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Iwata T, Mori T , Tajiri H, Uesugi T, Nakazaki M Department of Stroke Treatment

Angioplasty and Stenting for the Internal Carotid or Middle Cerebral Artery Occlusion in a Subacute Stroke Stage in Deteriorating Patients with the Internal Border Zone Infarcts. Iwata T, Mori T , Tajiri H, Uesugi T, Nakazaki M Department of Stroke Treatment

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Iwata T, Mori T , Tajiri H, Uesugi T, Nakazaki M Department of Stroke Treatment

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  1. Angioplasty and Stenting for the Internal Carotid or Middle Cerebral Artery Occlusion in a Subacute Stroke Stage in Deteriorating Patients with the Internal Border Zone Infarcts Iwata T, Mori T, Tajiri H, Uesugi T, Nakazaki M Department of Stroke Treatment Shonan Kamakura General Hospital Stroke Center, KamakuraCity,Japan

  2. Background • Neurological symptoms of some patients with the internal carotid artery (ICA) or the middle cerebral artery (MCA) occlusion are mild at onset but deteriorate day by day. • Several days after the onset, the internal border zone (IBZ) infarcts occurs. • However, it is not established how to treat them in a subacute stroke stage and how to improve their clinical outcome.

  3. Purpose The internal border zone (IBZ) means an arterial border zone differentiated from the cortical border zone(CBZ). The purpose of our retrospective study is to investigate whether or not angioplasty and/or stenting for the ICA or MCA occlusion in a subacute stroke stage can improve clinical outcome in severely disabled patients due to the internal border zone (IBZ) infarcts.

  4. IBZ(A) and CBZ(B) infarcts Contour map of frequency of affected sites in the IBZ (A) and CBZ (B) infarcts. The location of the IBZ can vary along the lateral ventricle, whereas the CBZ is distributed more heterogeneously as wedged areas that extend from the frontal and occipital horn of the lateral ventricle or within the paramedian white matter at the supraventricular level. Seok Woo Yong, et.al. Stroke. 2006;37:841-846

  5. Patients (1) • Acute ischemic stroke patients • Period: Jan 2004 to Dec 2008 • Onset-to arrival tine: within 72 hours • Emergency MRA showed the ICA or MCA occlusion • DWIs showed no extensive infarcts in the ICA or MCA territory. • No cerebral hemorrhage on CT scans

  6. Patients (2) • Their neurological symptoms were mild at onset and modified Rankin Scale (mRS)was 2 or less then. • They deteriorated day by day despite dual antiplatelets. • Modified RS (mRS) was 4 or more on the 7th day. • CT scans or MR images on the 7th day demonstrated the internal border zone (IBZ) infarcts.

  7. Groups of the patients group E: patients who gave written informed consent and underwent angioplasty and/or stenting for the ICA or MCA occlusion from 7 to 14 days after the stroke onset group C: patients who did not.

  8. Evaluation • Patients’ baseline features • NIHSS on admission • NIHSS on the 7th day • NIHSS on discharge • Hospitalization periods • mRS on discharge • mRS at 3 months Compared between two groups.

  9. Results (1) • Group E Group C p Value • (n=6) (n=11) • Age, median, • (IR) [years] 71.5 (64-75) 82 (72-86) NS • Male sex, • no., (%) 4 (66.7%) 7 (63.6%) NS • Hypertension , • no.(%) 6 (100.0%) 10 (90.9%) NS • Hyperlipidemia, • no.(%) 4 (66.7%) 6 (54.5%) NS • Diabetes mellitus, • no.(%)4 (66.7%) 6 (54.5%) NS • MCA occlusion, • no., (%) 4 (66.7%) 8 (72.7%) NS

  10. Results (2) Group E Group C p Value (n=6)(n=11) NIHSS on admission, median, (IR) 6.5 (5.25-11.5) 6 (4-9.5) NS NIHSS on the 7th day, median, (IR) 13 (12-16.25) 12 (10-13.5) NS NIHSS on discharge, median, (IR) 7 (6.25-10.75) 13 (11-18.5) NS mRS on discharge median, (IR) 4.5 (4-5) 5 (4-5) NS Hospitalization period [days], (IR) 11 (11-11) 12 (9-13) NS mRS at 3 month(m) 2.5 (2-3.75) 4(4-5.5) 0.0127**

  11. Case (the MCA Occlusion) A 63-year-old woman was admitted to our institution, since her right-sided hemiparesis deteriorated over 60 hours.

  12. DWI CT T2WI CT and MRI on admission (3rd day) 63-yo-female

  13. MRI and MRA on admission MRA PWI (time-intensity curve) Left MCA territory

  14. Treatment and clinical course She took dual antiplatelets agents. However, her neurological symptoms deteriorated day by day.

  15. Diagnostic left carotid angiography(6th day) Total occlusion of the Left MCA A-P view Lateral view

  16. Left MCA occlusion Estimated length of the occlusion M1 Probable peripheral branch of the MCA opacified via collateral circulation

  17. CT scans (8th day) The NIHSSscore rose up to 30. CT scans showed the IBZ infarcts.

  18. Balloon Angioplasty for the Left MCA Occlusion (9th day) Synchro-14S 300cm Gateway 2.0mm×12mm Total occlusion of the Left MCA AP view

  19. Successful balloon angioplasty (9th day) Anteroposterior view Lateral view

  20. Clinical outcome of the patient • NIHSS on the 3rd day: 23 • NIHSS on the 7th day: 30 • NIHSS on the 11th day:18 • Hospitalization periods: 11 days • mRS on discharge: 5 • mRS at 3 months: 3

  21. Conclusion Angioplasty and stenting for the ICA or MCA occlusion, even more than 7 days after the stroke onset, may be feasible and effective in improving their 3-month clinical outcome in severely disabled patients due to the internal border zone infarcts .

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