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Figures
- Fig 1.
Flow diagram of patient selection for stent-patency analysis.
- Fig 2.
Distribution of mRS scores at discharge in patients with patent-versus-occluded carotid stents. Among patients with delayed stent occlusion, only 1 (7.1%) was independent (mRS ≤2) at discharge, compared with 33 (55.9%) patients with patent stents (P = .001).
- Fig 3.
Illustrative case. A patient in his sixties with a history of type 2 diabetes, severe chronic obstructive pulmonary disease, and siderosis was found by his wife hemiplegic and aphasic on wake-up. Initial examination showed depressed consciousness (Glasgow Outcome Score, 7) and signs of respiratory failure for which orotracheal intubation was necessary. Emergency MR imaging showed a relatively small acute ischemic lesion in diffusion imaging (A) not visible in FLAIR imaging, as well as occlusion of the left internal carotid and middle cerebral (arrowhead) arteries (B). Given the important clinicoradiologic mismatch, we proceeded to thrombectomy (C). There was calcified atheroma at the origin of the ICA with floating thrombus. An IV bolus of aspirin, 250 mg, was administered, and a 9 × 50 mm Wallstent was deployed and postdilated with a 6 × 20 mm balloon. Then the MCA occlusion was treated by 2 passages of a stent retriever with TICI 3 recanalization. The final cervical angiographic run showed excellent patency of the carotid stent with images suggestive of plaque protrusion but no in-stent thrombus. However, the next day, Doppler sonography demonstrated stent occlusion. The patient remained intubated, with signs of right hemiplegia. Because repeat MR imaging (D) showed flow across the anterior communicating artery and patency of the left MCA, recanalization was not attempted. The patient remains dependent with an NIHSS score of 9 and mRS score of 4 at 3-month follow-up.
Tables
Multivariable regression analysis of predictors for delayed stent thrombosis and clinical outcome at dischargea
Predictors OR (95% CI) P Value Delayed stent thrombosis Admission NIHSS (per 1-point increase) 1.1 (1.01–1.28) .03 Diabetes 6.07 (1.2–30.6) .02 In-stent thrombus on final angiographic run 6.2 (1.4–27.97) .01 Unfavorable clinical outcome at discharge (mRS > 2)b Delayed stent thrombosis 19.78 (2.78–296.83) .001 Admission NIHSS (per 1-point increase) 1.27 (1.12–1.51) <.001 Symptomatic hemorrhagic transformation 23.65 (1.85–3478.94) .012 ↵a Candidate predictors for delayed stent thrombosis were the following: antiplatelet treatment (aspirin vs aspirin and clopidogrel), admission NIHSS, diabetes, diffusion ASPECTS of <7, visualization of in-stent thrombus on final angiographic run, presence of cervical thrombus distal to the proximal lesion, and time from onset to recanalization. Candidate predictors for clinical outcome at discharge were the following: delayed stent thrombosis, admission NIHSS, location of distal occlusion (M2 versus ICA/M1), presence of cervical thrombus distal to the proximal lesion, diffusion ASPECTS of <7, symptomatic hemorrhagic transformation, and time from onset to recanalization.
↵b Because none of the patients with good clinical outcome had symptomatic hemorrhagic transformation, a logistic regression model using the Firth bias reduction method was fitted to handle separation in our data for the clinical outcome at discharge.
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