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Internal Carotid Artery Stent Implantation in 25 Patients with Acute Stroke: Preliminary Results¹

¹ From the Institute of Diagnostic and Interventional Neuroradiology (K.N., C.B., L.R., C.O., G.S.), Clinic of Angiology (D.D.D.), and Clinic of Neurology (M.A., H.P.M.), University of Bern, Inselspital, Freiburgstrasse 4, 3010 Bern, Switzerland. Received September 20, 2004; revision requested November 24; revision received December 20; accepted January 27, 2005. Supported in part by a grant from the Swiss National Science Foundation (SNF 3100-66348.01). Address correspondence to G.S. (e-mail: gerhard.schroth{at}insel.ch).

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION References

 
PURPOSE: To evaluate retrospectively the outcome for patients with acute ischemic stroke in the territory of the middle cerebral artery (MCA) who had undergone stent implantation in the proximal segment of the internal carotid artery (ICA) in addition to intraarterial thrombolysis (IAT).

MATERIALS AND METHODS: Stent implantation and retrospective analysis of clinical and radiologic data were approved by the institutional ethical committee. Endovascular treatment was performed after obtaining informed consent from patients or their closest relatives. Informed consent for retrospective review was not required. After pharmacologic and/or mechanical IAT, 25 consecutive patients (seven women, 18 men; mean age, 59 years ± 14 [standard deviation]) underwent stent implantation in the proximal segment of the ICA (endovascular group). The clinical and radiologic characteristics (ie, interval from symptom onset to arrival at the emergency department, prevalence of vascular risk factors, causes of stroke, stroke severity, early signs of cerebral ischemia, duration of endovascular intervention, type of occlusion, and prevalence of leptomeningeal collateral vessels), recanalization rates, and clinical outcomes for patients in the endovascular group were compared with those for patients in the medical group (10 women, 21 men; mean age, 62 years ± 12) who experienced ischemic stroke in the territory of the MCA as a result of ICA occlusion and who received antithrombotic treatment only. Differences between groups were assessed by using the ² test. A logistic regression analysis was performed to assess the effect of clinical and radiologic factors on recanalization rates and outcome.

RESULTS: ICA recanalization was successful in 21 patients. Good recanalization of the MCA was achieved in 11 patients. In nine of these patients, recanalization of the MCA was achieved by using mechanical IAT only. In the remaining 12 patients, administration of intraarterial urokinase was performed in addition to mechanical thrombolysis. Two patients from the endovascular group experienced symptomatic intracerebral hemorrhage. At 3 months, 56% of the endovascular group and 26% of the medical group had a favorable outcome. Mortality was 20% in the endovascular and 16% in the medical group.

CONCLUSION: IAT and stent implantation in the proximal segment of the ICA seem to improve the outcome for patients with ischemic stroke caused by occlusion of the cervical portion of the ICA.

© RSNA, 2005

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION References

 
Intravenous recombinant tissue-type plasminogen activator (rtPA) and intraarterial recombinant prourokinase have been shown to improve the outcome of patients with acute ischemic stroke (1,2). The effectiveness of this treatment is associated with recanalization of the occluded cerebral vessel (3).

A subset analysis of data obtained from the National Institute of Neurological Disorders and Stroke rtPA Stroke Study demonstrated that intravenous rtPA may be less efficacious for proximal vessel occlusions (4). In particular, researchers found that strokes occurring after occlusion of the internal carotid artery (ICA) respond poorly to intravenous thrombolysis (5,6).

Intraarterial thrombolysis (IAT) may achieve better results if the treatment can be performed within 3 hours of stroke onset and before either endarterectomy or angioplasty for residual stenosis (7). Endarterectomy and angioplasty, however, are usually postponed for days or weeks after the ictus. During the first hours and days after a stroke, the risk of reocclusion or recurrent arterioarterial embolism remains.

To reduce this risk, we developed a protocol for endovascular treatment that consisted of IAT and stent implantation in the proximal segment of the ICA. Both IAT and stent implantation were performed within the therapeutic time window of 6 hours and during the same angiographic session. Thus, the purpose of our study was to evaluate retrospectively the outcome for patients with acute ischemic stroke in the territory of the middle cerebral artery (MCA) who had undergone stent implantation in the proximal segment of the ICA in addition to IAT.

	MATERIALS AND METHODS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION References

 
Patient Selection
From August 1997 to December 2003, 56 consecutive patients with acute ischemic stroke in the territory of the MCA occurring after occlusion in the ipsilateral ICA underwent diagnostic angiography at our university-based stroke center within 6 hours of symptom onset. Angiography was performed by two of four interventional neuroradiologists (G.S., D.D.D., L.R., or C.B., with 15, 10, 8, and 2 years of experience in endovascular treatment, respectively). Endovascular treatment to recanalize the tandem ICA and MCA occlusion was attempted in 25 patients (seven women, 18 men; mean age, 59 years ± 14 [standard deviation]); patients who underwent endovascular treatment were referred to as the endovascular group. In 21 (84%) of these 25 patients, the ICA was recanalized successfully. In four patients, both passage of the guidewire through the occluded ICA and recanalization failed. In 31 patients (10 women, 21 men; mean age, 62 years ± 12), recanalization of the ICA was not attempted. These patients received antiplatelet drugs or heparin and were referred to as the medical group. Reasons to withhold endovascular treatment included good or moderate leptomeningeal collateral flow to the territory of the occluded MCA (n = 15), elapse of the 6-hour time limit for thrombolysis during the diagnostic procedure (n = 8), and computed tomographic (CT) signs of ischemia that affected more than one-third of the MCA territory (n = 8).

In Switzerland, intraarterial urokinase is approved for treatment of acute arterial occlusions. ICA stent implantation was approved by the institutional ethical committee. Our retrospective analysis of clinical and radiologic data was approved by the institutional ethical committee; informed consent was not required for this analysis. Endovascular treatment, however, was performed after obtaining informed consent from all patients or, in the event that patients experienced a reduced level of consciousness, from their closest relatives.

Diagnostic Work-up before Intervention
The diagnosis of ischemic stroke was based on a focal neurologic deficit with or without corresponding ischemic lesions demonstrated at brain imaging after admission (8). The severity of the neurologic deficit at admission was assessed by staff neurologists by using the National Institutes of Health Stroke Scale (NIHSS) (9).

All patients were investigated by using a standard protocol, which included determination of red and white blood cell and platelet counts; analysis of glucose, cholesterol, electrolyte, transaminase, creatinine, and urea levels; measurement of prothrombin and activated partial thromboplastin time; and examination with 12-lead electrocardiography.

Cranial CT was performed in 52 patients. Magnetic resonance (MR) imaging was performed in seven patients by using a 1.5-T system (Magnetom Sonata; Siemens, Erlangen, Germany) that provided transverse T1-weighted, T2-weighted, and intermediate-weighted MR images; gadolinium-enhanced T1-weighted MR images; fat-suppressed MR images of the cervical portion of the ICA, which were obtained for diagnosis of carotid artery dissections; and diffusion- and perfusion-weighted MR images (10). Three patients underwent both CT and MR imaging.

