http://www.springerlink.com/content/64rr0h3827k1g5p7/

Patients with acute stroke with large vessel occlusion and carotid stenosis have been stented and then thrombolysed, or the stenosis simply left as it is, in the past. However, a problem arises if a visible clot sticks in the lumen at the stenotic site. No need to worry. You can stent this as well and then perform thrombolysis, as done by the authors of this paper. Of course one needs to use a distal filter device!

Abstract

Introduction 

Carotid stenosis with intraluminal thrombus is associated with a high risk of early recurrent stroke. We evaluated the feasibility and outcome of carotid stenting in acute ischemic stroke patients with carotid stenosis and intraluminal thrombus.

Methods 

Among 295 consecutive acute ischemic stroke patients who were referred for intra-arterial thrombolytic (IAT) therapy, six patients with carotid stenosis and intraluminal thrombus were treated by stent assisted angioplasty. The clinical characteristics, feasibility, and clinical outcomes were assessed.

Results 

All patients had severe stenosis of the underlying carotid bulb (mean, 86.8%; range, 71–99%) with adjacent intraluminal thrombus. Stent assisted angioplasty resulted in successful recanalization in all six patients. Thrombus was captured with the filter device in four patients. Three patients with tandem occlusion of the ipsilateral proximal middle cerebral artery were successfully recanalized with intra-arterial urokinase. No patients suffered procedure related complications or symptomatic hemorrhage. Four patients showed good long-term outcome (3 month mRS; 0–2).

Conclusions 

Stent assisted angioplasty is a feasible treatment option for acute ischemic stroke patients caused by carotid stenosis with intraluminal thrombus and may be effective in preventing early recurrent stroke.

Keywords  Carotid stenosis – Angioplasty – Stent – Thrombolytic therapy

http://www.springerlink.com/content/u315778702g1jj86/

Jee-Hyun Kwon, Shang Hun Shin, Young Cheol Weon, Jae Cheol Hwang and Seung Kug Baik. Intra-arterial adjuvant tirofiban after unsuccessful intra-arterial thrombolysis of acute ischemic stroke: preliminary experience in 16 patients. NeuroradiologyVolume 53, Number 10, 779-785, DOI: 10.1007/s00234-011-0939-y

Intra-arterial chemical thrombolytic therapy of acute stroke is rapidly gaining strides. However, the drugs and their dosage to be used is far from clear, with ever neurointerventionist using a different protocol. Even then, few points are becoming lucid;

1. Fibrin busting drugs e.g tPA or urokinase is not effective in a substantial number of patients

2. Antiplatelets are vey handy in intra-arterial thrombolysis

3. Intra-arterial heparin also can be handy in many instances

Reports of  groups using antiplatelets have been published.

A recent one studied 16 patients with failed thrombolysis after IA urokinase, in whom tirofiban was used. They achieved good recanalisation rates. However, 6 patients had ICH, which to my mind does not really augur well for this idea, even though the authors themselves say that it is a good result.

Probably we need to design a chemical IA thrombolysis dosage using both Urokinase/tPA and antiplatelets rather than using one after the other has failed.

Abstract

Introduction 

Intra-arterial (IA) thrombolysis with plasminogen activator is well-known, but the use of IA tirofiban as an adjuvant for IA thrombolysis is not well-known. We investigated the feasibility of IA tirofiban as an adjuvant after unsuccessful IA recanalization with urokinase (UK) for acute ischemic stroke.

Methods 

We retrospectively analyzed all 16 consecutive patients (11 men and five women; mean age, 61.3 years; range, 36–85 years) who were treated with IA tirofiban after isolated IA thrombolysis with UK or bridging therapy with systemic recombinant tissue plasminogen activator (rt-PA; 0.6 mg/Kg) and IA UK for acute ischemic stroke. Outcome measures included angiographic recanalization (thrombolysis in cerebral infarction, TICI), symptomatic and asymptomatic intracerebral hemorrhage (ICH), mortality, and functional independence at 3 months (modified Rankin Scale, 0–2).

Results 

Among the 16 patients treated with IA tirofiban as an adjuvant, 10 patients had conventional dose (<25 ug/kg, bolus) and six patients had high dose (≥25 ug/kg, bolus) of IA tirofiban after unsuccessful IA thrombolysis whether systemic rt-PA used or not. Successful angiographic recanalization (TICI grade 2b or 3) was achieved in 13 patients (13/16) and a functional independence at 3 months in eight patients (8/16). Three months after therapy, three patients had died. There were two patients of symptomatic ICH and four asymptomatic ICH.

Conclusion 

Conventional dose of IA tirofiban as an adjuvant during IA thrombolysis for acute ischemic stroke seems feasible. However, further dose escalation studies should be performed regarding the IA use of tirofiban for acute ischemic stroke.

Keywords  Acute ischemic stroke – Intra-arterial – Tirofiban – Thrombolysis

    Click to open the article in the journal website

Charlotte Rosso, Olivier Colliot, Romain Valabrègue, Sophie Crozier, Didier Dormont, Stéphane Lehéricy and Yves Samson. Tissue at risk in the deep middle cerebral artery territory is critical to stroke outcome. Neuroradiology Volume 53, Number 10, 763-771, DOI: 10.1007/s00234-011-0916-5

We have often seen that patients with predominant cortical ischemia do well over time however, the ones with large deep white matter infarcts have poor outcomes. A growing body of evidence has been accumulating the same. In this recent article, the authors have used voxel based ADC mapping and diffusion tensor imaging to establish this fact.

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Abstract

Introduction 

The clinical efficacy of thrombolysis in stroke patients is explained by the increased rate of recanalization, which limits infarct growth. However, the efficacy could also be explained by the protection of specific sites of the brain. Here, we investigate where is this outcome-related tissue at risk using voxel-based analysis.

Methods 

We included 68 acute stroke patients with middle cerebral artery (MCA) occlusion on the admission MRI performed within 6 h of symptoms onset (H6) and 16 controls. MCA recanalization was assessed using the magnetic resonance angiography performed at day 1 (D1). Apparent diffusion coefficient (ADC) changes were analyzed using a voxel-based method between patients vs. controls group at admission (H6) in non-recanalized vs. recanalized and in 3-month poor vs. good outcome patients at D1.

Results 

Complete or partial MCA recanalization was observed in 52 of 68 patients. Good outcome at 3 months occurred in 40 patients (59%). In non-recanalized patients, ADC was decreased in the deep MCA and watershed arterial territory (the lenticular nucleus, internal capsule, and the overlying periventricular white matter). This decrease was not observed in recanalized patients at D1 or patients at H6. Fiber tracking suggested that the area is crossed by the cortico-spinal, cerebellar, and intra-hemispheric association tracts. Finally, this area almost co-localized with the area associated with poor outcome.

Conclusions 

A clinically relevant area of tissue at risk may occur in patients with MCA infarcts at the level of deep white matter fiber tracts. These findings suggest that neuroprotection research should be refocused on white matter.

Keywords  Stroke – Recanalization – Outcome – MRI – DWI