Clinical Neurology and Neurosurgery 127 (2014) 15–18
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Endovascular stroke intervention in the very young Mario Zanaty a , Nohra Chalouhi a , Robert M. Starke b , Stavropoula Tjoumakaris a , David Hasan c , Shannon Hann a , Norman Ajiboye a , Kenneth C. Liu b , Robert H. Rosenwasser a , Philip Manasseh a , Pascal Jabbour a,∗ a b c
Department of Neurosurgery, Thomas Jefferson University, Philadelphia, USA Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, USA Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, USA
a r t i c l e
i n f o
Article history: Received 12 August 2014 Received in revised form 15 September 2014 Accepted 26 September 2014 Available online 5 October 2014 Keywords: Endovascular therapy Large vessel occlusion Stroke Young
a b s t r a c t Object: This study aims to evaluate the use of endovascular therapy to treat very young (≤35 years) patients with acute ischemic stroke from large vessel occlusion. Methods: We identified from a prospectively maintained database young patients (≤35 years) undergoing endovascular intervention for AIS at two cerebrovascular referral centers. The study only included patients with a confirmed large vessel occlusion. Modified Rankin scale (mRS) scores were determined at 90 days during a follow-up visit. Results: A total of 15 patients met the inclusion criteria. Mean age was 27.93 years ± 6.75 years (range: 9–35 years). On admission, the mean NIHSS score was 14.07 ± 9.16. Mechanical thrombectomy was performed using the Solitaire FR device in 4 of 15 (26.67%) patients and the Merci/Penumbra systems in 11 (73.33%) patients. Successful recanalization (TICI 2–3) was achieved in all but one patient (14/15; 93.33%). Only one patient (6.67%) had a hemorrhagic conversion following intervention; he later expired. The rate of 90-day favorable outcome (mRS 0–2) was 86.67% (13/15). Conclusion: Endovascular treatment in the very young population may be carried out with limited complications and attain remarkably high rate of recanalization and favorable outcome. This study supports the role of aggressive management strategies for very young patients with large vessel occlusion. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Stroke remains the leading cause of adult permanent disability and the third-leading cause of death in United States [1]. In USA, the incident of new or recurrent stroke is approximately 795,000 per year [2], and is predicted to increase to 1.2 million per year by 2025 [3]. It is not surprising, giving these numbers, that the management of stroke is consistently evolving and includes medical treatment as well as interventional management such as open and endovascular surgery. Medical treatment consists of intravenous (IV) recombinant tissue plasminogen activator (rtPA), which is the only therapy approved by the Food and Drug Administration for
∗ Corresponding author at: Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA. Tel.: +1 2159557000; fax: +1 2155037038. E-mail addresses: [email protected], [email protected] (P. Jabbour). http://dx.doi.org/10.1016/j.clineuro.2014.09.022 0303-8467/© 2014 Elsevier B.V. All rights reserved.
treatment of acute ischemic stroke (AIS) [4]. Endovascular management is currently indicated for patients who fail or are ineligible for IV rtPA [5–8]. Recent data suggests that endovascular management is particularly beneficial in the settings of large vessels occlusion [9,10]. However, data on the endovascular management of stroke in the very young patients (≤35 years) is limited. The devastating long-term disability and the potential for recovery in very young patients may drive aggressive interventional strategies in this subset of patients. We therefore present our experience with the use of endovascular therapy for very young patients (≤35 years) who presented with acute ischemic stroke (AIS) from large vessel occlusions. 2. Methods 2.1. Settings A retrospective review of young patients (≤35 years) who underwent endovascular intervention for AIS at two
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M. Zanaty et al. / Clinical Neurology and Neurosurgery 127 (2014) 15–18
Table 1 Thrombolysis in cerebral infarction classification. TICI 0 TICI 1 TICI 2a TICI 2b TICI 3
No flow beyond occlusion or no recanalization Flow passes beyond occlusion but cannot opacify the entire cerebral bed or minimal recanalization Flow opacifies the distal bed but a slower rate then normal (compared with opposite cerebral artery or proximal bed) Flow surpasses >2/3 of the expected vascular tree Complete perfusion or complete recanalization
cerebrovascular referral centers between January 2008 and January 2014 was carried out. The study was approved by the university Institutional Review Board at each institution. The patients were identified from a prospectively maintained database. Inclusion criteria consisted of a confirmed large vessel occlusion (vertebral, basilar, internal carotid, middle and anterior cerebral arteries) in patients aged ≤35 years. A total of 15 patients met the inclusion criteria and constituted our study population. 2.2. Data collection Data was collected on the patient’s neurological status before and after the intervention, perioperative complications, recanalization rate, and mortality. Patient’s neurological status was assessed using the National Institutes of Health Stroke Scale (NIHSS) on admission. The extent of recanalization was classified according to the thrombolysis in cerebral infarction (TICI) grading system (Table 1). For simplification purpose, TICI 2a and 2b were grouped together as TICI 2, which reflects partial recanalization. Safety outcome was assessed by: intracranial hemorrhage post-intervention, device-induced vessel damage and further propagation of thrombus, and mortality rate at 90 days. Intracranial hemorrhage was classified as symptomatic when it was associated with worsening of NIHSS score by 4 or more points, per the classification of the European-Australasian Acute Stroke Study (ECASS) [11]. Clinical outcomes were determined during a follow-up visit according to the modified Rankin scale (mRS). Data was also collected on the use of IV-rtPA before the intervention and on the time from symptom onset to femoral puncture.
