Clinical Impact of Intracerebral Hemorrhage after Hyperacute Extracranial Stenting in Patients with Ischemic Stroke

Abstract

PurposeEmergent intracranial occlusions causing acute ischemic stroke are often related to extracranial atherosclerotic stenosis. This study aimed to investigate the association between post-procedure intracerebral hemorrhage (ICH) and emergent extracranial artery stenting and assess their effects on clinical outcomes in patients with acute ischemic stroke.Materials and MethodsWe retrospectively analyzed patients undergoing hyperacute endovascular treatment for cervicocephalic vascular occlusion in three Korean hospitals between January 2011 and February 2016. Patients who had extracranial artery involvement and were treated from 24 hours of symptom onset to puncture were included in this study, and they were divided into the extracranial stenting (ES) and non-ES groups. Any type of petechial hemorrhages and parenchymal hematoma was defined as ICH for the current study.ResultsIn total, 76 patients were included in this study. Among them, 56 patients underwent ES, and 20 patients did not. Baseline characteristics, risk factors, laboratory data, treatment methods, successful reperfusion rates, and baseline stenotic degrees of extracranial internal carotid artery did not differ between these two groups. However, atrial fibrillation was more frequent in patients without than with ES (P=0.002), and post-procedure ICH was more frequent in patients with than without ES (P=0.035). Logistic regression models revealed that ES was independently associated with post-procedure ICH (odds ratio [OR], 7.807; 95% confidence interval [CI], 1.213–50.248; P=0.031), and ICH was independently associated with poor clinical outcomes (OR, 0.202; 95% CI, 0.054–0.759; P=0.018); however, ES itself was not associated with clinical outcomes (OR, 0.530; 95% CI, 0.117–2.395; P=0.409). Notably, ICH and ES had interaction for predicting good outcomes (P=0.041).ConclusionPost-procedure ICH was associated with ES and poor clinical outcomes. Therefore, ES should be cautiously considered in patients with hyperacute stroke.

Cervical carotid occlusion in acute ischemic stroke: Should we give tPA?

“…In contrast, numerous authors argue against the use of CAS in the emergent setting. [12,21] A 2018 large database study of patients who underwent CEA or CAS for cICA occlusion saw higher rates of ICH and post procedural strokes in patients who received tPA compared to patients who did not receive tPA before the intervention, and concluded that IV thrombolysis is an independent predictor of poor outcome after revascularization. [21] is study also found that the risk for these adverse events declined with time after thrombolytic administration, and that after 7 days, postoperative ICH and stroke rates were equivalent to those seen in patients who did not receive thrombolytics before revascularization, suggesting that delaying revascularization may be appropriate in certain patients.…”

“…A 2019 study of 76 patients with cICA occlusions compared outcomes between patients who underwent acute CAS versus those who did not, reporting acute CAS to be independently associated with post procedure ICH as well as poor clinical outcomes, and no difference between the two groups in regards to reperfusion success rate. [12] However, IV thrombolytics were administered in approximately half of the patients within each group and outcomes were not compared between those who received tPA and those who did not.…”

“…[5] MT with emergent CAS is a well-documented approach utilized to treat AIS due to extracranial occlusion with severe atherosclerotic stenosis; however, the safety of this approach is of ongoing debate due to reports of increased rate of ICH with emergent CAS. [12,[19][20][21]25] Furthermore, despite the associated ICH risks, there are no specific antiplatelet therapy recommendations for the acute phase of management following CAS. [9] Anti-thrombotic agents are required to prevent intraluminal stent thrombosis; however, this therapy is contraindicated in the first 24 h following tPA administration.…”

A 51-year-old man who presented with acute onset aphasia, right sided weakness - Case Report

“…2,3 Revascularization of cervical ICA occlusions in AIS involves emergent carotid artery stenting, which although a well-documented approach to treating AIS, is subject to ongoing debate given data suggesting a higher rate of intracerebral hemorrhage with emergent stenting. [4][5][6] In the setting of this patient's tenuous cerebral perfusion, the patient was made supine and his intravascular volume was increased by uid resuscitation. These steps resulted in an improvement in the patient's clinical exam.…”