomy (MT) in PCS vs ACS using Fisher exact test, t-test and non-parametric tests. We then performed multivariable logistic regression adjusted for baseline differences to determine the associations between PCS and tPA or MT. Results: Of the 2084 patients in IAC cohort, 1589 met inclusion criteria for this study, in which 294 (22.7%) had PCS. Mean age was 76.8 years, 29.3% received tPA and 26.9% had MT. When compared to ACS, patients with PCS were more likely to be men (55.4% vs 45.6%, p=0.003), have diabetes (42.8% vs 29.8, p< 0.001) and lower median NIHSS score on admission (4 vs 8, p<0.001). Patients with PCS were less likely to receive tPA (16.3% vs 32.3%, p<0.001) or MT (10.9% vs 30.6%, p<0.001). Other variables were not significantly different. When adjusted for baseline differences, patients with PCS remained less likely to be treated with tPA (adjusted OR 0.49, 95%CI 0.35-0.70, p<0.001) or MT (adjusted OR 0.38, 95%CI 0.25-0.58, p<0.001). Conclusion: Posterior circulation strokes are half as likely to receive thrombolytic therapy and almost a third as likely to have thrombectomy, even after adjusting for baseline stroke severity scores. This is possibly due to difficulty in timely identification and diagnostic delays. There is need for better tools incorporating posterior circulation stroke signs and symptoms to allow for early detection and treatment.
May 9, 2019April 9, 2019Free AccessCocaine Use Associated with Bilateral Globus Pallidus Changes; Similar to Carbon Monoxide intoxication. (P5.6-025)Muhammad Umer Azeem, Seydeh Nasim Cheraghi, Muhammad Nagy, Van Vu, Vinay Maliakal, Nils Henninger, and Kate DanielloAuthors Info & AffiliationsApril 9, 2019 issue92 (15_supplement) Letters to the Editor
Background: Real-time regional cerebral oxygen saturation (rScO 2 ) measurement using near-infrared spectroscopy (NIRS) may aid in the identification of intracerebral ischemia in critically ill patients. Ischemia to the cerebral white matter results in injury detectable by brain MRI as white matter hyperintensities (WMH). We hypothesized that rScO 2 as assessed by NIRS correlates with the degree of WMH progression in patients admitted to a neurocritical care unit (NCCU). Materials and Methods: Retrospective study of eight comatose patients (Glasgow Coma Scale ≤8) in the NCCU who were continuously monitored for three days after their coma onset with NIRS to assess rScO 2, and who had a brain MRI upon admission and before their hospital discharge. Semi-automated volumetry based on intensity thresholding was used to quantify the WMH volume on FLAIR sequences. The degree of WMH progression was calculated by subtracting the WMH volume of the admission MRI from discharge MRI. Spearman rank correlation was used to determine the strength of association between the rScO 2 (averaged over the monitoring period) and the degree of WMH progression. Results: The median averaged rScO 2 was 61 (IQR (48-73) and the lowest 45. Overall, rScO 2 inversely correlated with WMH progression (rho -.738, p= 0.037); i.e., a lower rScO 2 was associated with greater WMH progression (Figure 1). Patients with greater WMH progression had a worse modified Rankin Scale on discharge (rho .769, p= 0.026). Interpretation: Our study provides proof of principle that rScO 2 as assessed by non-invasive NIRS monitoring may aid detection of cerebral white matter injury.
Background and purpose A subset of ischaemic stroke patients with atrial fibrillation (AF) have ischaemic stroke despite anticoagulation. We sought to determine the association between prestroke anticoagulant therapy and recurrent ischaemic events and symptomatic intracranial haemorrhage (sICH). Methods We included consecutive patients with acute ischaemic stroke and AF from the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study from eight comprehensive stroke centres in the USA. We compared recurrent ischaemic events and delayed sICH risk using adjusted Cox regression analyses between patients who were prescribed anticoagulation (ACp) versus patients who were naïve to anticoagulation therapy prior to the ischaemic stroke (anticoagulation naïve). Results Among 2084 patients in IAC, 1518 had prior anticoagulation status recorded and were followed for 90 days. In adjusted Cox hazard models, ACp was associated with some evidence of a higher risk higher risk of 90-day recurrent ischaemic events only in the fully adjusted model (adjusted HR 1.50, 95% CI 0.99 to 2.28, p=0.058) but not increased risk of 90-day sICH (adjusted HR 1.08, 95% CI 0.46 to 2.51, p=0.862). In addition, switching anticoagulation class was not associated with reduced risk of recurrent ischaemic events (adjusted HR 0.41, 95% CI 0.12 to 1.33, p=0.136) nor sICH (adjusted HR 1.47, 95% CI 0.29 to 7.50, p=0.641). Conclusion AF patients with ischaemic stroke despite anticoagulation may have higher recurrent ischaemic event risk compared with anticoagulation-naïve patients. This suggests differing underlying pathomechanisms requiring different stroke prevention measures and identifying these mechanisms may improve secondary prevention strategies.
