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B.ExtendingtheTherapeuticWindowforMechanicalThrombectomy
A.MechanicalThrombectomyforAnteriorCirculation
MechanicalthrombectomyforanteriorcirculationLVOsis nowstandard ofcareforpatientspresenting
within6hoursofstrokeonset.Althoughtimeisanimportantfactor,collateralvascularnetworksarealso
important in predictingriskofstroke completion.Indeed, two recenttrials—DAWNandDEFUSE-3—
haveextendedthetherapeuticwindowformechanicalthrombectomyto16-24hoursfromlastknownwell
incarefullyselectedpatientswithevidenceofgoodcollateralcirculations.
7,8
C.ChasingMoreDistalClots
WhilethemajormechanicalthrombectomytrialsfocusedonmajorbranchocclusionsoftheCOW,more
distalclotscanalsoresultindisproportionatelylarge,disablingstrokes.Growingevidencesuggeststhat
chasing more distal clots may be of substantial benefit when facing a potentially large, or disabling,
strokesyndrome,eg,aphasia.
56
D.ExampleCasesFromYaleNewHavenHospital(YNHH)
Case1
A65-year-oldmanwithmultiplecardiovascularriskfactorssuddenlydevelopsleft-sidedhemiplegiaand
dysarthria consistent with a large right MCA syndrome (NIHSS 17). He is emergently transferred to
YNHHwhereaCToftheheaddemonstratesnoevidenceofintracerebralhemorrhageandminimalEICs.
Becauseheiswithin4.5hoursofsymptomonsetandhehasnocontraindications,IVtPAisadministered.
A CTA confirms a proximal R MCA occlusion, and the patient is taken emergently for mechanical
thrombectomy.Heisan“MRCLEAN”patient,similartothoseenrolledinthe2015clinicaltrials(Fig.
2.1).
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FIGURE2.1 A,NormalnoncontrastheadCT.B,APprojectionofarightinternalcarotidarteryinjectionrevealinga
mid-M1occlusion.C,Frontalprojectionofarightinternalcarotidarteryinjectionafterthrombectomyshowing
recanalizationoftherightMCA.D,MRIDWIsequencedemonstratingfinalstrokeburden.E,Stentretrieverwith
clot.
Theprocedureisperformedunderconscioussedation.An8Fshortsheathisinsertedattherightgroin.A
6F long sheath is positioned inthe proximal R common carotid artery. Under roadmap guidance, the
proximal right MCA occlusion is crossed with a 027 microcatheter navigated over a soft 014
microguidewire. A 068 reperfusion catheter is positioned at the face of the clot. A stent retriever is
deployedacrosstheocclusion,themicrocatheterwithdrawn,andthereperfusioncatheterplacedonpump
suction.Afterseveralminutes,thereperfusioncatheterandstentretrieverarewithdrawninunison.Clot
fragments are demonstrated on the stent retriever and within the reperfusion catheter. Control runs
demonstrate complete revascularization after “one pass.” Time from groin puncture to
revascularization=16minutes.
Clinicalexaminationontheangiographytableconfirmsarapidlyimprovingexaminationresult.Oneday
aftertheprocedure,hehadnearlyfullstrengthonhisleftsidewithmild,persistentdysarthria.Athis3monthfollow-up,hehadmadeanear-completeclinicalrecovery.
Case2
A75-year-oldmanwithatrialfibrillation(notonanticoagulation)wasfoundslumpedoverthesteering
wheelofhiscar.Hewaslastseennormal8hoursagoafterdroppinghisgranddaughteroffatschool.He
is emergently transferred to YNHH. Clinical examination reveals a large left MCA stroke syndrome
(NIHSS22)characterizedbyright-sidedhemiplegiaandglobalaphasia.ACToftheheaddemonstrates
no evidence of intracerebral hemorrhage and minimal EICs. Because he is more than 8 hours from
symptomonset,IVtPAisnotadministered.ACTAconfirmsaproximalLMCAocclusion.Ahyperacute
MRIdemonstratesasmallischemiccoreandlargeterritoryatrisk.Heistakenemergentlyformechanical
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thrombectomy(Fig.2.2).
