Endovascular treatment of acute embolism of the major cerebral arteries. The value of balloon disruption of the embolus.
This study evaluated: 1) the effect of recanalization on changing clinical outcome, 2) the relationship between dose of Urokinase (UK) and incidence of recanalization and intracranial haemorrhage, and 3) the efficacy and feasibility of balloon disruption (BD) in the treatment of acute cerebral embolism. Sixty-one patients with acute embolism of the major cerebral arteries treated by endovascular approaches over the past nine years were retrospectively evaluated. Among them, 30 cases were treated by BD alone or in conjunction with intra- arterial fibrinolysis in the last five years. The other 31 cases, mostly treated in the first four years, were treated with intra-arterial fibrinolysis alone and were used as controls to evaluate the efficacy of BD. Control angiography was performed just after the reperfusion procedure to evaluate the degree of recanalization. Angiographic responses were graded using modified Thrombolysis in Myocardial Infarction (TIMI) criteria. Clinical outcome was evaluated using modified Rankin Scale (mRS) score at the time of discharge. Thirty-six of the 61 patients (59.0%) achieved high-grade recanalization (TIMI grade 3). Significantly more patients attained favorable outcome (mRS score 0-1) in the high-grade recanalization group than the low-grade recanalization group (41.7% vs. 16.0%, p < 0.05). Concerning patients treated with BD, significantly more patients attained good recanalization and significantly more patients were ambulatory (mRS score 0-3) than those treated with intra-arterial fibrinolysis alone (76.7% vs. 41.9%, p < 0.01; 70.0% vs. 41.9%, p < 0.05, respectively). A significantly lower dose of UK was used, and relatively less intracranial haemorrhage was seen in patients treated with BD than those treated with intra- arterial fibrinolysis (194,000 +/- 191,000 units vs. 388,000 +/- 231,000 units, p=0.001; 16.7% vs. 38.7%, p=0.055, respectively). Concerning morbidity and mortality of BD, there was one death caused by dissection of the M2 portion of the middle cerebral artery (MCA) that happened during BD on a distally migrated embolus. Although no conclusions can be drawn from our study, a favorable outcome for acute embolism of the major cerebral arteries is expected by attaining good recanalization. In addition, BD is an effective technique that can achieve high-grade recanalization alone, or reducing the dose of fibrinolytic agent.
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Departmental and institutional affiliation, 1-5: Brain Attack Center Oota Memorial Hospital, Fukuyama, Hiroshima; Japan - shinzo@urban.ne.jp.
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Inoue
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