A member of the stroke team informed the patients, their closest relatives, or both about the benefits and potential risks of the catheter-based revascularization therapy, including IAT. Patients who gave informed consent were transferred to the angiography room. After a local anesthetic was administered, patients underwent diagnostic four-vessel angiography, and a general anesthetic was administered if needed. For the first step of this procedure, biplanar high-resolution angiography of the common carotid artery was performed contralateral to the presumed side of the occlusion. After this procedure, angiography of the vertebrobasilar system was performed. As a result, collateral flow to the infarcted cerebral hemisphere could be systematically assessed. The artery that was clinically presumed to be occluded was investigated last. Thus, endovascular therapy was performed directly after diagnostic angiography.

ICA occlusions were distinguished with respect to the affected segment and included (a) occlusion of the cervical segment, (b) occlusion of the cervical and petrous segments, (c) occlusion of the cervical, petrous, and cavernous segments extending to the origin of the ophthalmic artery, (d) occlusion of the cervical, petrous, and cavernous segments extending to the origin of the posterior communicating artery, and (e) occlusion of the entire cervical, petrous, and cavernous segments (ie, a carotid T occlusion). MCA occlusions were classified as (a) occlusion of the horizontal (M1) segment, (b) occlusion of the insular (M2) segment, or (c) occlusion of the distal (M3 and M4) segments. Furthermore, collateral flow was evaluated through (a) the circle of Willis, (b) the anastomosis of the external carotid artery and ICA (especially flow reversal in the ophthalmic artery), or (c) the leptomeningeal collateral pathways from the territories of the ipsilateral posterior cerebral artery and anterior cerebral artery. Leptomeningeal collateral vessels from the anterior and posterior cerebral arteries were classified into two groups—poor if no or minimal leptomeningeal anastomoses were present but no sufficient filling of the occluded vessel territory was visible and good if moderate or maximal leptomeningeal anastomoses with sufficient filling of the occluded vessel territory were observed, including opacification of a parenchymal and venous phase in the brain area supplied by the leptomeningeal anastomoses (11).

Protocol for Endovascular Treatment of Tandem ICA and MCA Occlusions
Patients were considered suitable candidates for endovascular treatment if they fulfilled the following inclusion criteria: (a) focal neurologic deficit that correlated to ICA and MCA occlusion, (b) baseline NIHSS score of 4 or greater, (c) CT or MR imaging results that excluded intracranial hemorrhage, (d) no individual, clinical, or laboratory findings to contraindicate the use of thrombolytic agents, (e) no malignant tumors and no renal or hepatic failure, and (f) expected time interval of less than 6 hours from symptom onset to initiation of IAT.

Endovascular treatment was performed by the same interventional neuroradiologists who performed angiography. Whereas diagnostic four-vessel angiography was performed after administration of local anesthetic, recanalization and stent implantation were performed after administration of general anesthetic (12). The diagnostic 5-F catheter (Valavanis; Cook, Bloomington, Ind) that was initially used for diagnostic angiography was exchanged over a long guidewire by using a biplanar roadmap, and an 8-F guide catheter (Guider Softip; Boston Scientific, Fremont, Calif) was placed proximal to the site of occlusion and into the distal segments of the common carotid artery or ICA. A guidewire was then advanced to the proximity of the occlusion and was carefully navigated through the obstacle. The 8-F guide catheter was tightly advanced over the guidewire and into the occluded ICA. Negative pressure was maintained as the guide catheter was carefully navigated further through the occlusion. If further navigation was impossible owing to high resistance, a 120-cm infusion catheter (Tracker 38 NYL; Target Therapeutics, Fremont, Calif) was introduced over the long guidewire and through the 8-F catheter. The infusion catheter was then primarily advanced through the site of occlusion. Navigation of both the 8-F guide catheter and the infusion catheter over the guidewire was necessary in patients who had tight, partially calcified stenoses at the origin of the ICA. In these cases, the infusion catheter was introduced coaxially through the 8-F catheter while the guide catheter was in its most distal position.

Depending on the anatomy of the individual and on the angle of the carotid siphon, aspiration was possible for thrombotic material extending to the C1 segment of the ICA and even for thrombotic material extending to the M1 segment of the MCA. If aspiration led to complete blockage of the backflow of blood, the infusion catheter was withdrawn while negative pressure was maintained for both the 8-F guide catheter and the infusion catheter. This maneuver was repeated until the ICA was recanalized. Thrombotic material from the distal segments of the ICA and from the proximal segment of the MCA and anterior cerebral artery was aspirated through the infusion catheter and photographed with a digital camera. In this way, the 8-F guide catheter served as a protective device that maintained complete blood flow blockage and negative pressure in the ICA.

After recanalization, a stent was deployed at the site of the ICA stenosis. Initially, we used the Palmaz stent (Cordis Europe, Roden, the Netherlands) (n = 2) and Easy Wallstent (Boston Scientific) (n = 1). More recently, we used the Carotid Wallstent Monorail (Boston Scientific) (n = 10) and tapered Acculink stent (Guidant, Santa Clara, Calif) (n = 8). Stent placement was performed by using the 8-F guide catheter, which was placed with its tip distal to the site of stenosis or occlusion. Thus, deployment could be easily performed by withdrawing the guide catheter below the site of occlusion, thereby leaving the stent and guidewire above the site of occlusion.

If it was impossible to remove the occluding clot completely, local IAT was performed during the same session. By using a microcatheter—usually a FasTracker 18 microcatheter (Target Therapeutics)—we infiltrated urokinase (dosage, 250 000–1 000 000 IU for 1.0–1.5 hours) into the thrombus. After the procedure, follow-up angiography was performed to assess the flow of blood through the ICA and MCA. The duration of the intervention and the total dose of lytic agents were recorded. All raw data obtained during biplanar angiography and intervention were stored digitally and were reviewed retrospectively for the purpose of this study.

Diagnostic Work-up after Intervention
In the days after acute stroke management, a diagnostic work-up was completed to determine the cause of stroke (if not already known) by using the appropriate diagnostic techniques. For categorization of stroke causes, the Trial of ORG 10172 in Acute Stroke Treatment classification was used (13). Several vascular risk factors, including (a) sex, (b) hypertension, (c) diabetes mellitus, (d) current cigarette smoking, (e) hypercholesterolemia, (f) heart disease, and (g) history of amaurosis fugax (monocular blindness lasting less than 24 hours), retinal infarct (monocular blindness lasting 24 hours or more), transient ischemic attack (neurologic deficit lasting less than 24 hours), or ischemic stroke, were systematically assessed by staff neurologists. Hypertension was determined after review of the patient's preadmission history and medical records. Diabetes mellitus was defined as a venous plasma glucose concentration of 7.0 mmol/L or greater that was measured after an overnight fast on at least two separate occasions and/or as a venous plasma glucose concentration of 11.1 mmol/L or greater that was measured once at 2 hours after ingestion of 75 g oral glucose and again at one other occasion during the 2-hour test. Hypercholesterolemia was defined as a total venous plasma cholesterol concentration of greater than 5 mmol/L.