FIGURE2.2 A,NoncontrastheadCTrevealingahyperdenseleftMCAsign.B,CoronalCTArevealingproximal
occlusionoftheleftM1segment.C,HyperacuteMRIdemonstratingsmallcoreinfarct.D,Frontalprojection
angiogramconfirmingproximalM1occlusion.E,Frontalprojectionafterthrombectomyrevealingrecanalization.F,
Stentretrieverwithclot.
Again, the procedure is performed under conscious sedation. Two “passes” are required of a stent
retrieverusedinconjunctionwithalarge-borereperfusioncatheterplacedonpumpsuctionatthefaceof
theclot.Clotfragmentsareretrievedon thestentretriever andwithinthe reperfusioncatheter.Control
runs demonstrate near-complete revascularization. Time from groin puncture to
revascularization=34minutes.
Clinical examinationontheangiography table confirms aslowly improving examination result.Bythe
nextmorning,hehasdefinitelyimprovedright-sidedstrengthandcananswersimplequestionscorrectly.
Athis3-monthfollow-up,hehasmadeanear-completemotorrecoveryandhaspersistent,mildwordfindingdifficulty.
Case3
A43-year-oldwomanwithahistoryofpriorstrokespresentstoanoutsideemergencyroomwithvague
complaints ofvertigo,nauseaandvomiting, and tingling in her arms. Several hourslater she develops
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hearinglossanddoublevision.ACToftheheaddemonstratesnilacute.Severalhourslatershesuddenly
becomes unresponsive withextensor posturing (NIHSS 33). She is intubated forairway protection. A
repeatCToftheheadagaindemonstratesnilacute,buta CTAshowsanacutebasilararteryocclusion.
Althoughacutebasilararteryocclusionswerenotwellstudiedinthe2015(orsubsequent)clinicaltrials,
itportendsagraveprognosiswithoutaggressiveintervention.SheistransferredtoYNHHformechanical
thrombectomymorethan16hoursaftersymptomonset(Fig.2.3).
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FIGURE2.3 A,CTAdemonstratingopacificationofthebilateralinternalcarotidarterieswithoutopacificationofthe
basilarartery.B,Lateralprojectionangiogramrevealingbasilarsummitocclusion.C,Frontalprojectionangiogram
performedthroughthemicrocatheterplaceddistaltotheocclusionrevealingapatentrightposteriorcerebralartery
distaltotheclot.D,Frontalprojectionangiogramperformedafterthrombectomyrevealingrecanalizationofthe
posteriorcirculationafterthrombectomy.
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Asinglepassisperformedwithastentretrieveralone.Clotfragmentsareretrievedonthestentretriever.
Control runs demonstrate near-complete revascularization. Time from groin puncture to
revascularization=18minutes.
Threedayslater,shehasamarkedlyimprovedclinicalexaminationwithnormallevelofconsciousness,
right-greater-than-left-sided weakness, and double vision.Ather3-monthfollow-up,sheis ambulating
independentlyandcaringforherself.Prismglasseshelpwithpersistentdoublevision.
ClinicalPearls
■Aclinicianatthebedsidecannotdeterminewhetherapatientwithanacuteischemicstroke,
eg,acute-onsethemiplegia,hasapenumbral(reversible)orcore(irreversible)neurological
deficit.
■Althoughnot essential for triageand evaluation of every acute stroke patients, perfusion
imaging provides invaluable data in complex clinical decision-making and may be of
substantialbenefitwhenthediagnosisofstrokeisindoubtorlateinthetherapeuticwindow.
■The 2015 stentretriever trials defined a new standard of care for acute ischemic stroke
secondarytoanteriorcirculationLVOs.
SuggestedReadings
1.CampbellBCV,DonnanGA,LeesKR,etal.Endovascularstentthrombectomy:thenewstandardofcareforlargevesselischaemic
stroke.LancetNeurol.2015;14:846-854.
