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Ischemic stroke
ORIGINAL RESEARCH
Extracranial carotid artery stenting followed by intracranial stent-based thrombectomy for acute tandem occlusive disease José E Cohen,1,2 J Moshe Gomori,2 Gustavo Rajz,3 Eyal Itshayek,1 Roni Eichel,4 Ronen R Leker4 1
Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel 2 Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel 3 Department of Neurosurgery, Sheba Medical Center, Tel Aviv, Israel 4 Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel Correspondence to Professor José E Cohen, Department of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel; [email protected] Received 18 February 2014 Revised 20 March 2014 Accepted 27 March 2014 Published Online First 12 April 2014
ABSTRACT Objective Acute tandem occlusions of the extracranial internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous tissue plasminogen activator (tPA) and present an endovascular challenge. We describe our experience with emergency stentassisted ICA angioplasty and intracranial stent-based thrombectomy of tandem occlusions. Methods Procedures were performed from March 2010 to December 2013. National Institutes of Health Stroke Score (NIHSS) and Alberta Stroke Program Early CT Score (ASPECTS), occlusion sites, collateral supply, procedural details, and outcomes were retrospectively reviewed with IRB waiver of informed consent. Results 24 patients, mean age 66 years, mean admission NIHSS 20.4, and mean ASPECTS 9 were included. Occlusion sites were proximal ICA–middle cerebral artery (MCA) trunk in 17 patients, proximal ICA–ICA terminus in six, and ICA–MCA–anterior cerebral artery in one. Stent-assisted cervical ICA recanalization was achieved in all patients, with unprotected preangioplasty in 24/24, unprotected stenting in 16/24 (67%), and protected stenting in 8/24 (33%), followed by stent-thrombectomy in 25 intracranial occlusions. There was complete recanalization/complete perfusion in 19/24 (79%), complete recanalization/partial perfusion in 3/24 (13%), and partial recanalization/partial perfusion in 2/24 (8%) with no procedural morbidity/ mortality. Mean time to therapy was 3.8 h (range 2–5.5) and mean time to recanalization was 51 min (range 38–69). At 3-month follow-up, among 17/22 surviving patients (77%), 13/17 (76%) were modified Rankin Scale (mRS) 0–2 and 3/17 (18%) were mRS 3. Conclusions In acute tandem ICA–MCA/distal ICA occlusions, extracranial stenting followed by intracranial stent-based thrombectomy appears feasible, effective, and safe. Further evaluation of this treatment strategy is warranted.
INTRODUCTION
To cite: Cohen JE, Gomori JM, Rajz G, et al. J NeuroIntervent Surg 2015;7:412–417. 412
Acute extracranial internal carotid artery (ICA) occlusion with tandem distal occlusion is usually associated with major stroke leading to severe disability or death1 2; intravenous thrombolysis and other combined approaches have met with limited success.3–7 A significant clot burden and limited delivery of the thrombolytic drug to the distal occlusion may explain the poor results.8 In selected cases, successful revascularization of carotid occlusion with stent implantation immediately followed by intracranial
intra-arterial thrombolysis, balloon angioplasty, or thromboaspiration has been reported.9–13 The recent widespread use of self-expanding stents as a thrombectomy device for major embolic occlusions14–16 has led to a new endovascular approach consisting of extracranial angioplasty and stenting followed by intracranial stent-based thrombectomy.17 18 We present our recent experience with this endovascular approach in the management of acute tandem occlusive disease.
