Endovascular treatment for calcified cerebral emboli in patients with acute ischemic stroke

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  • 1 Departments of Radiology and Nuclear Medicine,
  • | 2 Biomedical Engineering and Physics, and
  • | 3 Neurology, Amsterdam University Medical Centers, AMC, Amsterdam;
  • | 4 Departments of Radiology and Nuclear Medicine,
  • | 5 Neurology, and
  • | 6 Public Health,
  • | 7 Histology and MS Imaging Lab at Experimental Cardiology, and
  • | 8 Department of Hematology, Erasmus MC, University Medical Center, Rotterdam;
  • | 9 Department of Radiology, Haaglanden MC, Den Haag;
  • | 10 Department of Radiology and Nuclear Medicine, Leiden University Medical Center, Leiden; and
  • | 11 Department of Radiology and Nuclear Medicine, School for Mental Health and Sciences, Maastricht University Medical Center, Maastricht, The Netherlands
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OBJECTIVE

Calcified cerebral emboli (CCE) are a rare cause of acute ischemic stroke. The authors aimed to assess the association of CCE with functional outcome, successful reperfusion, and mortality. Furthermore, they aimed to assess the effectiveness of intravenous alteplase treatment and endovascular treatment (EVT), as well as the best first-line EVT approach in patients with CCE.

METHODS

The Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry is a prospective, observational multicenter registry of patients treated with EVT for acute ischemic stroke in 16 intervention hospitals in the Netherlands. The association of CCE with functional outcome, reperfusion, and mortality was evaluated using logistic regression models. Univariable comparisons were made to determine the effectiveness of intravenous alteplase treatment and the best first-line EVT approach in CCE patients.

RESULTS

The study included 3077 patients from the MR CLEAN Registry. Fifty-five patients (1.8%) had CCE. CCE were not significantly associated with worse functional outcome (adjusted common OR 0.71, 95% CI 0.44–1.15), and 29% of CCE patients achieved functional independence. An extended Thrombolysis in Cerebral Infarction score ≥ 2B was significantly less often achieved in CCE patients compared to non-CCE patients (adjusted OR [aOR] 0.52, 95% CI 0.28–0.97). Symptomatic intracranial hemorrhage occurred in 8 CCE patients (15%) vs 171 of 3022 non-CCE patients (6%; p = 0.01). The median improvement on the National Institutes of Health Stroke Scale (NIHSS) was 2 in CCE patients versus 4 in non-CCE patients (p = 0.008). CCE were not significantly associated with mortality (aOR 1.16, 95% CI 0.64–2.12). Intravenous alteplase use in CCE patients was not associated with functional outcome or reperfusion. In CCE patients with successful reperfusion, stent retrievers were more often used as the primary treatment device (p = 0.04).

CONCLUSIONS

While patients with CCE had significantly lower reperfusion rates and less improvement on the NIHSS after EVT, CCE were not significantly associated with worse functional outcome or higher mortality rates. Therefore, EVT should still be considered in this specific group of patients.

ABBREVIATIONS

acOR = adjusted common OR; aOR = adjusted OR; ASPECTS = Alberta Stroke Program Early CT Score; CBS = clot burden score; CCE = calcified cerebral emboli; CTA = CT angiography; DSA = digital subtraction angiography; eTICI = extended Thrombolysis in Cerebral Infarction; EVT = endovascular treatment; HU = Hounsfield unit; ICA = internal carotid artery; IQR = interquartile range; MR CLEAN = Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; mRS = modified Rankin Scale; NCCT = noncontrast CT; NIHSS = National Institutes of Health Stroke Scale; OR = odds ratio; RF = resorcin-fuchsin; ROI = region of interest; ucOR = unadjusted common OR.

Supplementary Materials

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Illustration from Fan et al. (pp 1298–1309). Copyright Jun Fan. Published with permission.

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