2.GoyalM,MenonBK,vanZwamWH,etal.Endovascularthrombectomyafterlarge-vesselischaemicstroke:ameta-analysisof
individualpatientdatafromfiverandomisedtrials.Lancet.2016;387:1723-1731.
References
1.BerkhemerOA,FransenPS,BeumerD,etal.Arandomizedtrialofintraarterialtreatmentforacuteischemicstroke.NEnglJMed.
2015;372:11-20.
2.CampbellBC,MitchellPJ,KleinigTJ,etal.Endovasculartherapyforischemicstrokewithperfusion-imagingselection.NEnglJMed.
2015;372:1009-1018.
3.GoyalM,DemchukAM,MenonBK,etal.Randomizedassessmentofrapidendovasculartreatmentofischemicstroke.NEnglJMed.
2015;372:1019-1030.
4.JovinTG,ChamorroA,CoboE,etal.Thrombectomywithin8hoursaftersymptomonsetinischemicstroke.NEnglJMed.
2015;372:2296-2306.
5.SaverJL,GoyalM,BonafeA,etal.Stent-retrieverthrombectomyafterintravenoust-PAvs.t-PAaloneinstroke.NEnglJMed.
2015;372:2285-2295.
6.GoyalM,MenonBK,vanZwamWH,etal.Endovascularthrombectomyafterlarge-vesselischaemicstroke:ameta-analysisof
individualpatientdatafromfiverandomisedtrials.Lancet.2016;387:1723-1731.
7.NogueiraRG,JadhavAP,HaussenDC,etal.Thrombectomy6to24hoursafterstrokewithamismatchbetweendeficitandinfarct.N
EnglJMed.2018;378:11-21.
8.AlbersGW,MarksMP,KempS,etal.Thrombectomyforstrokeat6to16hourswithselectionbyperfusionimaging.NEnglJMed.
2018;378:708-718.
9.CampbellBCV,DonnanGA,LeesKR,etal.Endovascularstentthrombectomy:thenewstandardofcareforlargevesselischaemic
stroke.LancetNeurol.2015;14:846-854.
10.SaccoRL,KasnerSE,BroderickJP,etal.Anupdateddefinitionofstrokeforthe21stcentury:astatementforhealthcareprofessionals
fromtheAmericanHeartAssociation/AmericanStrokeAssociation.Stroke.2013;44:2064-2089.
11.WritingGroupM,MozaffarianD,BenjaminEJ,etal.Executivesummary:heartdiseaseandstrokestatistics–2016update:areportfrom
theAmericanHeartAssociation.Circulation.2016;133:447-454.
12.FengW,HendryRM,AdamsRJ.Riskofrecurrentstroke,myocardialinfarction,ordeathinhospitalizedstrokepatients.Neurology.
https://t.me/med1917
2010;74:588-593.
13.BenjaminEJ,ViraniSS,CallawayCW,etal.Heartdiseaseandstrokestatistics-2018update:areportfromtheAmericanHeart
Association.Circulation.2018;137:e67-e492.
14.SmithWS,LevMH,EnglishJD,etal.SignificanceoflargevesselintracranialocclusioncausingacuteischemicstrokeandTIA.Stroke.
2009;40:3834-3840.
15.RaiAT,SeldonAE,BooS,etal.Apopulation-basedincidenceofacutelargevesselocclusionsandthrombectomyeligiblepatients
indicatessignificantpotentialforgrowthofendovascularstroketherapyintheUSA.JNeurointervSurg.2017;9:722-726.
16.AstrupJ,SiesjoBK,SymonL.Thresholdsincerebralischemia–theischemicpenumbra.Stroke.1981;12:723-725.
17.Krabbe-HartkampMJ,vanderGrondJ,deLeeuwFE,etal.CircleofWillis:morphologicvariationonthree-dimensionaltime-of-flight
MRangiograms.Radiology.1998;207:103-111.