Outcome Parameters
The radiologic outcome was assessed by determining the rate of recanalization achieved in the ICA and MCA. Two neuroradiologists (G.S. and C.B., with 20 and 10 years of experience evaluating digital subtraction angiograms, respectively) and one neurologist (K.N., 12 years of experience evaluating digital subtraction angiograms) conducted a consensus review of the stored images obtained during biplanar angiography and intervention. Recanalization rates of the MCA were classified according to the Thrombolysis in Myocardial Infarction (TIMI) trial criteria: TIMI grade 0, no recanalization; TIMI grade 1, minimal recanalization; TIMI grade 2, partial recanalization; and TIMI grade 3, complete recanalization (14). Vessel wall ruptures, dissections, and wall hematomas that occurred as a result of endovascular intervention were also noted. Malignant edema in the infarcted territory was correlated with the recanalization rate that was achieved. Two authors (M.A., H.P.M.) assessed clinical outcome at 3 months by using the modified Rankin scale (15). Modified Rankin scale scores of 0–2 were classified as a favorable outcome, and scores of 3–5 were classified as an unfavorable outcome. Death was indicated by a score of 6. With regard to adverse effects, special attention was given to intracerebral hemorrhage that was visible at CT 24 hours after intervention. The individual doses of urokinase were recorded and related to possible complications.

Statistical Analysis
Quantitative data are expressed as mean values ± standard deviation. The NIHSS score for each patient at admission is given as a median value. Differences between groups and the effect of patient characteristics (ie, sex, cause of stroke, vascular risk factors, early CT or MR imaging signs of cerebral ischemia, presence of dense artery sign, extent of ICA occlusion, location of the MCA occlusion [M1 or M2 segment], and collateral flow) on recanalization rates, clinical outcome, and complications (symptomatic intracerebral hemorrhage and malignant edema) were assessed by using the ² test. The Spearman rank correlation was used to assess the effects of age, initial stroke severity, time from symptom onset to intervention, and urokinase dose on the outcome parameter. A logistic regression analysis, which included variables that showed significant differences on univariate comparison, was performed. A P value of less than .05 was considered to indicate a statistically significant difference.

	RESULTS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION References

 
Clinical Characteristics
A summary of the clinical characteristics and results of clinical work-up for patients in the endovascular and medical groups are given in Table 1. Both groups comprised more men than women. The mean age was 59 years ± 14 in the endovascular group and 62 years ± 12 in the medical group. The interval from symptom onset to arrival at the emergency department did not differ between groups. The prevalence of common vascular risk factors was also similar between groups. All patients had moderate to severe neurologic deficit (median NIHSS score of 12.0 in the endovascular group and 11.5 in the medical group). In addition, seven (28%) of 25 patients in the endovascular group and six (19%) of 31 patients in the medical group showed a reduced level of consciousness at the time of arrival at the stroke center. At admission, early signs of cerebral ischemia were present at CT or MR imaging in 19 (76%) of 25 patients in the endovascular group and 19 (61%) of 31 patients in the medical group. In five (20%) of 25 patients in the endovascular and eight (26%) of 31 patients in the medical group, the ischemic area affected more than one-third of the MCA territory. At admission, a radiologic correlate of the MCA occlusion (ie, the dense artery sign) was seen on CT scans in 15 (60%) of 25 patients in the endovascular group and in 11 (35%) of 31 patients in the medical group.

The duration of diagnostic four-vessel angiography was 11.3 minutes in the endovascular group and 9.5 minutes in the medical group (Table 2). The groups did not differ with respect to either the location or the extension of tandem occlusions in the ICA and the MCA. The cervical segment of the ICA was occluded in all patients; extension of the occlusions into the distal portion of the ICA toward the carotid T was variable. A majority of MCA occlusions were located in the horizontal segment (M1), and a minority of MCA occlusions were located in the insular segment (M2).

View larger version (104K): [in this window] [in a new window] [Download PPT slide]   Figure 1a. Images obtained in 65-year-old man with right-sided hemiparesis and aphasia. (a, b) MR images demonstrate widespread mismatch between extent of lesion (arrows) on (a) transverse apparent diffusion coefficient maps and (b) transverse time-to-peak maps. (c) Lateral angiogram of right common carotid artery reveals high-grade stenosis of ICA (arrow). (d) Frontal angiogram demonstrates hypoplasia of A1 segment (arrow) of right anterior cerebral artery that precludes cross flow through anterior communicating artery. (e, f) Lateral angiograms of left common carotid artery show (e) occlusion of left ICA (arrow) and (f) subtle filling of carotid siphon through anastomoses of external carotid and ophthalmic arteries (arrowheads). (g) Lateral roadmap angiogram demonstrates infusion catheter, which is introduced into origin of left MCA (arrowhead), and 8-F guide catheter, which is placed at horizontal petrous segment of ICA (arrow). (h) Image of aspirated white and red thrombus. (i) Frontal angiogram of left common carotid artery demonstrates implantation of tapered nitinol carotid stent, which resulted in normal flow in ICA, anterior cerebral artery, and MCA.

View larger version (90K): [in this window] [in a new window] [Download PPT slide]   Figure 1b. Images obtained in 65-year-old man with right-sided hemiparesis and aphasia. (a, b) MR images demonstrate widespread mismatch between extent of lesion (arrows) on (a) transverse apparent diffusion coefficient maps and (b) transverse time-to-peak maps. (c) Lateral angiogram of right common carotid artery reveals high-grade stenosis of ICA (arrow). (d) Frontal angiogram demonstrates hypoplasia of A1 segment (arrow) of right anterior cerebral artery that precludes cross flow through anterior communicating artery. (e, f) Lateral angiograms of left common carotid artery show (e) occlusion of left ICA (arrow) and (f) subtle filling of carotid siphon through anastomoses of external carotid and ophthalmic arteries (arrowheads). (g) Lateral roadmap angiogram demonstrates infusion catheter, which is introduced into origin of left MCA (arrowhead), and 8-F guide catheter, which is placed at horizontal petrous segment of ICA (arrow). (h) Image of aspirated white and red thrombus. (i) Frontal angiogram of left common carotid artery demonstrates implantation of tapered nitinol carotid stent, which resulted in normal flow in ICA, anterior cerebral artery, and MCA.

