Article Figures & Data
Figures
- Fig 1.
Patient 2.
A, Cerebral angiogram shows occlusion of the right middle cerebral artery (M1 segment, grade 3A).
B, Partial recanalization of the M1 and M2 segments is observed after the administration of 2 U of reteplase.
C, Reocclusion is observed involving the M2 segment of the middle cerebral artery.
D, Recanalization is observed in the middle cerebral artery after administration of an additional 1 U of reteplase.
- Fig 2.
Patient 4.
A, Cerebral angiogram shows occlusion of the right internal carotid artery (supraclinoid segment, grade 5).
B, Recanalization is observed after administration of thrombolytics and snare maneuver. The filling defect at the junction of the internal carotid and middle cerebral arteries (arrow) indicates the presence of residual thrombus.
C, Reocclusion of the supraclinoid segment of the internal carotid artery is observed after administration of further thrombolytics.
D, Recanalization of the middle cerebral artery after stent placement in the M1 segment of the middle cerebral artery.
Tables
Grade Type of Occlusion 0 No occlusion 1 MCA occlusion (M3 segment) ACA occlusion (A2 or distal segments) 1 BA and/or VA branch occlusion 2 MCA occlusion (M2 segment) ACA occlusion (A1 and A2 segments) ≥2 BA and/or VA branch occlusions 3 MCA occlusion (M1 segment) 3A Lenticulostriate arteries spared and/or leptomeningeal collaterals visualized 3B No sparing of lenticulostriate arteries and no leptomeningeal collaterals visualized 4 ICA occlusion (collaterals present) BA occlusion (partial filling, direct or via collaterals) 4A Collaterals fill MCA Anterograde filling* 4B Collaterals fill ACA Retrograde filling* 5 ICA occlusion (no collaterals) BA occlusion (complete) Note.—Grading system is from Qureshi AI: New grading scheme for angiographic evaluation of arterial occlusions and recanalization response to intra-arterial thrombolysis in acute ischemic stroke.
Neurosurgery 2002;50:1405–1415 (7). MCA indicates middle cerebral artery; ACA, anterior cerebral artery; BA, basilar artery; VA, vertebral artery; ICA, internal carotid artery.
* Predominant pattern of filling.
- TABLE 2:
Clinical characteristics of patients with acute ischemic stroke for whom angiography showed reocclusion after initial recanalization
Patient No. Age (yr)/Sex Initial NIHSS Score Site and Initial Grade* of Occlusion ACT (s) Treatment before Reocclusion Treatment for Reocclusion† Final Gradeb of Occlusion Outcomed 1 76/M 26 MCA, 3A 269 Reteplase (3 U), snare (n = 1) Reteplase (1U), snare (n = 1), angioplasty (n = 1) 2 Death 2 84/M 18 MCA, 3A 252 Reteplase (3 U) Reteplase (1 U) 1 Death 3 87/M 21 MCA, 3B 251 Reteplase (2 U), snare (n = 1), angioplasty (n = 2) Reteplase (1 U), angioplasty (n = 1) 2 Death 4 68/M 32 ICA, 5 255 Reteplase (3 U), snare (n = 1) Angioplasty (n = 1), 2.5 × 12-mm S660 stent (n = 1) 1 Death 5 50/F 26 MCA, 3A NA Reteplase (3 U), angioplasty (n = 1) Reteplase (1 U), angioplasty (n = 1) 2 Death 6 83/M 14 MCA, 3A 250 Reteplase (3 U), angioplasty (n = 1) Reteplase (2 U), snare (n = 1), 2.25 × 13-mm Bx VELOCITY stent (n = 1) 3A mRS 4 7 73/M 30 BA, 4B NA Reteplase (3 U), angioplasty (n = 1) Reteplase (1 U), snare (n = 1) 4A Death 8 75/F 20 ICA, 4A 257 Reteplase (2 U), snare (n = 1) Reteplase (2 U), snare (n = 1), angioplasty (n = 1) 2 mRS 5 Note.—NIHSS indicates National Institutes of Health Stroke Scale; ACT, activated coagulation time; M, male; F, female; MCA, middle cerebral artery; ICA, internal carotid artery; BA, basilar artery; NA, not available; mRS, modified Rankin scale.
* Grading system from Qureshi AI (7).
† S660 stents were manufactured by Guidant, Temecula, CA; Bx VELOCITY stents were manufactured by Cordis, Miami Lakes, FL.
‡ mRS scores were determined at follow-up 1 to 3 months after thrombolysis.
- TABLE 3:
Comparison of demographic and clinical characteristics and outcomes for patients whose angiograms did and did not reveal reocclusion
Characteristics No Reocclusion (n = 38) Reocclusion (n = 8) P Value Mean age (yr ± SD) 69.5±16.9 74.5±11.7 .4 Sex, male 21 6 .4 Mean time to treatment (hr ± SD) 4.7±1.7 4.4±1.2 .6 Occlusion site Basilar 5 1 ICA 13 2 MCA 20 5 Initial NIHSS score (mean ± SD) 22±8.7 23.3±6.2 .7 Initial angiographic grade* 1 1 0 .8 2 4 0 3A 10 4 3B 3 1 4A 7 1 4B 8 1 5 3 1 Undetermined 2 0 Final angiographic grade* 0 13 0 .5 1 10 2 2 7 4 3A 3 1 3B 1 0 4A 2 1 4B 1 0 5 1 0 Asymptomatic ICH 4 1 NIHSS score at 7 days (mean ± SD) 19±17.6 27.6±17.4 .2 mRS score 0–2 at 1–3 months 17 0 mRS score 3–6 at 1–3 months 21 8 Note.—ICA indicates internal carotid artery; MCA, middle cerebral artery; NIHSS, National Institutes of Health Stroke Scale; ICH, intracerebral hemorrhage; mRS, modified Rankin Scale.
* Angiographic grading is according to the grading scheme presented by Qureshi (7).
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