MATERIAL AND METHODS Participants included consecutive patients with acute ischemic stroke secondary to tandem occlusion of the ICA and middle cerebral artery (MCA) at a single institution (Hadassah-Hebrew University Medical Center) from March 2010 to December 2013. Among the participants in this study, all proximal occlusions were treated by stent-assisted carotid angioplasty and all distal embolic occlusions were managed with self-expanding microstents used as a thrombectomy device (stent-thrombectomy, Solitaire; ev3/Covidien, Plymouth, Minnesota, USA). Patients managed with alternative endovascular or other techniques and those who presented with major intracranial occlusions associated with underlying atherosclerotic stenosis requiring a permanent stent implant were excluded from the study. Endovascular procedures were performed within 6 h of symptom onset in patients with National Institutes of Health Stroke Scale (NIHSS) score >10 upon presentation to the emergency department where there was no cerebral hemorrhage and no clear sign of early cerebral infarction involving more than one-third of the endangered territory. Tandem occlusion was demonstrated on admission cranial CT angiography and confirmed by digital subtraction angiography (DSA). MR studies were performed for penumbra evaluation only in selected cases (ie, conflicting clinicalneuroradiological findings, unclear stroke onset time) to determine whether there was indication for endovascular revascularization. Comorbidities and current medications were taken into consideration when the therapeutic options were weighed. Selected clinical, radiographic, and interventional data are presented in table 1. Clinical data included age, admission NIHSS, time to endovascular therapy (defined as interval from stroke onset to arrival in the angiography suite), and modified Rankin Scale (mRS) at 1–3 month follow-up.
Cohen JE, et al. J NeuroIntervent Surg 2015;7:412–417. doi:10.1136/neurintsurg-2014-011175
Downloaded from http://jnis.bmj.com/ on August 31, 2015 - Published by group.bmj.com
Ischemic stroke Table 1 Demographic, clinical, and procedural data of 24 patients with tandem occlusions of the anterior circulation
Demographic characteristics Gender Age Presentation NIHSS ASPECTS Tandem occlusions Lt ICA–Lt MCA trunk Rt ICA–Rt MCA trunk Lt ICT–Lt ICA terminus Rt ICA–Rt ICA terminus ICA–MCA trunk–ACA ASITN/SIR Endovascular procedure Unprotected pre-angioplasty Unprotected ICA stenting Protected ICA stenting Conservative post-dilation Extracranial ICA recanalization Stent-thrombectomy of distal occlusion(s) Outcomes Time to therapy Time to recanalization Complete recanalization/complete reperfusion (TIMI 3/TICI 2b) Complete recanalization/partial reperfusion (TIMI 3/TICI 2a) Partial recanalization/partial reperfusion (TIMI 2/TICI 2a) Procedural complications Procedure-related mortality Mortality (all cause, within 3 months) 3-month mRS (17/22 living patients, 71%) 6-month mRS (20/22 living patients)
Men: 20 (83%), women: 4 (17%) Mean 66 years (range 51–77) Mean 20.4, median 18 (range 14–28) Mean 9, median 9 (range 7–10) 11 (46%) 6 (25%) 4 (17%) 2 (8%) 1 (4%) 0–2 (poor): 24 24 (100%) 16 (67%) 8 (33%) 14 (58%) 24 (100%) 24 patients/25 occlusions (100%) Mean 3.3 hours (range 2–5.2) Mean 51 min (range 38–69) 19 (79%) 3 (13%) 2 (8%) 0 0 2 (8%) 0–2: 13 (76%) 3: 4 (24%) 0–2: 14 (70%) 3: 6 (30%)
ACA, anterior cerebral artery; ASITN/SIR, American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology collateral flow grading system; ASPECTS, Alberta Stroke Program Early CT Score; ICA, internal carotid artery; Lt, left; MCA, middle cerebral artery; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Score; Rt, right; TICI, Thrombolysis in Cerebral Infarction grade; TIMI, Thrombolysis in Myocardial Infarction grade.