View larger version (135K): [in this window] [in a new window] [Download PPT slide]   Figure 1c. Images obtained in 65-year-old man with right-sided hemiparesis and aphasia. (a, b) MR images demonstrate widespread mismatch between extent of lesion (arrows) on (a) transverse apparent diffusion coefficient maps and (b) transverse time-to-peak maps. (c) Lateral angiogram of right common carotid artery reveals high-grade stenosis of ICA (arrow). (d) Frontal angiogram demonstrates hypoplasia of A1 segment (arrow) of right anterior cerebral artery that precludes cross flow through anterior communicating artery. (e, f) Lateral angiograms of left common carotid artery show (e) occlusion of left ICA (arrow) and (f) subtle filling of carotid siphon through anastomoses of external carotid and ophthalmic arteries (arrowheads). (g) Lateral roadmap angiogram demonstrates infusion catheter, which is introduced into origin of left MCA (arrowhead), and 8-F guide catheter, which is placed at horizontal petrous segment of ICA (arrow). (h) Image of aspirated white and red thrombus. (i) Frontal angiogram of left common carotid artery demonstrates implantation of tapered nitinol carotid stent, which resulted in normal flow in ICA, anterior cerebral artery, and MCA.

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 1d. Images obtained in 65-year-old man with right-sided hemiparesis and aphasia. (a, b) MR images demonstrate widespread mismatch between extent of lesion (arrows) on (a) transverse apparent diffusion coefficient maps and (b) transverse time-to-peak maps. (c) Lateral angiogram of right common carotid artery reveals high-grade stenosis of ICA (arrow). (d) Frontal angiogram demonstrates hypoplasia of A1 segment (arrow) of right anterior cerebral artery that precludes cross flow through anterior communicating artery. (e, f) Lateral angiograms of left common carotid artery show (e) occlusion of left ICA (arrow) and (f) subtle filling of carotid siphon through anastomoses of external carotid and ophthalmic arteries (arrowheads). (g) Lateral roadmap angiogram demonstrates infusion catheter, which is introduced into origin of left MCA (arrowhead), and 8-F guide catheter, which is placed at horizontal petrous segment of ICA (arrow). (h) Image of aspirated white and red thrombus. (i) Frontal angiogram of left common carotid artery demonstrates implantation of tapered nitinol carotid stent, which resulted in normal flow in ICA, anterior cerebral artery, and MCA.

View larger version (160K): [in this window] [in a new window] [Download PPT slide]   Figure 1e. Images obtained in 65-year-old man with right-sided hemiparesis and aphasia. (a, b) MR images demonstrate widespread mismatch between extent of lesion (arrows) on (a) transverse apparent diffusion coefficient maps and (b) transverse time-to-peak maps. (c) Lateral angiogram of right common carotid artery reveals high-grade stenosis of ICA (arrow). (d) Frontal angiogram demonstrates hypoplasia of A1 segment (arrow) of right anterior cerebral artery that precludes cross flow through anterior communicating artery. (e, f) Lateral angiograms of left common carotid artery show (e) occlusion of left ICA (arrow) and (f) subtle filling of carotid siphon through anastomoses of external carotid and ophthalmic arteries (arrowheads). (g) Lateral roadmap angiogram demonstrates infusion catheter, which is introduced into origin of left MCA (arrowhead), and 8-F guide catheter, which is placed at horizontal petrous segment of ICA (arrow). (h) Image of aspirated white and red thrombus. (i) Frontal angiogram of left common carotid artery demonstrates implantation of tapered nitinol carotid stent, which resulted in normal flow in ICA, anterior cerebral artery, and MCA.

View larger version (150K): [in this window] [in a new window] [Download PPT slide]   Figure 1f. Images obtained in 65-year-old man with right-sided hemiparesis and aphasia. (a, b) MR images demonstrate widespread mismatch between extent of lesion (arrows) on (a) transverse apparent diffusion coefficient maps and (b) transverse time-to-peak maps. (c) Lateral angiogram of right common carotid artery reveals high-grade stenosis of ICA (arrow). (d) Frontal angiogram demonstrates hypoplasia of A1 segment (arrow) of right anterior cerebral artery that precludes cross flow through anterior communicating artery. (e, f) Lateral angiograms of left common carotid artery show (e) occlusion of left ICA (arrow) and (f) subtle filling of carotid siphon through anastomoses of external carotid and ophthalmic arteries (arrowheads). (g) Lateral roadmap angiogram demonstrates infusion catheter, which is introduced into origin of left MCA (arrowhead), and 8-F guide catheter, which is placed at horizontal petrous segment of ICA (arrow). (h) Image of aspirated white and red thrombus. (i) Frontal angiogram of left common carotid artery demonstrates implantation of tapered nitinol carotid stent, which resulted in normal flow in ICA, anterior cerebral artery, and MCA.

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 1g. Images obtained in 65-year-old man with right-sided hemiparesis and aphasia. (a, b) MR images demonstrate widespread mismatch between extent of lesion (arrows) on (a) transverse apparent diffusion coefficient maps and (b) transverse time-to-peak maps. (c) Lateral angiogram of right common carotid artery reveals high-grade stenosis of ICA (arrow). (d) Frontal angiogram demonstrates hypoplasia of A1 segment (arrow) of right anterior cerebral artery that precludes cross flow through anterior communicating artery. (e, f) Lateral angiograms of left common carotid artery show (e) occlusion of left ICA (arrow) and (f) subtle filling of carotid siphon through anastomoses of external carotid and ophthalmic arteries (arrowheads). (g) Lateral roadmap angiogram demonstrates infusion catheter, which is introduced into origin of left MCA (arrowhead), and 8-F guide catheter, which is placed at horizontal petrous segment of ICA (arrow). (h) Image of aspirated white and red thrombus. (i) Frontal angiogram of left common carotid artery demonstrates implantation of tapered nitinol carotid stent, which resulted in normal flow in ICA, anterior cerebral artery, and MCA.

View larger version (71K): [in this window] [in a new window] [Download PPT slide]   Figure 1h. Images obtained in 65-year-old man with right-sided hemiparesis and aphasia. (a, b) MR images demonstrate widespread mismatch between extent of lesion (arrows) on (a) transverse apparent diffusion coefficient maps and (b) transverse time-to-peak maps. (c) Lateral angiogram of right common carotid artery reveals high-grade stenosis of ICA (arrow). (d) Frontal angiogram demonstrates hypoplasia of A1 segment (arrow) of right anterior cerebral artery that precludes cross flow through anterior communicating artery. (e, f) Lateral angiograms of left common carotid artery show (e) occlusion of left ICA (arrow) and (f) subtle filling of carotid siphon through anastomoses of external carotid and ophthalmic arteries (arrowheads). (g) Lateral roadmap angiogram demonstrates infusion catheter, which is introduced into origin of left MCA (arrowhead), and 8-F guide catheter, which is placed at horizontal petrous segment of ICA (arrow). (h) Image of aspirated white and red thrombus. (i) Frontal angiogram of left common carotid artery demonstrates implantation of tapered nitinol carotid stent, which resulted in normal flow in ICA, anterior cerebral artery, and MCA.