3. Results 3.1. Demographic findings Nine of 15 patients (60.00%) were females and six (40.00%) were males. Mean age was 27.93 years ± 6.75 years (range: 9–35 years). One-third (5/15; 33.33%) of the patients were younger than 25 years. The mean NIHSS score on admission was 14.07 ± 9.16. IV-rtPA was administered before initiation of intra-arterial therapy in seven (7/15; 46.67%) patients. CT perfusion assisted with patient selections for revascularization in nine (9/15; 60.00%) cases. Mean time from symptom onset to femoral artery puncture was 5.67 ± 3.10 h. Arterial occlusion sites were as follows: middle cerebral artery (MCA) in eight (8/15; 53.33%), internal carotid artery (ICA) occlusion in two (2/15; 3.56%), T occlusion in two (2/15; 13.33%), vertebral artery in one (1/15; 6.67%), and basilar artery in two (2/15; 13.33%). Mechanical thrombectomy was performed using the Solitaire FR device in four (4/15; 26.67%) patients and the Merci/Penumbra systems in 11 (11/15; 73.33%) patients. 3.2. Clinical outcomes
Suspected acute stroke patients are either admitted from the institutions’ emergency department, transferred from affiliated community hospitals, or directly accepted by the attending physician by telestroke consult [12]. Patients with NIHSS ≥ 5–8 and evidence of a main arterial thrombus on CTA [13] are selected to undergo an endovascular intervention. Contraindications to endovascular treatment consisted of improving neurological status with low NIHSS, and multiple medical comorbidities.
Successful recanalization (TICI 2–3) was achieved in all but one patient (14/15; 93.33%). TICI scores were as follows: I in one (1/15; 6.67%) patient, II in two (2/15; 13.33%) patients, and III in 12 (12/15; 80.00%) patients. We had no patients with TICI 0 after treatment. One patient had a groin hematoma (1/15; 6.67%) that did not require intervention. Only one (1/15; 6.67%) patient had a symptomatic intracranial hemorrhage (ICH) following intervention. This was the case of a 24-year-old gentleman who presented with an acute occlusion of the ICA and a NIHSS score of 25. The patient was not IV-tPA eligible and he underwent mechanical thrombectomy with the Merci Retriever. The ischemic infarct underwent hemorrhagic transformation and the patients expired despite resuscitative efforts. All patients were available for clinical follow-up. The rate of 90day favorable outcome (mRS 0–2) was 86.67% (13/15). Satisfactory outcome at 90 days was achieved in all except the patient who died (14/15; 93.33%). The mRS score was 0 in 4 patients (4/15; 26.67%), 1 in seven patients (7/15; 14.28%), 2 in two patients (2/15; 13.33%), 3 in one patient (1/15; 6.67%), and 6 in the expired patient (1/15; 6.67%). The 90-day overall morbidity rate was 13.33% (2/15) and that of mortality was 6.67% (1/15). All patients (4/4; 100%) treated with Solitaire FR device had a mRS score of 0–1. Favorable outcomes (mRS 0–2) were noted in 81.81% (9/11) of those treated with Merci/Penumbra. Excluding the patient who died, all our patients were functionally independent after 3 months of follow-up. We did not have any vessel perforation or device-induced vessel damage such as thrombus formation/propagation.