Introduction : Coil migration after endovascular embolization of intracranial aneurysms is one of the periprocedural complications in 2–6% of patients. Stent retriever use is well‐established in treatment of ischemic stroke but has not been well established to address coil retrieval as rescue therapy. We describe three cases with successful removal of migrated coils using stent retrievers. Methods : A retrospective review at a single center university hospital was performed for all Neuro‐endovascular case log from December 2018 to November 2020. Cases of coil migration were reviewed and coil retraction with Stent Retriever with successful coil mass extraction was considered an endpoint. Number of attempts, types of stent retrievers used and time taken for extraction were noted. Results : Case 1: 56‐year‐old female presented with ruptured tri‐lobed 4 × 3 mm Anterior communicating artery aneurysm. Hunt and Hess (H&H) Grade 2. Modified Fisher scale (MFS) 4. Underwent primary coil embolization. Two 2mmx2cm Galaxy Orbit coils were deployed within aneurysm. During deployment of third coil the first two coils displaced out of the aneurysm migrating into left A2 segment. Stryker’s Trevo 3 × 20 mm stent retriever was used for retrieval of coils however they dislodged at the left internal carotid artery (ICA) terminus and migrated distally into the left middle cerebral artery (MCA) M2 superior division. Subsequently, Medtronic’s Solitaire 4 × 40 mm stent retriever was successfully deployed retrieving the migrated coils with full recanalization. Case 2: 64‐year‐old female presented with ruptured 3 × 5.3 mm right posterior communicating artery (Pcom) aneurysm. H&H 5 and MFS 4. Underwent primary coil embolization with placement of Galaxy Orbit 2.5mmx3.5cm coil. On follow up run, coil mass had migrated into the origin of right fetal Pcom. Migrated coil was successfully retrieved using Stryker’s 4 × 40 mm stent retriever with complete recanalization. Case 3: 65‐year‐old female with presented ruptured 8.5 × 6.8 mm right supraclinoid ICA irregular aneurysm. H&H Grade 1. MFS 3. Underwent primary coil embolization with one Galaxy coil (5mm x 10cm) with plan for future flow diversion. Two weeks later, patient experienced acute neurological worsening with new left sided hemiparesis and right gaze deviation. Imaging revealed acute occlusion of right middle cerebral artery M1 segment occlusion with thrombosed migrated coil. Patient underwent retrieval of the coil and superimposed thrombus utilizing Stryker’s Trevo (4*30 mm) stent retriever with resultant full recanalization. Conclusions : These cases demonstrate successful endovascular mechanical removal of migrated coils using stent retrievers. They add to the limited experience of stent retrievers utilization as effective tools for dealing with such complications.
In patients with acute ischemic stroke and atrial fibrillation, treatment with low molecular weight heparin increases early hemorrhagic risk without reducing early recurrence, and there is limited data comparing warfarin to direct oral anticoagulant (DOAC) therapy. We aim to compare the effects of the treatments above on the risk of 90-day recurrent ischemic events and delayed symptomatic intracranial hemorrhage. We included consecutive patients with acute ischemic stroke and atrial fibrillation from the IAC (Initiation of Anticoagulation after Cardioembolic) stroke study pooling data from stroke registries of 8 comprehensive stroke centers across the United States. We compared recurrent ischemic events and delayed symptomatic intracranial hemorrhage between each of the following groups in separate Cox-regression analyses: (1) DOAC versus warfarin and (2) bridging with heparin/low molecular weight heparin versus no bridging, adjusting for pertinent confounders to test these associations. We identified 1289 patients who met the bridging versus no bridging analysis inclusion criteria and 1251 patients who met the DOAC versus warfarin analysis inclusion criteria. In adjusted Cox-regression models, bridging (versus no bridging) treatment was associated with a high risk of delayed symptomatic intracranial hemorrhage (hazard ratio, 2.74 [95% CI, 1.01-7.42]) but a similar rate of recurrent ischemic events (hazard ratio, 1.23 [95% CI, 0.63-2.40]). Furthermore, DOAC (versus warfarin) treatment was associated with a lower risk of recurrent ischemic events (hazard ratio, 0.51 [95% CI, 0.29-0.87]) but not delayed symptomatic intracranial hemorrhage (hazard ratio, 0.57 [95% CI, 0.22-1.48]). Our study suggests that patients with ischemic stroke and atrial fibrillation would benefit from the initiation of a DOAC without bridging therapy. Due to our study limitations, these findings should be interpreted with caution pending confirmation from large prospective studies.
