Use of a vascular reconstruction device to salvage acute ischemic occlusions refractory to traditional endovascular recanalization methods

Clinical article

J Mocco M.D., M.S. 1 , Ricardo A. Hanel M.D., Ph.D. 2 , Jitendra Sharma M.D., M.S. 3 , Erik F. Hauck M.D., Ph.D. 4 , Kenneth V. Snyder M.D., Ph.D. 4 , Sabareesh K. Natarajan M.D., M.S. 4 , Italo Linfante M.D. 5 , Adnan H. Siddiqui M.D., Ph.D. 4 , L. Nelson Hopkins M.D. 4 , Alan S. Boulos M.D. 6 and Elad I. Levy M.D. 4
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  • 1 Department of Neurosurgery, University of Florida, Gainesville, Florida;
  • 2 Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida;
  • 3 Buffalo Neuroimaging Analysis Center and the Jacobs Neurological Institute, University at Buffalo, State University of New York, Buffalo, New York;
  • 4 Departments of Neurosurgery & Radiology and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, and Department of Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, Buffalo, New York;
  • 5 Endovascular Neurosurgery and Interventional Neuroradiology, Baptist Hospital Neuroscience Center and Baptist Cardiac & Vascular Institute, Miami, Florida; and
  • 6 Division of Neurosurgery, Albany Medical Center Hospital, Albany, New York
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Object

Acute revascularization has been associated with improved stroke outcomes. The Prolyse in Acute Cerebral Thromboembolism (PROACT II) trial achieved recanalization rates of 66%. The Multi Mechanical Embolus Removal in Cerebral Ischemia (Multi MERCI) trial achieved recanalization in 70% of patients. However, these interventional tools are not always successful. The Enterprise vascular reconstruction device was recently introduced for treatment of cerebral aneurysms previously untreatable with endovascular techniques. The authors evaluated a multicenter experience using this stent as a salvage revascularization tool for acute stroke treatment.

Methods

Four medical centers participated in a retrospective review of endovascularly treated patients with acute stroke for cases treated with the Enterprise stent after routine interventions had been unsuccessful. Data collected included preprocedure information, intraprocedure findings, and outcomes.

Results

Twenty patients with acute stroke (mean age 61.6 ± 22 years) were treated with the Enterprise stent. Ten patients received intravenous recombinant tissue plasminogen activator before catheter intervention, without improvement. Intraarterial interventions attempted unsuccessfully before Enterprise deployment included the Merci retriever (12 patients), angioplasty (7 patients), glycoprotein IIb–IIIa inhibitor administration (12 patients), intraarterial nitroglycerin (1 patient), Wingspan stent deployment (3 patients), and Xpert stent deployment (1 patient). The mean preintervention National Institutes of Health Stroke Scale (NIHSS) score was 17 ± 6 (median 17). All patients presented with a Thrombolysis in Myocardial Infarction (TIMI) score of 0 or 1. Revascularization was achieved in all patients (75% with a TIMI score of 3, 25% with a TIMI score of 2). Improvement (≥ 4 points on the NIHSS) was documented in 75% of patients. Mean NIHSS improvement from intervention to discharge was 8 ± 7 points (median 9 points).

Conclusions

These preliminary data suggest a potential benefit to the use of the Enterprise stent when routine intervention methods fail.

Abbreviations used in this paper: CBV = cerebral blood volume; GP = glycoprotein; ICA = internal carotid artery; ICH = intracranial hemorrhage; IMS = Interventional Management of Stroke; MCA = middle cerebral artery; NIHSS = National Institutes of Health Stroke Scale; PEG = percutaneous endoscopic gastrostomy; TIMI = Thrombolysis in Myocardial Infarction; tPA = tissue plasminogen activator.

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Contributor Notes

Address correspondence to: Elad I. Levy, M.D., University at Buffalo Neurosurgery, Millard Fillmore Gates Hospital, Kaleida Health, 3 Gates Circle, Buffalo, New York 14209. email: ELevy@ubns.com.

Please include this information when citing this paper: published online September 18, 2009; DOI: 10.3171/2009.8.JNS09231.

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