Vessel Wall Enhancement and Blood–Cerebrospinal Fluid Barrier Disruption After Mechanical Thrombectomy in Acute Ischemic Stroke

Abstract

T he most effective treatment approach in acute ischemic stroke is early reperfusion, which includes the administration of the r-tPA (recombinant tissue-type plasminogen activator) or the use of mechanical thrombectomy (MT). 1 However, less than half of patients who are treated obtain permanent clinical benefits.1 Early blood-brain barrier (BBB) disruption is one of the main mechanisms implicated in reperfusion ineffectiveness, and it has been associated to the severity of ischemia, adverse effects of thrombolytic drugs, and thrombectomy-related direct vessel damage.2 In experimental brain ischemia, MT causes direct vessel injury in the intimal and medial layers of the arterial wall.3-5 Besides direct mechanical injury, ischemia itself, thrombus inflammatory components, and r-tPA-related toxicity may also compromise the integrity of the endothelial surface.6 Overall, these changes may result in increased endothelial permeability and can be imaged with contrast-enhanced magnetic resonance imaging (MRI). 7,8 Likewise, postgadolinium enhancement of the cerebrospinal fluid space visible on postcontrast fluidattenuated inversion recovery (FLAIR) is an established neuroimaging marker of blood-cerebrospinal fluid barrier (BCSFB) or BBB disruption. In acute ischemic stroke, it has been associated with increased risk of hemorrhage, poor clinical outcome, r-tPA-induced reperfusion injury, and poor early neurological recovery after MT.9-12 However, whether there is a link between vessel wall enhancement and diffuse BCSFB disruption has not been studied previously. Thus, clarifying this potential relationship may be of relevance for Background and Purpose-Less than half of acute ischemic stroke patients treated with mechanical thrombectomy obtain permanent clinical benefits. Consequently, there is an urgent need to identify mechanisms implicated in the limited efficacy of early reperfusion. We evaluated the predictors and prognostic significance of vessel wall permeability impairment and its association with blood-cerebrospinal fluid barrier (BCSFB) disruption after acute stroke treated with thrombectomy. Methods-A prospective cohort of acute stroke patients treated with stent retrievers was analyzed. Vessel wall permeability impairment was identified as gadolinium vessel wall enhancement (GVE) in a 24-to 48-hour follow-up contrast-enhanced magnetic resonance imaging, and severe BCSFB disruption was defined as subarachnoid hemorrhage or gadolinium sulcal enhancement (present across >10 slices). Infarct volume was evaluated in follow-up magnetic resonance imaging, and clinical outcome was evaluated with the modified Rankin Scale at day 90. Results-A total of 60 patients (median National Institutes of Health Stroke Scale score, 18) were analyzed, of whom 28 (47%) received intravenous alteplase before mechanical thrombectomy. Overall, 34 (57%) patients had GVE and 27 (45%) had severe BCSFB disruption. GVE was significantly associated with alteplase use before thrombectomy and with more stent retriever passes, along with the pr...

Clinical Imaging of Choroid Plexus in Health and in Brain Disorders: A Mini-Review

“…A case of contrast leakage mimicking intraventricular hemorrhage was recently described in an ischemic stroke patient who had been treated with intravenous thrombolysis (IVT) (Park et al, 2017). A study investigating a small series of ischemic stroke patients undergoing mechanical thrombectomy in combination with IVT reported a blood-CSF arachnoid barrier disruption only (Renu et al, 2017). In pre-clinical ischemic stroke studies, two teams have reported MRI contrast medium leakage into the ventricles early after reperfusion (Nagahiro et al, 1994; Batra et al, 2010), in line with a previous study showing an increase in BCSFB permeability in rat models of focal cerebral ischemia (Ennis and Keep, 2006).…”

MRI Vessel Wall Imaging after Intra-Arterial Treatment for Acute Ischemic Stroke

“…12 In addition, some follow-up studies (ranging from several days to 2 years) reported delayed arterial vessel wall abnormalities, postulating that these might be attributable to endothelial damage after IAT. 3,6,8,25,26 On the other hand, in a study with 23 patients with stroke who were scanned within 1 week after thrombectomy, major vessel wall damage such as disruption and stenosis was rare. 10 We limited our study to patients treated with a thrombosuction device.…”

“…[3][4][5][6] Histopathologic preclinical studies have shown endothelial damage to the vessel wall after thrombectomy, more evident with stent-retriever devices than with thrombosuction devices. [3][4][5][8][9][10] In recent MR imaging studies and other imaging studies performed after IAT, damage to a major vessel wall such as dissection or stenosis was only rarely reported. 5,[8][9][10][11][12] However, the arterial vessel wall more often showed contrast enhancement or wall thickening than arteries of patients who did not undergo IAT.…”

“…[3][4][5][8][9][10] In recent MR imaging studies and other imaging studies performed after IAT, damage to a major vessel wall such as dissection or stenosis was only rarely reported. 5,[8][9][10][11][12] However, the arterial vessel wall more often showed contrast enhancement or wall thickening than arteries of patients who did not undergo IAT. [11][12][13] In these series, patients were treated mostly with stent retrievers, and scanning was performed with 3T MR imaging scanners in the acute setting (first day to first week) after IAT.…”

Novel Distal Emboli Protection Technology: The EmboTrap

“…Loss of interaction between clot and stent retriever when passing the tortuous cerebral arteries can result in partial or failed thrombectomy, which increases the need for multiple passes and additional rescue therapy. Multiple passes may be associated with poorer clinical outcomes due to delay of recanalization [12] or injury to the vessel [13,14,15,16]. …”