Fibrinolytic therapy of acute cerebral infarct

On the basis of our upon own results of local intra-arterial fibrinolysis (LIF), this article gives a short overview of recently established thrombolytic therapy in acute ischemic stroke. Fifty patients with acute occlusions of vertebrobasilar arteries and 118 patients showing occlusions of branches of the internal carotid artery were treated with LIF. The Occlusion type, occlusion site and successful recanalization were associated with a favorable outcome: 92% of embolic occlusions in the vertebrobasilar territory were recanalized and resulted in 50% in a favorable outcome. In the carotid territory, optimal outcome was achieved in main stem and branch occlusions of the middle cerebral artery, due to recanalization rates of 49%-64%. In contrast, occlusions of the intracranial bifurcation of the carotid artery (carotid-"T") resulted in death in 59%. Despite the lack of randomized trials, LIF is an established form of therapy in the vertebrobasilar territory. In the carotid territory randomized clinical studies could demonstrate the efficacy of intravenous fibrinolytic therapy in some stroke patients. It can be presumed from pilot studies that LIF is superior to the intravenous version in the carotid territory.     

Endovascular treatment of carotid artery occlusion in progressive stroke syndromes: technical note

OBJECTIVE AND IMPORTANCE: We describe two patients, with progressing neurological deficits, who showed improvement after revascularization of their carotid arteries using stents. CLINICAL PRESENTATION: One patient presented clinically with the symptoms of a middle cerebral artery territory stroke. Angiography demonstrated total occlusion of the right internal carotid artery (ICA), with evidence of clot from the origin of the ICA to the middle cerebral artery trifurcation. The second patient presented with bilateral ICA occlusions and evidence of a progressing left hemispheric deficit; she was receiving therapeutic levels of heparin at the time of deterioration of her condition. INTERVENTION: Thrombolysis and stenting successfully recanalized the occluded vessels, and the deficits of the first patient were reversed. With the second patient, a dissected carotid loop was encountered. Straightening of the loop with a wire and stenting of the carotid artery using two stents allowed revascularization of the left hemisphere and resolution of most of the deficits of this patient. CONCLUSION: This report demonstrates the technical feasibility of placing stents in high-risk patients with carotid artery occlusions from either dissection or atherosclerosis. Both patients sustained much smaller infarctions than would have been expected if the carotid artery territory had been infarcted. We report on the technical feasibility of reopening acutely closed ICAs by using endovascular methods.     

Endovascular treatment of acute thrombotic occlusion of the cervical internal carotid artery associated with embolic occlusion of the middle cerebral artery: case report

A 68-year-old man with acute, total thrombotic occlusion of the right cervical internal carotid artery, associated with embolic occlusion of the ipsilateral middle cerebral artery, was treated by the endovascular approach, i.e., intra-arterial fibrinolysis and balloon angioplasty. Endovascular treatment for a totally occluded internal carotid artery is indicated in the very early stage where there is no thrombus or a short thrombus that can be evacuated. Fibrinolysis of the associated embolus in the middle cerebral artery, if any, can be done in the same session, enabling an early restoration of the blood flow.     

Effect of coat on rate of temperature increase in muscle during ultrasound treatment of dogs

BACKGROUND AND PURPOSE: The vasomotor response can be tested by means of transcranial Doppler sonography. If a constant vessel diameter is assumed, the flow velocity changes will reflect blood flow volume changes. This hypothesis is difficult to verify. Simultaneous assessment of intracranial flow velocity and extracranial flow volume changes may solve this problem. METHODS: We tested vasomotor response in 32 volunteers (age, 42+/-18 years) with 5% CO2. Acetazolamide (1 g) was tested in 15 volunteers (age, 28+/-8 years). To evaluate drug-dependent flow changes in the external carotid artery territory, acetazolamide was administered in 7 patients with unilateral occlusion of the internal carotid artery without evidence of collateralization through the ophthalmic artery (age, 67+/-12 years). Simultaneous recording included measurements of flow volume in the common carotid arteries (M-mode color duplex system) and flow velocity in the middle cerebral arteries. RESULTS: With CO2 and acetazolamide, intracranial flow velocity increased by 31% and 39%, respectively, with a simultaneous increase of common carotid artery flow volume of 47% and 50%, respectively. No change in extracranial flow volume was observed in patients with an occluded internal carotid artery. CONCLUSIONS: These data show not only the expected increase of flow velocity in the middle cerebral artery but also suggest an increase in cross-sectional vessel diameter of 6% and 4% with CO2 and acetazolamide, respectively. It remains unresolved whether this observation is due to a direct effect of the drug on the vessel walls or is simply pressure dependent.     