2.4. Intervention technique
4. Discussion
Procedures are performed under general endotracheal anesthesia and maintenance of systolic blood pressure between 160 and 200 mmHg (
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Endovascular stroke intervention in the very young Mario Zanaty a , Nohra Chalouhi a , Robert M. Starke b , Stavropoula Tjoumakaris a , David Hasan c , Shannon Hann a , Norman Ajiboye a , Kenneth C. Liu b , Robert H. Rosenwasser a , Philip Manasseh a , Pascal Jabbour a,∗ a b c
Department of Neurosurgery, Thomas Jefferson University, Philadelphia, USA Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, USA Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, USA
a r t i c l e
i n f o
Article history: Received 12 August 2014 Received in revised form 15 September 2014 Accepted 26 September 2014 Available online 5 October 2014 Keywords: Endovascular therapy Large vessel occlusion Stroke Young
a b s t r a c t Object: This study aims to evaluate the use of endovascular therapy to treat very young (≤35 years) patients with acute ischemic stroke from large vessel occlusion. Methods: We identified from a prospectively maintained database young patients (≤35 years) undergoing endovascular intervention for AIS at two cerebrovascular referral centers. The study only included patients with a confirmed large vessel occlusion. Modified Rankin scale (mRS) scores were determined at 90 days during a follow-up visit. Results: A total of 15 patients met the inclusion criteria. Mean age was 27.93 years ± 6.75 years (range: 9–35 years). On admission, the mean NIHSS score was 14.07 ± 9.16. Mechanical thrombectomy was performed using the Solitaire FR device in 4 of 15 (26.67%) patients and the Merci/Penumbra systems in 11 (73.33%) patients. Successful recanalization (TICI 2–3) was achieved in all but one patient (14/15; 93.33%). Only one patient (6.67%) had a hemorrhagic conversion following intervention; he later expired. The rate of 90-day favorable outcome (mRS 0–2) was 86.67% (13/15). Conclusion: Endovascular treatment in the very young population may be carried out with limited complications and attain remarkably high rate of recanalization and favorable outcome. This study supports the role of aggressive management strategies for very young patients with large vessel occlusion. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Stroke remains the leading cause of adult permanent disability and the third-leading cause of death in United States [1]. In USA, the incident of new or recurrent stroke is approximately 795,000 per year [2], and is predicted to increase to 1.2 million per year by 2025 [3]. It is not surprising, giving these numbers, that the management of stroke is consistently evolving and includes medical treatment as well as interventional management such as open and endovascular surgery. Medical treatment consists of intravenous (IV) recombinant tissue plasminogen activator (rtPA), which is the only therapy approved by the Food and Drug Administration for
∗ Corresponding author at: Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA. Tel.: +1 2159557000; fax: +1 2155037038. E-mail addresses: [email protected], [email protected] (P. Jabbour). http://dx.doi.org/10.1016/j.clineuro.2014.09.022 0303-8467/© 2014 Elsevier B.V. All rights reserved.
treatment of acute ischemic stroke (AIS) [4]. Endovascular management is currently indicated for patients who fail or are ineligible for IV rtPA [5–8]. Recent data suggests that endovascular management is particularly beneficial in the settings of large vessels occlusion [9,10]. However, data on the endovascular management of stroke in the very young patients (≤35 years) is limited. The devastating long-term disability and the potential for recovery in very young patients may drive aggressive interventional strategies in this subset of patients. We therefore present our experience with the use of endovascular therapy for very young patients (≤35 years) who presented with acute ischemic stroke (AIS) from large vessel occlusions. 2. Methods 2.1. Settings A retrospective review of young patients (≤35 years) who underwent endovascular intervention for AIS at two
16
M. Zanaty et al. / Clinical Neurology and Neurosurgery 127 (2014) 15–18
Table 1 Thrombolysis in cerebral infarction classification. TICI 0 TICI 1 TICI 2a TICI 2b TICI 3
No flow beyond occlusion or no recanalization Flow passes beyond occlusion but cannot opacify the entire cerebral bed or minimal recanalization Flow opacifies the distal bed but a slower rate then normal (compared with opposite cerebral artery or proximal bed) Flow surpasses >2/3 of the expected vascular tree Complete perfusion or complete recanalization
cerebrovascular referral centers between January 2008 and January 2014 was carried out. The study was approved by the university Institutional Review Board at each institution. The patients were identified from a prospectively maintained database. Inclusion criteria consisted of a confirmed large vessel occlusion (vertebral, basilar, internal carotid, middle and anterior cerebral arteries) in patients aged ≤35 years. A total of 15 patients met the inclusion criteria and constituted our study population. 2.2. Data collection Data was collected on the patient’s neurological status before and after the intervention, perioperative complications, recanalization rate, and mortality. Patient’s neurological status was assessed using the National Institutes of Health Stroke Scale (NIHSS) on admission. The extent of recanalization was classified according to the thrombolysis in cerebral infarction (TICI) grading system (Table 1). For simplification purpose, TICI 2a and 2b were grouped together as TICI 2, which reflects partial recanalization. Safety outcome was assessed by: intracranial hemorrhage post-intervention, device-induced vessel damage and further propagation of thrombus, and mortality rate at 90 days. Intracranial hemorrhage was classified as symptomatic when it was associated with worsening of NIHSS score by 4 or more points, per the classification of the European-Australasian Acute Stroke Study (ECASS) [11]. Clinical outcomes were determined during a follow-up visit according to the modified Rankin scale (mRS). Data was also collected on the use of IV-rtPA before the intervention and on the time from symptom onset to femoral puncture.