Radiological data included Alberta Stroke Program Early CT Score (ASPECTS),19 occlusion site, extent of collateral supply on CT angiogram, MR (when available), and post-procedural head CT evaluation. Interventional data included anesthesia type, medications during endovascular treatment, endovascular techniques, time-to-recanalization (TTR, defined as the interval between introducer sheath placement to first angiographic run showing recanalization), Thrombolysis in Myocardial Infarction flow grade (TIMI) at recanalization, and Thrombolysis in Cerebral Infarction (TICI) grade.17 18 Collateral supply was evaluated as good, fair, or poor based on the ratio of the area of parenchyma supplied by collaterals to
the total area that should have been supplied by the thrombosed vessel, as assessed by CT, MRI, and/or DSA; good supply was defined as a ratio >66%, fair as 33–66%, and poor as 60 years with a history of controlled vascular risk factors was urgently transferred to our center 2.5 h after stroke onset. Upon arrival the patient was alert, with global dysphasia, gaze deviation, and left hemiplegia (National Institutes of Stroke Score (NIHSS) 18). (A–D) Head CT followed by CT angiogram showed no signs of right hemispheric ischemia (Alberta Stroke Program Early CT Score (ASPECTS) 10), with tandem occlusion of the right internal carotid artery (ICA) and proximal middle cerebral artery (MCA). (E) Under general anesthesia, diagnostic angiography confirmed proximal occlusion of the right ICA. A small angiographic spike marked the ICA ostium. The left ICA occlusion was crossed with a microsystem and the angiogram obtained through the microcatheter confirmed its location at the left cervical ICA. The microcatheter was exchanged for a balloon and angioplasty was performed at the proximal left ICA occlusion, achieving partial revascularization. The balloon was exchanged for a protection device and a closed-cell carotid stent was implanted across the plaque. The guiding catheter was advanced beyond the stented segment. (F) Angiography confirmed proximal right MCA occlusion. A 0.021 microcatheter was navigated across the intracranial occlusion. (G,H) Stent-assisted thrombectomy allowed complete recanalization of the MCA after a single pass (Thrombolysis in Myocardial Infarction grade (TIMI) 3, Thrombolysis in Cerebral Infarction grade (TICI) 3). The patient’s condition improved, with neurological assessment reaching NIHSS 0 after 1 week. 414
Cohen JE, et al. J NeuroIntervent Surg 2015;7:412–417. doi:10.1136/neurintsurg-2014-011175
Downloaded from http://jnis.bmj.com/ on August 31, 2015 - Published by group.bmj.com
Ischemic stroke
Figure 2 (A,B) A middle-aged patient with a history of multiple poorly controlled vascular risk factors was transferred to our center with a wake-up stroke of unclear onset time. The patient had last been seen well 7 h earlier and was found unconscious on the bedroom floor. Upon arrival the patient was drowsy with global dysphasia and gaze deviation, and presented with right dense hemiplegia NIHSS 24. Head CT followed by CT angiography showed unclear signs of left hemispheric ischemia (ASPECTS 10), with tandem occlusion of the left ICA and proximal MCA Emergency MRI stroke protocol confirmed the presence of a significant diffusion-perfusion mismatch. (C) Under general anesthesia, diagnostic angiography confirmed proximal occlusion of the left ICA. A small angiographic spike marked the ICA ostium. The left ICA occlusion was crossed with a microsystem. Angiogram obtained through the microcatheter confirmed its location at the cervical left ICA. The microcatheter was exchanged for a balloon and angioplasty was performed at the proximal left ICA occlusion. The balloon was exchanged for a protection device and a closed-cell carotid stent was implanted across the plaque. (D) Angiography demonstrates recanalization of the left ICA. (E) The guiding catheter was advanced beyond the stented segment. (F) Angiography confirmed proximal left MCA occlusion. A 0.021 microcatheter was navigated across the intracranial occlusion and stent-assisted thrombectomy was performed. (G,H) In 47 min, after one pass, the left MCA was completely recanalized and reperfused (Thrombolysis in Myocardial Infarction grade 3, Thrombolysis in Cerebral Infarction grade 3). The patient’s condition improved, with neurological assessment reaching NIHSS 3 after 1 week.
CT findings Routine CT scans performed after recanalization in 18/24 patients (75%) demonstrated cortical sparing (>80% of cortex at risk). This is particularly remarkable considering that patients in this series presented with very limited collateral flow at admission angiography. Lenticulostriate/subinsular residual infarct (volume 0.8–9 cm3) was noted in 19/24 patients (79.2%). No patient required decompressive craniectomy for mass effect or infarction. Six patients had petechial hemorrhages; none presented with intracerebral or intraventricular hemorrhage. The sample size and low rates of hemorrhage precluded analysis of the effect of intravenous tPA or antiplatelet loading dose administration.
Sonographic findings None of the 20 patients with follow-up Doppler examination had stent occlusion. Four patients with known post-angioplasty residual stenosis (>30%) were followed more closely and remain asymptomatic; one patient with stenosis progression on sonographic and angiographic follow-up sustained uneventful re-angioplasty 4 months after primary treatment.