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 1i. Images obtained in 65-year-old man with right-sided hemiparesis and aphasia. (a, b) MR images demonstrate widespread mismatch between extent of lesion (arrows) on (a) transverse apparent diffusion coefficient maps and (b) transverse time-to-peak maps. (c) Lateral angiogram of right common carotid artery reveals high-grade stenosis of ICA (arrow). (d) Frontal angiogram demonstrates hypoplasia of A1 segment (arrow) of right anterior cerebral artery that precludes cross flow through anterior communicating artery. (e, f) Lateral angiograms of left common carotid artery show (e) occlusion of left ICA (arrow) and (f) subtle filling of carotid siphon through anastomoses of external carotid and ophthalmic arteries (arrowheads). (g) Lateral roadmap angiogram demonstrates infusion catheter, which is introduced into origin of left MCA (arrowhead), and 8-F guide catheter, which is placed at horizontal petrous segment of ICA (arrow). (h) Image of aspirated white and red thrombus. (i) Frontal angiogram of left common carotid artery demonstrates implantation of tapered nitinol carotid stent, which resulted in normal flow in ICA, anterior cerebral artery, and MCA.

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 2a. Images of 66-year-old man with right-sided hemiplegia, aphasia, and subsequent craniocerebral trauma. (a) Transverse CT scan obtained 2 hours after symptom onset demonstrates small hemorrhagic contusions (arrowheads) that prevent pharmacologic thrombolysis. (b, c) Perfusion CT scans show (b) prolongation of mean transit time of contrast material (arrow) and (c) critically reduced cerebral blood flow in territory of left MCA (arrow). Cerebral angiography performed 2 hours after onset of symptoms revealed high-grade stenoses of right ICA and vertebral arteries (not shown). (d) Lateral angiogram of the left common carotid artery demonstrates occlusion of left ICA (arrow). (e) Lateral angiogram obtained after contrast material injection through guide catheter (with tip of infusion catheter in petrous segment) demonstrates occlusion of cavernous segement of ICA (arrow). (f) Image demonstrates shape of aspirated thrombus, which fits that of occluded segments of ICA and MCA. (g, h) Lateral angiograms obtained after contrast material injection through guide catheter demonstrate (g) revascularization of ICA, MCA, and anterior cerebral artery and (h) subsequent carotid artery stent implantation (arrow), with distal protection of filter wire (arrowhead). (i) Final frontal angiogram demonstrates normal blood flow through stent and through branches of left ICA.

View larger version (104K): [in this window] [in a new window] [Download PPT slide]   Figure 2b. Images of 66-year-old man with right-sided hemiplegia, aphasia, and subsequent craniocerebral trauma. (a) Transverse CT scan obtained 2 hours after symptom onset demonstrates small hemorrhagic contusions (arrowheads) that prevent pharmacologic thrombolysis. (b, c) Perfusion CT scans show (b) prolongation of mean transit time of contrast material (arrow) and (c) critically reduced cerebral blood flow in territory of left MCA (arrow). Cerebral angiography performed 2 hours after onset of symptoms revealed high-grade stenoses of right ICA and vertebral arteries (not shown). (d) Lateral angiogram of the left common carotid artery demonstrates occlusion of left ICA (arrow). (e) Lateral angiogram obtained after contrast material injection through guide catheter (with tip of infusion catheter in petrous segment) demonstrates occlusion of cavernous segement of ICA (arrow). (f) Image demonstrates shape of aspirated thrombus, which fits that of occluded segments of ICA and MCA. (g, h) Lateral angiograms obtained after contrast material injection through guide catheter demonstrate (g) revascularization of ICA, MCA, and anterior cerebral artery and (h) subsequent carotid artery stent implantation (arrow), with distal protection of filter wire (arrowhead). (i) Final frontal angiogram demonstrates normal blood flow through stent and through branches of left ICA.

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 2c. Images of 66-year-old man with right-sided hemiplegia, aphasia, and subsequent craniocerebral trauma. (a) Transverse CT scan obtained 2 hours after symptom onset demonstrates small hemorrhagic contusions (arrowheads) that prevent pharmacologic thrombolysis. (b, c) Perfusion CT scans show (b) prolongation of mean transit time of contrast material (arrow) and (c) critically reduced cerebral blood flow in territory of left MCA (arrow). Cerebral angiography performed 2 hours after onset of symptoms revealed high-grade stenoses of right ICA and vertebral arteries (not shown). (d) Lateral angiogram of the left common carotid artery demonstrates occlusion of left ICA (arrow). (e) Lateral angiogram obtained after contrast material injection through guide catheter (with tip of infusion catheter in petrous segment) demonstrates occlusion of cavernous segement of ICA (arrow). (f) Image demonstrates shape of aspirated thrombus, which fits that of occluded segments of ICA and MCA. (g, h) Lateral angiograms obtained after contrast material injection through guide catheter demonstrate (g) revascularization of ICA, MCA, and anterior cerebral artery and (h) subsequent carotid artery stent implantation (arrow), with distal protection of filter wire (arrowhead). (i) Final frontal angiogram demonstrates normal blood flow through stent and through branches of left ICA.

View larger version (147K): [in this window] [in a new window] [Download PPT slide]   Figure 2d. Images of 66-year-old man with right-sided hemiplegia, aphasia, and subsequent craniocerebral trauma. (a) Transverse CT scan obtained 2 hours after symptom onset demonstrates small hemorrhagic contusions (arrowheads) that prevent pharmacologic thrombolysis. (b, c) Perfusion CT scans show (b) prolongation of mean transit time of contrast material (arrow) and (c) critically reduced cerebral blood flow in territory of left MCA (arrow). Cerebral angiography performed 2 hours after onset of symptoms revealed high-grade stenoses of right ICA and vertebral arteries (not shown). (d) Lateral angiogram of the left common carotid artery demonstrates occlusion of left ICA (arrow). (e) Lateral angiogram obtained after contrast material injection through guide catheter (with tip of infusion catheter in petrous segment) demonstrates occlusion of cavernous segement of ICA (arrow). (f) Image demonstrates shape of aspirated thrombus, which fits that of occluded segments of ICA and MCA. (g, h) Lateral angiograms obtained after contrast material injection through guide catheter demonstrate (g) revascularization of ICA, MCA, and anterior cerebral artery and (h) subsequent carotid artery stent implantation (arrow), with distal protection of filter wire (arrowhead). (i) Final frontal angiogram demonstrates normal blood flow through stent and through branches of left ICA.