Sanguineous cerebrospinal fluid in recanalized cerebral infarction

To clarify the causal relationship between spontaneous recanalization of the occluded cerebral artery and development of hemorrhagic infarction, 15 patients with internal carotid or middle cerebral arterial axis occlusion were submitted to consecutive lumbar punctures and follow-up cerebral angiography. Consequently, six of seven recanalized patients had sanguineous cerebrospinal fluid (CSF) on the second or third day after ictus, while only one of eight non-recanalized patients had bloody CSF. It was strongly suggested that recanalization might have an initimate relationship with the development of hemorrhagic infarction.     

Surgical treatment of common carotid artery occlusion

Eight patients with common carotid artery (CCA) occlusion underwent bypass with saphenous vein to either the carotid bifurcation (five), the internal carotid artery (two), or the external carotid artery (one). Indications included ipsilateral transient ischemic attack (two), recent nondisabling hemispheric stroke (two), and transient nonhemispheric cerebral symptoms (two). Two asymptomatic patients with CCA occlusion and contralateral internal carotid stenosis underwent prophylactic revascularization prior to planned aortic surgery. There were no perioperative strokes, occlusions, or deaths. Late ipsilateral stroke occurred in two patients, and one patient had a single transient ischemic attack after 2 years. The four patients with preoperative transient cerebral ischemia experienced relief of their symptoms. Duplex ultrasound is an accurate screening modality for distal patency. Collateral filling of the internal or external carotid artery can usually be demonstrated after aortic arch or retrograde brachial contrast injection. End-to-end distal anastomosis after endarterectomy eliminates the original occlusive plaque as a potential source of emboli. The subclavian artery is preferred for inflow on the left. The CCA origin is easily accessible for inflow on the right. Bypass of the occluded CCA is safe and may be effective in relieving transient cerebral ischemic symptoms, although long-term ipsilateral neurologic sequelae may still occur.     

The placebo in modern medicine

PURPOSE: To report the results of balloon angioplasty in recurrent carotid occlusive disease and evaluate the potential for stent implantation. METHODS AND RESULTS: Between April 1991 and September 1995, 15 patients with carotid restenosis underwent 17 endoluminal procedures in 3 common carotid and 14 internal carotid arteries. Two postdilation complications (dissection and acute occlusion) required prompt stenting; one common carotid artery was stented for postdilation residual stenosis. One recurrent lesion was also stented 6 months after initial angioplasty. One stroke, 1 silent cerebral infarction, and 3 transient ischemic attacks occurred in the balloon angioplasty patients (33% neurological complication rate). The common carotid stent patient died 3 days postoperatively due to hyperperfusion syndrome. Long-term follow-up in two stent patients showed no restenosis at 18 and 48 months, respectively. The 11 balloon angioplasty patients likewise have not demonstrated restenosis. CONCLUSIONS: Balloon angioplasty alone appears too risky for treating recurrent carotid disease. Stents may offer a safer alternative, particularly when implanted primarily.     

Progressive intracranial occlusive disease associated with deficiency of protein S. Report of two cases

BACKGROUND AND PURPOSE: Deficiency of the free fraction of protein S has been associated with arterial or venous stroke. The pathogenesis of vascular occlusion in patients with protein S deficiency is not known. We present two cases of cerebral infarction and deficiency of protein S in which the subjects had progressive intracranial occlusions. CASE DESCRIPTION: A 16-year-old girl was admitted because of left brain stem infarction and protein S deficiency. Cerebral angiography disclosed stenosis of the right intracranial vertebral artery and occlusion of the left posterior cerebral artery. A second angiogram performed 18 months later disclosed occlusion of the right vertebral intracranial artery. In the second case, a 17-year-old girl was admitted because of left hemispheric cerebral infarction and protein S deficiency. Cerebral angiography showed stenosis of the left anterior cerebral artery, left supraclinoid internal artery, and left middle cerebral artery. A second cerebral angiogram performed 5 months later disclosed occlusion of the left anterior cerebral artery and poor hemispheric perfusion through the left middle cerebral artery. CONCLUSIONS: Based on our cases, we postulate that some patients with prothrombotic states may develop progressive intracranial arterial occlusions, possibly secondary to a permanent thrombogenic stimulus. We suggest routinely searching for prothrombotic states in young patients with intracranial occlusion, especially if the occlusion is progressive and other causes are not obvious.     

