|ECR 2013 / C-2384|
|Imaging diagnostic, treatment and outcomes of acute intracranial vertebrobasilar artery occlusion: Our experience.|
Methods and Materials
Fifteen patients were diagnosed with VBO in our institution between April 2010 and August 2012. All received CT/CTA, in wake up strokes also CTP or RM perfusion were done. All included patients had criteria of VBO, clinical data of 15 patients were comprised of 13 male patients and 2 female patients with ages from 40 to 78 years (mean, 62.4 years).
CT scanning was obtained on a 16-row scanner. For CTP/CT-angiography, serial CT was performed with a rapid bolus injection of contrast material and adjacent 0’6 mm thick sections were obtained. CTA with maximum intensity projection (MIP) was used to assess location of the occlusion. The anatomical imaging reference used to position the dynamic perfusion studies was the internal auditory canal. In CTP, cerebral blood volume (CBV), cerebral blood flow (CBF) and (MTT) medium transit time maps were calculated using commercially available semi-automated perfusion analysis software based on the maximum slope model of perfusion.
In some patients with wake-up stroke or basilar artery occlusions lasting >4.5 hour, magnetic resonance with DWI was used to rule out patients with severe ADC map abnormalities.
Seven years ago we became a qualified Stroke Center, with specialized stroke unit, where patients are treated with thrombolytic therapy within 4.5 h of stroke onset. In April 2010 we were recognized as reference center in Catalonia for neurointerventional stroke treatment, 24 hours a day and 365 days a year. It implies that since then CT, CT perfusion/CT angiography (CTP/CTA) and endovascular treatment are systematically available at stroke admission. CTP/CTA was performed after thrombolytic therapy had been infused for 30 minutes. If CTP/CTA confirms persistence of a large vessel occlusion (basilar or vertebral arteries, and P1 or P2 posterior cerebral segments), endovascular treatment was initiated.
In patients admitted > 4.5 h of stroke onset, or in wake-up strokes, CTP and CTA were performed, as intravenous thrombolytic therapy is contraindicated, and the patients were considered eligible to receive endovascular treatment when a target mismatch and a proximal occlusion were present and there was not a malignant profile. Age was not considered an exclusion criterion.
All the patients were admitted to our stroke Unit. Daily NIHSS evaluation was performed by neurologist specialized in stroke with current NIHSS certification and modified Rankin scale was assessed at 3 months. Follow-up CT scan was performed always 24h after thrombolysis or before if clinical worsening in the NIHSS score occurred.
For revascularization procedure informed written consent was obtained from the patients or their relatives. All procedures were performed on a biplane angiograph, without general anesthetic if possible. In 10 cases (67 %) general anesthesic was necessary because of impairment of consciousness, hemodynamic and respiratory function instability or extreme agitation.
Devices used for mechanical thrombectomy were SOLITAIRE Ev3, (most frequently used) and TREVO (Concentric Medical) (Fig. ---). Devices used for stenting were ENTERPRISE and WINGSPAN stents. Angioplasty balloons used were MUSO and ULTRASOFT.
A 6F femoral guiding catheter (Neuron) was used. In particularly tortuous vessels a 4.3 to 5.2 F coaxial distal access catheter (DAC) was used. A 0.014-inch micro-wire was used to advance along the artery until a 0.18 micro catheter could be located distally to the thrombus. The device was placed at the site of the thrombus, maintaining it open for at least 5 minutes. We always used continuous aspiration from the guiding catheter while the device was being removed.
A maximum of six attempts were done with Solitaire/Trevo, achieving a total revascularization rate of 76%.
Occlusion location, time to endovascular treatment, successful recanalization (Thrombolysis-in-Cerebral-Infarction-[TICI]/score 2-3), time to revascularization, devices used, intravenous thrombolysis good outcome (modified-Rankin-Scale-[mRS]score/0-2) and mortality were retrospectively analyzed.
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