View larger version (106K): [in this window] [in a new window] [Download PPT slide]   Figure 2e. Images of 66-year-old man with right-sided hemiplegia, aphasia, and subsequent craniocerebral trauma. (a) Transverse CT scan obtained 2 hours after symptom onset demonstrates small hemorrhagic contusions (arrowheads) that prevent pharmacologic thrombolysis. (b, c) Perfusion CT scans show (b) prolongation of mean transit time of contrast material (arrow) and (c) critically reduced cerebral blood flow in territory of left MCA (arrow). Cerebral angiography performed 2 hours after onset of symptoms revealed high-grade stenoses of right ICA and vertebral arteries (not shown). (d) Lateral angiogram of the left common carotid artery demonstrates occlusion of left ICA (arrow). (e) Lateral angiogram obtained after contrast material injection through guide catheter (with tip of infusion catheter in petrous segment) demonstrates occlusion of cavernous segement of ICA (arrow). (f) Image demonstrates shape of aspirated thrombus, which fits that of occluded segments of ICA and MCA. (g, h) Lateral angiograms obtained after contrast material injection through guide catheter demonstrate (g) revascularization of ICA, MCA, and anterior cerebral artery and (h) subsequent carotid artery stent implantation (arrow), with distal protection of filter wire (arrowhead). (i) Final frontal angiogram demonstrates normal blood flow through stent and through branches of left ICA.

View larger version (224K): [in this window] [in a new window] [Download PPT slide]   Figure 2f. Images of 66-year-old man with right-sided hemiplegia, aphasia, and subsequent craniocerebral trauma. (a) Transverse CT scan obtained 2 hours after symptom onset demonstrates small hemorrhagic contusions (arrowheads) that prevent pharmacologic thrombolysis. (b, c) Perfusion CT scans show (b) prolongation of mean transit time of contrast material (arrow) and (c) critically reduced cerebral blood flow in territory of left MCA (arrow). Cerebral angiography performed 2 hours after onset of symptoms revealed high-grade stenoses of right ICA and vertebral arteries (not shown). (d) Lateral angiogram of the left common carotid artery demonstrates occlusion of left ICA (arrow). (e) Lateral angiogram obtained after contrast material injection through guide catheter (with tip of infusion catheter in petrous segment) demonstrates occlusion of cavernous segement of ICA (arrow). (f) Image demonstrates shape of aspirated thrombus, which fits that of occluded segments of ICA and MCA. (g, h) Lateral angiograms obtained after contrast material injection through guide catheter demonstrate (g) revascularization of ICA, MCA, and anterior cerebral artery and (h) subsequent carotid artery stent implantation (arrow), with distal protection of filter wire (arrowhead). (i) Final frontal angiogram demonstrates normal blood flow through stent and through branches of left ICA.

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 2g. Images of 66-year-old man with right-sided hemiplegia, aphasia, and subsequent craniocerebral trauma. (a) Transverse CT scan obtained 2 hours after symptom onset demonstrates small hemorrhagic contusions (arrowheads) that prevent pharmacologic thrombolysis. (b, c) Perfusion CT scans show (b) prolongation of mean transit time of contrast material (arrow) and (c) critically reduced cerebral blood flow in territory of left MCA (arrow). Cerebral angiography performed 2 hours after onset of symptoms revealed high-grade stenoses of right ICA and vertebral arteries (not shown). (d) Lateral angiogram of the left common carotid artery demonstrates occlusion of left ICA (arrow). (e) Lateral angiogram obtained after contrast material injection through guide catheter (with tip of infusion catheter in petrous segment) demonstrates occlusion of cavernous segement of ICA (arrow). (f) Image demonstrates shape of aspirated thrombus, which fits that of occluded segments of ICA and MCA. (g, h) Lateral angiograms obtained after contrast material injection through guide catheter demonstrate (g) revascularization of ICA, MCA, and anterior cerebral artery and (h) subsequent carotid artery stent implantation (arrow), with distal protection of filter wire (arrowhead). (i) Final frontal angiogram demonstrates normal blood flow through stent and through branches of left ICA.

View larger version (142K): [in this window] [in a new window] [Download PPT slide]   Figure 2h. Images of 66-year-old man with right-sided hemiplegia, aphasia, and subsequent craniocerebral trauma. (a) Transverse CT scan obtained 2 hours after symptom onset demonstrates small hemorrhagic contusions (arrowheads) that prevent pharmacologic thrombolysis. (b, c) Perfusion CT scans show (b) prolongation of mean transit time of contrast material (arrow) and (c) critically reduced cerebral blood flow in territory of left MCA (arrow). Cerebral angiography performed 2 hours after onset of symptoms revealed high-grade stenoses of right ICA and vertebral arteries (not shown). (d) Lateral angiogram of the left common carotid artery demonstrates occlusion of left ICA (arrow). (e) Lateral angiogram obtained after contrast material injection through guide catheter (with tip of infusion catheter in petrous segment) demonstrates occlusion of cavernous segement of ICA (arrow). (f) Image demonstrates shape of aspirated thrombus, which fits that of occluded segments of ICA and MCA. (g, h) Lateral angiograms obtained after contrast material injection through guide catheter demonstrate (g) revascularization of ICA, MCA, and anterior cerebral artery and (h) subsequent carotid artery stent implantation (arrow), with distal protection of filter wire (arrowhead). (i) Final frontal angiogram demonstrates normal blood flow through stent and through branches of left ICA.

View larger version (142K): [in this window] [in a new window] [Download PPT slide]   Figure 2i. Images of 66-year-old man with right-sided hemiplegia, aphasia, and subsequent craniocerebral trauma. (a) Transverse CT scan obtained 2 hours after symptom onset demonstrates small hemorrhagic contusions (arrowheads) that prevent pharmacologic thrombolysis. (b, c) Perfusion CT scans show (b) prolongation of mean transit time of contrast material (arrow) and (c) critically reduced cerebral blood flow in territory of left MCA (arrow). Cerebral angiography performed 2 hours after onset of symptoms revealed high-grade stenoses of right ICA and vertebral arteries (not shown). (d) Lateral angiogram of the left common carotid artery demonstrates occlusion of left ICA (arrow). (e) Lateral angiogram obtained after contrast material injection through guide catheter (with tip of infusion catheter in petrous segment) demonstrates occlusion of cavernous segement of ICA (arrow). (f) Image demonstrates shape of aspirated thrombus, which fits that of occluded segments of ICA and MCA. (g, h) Lateral angiograms obtained after contrast material injection through guide catheter demonstrate (g) revascularization of ICA, MCA, and anterior cerebral artery and (h) subsequent carotid artery stent implantation (arrow), with distal protection of filter wire (arrowhead). (i) Final frontal angiogram demonstrates normal blood flow through stent and through branches of left ICA.

Early hematomas or dissections of the carotid and middle cerebral arteries were not observed during intervention. Two (8%) of 25 patients, however, experienced symptomatic intracerebral hemorrhage. These two patients died 2 and 3 days after stroke onset. The first patient experienced a transient ischemic attack 1 day prior to the index event. In the second patient, the MCA occlusion was recanalized mechanically by using thromboaspiration 6 hours 15 minutes after stroke onset. Urokinase was not administered in either patient.

Two (8%) of 25 patients died because of malignant cerebral edema on the second day after symptom onset. No recanalization of the MCA was achieved in either patient.