Bypass surgery for vascular disease of the carotid system

A series of 58 operations on 56 patients, in whom a branch of the superficial temporal artery was anastomosed to a branch of the middle cerebral artery (STA-MCA bypass or Yasargil procedure), is reviewed. These operations were performed chiefly for occlussions or for inaccessible stenotic lesions of the internal carotid or middle cerebral arteries. Patency in eight patients operated on from April 1971 through November 1973 was low (25%). Patency in patients operated on since July 1974 has been high (95%). There have been no deaths and no major ischemic strokes attributable to the surgery. The rationale for this procedure is considered in relationship to the anatomy and physiology of the cerebral circulation and the pathogenesis of syndromes of cerebral ischemia. The operation appears to have a low morbidity in good-risk patients. The role of this operation in managing common manifestations of cerebral vascular disease such as focal transient cerebral ischemic attacks (TIAs) and amaurosis fugax, although not fully established, appears encouraging. The procedure seems useful for orthostatic cerebral ischemia caused by multiple occlusions of major extracranial (and intracranial) vessels and, occasionally, for progressing strokes related to internal carotid artery occlusion, both of which are relatively uncommon manifestations of cerebral vascular occlusive disease. It may have application in the rare "slow stroke." The procedure is probably of limited value, if any, in the management of large completed infarcts but may be indicated in selected patients with small infarctions who have preserved most of their cerebral function and who have had evidence of subsequent focal ischemic events. The procedure is useful for bypassing giant aneurysms or basofrontal tumors invading major vessels. It may have a role in the management of fibromuscular disease of the internal carotid artery.     

Brain lipid peroxidation and antioxidant levels in fetal lambs 72 hours after asphyxia by partial umbilical cord occlusion

Giant middle cerebral artery (MCA) trifurcation aneurysms that cannot be excluded directly can be treated by flow inversion achieved by creation of an extracranial-intracranial bypass distal to the aneurysm, followed by occlusion of the parent vessel proximal to the aneurysm. As opposed to surgical occlusion, endovascular occlusion avoids dissection of the aneurysm area, and the site of occlusion can be chosen according to the flow distribution demonstrated on angiography performed during test occlusions. Two patients with giant aneurysms of the MCA trifurcation benefited from flow inversion treatment. Forty-eight hours after an MCA-superficial temporal artery bypass had been created, the M1 segment was occluded by inserting a coil in the first patient and the internal carotid artery was occluded with balloons in the second patient (there was no communicating artery in the latter case). Both occlusions were performed immediately after a clinical test of occlusion tolerance. The patients were clinically intact during the postoperative course. Follow-up angiography performed 11 and 4 months, respectively, after vessel occlusion showed that the aneurysm occlusion was stable.     

Angioplasty after intra-arterial thrombolysis for acute occlusion of intracranial arteries

