Atlas condemned to hold up the celestial heavens and bailout the mechanical thrombectomy failures in stroke?

Atlas condenado a segurar os céus e resgatar falhas da trombectomia mecânica no acidente vascular cerebral isquêmico?

Despite the efficacy (70-80%) of large vessel occlusion (LVO) strokes mechanical thrombectomy (MT)¹, some cases do not result in recanalization. Major causes of MT failure is mainly due to intracranial atherosclerotic disease², but there are other reasons such as fibrin-rich clots and calcified thrombi³.

If calcified thrombus signals (Figure 1) associated with MT technique fail, bailout stenting with permanent placement of a self-expanding stent should be considered^4,5. The safety and efficacy of this rescue technique have already been described.

Figure 1.
(A) Non-contrast brain computed tomography basal ganglial level; (B) non-contrast brain computed tomography corona radiate level; (C) non-contrast computed tomography demonstrates a calcified clot in the left M1 segment (arrow); (D) computed tomography head bone window with the calcified clot in the left M1 segment (arrow); (E) internal carotid artery with left M1 occlusion (arrow).

We placed one laser cut stent (Figures 2 and 3) after 3 attempts of MT (SOLUMBRA technique and balloon guiding catheter) with a final thrombolysis in cerebral infarction (TICI) 2a. Patient was discharged from the hospital with National Institutes of Health Stroke Scale (NIHSS) of 17, and 30 days image follow-up is demonstrated in Figure 4.

Figure 2.
(A) Left internal carotid artery DSA image in the anteriorposterior projection shows the proximal occlusion of the left M1 segment; (B) DSA image after the first pass mechanical thrombectomy (SOLUMBRA technique) with TICI 0, asterisk in the occlusion site; (C) non subtraction image from the left internal carotid artery with a 4×40 mm Solitaire platinum Stent retriever (ev3/Covidien, Irvine, CA, USA) with the typical 3 radiopaque markers in each 10 mm (Stars); (D) Rebar 18 (ev3/Covidien, Irvine, CA, USA) microcatheter DSA image; (E) second pass non subtraction image from the left internal carotid artery with a 4×40 mm Solitaire platinum Stent retriever (ev3/Covidien, Irvine, CA, USA) with the typical 3 radiopaque markers in each 10 mm (Stars) and the large bore aspiration catheter ACE 68 (arrow) (Penumbra, Alameda, California, USA); (F) DSA image after the second pass mechanical thrombectomy (SOLUMBRA technique) with TICI 0, asterisk in the occlusion site; (G) Marksmann (ev3/Covidien, Irvine, CA, USA) microcatheter DSA image near the occlusion (asterisk); (H) third pass non subtraction image from the left internal carotid artery with a 4×40 mm Solitaire platinum Stent retriever (ev3/Covidien, Irvine, CA, USA) with the typical 3 radiopaque markers in each 10 mm (Stars) and the large bore aspiration catheter ACE 68 (arrow) (Penumbra, Alameda, California, USA) before the ACEC 68 approach to the clot; (I) DSA image after the third pass mechanical thrombectomy (SOLUMBRA technique) with TICI 0. Asterisk in the occlusion site.

Figure 3.
(A) 3×24 mm Neuroform Altas (Stryker Neurovascular, Fremont, California, USA) beyond the occlusion site; Stars in the radiopaque markers of the Stent. (B) Non subtraction image with the first Neuroform Altas (3×24 mm); Stars in the radiopaque markers of the Stent. (C) Second Neuroform Atlas (3×21 mm) in the right position; Stars in the radiopaque markers of the Stent. (D) Non subtraction image with both Neuroform Atlas Stents (3×24 mm - arrows in the radiopaque markers; 3×21 mm - Stars). (E) Left internal carotid artery DSA AP image after the bailout stenting rescue technique with a TICI 2a result. (F) Late arterial phase of the left internal carotid artery DSA AP image after the bailout stenting rescue technique with a TICI 2a result; (G) AP non subtraction image. (H) Left internal carotid artery DSA lateral image after the bailout stenting rescue technique with a TICI 2a result. (I) Late arterial phase of the internal carotid artery DSA lateral image after the bailout stenting rescue technique with a TICI 2a result. (J) Lateral non subtraction image. (K) Neuroform Atlas (Stryker Neurovascular, Fremont, California, USA): laser-cut self-expanding, open-cell, nitinol Stent.

Figure 4.
(A) 30 days follow-up non contrast brain computed tomography basal ganglial level; (B) 30 days follow-up non contrast brain CT corona radiata level. (B) 30 days follow-up non contrast brain CT corona radiata level.

References

• ¹
  Goyal M, Menon BK, Van Zwam WH, Dippel DWJ, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016 Apr;387(10029):1723-31. https://doi.org/10.1016/S0140-6736(16)00163-X
  » https://doi.org/https://doi.org/10.1016/S0140-6736(16)00163-X
• ²
  Jia B, Feng L, Liebeskind DS, Huo X, Gao F, Ma N, et al. Mechanical thrombectomy and rescue therapy for intracranial large artery occlusion with underlying atherosclerosis. J Neurointerv Surg. 2018 Aug;10(8):746-50. https://doi.org/10.1136/neurintsurg-2017-013489
  » https://doi.org/https://doi.org/10.1136/neurintsurg-2017-013489
• ³
  Dobrocky T, Piechowiak E, Cianfoni A, Zibold F, Roccatagliata L, Mosimann P, et al. Thrombectomy of calcified emboli in stroke. Does histology of thrombi influence the effectiveness of thrombectomy? J Neurointerv Surg. 2018 Apr;10(4):345-50. https://doi.org/10.1136/neurintsurg-2017-013226
  » https://doi.org/https://doi.org/10.1136/neurintsurg-2017-013226
• ⁴
  Stracke CP, Meyer L, Fiehler J, Leischner H, Bester M, Buhk JH, et al. Intracranial bailout stenting with the Acclino (Flex) Stent/NeuroSpeed Balloon Catheter after failed thrombectomy in acute ischemic stroke: a multicenter experience. J Neurointerv Surg. 2020 Jan;12(1):43-7. https://doi.org/10.1136/neurintsurg-2019-014957
  » https://doi.org/https://doi.org/10.1136/neurintsurg-2019-014957
• ⁵
  Peng F, Wan J, Liu W, Huang W, Wang L, Qiu T, et al. Efficacy and safety of rescue stenting following failed mechanical thrombectomy for anterior circulation large vessel occlusion: propensity score analysis. J Neurointerv Surg. 2020 Mar;12(3):271-3. https://doi.org/10.1136/neurintsurg-2019-015154
  » https://doi.org/https://doi.org/10.1136/neurintsurg-2019-015154

Publication Dates

• Publication in this collection
  19 Apr 2021
• Date of issue
  Mar 2021

History

• Received
  17 Apr 2020
• Reviewed
  22 Aug 2020
• Accepted
  24 Aug 2020