18.MiteffF,LeviCR,BatemanGA,etal.Theindependentpredictiveutilityofcomputedtomographyangiographiccollateralstatusinacute
ischaemicstroke.Brain.2009;132:2231-2238.
19.SilvestriniM,AltamuraC,CerquaR,etal.Earlyactivationofintracranialcollateralvesselsinfluencestheoutcomeofspontaneous
internalcarotidarterydissection.Stroke.2011;42:139-143.
20.BarberPA,DemchukAM,ZhangJ,etal.Validityandreliabilityofaquantitativecomputedtomographyscoreinpredictingoutcomeof
hyperacutestrokebeforethrombolytictherapy.ASPECTSStudyGroup.AlbertastrokeprogrammeearlyCTscore.Lancet.
2000;355:1670-1674.
21.MenonBK,SmithEE,ModiJ,etal.RegionalleptomeningealscoreonCTangiographypredictsclinicalandimagingoutcomesinpatients
withacuteanteriorcirculationocclusions.AJNRAmJNeuroradiol.2011;32:1640-1645.
22.d’EsterreCD,RoversiG,PadroniM,etal.CTperfusioncerebralbloodvolumedoesnotalwayspredictinfarctcoreinacuteischemic
stroke.NeurolSci.2015;36:1777-1783.
23.HatazawaJ,ShimosegawaE,ToyoshimaH,etal.Cerebralbloodvolumeinacutebraininfarction:acombinedstudywithdynamic
susceptibilitycontrastMRIand99mTc-HMPAO-SPECT.Stroke.1999;30:800-806.
24.MurphyBD,FoxAJ,LeeDH,etal.Identificationofpenumbraandinfarctinacuteischemicstrokeusingcomputedtomography
perfusion-derivedbloodflowandbloodvolumemeasurements.Stroke.2006;37:1771-1777.
25.HeissWD.Flowthresholdsoffunctionalandmorphologicaldamageofbraintissue.Stroke.1983;14:329-331.
26.LuiYW,TangER,AllmendingerAM,etal.EvaluationofCTperfusioninthesettingofcerebralischemia:patternsandpitfalls.AJNR
AmJNeuroradiol.2010;31:1552-1563.
27.CampbellBC,WeirL,DesmondPM,etal.CTperfusionimprovesdiagnosticaccuracyandconfidenceinacuteischaemicstroke.J
NeurolNeurosurgPsychiatry.2013;84:613-618.
28.BirenbaumD,BancroftLW,FelsbergGJ.Imaginginacutestroke.WestJEmergMed.2011;12:67-76.
29.vanEverdingenKJ,vanderGrondJ,KappelleLJ,etal.Diffusion-weightedmagneticresonanceimaginginacutestroke.Stroke.
1998;29:1783-1790.
30.PalaniswamiM,YanB.Mechanicalthrombectomyisnowthegoldstandardforacuteischemicstroke:implicationsforroutineclinical
practice.IntervNeurol.2015;4:18-29.
31.NationalInstituteofNeurologicalDisordersandStrokertPASSG.Tissueplasminogenactivatorforacuteischemicstroke.NEnglJMed.
1995;333:1581-1587.
32.HackeW,KasteM,BluhmkiE,etal.Thrombolysiswithalteplase3to4.5hoursafteracuteischemicstroke.NEnglJMed.
2008;359:1317-1329.
33.MarlerJR,TilleyBC,LuM,etal.Earlystroketreatmentassociatedwithbetteroutcome:theNINDSrt-PAstrokestudy.Neurology.
2000;55:1649-1655.
34.FinkJN,KumarS,HorkanC,etal.Thestrokepatientwhowokeup:clinicalandradiologicalfeatures,includingdiffusionandperfusion
MRI.Stroke.2002;33:988-993.
35.KleindorferD,KisselaB,SchneiderA,etal.Eligibilityforrecombinanttissueplasminogenactivatorinacuteischemicstroke:a
population-basedstudy.Stroke.2004;35:e27-e29.
36.ReevesMJ,AroraS,BroderickJP,etal.AcutestrokecareintheUS:resultsfrom4pilotprototypesofthePaulCoverdellnational
acutestrokeregistry.Stroke.2005;36:1232-1240.