BACKGROUND and PURPOSE: The purpose of this study was to report our experience with percutaneous transluminal angioplasty (PTA) of intracranial arteries in acute stroke patients who were resistant to intra-arterial thrombolysis alone. METHODS: PTA was performed within 6 hours from symptom onset in 13 acute stroke patients in whom no hypodensity areas were observed on initial CT. PTA was classified into 3 categories: immediate (3 patients), delayed (3 patients), and rescue (7 patients) angioplasty. Treatment results in the PTA group for 9 cases of middle cerebral artery (MCA) occlusion were compared with those in the thrombolysis alone group for 12 cases of thrombotic MCA occlusion. RESULTS: Technical success rates for immediate, delayed, and rescue angioplasty were 100%, 100%, and 71%, respectively, and that of angioplasty for the MCA was 100%. Ten patients (77%) showed improvement in the National Institutes of Health (NIH) stroke score after treatment. Improvement in NIH stroke scores in the PTA group for MCA occlusion was greater than that in the thrombolysis alone group (P<0.01). Nine patients (69%) had an excellent, good, or fair outcome 3 months after treatment. In 9 patients who had follow-up angiography 1 month after treatment, no restenosis or reocclusion was demonstrated. There were no symptomatic complications during or after treatment. CONCLUSIONS: This limited study demonstrates the technical feasibility of angioplasty for intracranial arteries in acute ischemic stroke and suggests that angioplasty may be an effective option for improving the success rate of recanalization and preventing reocclusion of the MCA. The present results encourage us to perform further clinical trials in a larger number of patients to assess the efficacy of this procedure.     

Fibromuscular dysplasia and multiple dissecting aneurysms of intracranial arteries. A further cause of Moyamoya syndrome

A 16-year-old boy, who had sudden left-sided hemiplegia, died two weeks following onset of symptoms. A right carotid angiogram showed stenosis at the termination of the internal carotid artery. The middle cerebral artery had a beaded appearance and some of its branches were occluded. A basal "moyamoya" syndrome and transdural anastomoses were present. At autopsy, multiple intracranial dissecting aneurysms were found. Arteries of the body displayed fibromuscular dysplasia (FMD). The relevance of dysplastic changes of intracranial arteries and the relationship to moyamoya syndrome are discussed.     

Tuberculous skeletal muscle involvement in acute leukemia: report on two cases

The role of thrombolysis in brain ischemia in patients with atrial myxoma is unknown. A patient with acute brain ischemia and previously undiagnosed atrial myxoma recanalized an occluded middle cerebral artery with intra-arterial thrombolysis. Arterial occlusion from presumed myxoma may be amenable to fibrinolysis. Angiography before treatment in patients with atrial myxoma excludes a myxomatous pseudoaneurysm and permits site-specific thrombolytic instillment.     

The hemodynamics and anatomy of the circle of Willis. The technic and clinical value of selective MR angiography

This study evaluates the usefulness of MR angiography in analysing the individual collateral flow dynamics and anatomy of the circle of Willis in 56 patients with high-grade extracranial carotid stenosis or occlusion. Selective MRA of the carotid or vertebrobasilar area was performed by means of presaturation up to the brain-supplying arteries at the level of the middle neck (angled presaturation slabs). Results obtained with selective and non-selective MRA in 56 consecutive patients were compared with the findings at transcranial Doppler ultrasonography and arterial angiography. Ischaemic cerebral infarctions were classified by computerized tomography and correlated with the results of collateral flow analysis: Sensitivity of selective MRA in detecting intracranial collateral flow via anterior or posterior communicating artery was 96 and 97%, respectively; sensitivity in depicting extracranial transorbital flow was lower (71%). Non-selective MRA was 100% sensitive in detecting a non-filling of the horizontal (A1) segment of the anterior cerebral artery and in identifying an origin of the posterior cerebral artery from the intracranial carotid artery. Slow flow infarctions occurred more frequently in patients with transorbital and posterior-to-anterior collateral flow than in patients with collateral flow via anterior communicating artery.     

Subarachnoid neurocysticercosis with occlusion of the major intracranial arteries: case report

Cysticercosis is the most common parasitic disease affecting the central nervous system. Stroke is a recognized complication of neurocysticercosis, occurring in 2 to 12% of cases, mostly in the form of small lacunar infarcts. We report a case of hemiparesis and aphasia in a 51-year-old Hispanic woman, which was secondary to complete occlusion of the left internal carotid and bilateral anterior cerebral arteries. Magnetic resonance imaging demonstrated the presence of enhancing subarachnoid material surrounding these occluded cerebral arteries, providing antemortem, noninvasive documentation of the inflammatory meningeal cysticercotic reaction that was presumably responsible for the occlusive arteritis causing the cerebral infarction. This represents the third reported case of internal carotid artery occlusion and the first reported case of anterior cerebral artery occlusion secondary to neurocysticercosis.     