Clinical outcome Rapid neurological recovery (NIHSS
Ischemic stroke
ORIGINAL RESEARCH
Extracranial carotid artery stenting followed by intracranial stent-based thrombectomy for acute tandem occlusive disease José E Cohen,1,2 J Moshe Gomori,2 Gustavo Rajz,3 Eyal Itshayek,1 Roni Eichel,4 Ronen R Leker4 1
Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel 2 Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel 3 Department of Neurosurgery, Sheba Medical Center, Tel Aviv, Israel 4 Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel Correspondence to Professor José E Cohen, Department of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel; [email protected] Received 18 February 2014 Revised 20 March 2014 Accepted 27 March 2014 Published Online First 12 April 2014
ABSTRACT Objective Acute tandem occlusions of the extracranial internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous tissue plasminogen activator (tPA) and present an endovascular challenge. We describe our experience with emergency stentassisted ICA angioplasty and intracranial stent-based thrombectomy of tandem occlusions. Methods Procedures were performed from March 2010 to December 2013. National Institutes of Health Stroke Score (NIHSS) and Alberta Stroke Program Early CT Score (ASPECTS), occlusion sites, collateral supply, procedural details, and outcomes were retrospectively reviewed with IRB waiver of informed consent. Results 24 patients, mean age 66 years, mean admission NIHSS 20.4, and mean ASPECTS 9 were included. Occlusion sites were proximal ICA–middle cerebral artery (MCA) trunk in 17 patients, proximal ICA–ICA terminus in six, and ICA–MCA–anterior cerebral artery in one. Stent-assisted cervical ICA recanalization was achieved in all patients, with unprotected preangioplasty in 24/24, unprotected stenting in 16/24 (67%), and protected stenting in 8/24 (33%), followed by stent-thrombectomy in 25 intracranial occlusions. There was complete recanalization/complete perfusion in 19/24 (79%), complete recanalization/partial perfusion in 3/24 (13%), and partial recanalization/partial perfusion in 2/24 (8%) with no procedural morbidity/ mortality. Mean time to therapy was 3.8 h (range 2–5.5) and mean time to recanalization was 51 min (range 38–69). At 3-month follow-up, among 17/22 surviving patients (77%), 13/17 (76%) were modified Rankin Scale (mRS) 0–2 and 3/17 (18%) were mRS 3. Conclusions In acute tandem ICA–MCA/distal ICA occlusions, extracranial stenting followed by intracranial stent-based thrombectomy appears feasible, effective, and safe. Further evaluation of this treatment strategy is warranted.
INTRODUCTION
To cite: Cohen JE, Gomori JM, Rajz G, et al. J NeuroIntervent Surg 2015;7:412–417. 412
Acute extracranial internal carotid artery (ICA) occlusion with tandem distal occlusion is usually associated with major stroke leading to severe disability or death1 2; intravenous thrombolysis and other combined approaches have met with limited success.3–7 A significant clot burden and limited delivery of the thrombolytic drug to the distal occlusion may explain the poor results.8 In selected cases, successful revascularization of carotid occlusion with stent implantation immediately followed by intracranial
intra-arterial thrombolysis, balloon angioplasty, or thromboaspiration has been reported.9–13 The recent widespread use of self-expanding stents as a thrombectomy device for major embolic occlusions14–16 has led to a new endovascular approach consisting of extracranial angioplasty and stenting followed by intracranial stent-based thrombectomy.17 18 We present our recent experience with this endovascular approach in the management of acute tandem occlusive disease.
