Severe carotid stenosis and delay of reperfusion in endovascular stroke treatment: an Interventional Management of Stroke-III study

Abstract

OBJECTIVE The impact of extracranial carotid stenosis on interventional revascularization of acute anterior circulation stroke is unknown. The authors examined the effects of high-grade carotid stenosis on the results of endovascular treatment of patients in the Interventional Management of Stroke (IMS)-III trial. METHODS The 278 patients in the endovascular arm of the IMS-III trial were categorized according to the degree of carotid stenosis as determined by angiography. In comparing patients with severe stenosis or occlusion (≥ 70%) to those without severe stenosis (< 70%), the authors evaluated the time to endovascular reperfusion, modified Thrombolysis in Cerebrovascular Infarction (mTICI) scores, 24-hour mean infarct volumes, symptomatic intracerebral hemorrhage rates, and modified Rankin Scale (mRS) scores at 90 days. RESULTS Compared with the 249 patients with less than 70% stenosis, patients with severe stenosis (n = 29) were found to have a significantly longer mean time to reperfusion (105.7 vs 77.7 minutes, p = 0.004); differences in mTICI scores, infarct volumes, hemorrhage rates, and mRS scores at 90 days did not reach statistical significance. Multiple regression analysis revealed that severe carotid stenosis (p < 0.0001) and higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (p = 0.004) were associated with an increase in time to reperfusion. Older age (p < 0.0001), higher NIHSS score (p < 0.0001), and the absence of reperfusion (p = 0.001) were associated with worse clinical outcomes. CONCLUSIONS Severe ipsilateral ICA stenosis was associated with a significantly longer time to reperfusion in the IMS-III trial. Although these findings may not translate directly to modern devices, this 28-minute delay in reperfusion has significant implications, raising concern over the treatment of tandem ICA stenosis and downstream large-vessel occlusion.

The prediction of acute ischemic stroke patients’ long-term functional outcomes treated with bridging therapy

“…It is also interesting to note that in a 2018 analysis of data from the Interventional Management of Stroke (IMS)-III trial, it was found that severe carotid stenosis (> 70%) was associated with increased time to reperfusion following endovascular treatment [22]. Baseline NIHSS was also associated with increased time to reperfusion in this study.…”

Assessment of carotid atherosclerotic disease using three-dimensional cardiovascular magnetic resonance vessel wall imaging: comparison with digital subtraction angiography

“…One potential limitation of their study is that they only assessed the consistency and accuracy of 3D BB MR in carotid lesions with > 50% stenosis. However, an increasing number of studies have found that carotid lesions with low-grade stenosis may also lead to stroke [4][5][6]. Moreover, cerebral angiography is often required before carotid artery stent implantation in order to observe the intracranial Willis ring opening and cerebral blood flow perfusion.…”

“…Carotid atherosclerosis is increasingly recognized as the leading cause of ischemic stroke [1][2][3]. Previous studies have shown that accurate evaluation of the degree of carotid stenosis would be beneficial for predicting the risk of stroke [4][5][6]. Digital subtraction angiography (DSA) is still considered the clinical gold standard for assessing the severity of carotid atherosclerosis [7,8].…”

Degradation of TRPML1 in Neurons Reduces Neuron Survival in Transient Global Cerebral Ischemia

“…Neurological deficits after resuscitation contribute to high rates of mortality among patients after cardiac arrest [1–3]. Although recent advances in cardiopulmonary resuscitation techniques have significantly increased the rate of return of spontaneous circulation, few cardiac arrest victims achieve meaningful neurologic recovery [4–6]. Transient global cerebral ischemia (TGCI) is a clinical outcome related to cardiac arrest and other situations that deprive the oxygen and glucose in the brain during a short period.…”