Stroke Game 1: Isolated Cervical Occlusion Management complicated of hemodynamic failure - SLICE Worldwide 2021

Stroke Game 1: Isolated Cervical Occlusion Management complicated of hemodynamic failure - SLICE Worldwide 2021

Stroke Game

Presentations of medical case resolutions in the form of a “serious game”. They are carried out live through challenges between teams of doctors on high-fidelity silicone models designed from the anatomy of real patients.


Isolated Cervical Occlusion Management complicated of hemodynamic failure

Presentations of case resolutions in the form of a “serious game”. Step by step, from the emergency call to the resolution on high fidelity silicon models in the angiosuite, the members of the SLICE Academy will work along with faculty members to solve these real cases reconstitutions.

Presentation of case resolution in the form of a “serious game”. 

Isolated symptomatic cervical occlusion with underlying double stenosis – in cervical and clinoid portion of ICA treated with thrombectomy and full carotid stent reconstruction. Video includes:

  • best management strategy facing cervical occlusion 
  • tips and tricks for carotid stenting
  • antiplatelet regimen discussion.

Isolated symptomatic cervical occlusion – data and main concerns

Conservative vs. interventional treatment – decision making process:

In favor of interventional treatment:

  • despite the time, patient is not developing collateral circulation and symptoms last for some time and increase
  • patient deteriorates when sitting (hemodynamic impairment)

Stroke incidence after TIA – in publications:

  • 4% of prevalence in general
  • increases with ABCD3-I Score (up to 40% of stroke recurrence when hemodynamic impairment associated with isolated ICA occlusion compare to 7% of stroke recurrence when carotid occlusion without hemodynamic insufficiency)

Minor stroke (NIHHS 8) due to isolate acute cervical ICA occlusion – in publications:

  • Complications: distal embolization 22%, ICA dissection 4%, vessel perforation 2%
  • Successful recanalization 92%
  • 3-month mRS 0-2: 65%

Conservative management of minor strokes due to isolated acute cervical ICA occlusion – in publications:

  • Anticoagulation (IV heparin) is associated with fewer recurrent strokes
  • Anticoagulation (IV heparin) is associated with increased ICA recanalization

MRI : easily helps to differentiate embolic vs. hemodynamic nature of a stroke (DWI - watershed infarcts, PWI – hypoperfusion)

Isolated symptomatic cervical occlusion – thrombectomy technique:

Precision is crucial – main goal – to restore the flow and to avoid distal embolization!

1/ Necessity to investigate whether it is only a clot or a clot with underlying disease :

  • pass the clot with microwire and microcatheter on inflated BCG - If ECA is supplying the intracranial part of ICA, place the BCG above its origin to maintain the flow above and do not cut off the collateral supply
  • do the distal run by microcatheter to confirm its proper position in the lumen

- option 1: trap the clot with aspiration catheter proximally and SR distally, with double aspiration on BCG and aspiration catheter while retrieving (disadvantage: you can injure the plaque in ICA origin when retrieving SR, you will have to re-cross the lesion once again)

- option 2: place distal protection device (Spider, Emboshield ect.) and perform thromboaspiration under double – proximal and distal protection

- option 3: do a simple aspiration by large bore intermediate catheter (on BCG inflation)

  • Assessment of ICA à make the decision whether to stent or not

In case of difficulties when passing by ICA origin:

  • BCG improves the stability and increases the support
  • If it is difficult to pass with microsystems, pass the occlusion site with 0.035” long hydrophilic wire (ex. Terumo), follow with 6F intermediate catheter, inflate the BCG and do the thromboaspiration. If it is difficult to bring up the aspiration catheter, do first PTA of the lesion with balloon catheter compliant with 0.035” wire (ex. Passeo-35) and then advance the aspiration catheter (you can exchange the wire on stiffer one – ex. Supra Core). You can maintain your wire at position and move back and forward intermediate catheter while aspirating on inflated BCG until you will fully clean up the lesion (the fact that you will have the continuous outflow in your aspiration tube/syringe means that there is backflow from upper parts of the artery so it is indirect sign of patency of the artery)
  • You can use an angulated diagnostic catheter 5F (ex. 5F 125 cm Vert) to easily direct to ICA and plug the extremity of the catheter to the stenosis (it will give you extra support). Then you advance above the stenosis with your diagnostic catheter. You can pass with microcatheter through the 5F diagnostic catheter (f.ex. Phenom 21), place SR in desire position, remove both 5F diagnostic catheter and microcatheter and then advance an aspiration catheter over the wire of SR
  • You can add the second wire 0.035” as a buddy wire and improve the stability
  • You can use a long balloon catheter and, after performing gentle PTA, jump on partially deflated balloon with you aspiration catheter and/or BCG

TIPS and TRICKS:

  • use BCG 9F in order to have the possibility to place large lumen aspiration catheter
  • you can evaluate the length of the thrombus by slowly removing microcatheter with slight contrast injection under fluoroscopy
  • it is worth putting patient under general anesthesia with particular emphasis on maintenance of high blood pressure
  • once you implant the stent, if there is still some occlusion intracranially, you need to cross the system with your BCG to “work above” the cervical lesion, otherwise the SR or distal protection device can get caught or fracture (if not possible, use the large bore aspiration catheter to cover the devices)

Underlying upper/long ICA lesions:

If there is a need to reconstruct the artery: multiple stents bridging 

- 2 approaches: from proximal to distal/ or from distal to proximal

- in the upper parts of ICA (f.ex siphon) it is possible to use:

  • flow diverters (possibly with pre-PTA, especially if it is atherosclerosis). 
  • short coronary stents (then continue with carotid stents from distal to proximal)
  • regular stents

- it is important to cover all the portions of ICA and to do the overlap with stents of at least 1 cm 

- at the end you can perfom post-PTA if needed

Medications:

  • if patient can take the medications - double antiplatelet therapy (Aspirin + Plavix/ Brilique/Efient)

or

  • in acute setting , if patient cannot take the medications - Aspirin iv. alone or Aspirin iv. + Cangerlor/Integrilin iv. (especially if full carotid reconstruction) 

Be aware of higher risk of hemorrhage in the patients with established infarcts (due to hemorrhagic transformation) or with hypoperfusion (due to reperfusion injury).

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