3. Results 3.1. Demographic findings Nine of 15 patients (60.00%) were females and six (40.00%) were males. Mean age was 27.93 years ± 6.75 years (range: 9–35 years). One-third (5/15; 33.33%) of the patients were younger than 25 years. The mean NIHSS score on admission was 14.07 ± 9.16. IV-rtPA was administered before initiation of intra-arterial therapy in seven (7/15; 46.67%) patients. CT perfusion assisted with patient selections for revascularization in nine (9/15; 60.00%) cases. Mean time from symptom onset to femoral artery puncture was 5.67 ± 3.10 h. Arterial occlusion sites were as follows: middle cerebral artery (MCA) in eight (8/15; 53.33%), internal carotid artery (ICA) occlusion in two (2/15; 3.56%), T occlusion in two (2/15; 13.33%), vertebral artery in one (1/15; 6.67%), and basilar artery in two (2/15; 13.33%). Mechanical thrombectomy was performed using the Solitaire FR device in four (4/15; 26.67%) patients and the Merci/Penumbra systems in 11 (11/15; 73.33%) patients. 3.2. Clinical outcomes
Suspected acute stroke patients are either admitted from the institutions’ emergency department, transferred from affiliated community hospitals, or directly accepted by the attending physician by telestroke consult [12]. Patients with NIHSS ≥ 5–8 and evidence of a main arterial thrombus on CTA [13] are selected to undergo an endovascular intervention. Contraindications to endovascular treatment consisted of improving neurological status with low NIHSS, and multiple medical comorbidities.
Successful recanalization (TICI 2–3) was achieved in all but one patient (14/15; 93.33%). TICI scores were as follows: I in one (1/15; 6.67%) patient, II in two (2/15; 13.33%) patients, and III in 12 (12/15; 80.00%) patients. We had no patients with TICI 0 after treatment. One patient had a groin hematoma (1/15; 6.67%) that did not require intervention. Only one (1/15; 6.67%) patient had a symptomatic intracranial hemorrhage (ICH) following intervention. This was the case of a 24-year-old gentleman who presented with an acute occlusion of the ICA and a NIHSS score of 25. The patient was not IV-tPA eligible and he underwent mechanical thrombectomy with the Merci Retriever. The ischemic infarct underwent hemorrhagic transformation and the patients expired despite resuscitative efforts. All patients were available for clinical follow-up. The rate of 90day favorable outcome (mRS 0–2) was 86.67% (13/15). Satisfactory outcome at 90 days was achieved in all except the patient who died (14/15; 93.33%). The mRS score was 0 in 4 patients (4/15; 26.67%), 1 in seven patients (7/15; 14.28%), 2 in two patients (2/15; 13.33%), 3 in one patient (1/15; 6.67%), and 6 in the expired patient (1/15; 6.67%). The 90-day overall morbidity rate was 13.33% (2/15) and that of mortality was 6.67% (1/15). All patients (4/4; 100%) treated with Solitaire FR device had a mRS score of 0–1. Favorable outcomes (mRS 0–2) were noted in 81.81% (9/11) of those treated with Merci/Penumbra. Excluding the patient who died, all our patients were functionally independent after 3 months of follow-up. We did not have any vessel perforation or device-induced vessel damage such as thrombus formation/propagation.
2.4. Intervention technique
4. Discussion
Procedures are performed under general endotracheal anesthesia and maintenance of systolic blood pressure between 160 and 200 mmHg (