Outcome
The endovascular and medical groups differed significantly regarding the clinical outcome at 3 months (P = .029). For the endovascular group, the clinical outcome at 3 months was favorable in 14 (56%) of 25 patients and unfavorable in six (24%) of 25 patient; five (20%) of 25 patients died (Table 4). For the medical group, the clinical outcome at 3 months was favorable in eight (26%) of 31 patients and unfavorable in 18 (58%) of 31 patients; five (16%) of 31 patients died.

Outcome Predictors
Logistic regression analysis revealed that a lower NIHSS score at admission (P = .001) and younger age (P = .012) were independent predictors of favorable clinical outcome. When the endovascular group was analyzed separately, good recanalization of the MCA was the only independent predictor of favorable outcome (P = .014). Independent predictors of favorable outcome in the medical group were lower NIHSS score at admission (P = .001), younger age (P = .007), and absence of early ischemic signs at CT and/or MR imaging (P = .033).

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION References

 
We present an endovascular approach that combines the use of IAT and stent implantation in the proximal segment of the ICA to treat acute ischemic stroke that is caused by ICA occlusion. This treatment is based on the implementation of approved and commercially available catheters and stents that are used in the daily practice of interventional neuroradiology. For our method, the implantation of a stent into the ICA is performed during the same angiographic session as IAT (ie, within 6 hours after onset of symptoms). To the best of our knowledge, this is the first larger case series to evaluate this treatment method in patients with acute symptomatic occlusion of the cervical segments of the ICA. Previously, Wang et al (16) reported data on six patients who underwent urgent catheter navigation through the occluded ICA, thrombolysis, and percutaneous transluminal angioplasty. Stent implantation was performed in three patients who subsequently had a favorable outcome at a mean follow-up of 8 months.

IAT with urokinase was first performed at our institution in 1992, and since then, more than 350 patients with cerebral or retinal ischemia have been treated (11,17,18). After considering the poor outcome of a substantial proportion of patients who had proximal vessel occlusions (especially those with carotid T [19] and basilar artery [20] occlusions), we increasingly applied more mechanical clot removal techniques to improve recanalization in the carotid and vertebrobasilar system (21). Since 1997, we have attempted thromboaspiration and stent deployment in the ICA for 25 patients with occlusions of the MCA that occurred as a result of ICA occlusion. The recanalization of the ICA was successful in 21 (84%) of 25 patients, and recanalization of the MCA was successful in 11 (52%) of 21 patients. Nine of the 11 successfully recanalized MCAs were reopened by using mechanical means only, and two additional MCAs regained blood flow (TIMI grade 2 or 3) after administration of urokinase.

The main finding of the present study is the effectiveness of this approach. At 3 months, 14 (56%) of 25 patients in the endovascular group compared with only eight (26%) of 31 patients in the medical group had a favorable clinical outcome (P = .029). In addition, a smaller percentage of patients with unfavorable outcome was noted in the endovascular group (ie, 24% for endovascular group vs 58% for the medical group). The mortality rate, however, was 20% in the endovascular and 16% in the medical group. In this series, favorable outcome was strongly and independently associated with a lower NIHSS score at admission and younger age. Good recanalization of the MCA was the only predictor of favorable outcome in the endovascular group, while lower NIHSS score at admission and younger age were predictors of favorable outcome in the medical group. These associations should be taken into consideration when making therapeutic decisions.

Experience with intravenous rtPA for treatment of stroke as a result of ICA occlusion is limited. Trouillas et al (6) treated 23 patients who experienced either atheromatous or dissectional thrombosis of the ICA within 7 hours of stroke onset. Researchers administered rtPA at a dose of 0.8 mg per kilogram body weight for 90 minutes. At 3 months, Trouillas et al (6) observed that 47.8% of their patients had a modified Rankin scale score 3 or less. If only atheromatous thromboses of the ICA were considered, this percentage was 31.2%.

There is a firm association between recanalization and clinical outcome. The recanalization rate, as seen at angiography in response to intravenous rtPA, has been low (22). Low recanalization rates have been observed when recanalization was performed with IAT but without mechanical dissolution of the clot (23–26). In the Prolyse in Acute Cerebral Thromboembolism II trial (2), spontaneous recanalization of the occluded M1 and M2 segments was 18% and 66%, respectively, after recombinant prourokinase. In our study, we were able to achieve 79% recanalization in patients with occlusions in the M1 or M2 segment by using urokinase and some mechanical disruption (but not aspiration) of the clot (18). Considering the low spontaneous MCA recanalization rates in patients without any obstruction of the ICA, an MCA recanalization rate of 52% in the complex situation of a tandem ICA and MCA occlusion in this series seems to be fairly promising. It supports the value of a combined mechanical and pharmacologic approach for recanalization from a pathophysiologic point of view.

IAT and stent implantation are performed after administration of general anesthetic, and thus, the availability of a multidisciplinary team of anesthesiologists, interventional neuroradiologists, and neurologists is needed. Nevertheless, endovascular treatment is feasible in stroke centers that have around-the-clock intensive care and neuroradiologic services. Furthermore, optimization of preadmission and in-hospital management would allow an increasing number of patients with acute ischemic stroke to receive endovascular treatment (27).

As for treatment safety, symptomatic intracerebral hemorrhages, vessel wall ruptures, dissections, and wall hematomas have been major concerns. Our rate of symptomatic intracerebral hemorrhage (8%) is on the same order as that measured in the Prolyse in Acute Cerebral Thromboembolism II cohort (10.2%) (2) and randomized intravenous rtPA trials (28,29). There were only two hemorrhages in our series. After undergoing intervention, one patient experienced a transient ischemic attack and thus was likely to have had a small lesion on the day before the main stroke and intervention. The other patient who experienced hemorrhaging underwent intervention after the 6-hour time limit. Both patients did not experience a meaningful MCA recanalization (eg, TIMI grade 0 or 1), as determined on the final angiograms. Vessel wall ruptures, dissections, and wall hematomas were not observed in the present series.

There is room for further improvements in the endovascular armamentarium and techniques. For instance, the use of guide catheters with balloons, which are used simultaneously with devices that maintain continuous negative pressure in the guide catheter, for temporary occlusion and flow arrest of the common carotid artery or ICA during the short phase of thrombus aspiration and the implementation of more flexible catheters have the potential to increase the effectiveness and safety of this treatment.

Our study had limitations. The main limitation is the nonrandomized character of the study. Therefore, a patient selection bias may have played a role. The decision to assign patients to endovascular treatment or conventional therapy with antithrombotic drugs was at the discretion of the treating neurologist and the interventional neuroradiologist. Nevertheless, the endovascular group and the medical group did not differ with respect to demographic factors or clinical and radiologic characteristics. The only significant difference was the origin of stroke (there were more carotid artery dissections in the medical group than in the endovascular group, P = .014).

In conclusion, endovascular treatment that combines thrombolysis and stent implantation seems to improve outcome in patients with acute stroke caused by occlusions of the MCA that result from ICA occlusion.