37.SchwammLH,AliSF,ReevesMJ,etal.Temporaltrendsinpatientcharacteristicsandtreatmentwithintravenousthrombolysisamong
acuteischemicstrokepatientsatgetwiththeguidelines-strokehospitals.CircCardiovascQualOutcomes.2013;6:543-549.
38.SmithWS,TsaoJW,BillingsME,etal.Prognosticsignificanceofangiographicallyconfirmedlargevesselintracranialocclusionin
patientspresentingwithacutebrainischemia.NeurocritCare.2006;4:14-17.
39.BhatiaR,HillMD,ShobhaN,etal.Lowratesofacuterecanalizationwithintravenousrecombinanttissueplasminogenactivatorin
ischemicstroke:real-worldexperienceandacallforaction.Stroke.2010;41:2254-2258.
40.delZoppoGJ,HigashidaRT,FurlanAJ,etal.PROACT:aphaseIIrandomizedtrialofrecombinantpro-urokinasebydirectarterial
deliveryinacutemiddlecerebralarterystroke.PROACTInvestigators.Prolyseinacutecerebralthromboembolism.Stroke.1998;29:4-11.
41.FurlanA,HigashidaR,WechslerL,etal.Intra-arterialprourokinaseforacuteischemicstroke.ThePROACTIIstudy:arandomized
controlledtrial.Prolyseinacutecerebralthromboembolism.JAMA.1999;282:2003-2011.
https://t.me/med1917
42.GwakMS,YangM,HahmTS,etal.Effectofcryoanalgesiacombinedwithintravenouscontinuousanalgesiainthoracotomypatients.J
KoreanMedSci.2004;19:74-78.
43.InvestigatorsIIT.Theinterventionalmanagementofstroke(IMS)IIstudy.Stroke.2007;38:2127-2135.
44.SmithWS,SungG,StarkmanS,etal.Safetyandefficacyofmechanicalembolectomyinacuteischemicstroke:resultsoftheMERCI
trial.Stroke.2005;36:1432-1438.
45.GobinYP,StarkmanS,DuckwilerGR,etal.MERCI1:aphase1studyofmechanicalembolusremovalincerebralischemia.Strok e.
2004;35:2848-2854.
46.SmithWS.Safetyofmechanicalthrombectomyandintravenoustissueplasminogenactivatorinacuteischemicstroke.Resultsofthemulti
mechanicalembolusremovalincerebralischemia(MERCI)trial,partI.AJNRAmJNeuroradiol.2006;27:1177-1182.
47.SmithWS,SungG,SaverJ,etal.Mechanicalthrombectomyforacuteischemicstroke:finalresultsofthemultiMERCItrial.Stroke.
2008;39:1205-1212.
48.NogueiraRG,LutsepHL,GuptaR,etal.TrevoversusMerciretrieversforthrombectomyrevascularisationoflargevesselocclusionsin
acuteischaemicstroke(TREVO2):arandomisedtrial.Lancet.2012;380:1231-1240.
49.CicconeA,ValvassoriL,NichelattiM,etal.Endovasculartreatmentforacuteischemicstroke.NEnglJMed.2013;368:904-913.
50.BroderickJP,PaleschYY,DemchukAM,etal.Endovasculartherapyafterintravenoust-PAversust-PAaloneforstroke.NEnglJ
Med.2013;368:893-903.
51.KidwellCS,JahanR,GornbeinJ,etal.Atrialofimagingselectionandendovasculartreatmentforischemicstroke.NEnglJMed.
2013;368:914-923.
52.BadhiwalaJH,NassiriF,AlhazzaniW,etal.Endovascularthrombectomyforacuteischemicstroke:ameta-analysis.JAMA.
2015;314:1832-1843.
53.DemchukAM,GoyalM,YeattsSD,etal.RecanalizationandclinicaloutcomeofocclusionsitesatbaselineCTangiographyinthe
interventionalmanagementofstrokeIIItrial.Radiology.2014;273:202-210.