MATERIAL AND METHODS Participants included consecutive patients with acute ischemic stroke secondary to tandem occlusion of the ICA and middle cerebral artery (MCA) at a single institution (Hadassah-Hebrew University Medical Center) from March 2010 to December 2013. Among the participants in this study, all proximal occlusions were treated by stent-assisted carotid angioplasty and all distal embolic occlusions were managed with self-expanding microstents used as a thrombectomy device (stent-thrombectomy, Solitaire; ev3/Covidien, Plymouth, Minnesota, USA). Patients managed with alternative endovascular or other techniques and those who presented with major intracranial occlusions associated with underlying atherosclerotic stenosis requiring a permanent stent implant were excluded from the study. Endovascular procedures were performed within 6 h of symptom onset in patients with National Institutes of Health Stroke Scale (NIHSS) score >10 upon presentation to the emergency department where there was no cerebral hemorrhage and no clear sign of early cerebral infarction involving more than one-third of the endangered territory. Tandem occlusion was demonstrated on admission cranial CT angiography and confirmed by digital subtraction angiography (DSA). MR studies were performed for penumbra evaluation only in selected cases (ie, conflicting clinicalneuroradiological findings, unclear stroke onset time) to determine whether there was indication for endovascular revascularization. Comorbidities and current medications were taken into consideration when the therapeutic options were weighed. Selected clinical, radiographic, and interventional data are presented in table 1. Clinical data included age, admission NIHSS, time to endovascular therapy (defined as interval from stroke onset to arrival in the angiography suite), and modified Rankin Scale (mRS) at 1–3 month follow-up.
Cohen JE, et al. J NeuroIntervent Surg 2015;7:412–417. doi:10.1136/neurintsurg-2014-011175
Downloaded from http://jnis.bmj.com/ on August 31, 2015 - Published by group.bmj.com
Ischemic stroke Table 1 Demographic, clinical, and procedural data of 24 patients with tandem occlusions of the anterior circulation
Demographic characteristics Gender Age Presentation NIHSS ASPECTS Tandem occlusions Lt ICA–Lt MCA trunk Rt ICA–Rt MCA trunk Lt ICT–Lt ICA terminus Rt ICA–Rt ICA terminus ICA–MCA trunk–ACA ASITN/SIR Endovascular procedure Unprotected pre-angioplasty Unprotected ICA stenting Protected ICA stenting Conservative post-dilation Extracranial ICA recanalization Stent-thrombectomy of distal occlusion(s) Outcomes Time to therapy Time to recanalization Complete recanalization/complete reperfusion (TIMI 3/TICI 2b) Complete recanalization/partial reperfusion (TIMI 3/TICI 2a) Partial recanalization/partial reperfusion (TIMI 2/TICI 2a) Procedural complications Procedure-related mortality Mortality (all cause, within 3 months) 3-month mRS (17/22 living patients, 71%) 6-month mRS (20/22 living patients)
Men: 20 (83%), women: 4 (17%) Mean 66 years (range 51–77) Mean 20.4, median 18 (range 14–28) Mean 9, median 9 (range 7–10) 11 (46%) 6 (25%) 4 (17%) 2 (8%) 1 (4%) 0–2 (poor): 24 24 (100%) 16 (67%) 8 (33%) 14 (58%) 24 (100%) 24 patients/25 occlusions (100%) Mean 3.3 hours (range 2–5.2) Mean 51 min (range 38–69) 19 (79%) 3 (13%) 2 (8%) 0 0 2 (8%) 0–2: 13 (76%) 3: 4 (24%) 0–2: 14 (70%) 3: 6 (30%)
ACA, anterior cerebral artery; ASITN/SIR, American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology collateral flow grading system; ASPECTS, Alberta Stroke Program Early CT Score; ICA, internal carotid artery; Lt, left; MCA, middle cerebral artery; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Score; Rt, right; TICI, Thrombolysis in Cerebral Infarction grade; TIMI, Thrombolysis in Myocardial Infarction grade.