	FOOTNOTES

 

Abbreviations: IAT = intraarterial thrombolysis • ICA = internal carotid artery • MCA = middle cerebral artery • NIHSS = National Institutes of Health Stroke Scale • rtPA = recombinant tissue-type plasminogen activator • TIMI = Thrombolysis In Myocardial Infarction

Authors stated no financial relationship to disclose.

Author contributions: Guarantor of integrity of entire study, G.S.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; approval of final version of submitted manuscript, all authors; literature research, K.N., C.B., C.O., M.A., H.P.M., G.S.; clinical studies, all authors; statistical analysis, K.N., C.O., M.A., G.S.; and manuscript editing, K.N., C.O., D.D.D., M.A., H.P.M., G.S.

	References

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION References

 

1. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581–1587.[Abstract/Free Full Text]
2. Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke: the PROACT II study—a randomized controlled trial. JAMA 1999;282:2003–2011.[Abstract/Free Full Text]
3. Kidwell CS, Saver JL, Mattiello J, et al. Thrombolytic reversal of acute human cerebral ischemic injury shown by diffusion/perfusion magnetic resonance perfusion imaging. Ann Neurol 2000;47:462–469.[CrossRef][Medline]
4. Tomsick T, Brott T, Barsan W, et al. Prognostic value of the hyperdense middle cerebral artery sign and stroke scale score before ultraearly thrombolytic therapy. AJNR Am J Neuroradiol 1996;17:79–85.[Abstract]
5. Rudolf J, Neveling M, Grond M, Schmulling S, Stenzel C, Heiss WD. Stroke following internal carotid artery occlusion: a contra-indication for intravenous thrombolysis? Eur J Neurol 1999;6:51–55.[CrossRef][Medline]
6. Trouillas P, Nighoghossian N, Derex L, et al. Thrombolysis with intravenous rtPA in a series of 100 cases of acute carotid territory stroke: determination of etiological, topographic, and radiological outcome factors. Stroke 1998;29:2529–2540.[Abstract/Free Full Text]
7. Endo S, Kuwayama N, Hirashima Y, Akai T, Nishijima M, Takaku A. Results of urgent thrombolysis in patients with major stroke and atherothrombotic occlusion of the cervical internal carotid artery. AJNR Am J Neuroradiol 1998;19:1169–1175.[Abstract]
8. Aho K, Harmsen P, Hatano S, Marquardsen J, Smirnov VE, Strasser T. Cerebrovascular disease in the community: results of a WHO collaborative study. Bull World Health Organ 1980;58:113–130.[Medline]
9. Brott T, Marler JR, Olinger CP, et al. Measurements of acute cerebral infarction: lesion size by computed tomography. Stroke 1989;20:871–875.[Abstract/Free Full Text]
10. Ozdoba C, Sturzenegger M, Schroth G. Internal carotid artery dissection: MR imaging features and clinical-radiologic correlation. Radiology 1996;199:191–198.[Abstract/Free Full Text]
11. Arnold M, Nedeltchev K, Sturzenegger M, et al. Thrombolysis in patients with acute stroke caused by cervical artery dissection: analysis of 9 patients and review of the literature. Arch Neurol 2002;59:549–553.[Abstract/Free Full Text]
12. Schroth G, Berlis A, Mayer T, et al. Therapeutic interventional neuroradiology in acute stroke [in German]. Ther Umsch 2003;60:569–583.[CrossRef][Medline]
13. Adams HP, Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial—TOAST: Trial of ORG 10172 in Acute Stroke Treatment. Stroke 1993;24:35–41.[Abstract/Free Full Text]
14. TIMI Study Group. The Thrombolysis in Myocardial Infarction (TIMI) trial: phase I findings. N Engl J Med 1985;312:932–936.[Medline]
15. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988;19:604–607.[Abstract/Free Full Text]
16. Wang H, Lanzino G, Fraser K, Tracy P, Wang D. Urgent endovascular treatment of acute symptomatic occlusion of the cervical internal carotid artery. J Neurosurg 2003;99:972–977.[Medline]
17. Gönner F, Remonda L, Mattle H, et al. Local intra-arterial thrombolysis in acute stroke. Stroke 1998;29:1894–1900.[Abstract/Free Full Text]
18. Arnold M, Schroth G, Nedeltchev K, et al. Intra-arterial thrombolysis in 100 patients with acute stroke due to middle cerebral artery occlusion. Stroke 2002;33:1828–1833.[Abstract/Free Full Text]
19. Arnold M, Nedeltchev K, Mattle HP, et al. Intra-arterial thrombolysis in 24 consecutive patients with internal carotid artery T occlusions. J Neurol Neurosurg Psychiatry 2003;74:739–742.[Abstract/Free Full Text]
20. Arnold M, Nedeltchev K, Schroth G, et al. Clinical and radiological predictors of recanalization and outcome in 40 patients with acute basilar artery occlusion treated with intra-arterial thrombolysis. J Neurol Neurosurg Psychiatry 2004;75:857–862.[Abstract/Free Full Text]
21. Nedeltchev K, Remonda L, Do DD, et al. Acute stenting and thromboaspiration in basilar artery occlusions due to embolism from the dominating vertebral artery. Neuroradiology 2004;46:686–691.[CrossRef][Medline]
22. del Zoppo GJ, Poeck K, Pessin MS, et al. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann Neurol 1992;32:78–86.[CrossRef][Medline]
23. Zeumer H. Vascular recanalising techniques in interventional neuroradiology. J Neurol 1985;231:287–294.[CrossRef][Medline]
24. Zeumer H, Freitag HJ, Zanella NF, Thie A, Arning C. Local intra-arterial therapy in patients with stroke: urokinase versus recombinant tissue plasminogen activatuor (rT-PA). Neuroradiology 1993;35:159–162.[CrossRef][Medline]
25. Maiza D, Theron J, Pelouze GA, et al. Local fibrinolytic therapy in ischemic carotid pathology. Ann Vasc Surg 1988;2:205–214.[Medline]
26. Del Zoppo GJ, Ferbert A, Otis S, et al. Local intra-arterial fibrinolytic therapy in acute carotid territory stroke: a pilot study. Stroke 1988;19:307–313.[Abstract/Free Full Text]
27. Nedeltchev K, Arnold M, Brekenfeld C, et al. Pre- and in-hospital delays from stroke onset to intra-arterial thrombolysis. Stroke 2003;34:1230–1234.[Abstract/Free Full Text]
28. Hacke W, Kaste M, Fieschi C, et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II): Second European-Australasian Acute Stroke Study Investigators. Lancet 1998;352:1245–1251.[CrossRef][Medline]
29. Clark WM, Wissman S, Albers GW, et al. Recombinant tissue-type plasminogen activator (alteplase) for ischemic stroke 3 to 5 hours after symptom onset: the ATLANTIS Study—a randomized controlled trial. JAMA 1999;282:2019–2026.[Abstract/Free Full Text]

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