54.SchonewilleWJ,WijmanCA,MichelP,etal.TreatmentandoutcomesofacutebasilararteryocclusionintheBasilarArtery
InternationalCooperationStudy(BASICS):aprospectiveregistrystudy.LancetNeurol.2009;8:724-730.
55.YeungJT,MatoukCC,BulsaraKR,etal.Endovascularrevascularizationforbasilararteryocclusion.IntervNeurol.2015;3:31-40.
56.SarrajA,SanghaN,HussainMS,etal.EndovasculartherapyforacuteischemicstrokewithocclusionofthemiddlecerebralarteryM2
segment.JAMANeurol.2016;73:1291-1296.
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C H A P T E R 3
CervicalCarotidandVertebralDisease
ReshmaNarulaMD,SamitM.ShahMD,PhD,MamadouL.SanogoMD,MicheleH.JohnsonMD,FACR,FASER
I.Introduction
A.Ultrasound
B.ComputedTomographicAngiography
C.MagneticResonanceAngiography
D.DigitalSubtractionAngiography
II.CervicalCarotidandVertebralDisease
III.AtheroscleroticDisease
A.CausesofIschemicStroke
B.RiskFactors
C.ModalityforRevascularization
D.DefiningCarotidArteryStenosis
E.SymptomaticVersusAsymptomaticExtracranialCarotidStenosis
IV.RevascularizationinExtracranialCarotidArteryStenosis
A.Evidence
B.Benefits
C.TrialsandStudies
V.PatientFactorsInfluencingRevascularization
A.NASCET
B.CREST
VI.TimingofRevascularization
A.TrialsandTrends
B.RestenosisAfterCarotidEndarterectomyorCarotidArteryStenting
C.IntracranialLargeArteryAtheroscleroticDisease
D.ExtracranialSymptomaticVertebralArteryDisease
VII.AdditionalDisordersoftheExtracranialVasculature
A.FibromuscularDysplasia
B.TraumaticCervicalVascularInjury
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VIII.TechniquesforCarotidandVertebralIntervention
A.RadialAccessforCarotidStenosis
IX.TechniquesforCarotidArteryStenting
A.AngioplastyandStenting
B.EVA-3STrial
C.StatutoryQualityAssurance(2009,2014)
X.EmbolicProtectionDevices
A.PurposeofEPDs
B.DistalEmbolicProtection
C.ProximalEPD
D.TranscarotidCarotidArteryRevascularization
E.Considerations
XI.Summary
KeyPoints
■Reviewimagingoptionsforassessmentofthecervicalvasculature.
■Recognizecommonpathologiesthataffectthecervicalcarotidand/orvertebralarteries.
■Review the indications, risks,andbenefits ofcarotid arterystenting and neuroprotection
options.
I.Introduction
Imagingassessmentoftheextracranialcarotidarteryincludesa varietyofcross-sectionalandcatheterbased techniques with different advantages, disadvantages, risks, and benefits. Cost, the need for
iodinatedcontrast,radiationdose, imaging-modality–related limitations, andcontraindications must be
considered.Familiaritywithfeaturesofeachimagingmodalityisimportantforconfidentlyselectingthe
bestmodalityforanindividualpatientandsuspecteddiseaseprocess.
A.Ultrasound
1.Duplexultrasound(DUS)ofthecervicalcarotidarteriesisthemainstayfornoninvasiveevaluationof
carotidstenosis(Fig.3.1).
1
2.DUSislow-costandreadilyaccessibleandprovidesbothanatomicandflowvelocityinformationthat
each reflect the hemodynamic degree of stenosis and morphological characteristics of atherosclerotic
plaque.
3. DUSis less useful forevaluationofthevertebralarteriesbecauseofthe intraosseouscourseofthe
vertebralarteriesthroughtheforaminatransversarium.
a. Soft,friableplaque,calcifiedplaque,andulceratedplaqueeachhavecharacteristicappearanceson
anatomicultrasound.
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