Post-traumatic middle cerebral artery occlusion: case report and review

Occlusion of extracranial carotid and vertebral arteries following closed craniocervical trauma is well known. However occlusion of intracranial arteries following closed head injuries is infrequently reported. In fact only 25 cases of post-traumatic middle cerebral artery occlusion have been adequately documented. This entity bears re-emphasis not only because of its rarity but also because of its clinical similarity to other intracranial mass lesions.     

Protease-catalyzed synthesis of Leu-enkephalin in a solvent-free system

Percutaneous transluminal angioplasty (PTA) is a well-established treatment for patients with stenosis of limb arteries. However, its efficacy for treatment of severe stenosis and occlusions of the subclavian artery is unclear. We attempted to recanalize the subclavian artery in 30 patients with severe stenosis or total occlusion of proximal subclavian artery and successful outcomes were seen in 27 cases (90%). In two patients the regional arterial thrombolysis with the PTA prcedure we used was found successful. There was no severe complications. During an average 6-month follow-up stenosis recurred in 2 patients, but the subclavian artery was recanalized by repedted PTA.     

Asymptomatic occlusive lesions of carotid and intracranial arteries in Japanese patients with ischemic heart disease: evaluation by brain magnetic resonance angiography

BACKGROUND AND PURPOSE: The purpose of this study was to elucidate the prevalence and degree of asymptomatic occlusive lesions in the carotid and intracranial arteries in Japanese patients with ischemic heart disease (IHD). METHODS: We performed carotid and intracranial MR angiography (MRA) on 67 patients (49 men, 18 women; age range, 40 to 78 years; mean age, 60.1 years) who had received selective coronary angiography for the clinical diagnosis of IHD. On the basis of these images, degree of stenosis in the regions of the bilateral carotid artery bifurcation and five regions of the intracranial arteries, ie, bilateral intracranial portions of the internal carotid arteries and the middle cerebral arteries and the basilar artery were estimated. RESULTS: Stenosis of more than 25% narrowing of the diameter of the target arteries was found in 15 patients (22.4%) in the extracranial carotid arteries and in 11 patients (16.4%) in the intracranial arteries. Most of the stenotic lesions were mild. The incidence of extracranial carotid stenosis and the severity of coronary atherosclerosis showed a significant correlation. The mean age of the patients with intracranial arterial lesions was statistically higher than those without intracranial lesions. CONCLUSIONS: Our data suggest that asymptomatic occlusive lesions in the carotid and intracranial arteries are fairly common in Japanese patients with IHD, although the degree of stenosis is relatively mild. Coexistence of carotid atherosclerosis should be suspected in IHD patients with severe coronary atherosclerosis, and the possibility of atherosclerosis in the intracranial arteries should be considered in aged IHD patients.     

Endovascular surgical approach to intracranial vascular diseases

PURPOSE: The endovascular surgical approach to complex disorders of the central nervous system has made rapid and significant advancements over the past decade. Patients with intracranial arterial aneurysms, traumatic carotid and vertebral artery lesions, including fistulas and pseudoaneurysms, hemodynamically significant atherosclerotic lesions, vasospasm, and acute stroke are now being approached and treated by newer and less invasive techniques, including cerebral angioplasty and thrombolytic therapy. METHODS: All procedures are usually performed from a transfemoral approach utilizing a variety of occlusion devices, including detachable silicone balloons, microcoils, electrolytic detachable coils, liquid tissue adhesives, and particulate emboli for vessel occlusion. For dilatation and reperfusion of vessels, balloon angioplasty catheters, stents, and thrombolytic drugs are being used. RESULTS: For the treatment of traumatic vascular injuries, such as carotid cavernous sinus fistulas and vertebral arteriovenous fistulas and pseudoaneurysms, endovascular therapy has become the treatment of choice. The endovascular approach for intracranial aneurysms is emerging as a therapeutic option in selected cases. For occlusive disorders in patients presenting with acute cerebral ischemia, extracranial angioplasty and cerebral thrombolysis techniques are currently under investigation. CONCLUSIONS: As these techniques continue to evolve, the field of interventional neuroradiology will expand the therapeutic options for managing complex cerebrovascular disorders and improve patient outcome in acute stroke therapy.