E-005 Emergent mechanical thrombectomy and outcome of acute ischaemic stroke patients who presented with internal carotid artery terminus occlusion due to thrombus-a case series
Authors: Lodi Y , Reddy V , Devasenapathy A , Petro G , Sethi K , Gaylon D , Bajwa S 
Published: July 2013

Background

Based on the natural history and literatures, acute ischaemic stroke (AIS) due to the occlusion of internal carotid artery terminus (ICA-T) is associated with no or poor recanalisation in both intravenous (IV) and inra-arterial thrombolysis, and associated with poor outcome. Additionally, the time required for revascularisation of ICA-T lesions using thrombolysis approach may be too long to salvage the ischaemic penumbra.

Objectives

It to evaluate the effect of emergent mechanical thrombectomy as a primary intension and approach in revascularisation of the ICA-T occlusion in patient with AIS. We also want to evaluate the functional clinical outcome of patients who underwent thrombectomy for ICA-T occlusion in AIS.

Methods

A prospective registry was maintained for all patients with acute ischaemic stroke who underwent acute stroke endovascular therapy. From this database patient with ICA-T occlusion with AIS were enrolled from May 2012 to December 2012. Patients demographic and haemodynamics including time of symptoms onset, presenting stroke scale, imaging data and peri-procedural information were collected. Additionally, a 90 days functional outcome was measure using National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS).

Results

7 patients (Male 4, Female 3) with median age of 53 (ranges 8 to 79) median NIHSS 15 (12-18) presented with AIS due to the occlusion of ICA-T identified by superfast computed topographic angiography (CTA) which was obtained at the same time of non-contrast scan. The mean time of thrombectomy enrollment from symptom onset was 6.2 hours with 2 patients of unknown onset. Of 7 patients; one was failed IV and others were not an intravenous thrombolytic candidate. The median time from groin puncture to middle cerebral artery microcatheter placement was 29.3 minutes. Five patients received IA thrombolytic (2 to 6 mg) except two (one with IV thrombolysis, other 13 hours of symptoms) followed by thrombectomy using Solitaire thrombectomy device 4x20 mm resulted in complete recanalisation in all cases. The median time from groin puncture to recanalisation was 61.9 minutes. Immediate significant improvement (≥10 point in NIHSS) was observed in 4 cases including two with NIHSS 0. 90 days good outcome (mRS ≤ 2) was observed in 6 patients (mRS 0 in 2, mRS 1 in 2, mRS 2 in 2). Poor outcome (mRS 4) was observed in one 28 years women with right ICA-T occlusion who presented with NIHSS 18 with unknown time of onset, developed malignant oedema required haemocraniactomy, ventriculostomy catheter and pentobarbital com. However this patient has now begun to walk with walker, has fluent speech and intact cognition.

Conclusions

Primary thrombectomy for ICA-T occlusion using mechanical clot retriever device (Solitaire) in acute ischaemic stroke patients who are either failed or not an IV thrombolytic candidate/beyond thrombolytic window not only achieves fast complete recanalisation but also associated with immediate and long-term good clinical outcome. Therefore, primary thrombectomy should be offered for all acute ischaemic stroke patients with large artery occlusion and have salvageable penumbra who are either failed or not an IV thrombolytic candidate or beyond thrombolytic window.

Disclosures

Y. Lodi: None. V. Reddy: None. A. Devasenapathy: None. G. Petro: None. K. Sethi: None. D. Gaylon: None. S. Bajwa: None.