Radiological data included Alberta Stroke Program Early CT Score (ASPECTS),19 occlusion site, extent of collateral supply on CT angiogram, MR (when available), and post-procedural head CT evaluation. Interventional data included anesthesia type, medications during endovascular treatment, endovascular techniques, time-to-recanalization (TTR, defined as the interval between introducer sheath placement to first angiographic run showing recanalization), Thrombolysis in Myocardial Infarction flow grade (TIMI) at recanalization, and Thrombolysis in Cerebral Infarction (TICI) grade.17 18 Collateral supply was evaluated as good, fair, or poor based on the ratio of the area of parenchyma supplied by collaterals to
the total area that should have been supplied by the thrombosed vessel, as assessed by CT, MRI, and/or DSA; good supply was defined as a ratio >66%, fair as 33–66%, and poor as 60 years with a history of controlled vascular risk factors was urgently transferred to our center 2.5 h after stroke onset. Upon arrival the patient was alert, with global dysphasia, gaze deviation, and left hemiplegia (National Institutes of Stroke Score (NIHSS) 18). (A–D) Head CT followed by CT angiogram showed no signs of right hemispheric ischemia (Alberta Stroke Program Early CT Score (ASPECTS) 10), with tandem occlusion of the right internal carotid artery (ICA) and proximal middle cerebral artery (MCA). (E) Under general anesthesia, diagnostic angiography confirmed proximal occlusion of the right ICA. A small angiographic spike marked the ICA ostium. The left ICA occlusion was crossed with a microsystem and the angiogram obtained through the microcatheter confirmed its location at the left cervical ICA. The microcatheter was exchanged for a balloon and angioplasty was performed at the proximal left ICA occlusion, achieving partial revascularization. The balloon was exchanged for a protection device and a closed-cell carotid stent was implanted across the plaque. The guiding catheter was advanced beyond the stented segment. (F) Angiography confirmed proximal right MCA occlusion. A 0.021 microcatheter was navigated across the intracranial occlusion. (G,H) Stent-assisted thrombectomy allowed complete recanalization of the MCA after a single pass (Thrombolysis in Myocardial Infarction grade (TIMI) 3, Thrombolysis in Cerebral Infarction grade (TICI) 3). The patient’s condition improved, with neurological assessment reaching NIHSS 0 after 1 week. 414
Cohen JE, et al. J NeuroIntervent Surg 2015;7:412–417. doi:10.1136/neurintsurg-2014-011175
Downloaded from http://jnis.bmj.com/ on August 31, 2015 - Published by group.bmj.com
Ischemic stroke
Figure 2 (A,B) A middle-aged patient with a history of multiple poorly controlled vascular risk factors was transferred to our center with a wake-up stroke of unclear onset time. The patient had last been seen well 7 h earlier and was found unconscious on the bedroom floor. Upon arrival the patient was drowsy with global dysphasia and gaze deviation, and presented with right dense hemiplegia NIHSS 24. Head CT followed by CT angiography showed unclear signs of left hemispheric ischemia (ASPECTS 10), with tandem occlusion of the left ICA and proximal MCA Emergency MRI stroke protocol confirmed the presence of a significant diffusion-perfusion mismatch. (C) Under general anesthesia, diagnostic angiography confirmed proximal occlusion of the left ICA. A small angiographic spike marked the ICA ostium. The left ICA occlusion was crossed with a microsystem. Angiogram obtained through the microcatheter confirmed its location at the cervical left ICA. The microcatheter was exchanged for a balloon and angioplasty was performed at the proximal left ICA occlusion. The balloon was exchanged for a protection device and a closed-cell carotid stent was implanted across the plaque. (D) Angiography demonstrates recanalization of the left ICA. (E) The guiding catheter was advanced beyond the stented segment. (F) Angiography confirmed proximal left MCA occlusion. A 0.021 microcatheter was navigated across the intracranial occlusion and stent-assisted thrombectomy was performed. (G,H) In 47 min, after one pass, the left MCA was completely recanalized and reperfused (Thrombolysis in Myocardial Infarction grade 3, Thrombolysis in Cerebral Infarction grade 3). The patient’s condition improved, with neurological assessment reaching NIHSS 3 after 1 week.
CT findings Routine CT scans performed after recanalization in 18/24 patients (75%) demonstrated cortical sparing (>80% of cortex at risk). This is particularly remarkable considering that patients in this series presented with very limited collateral flow at admission angiography. Lenticulostriate/subinsular residual infarct (volume 0.8–9 cm3) was noted in 19/24 patients (79.2%). No patient required decompressive craniectomy for mass effect or infarction. Six patients had petechial hemorrhages; none presented with intracerebral or intraventricular hemorrhage. The sample size and low rates of hemorrhage precluded analysis of the effect of intravenous tPA or antiplatelet loading dose administration.
Sonographic findings None of the 20 patients with follow-up Doppler examination had stent occlusion. Four patients with known post-angioplasty residual stenosis (>30%) were followed more closely and remain asymptomatic; one patient with stenosis progression on sonographic and angiographic follow-up sustained uneventful re-angioplasty 4 months after primary treatment.
Clinical outcome Rapid neurological recovery (NIHSS
