Procedure-Related Complications: Stroke




Abstract


Multiple recent randomized trials have shown that mechanical thrombectomy for acute ischemic stroke is superior to IV tissue plasminogen activator alone. Technologic advances have made this a relatively safe procedure. However, complications may occur, especially as more of these procedures are performed. Complication recognition, avoidance, and proper management are paramount in ensuring the best outcomes for patients.




Keywords

stroke intervention, thrombectomy, complication

 




Highlights





  • Post-thrombectomy symptomatic hemorrhage and hemorrhage requiring craniectomy are potentially devastating complications after successful endovascular intervention.



  • Vessel perforation from catheter manipulation carries significant morbidity and mortality with it.



  • Postprocedural intensive care monitoring and aggressive control of blood pressure help diminish the risk of post-reperfusion hemorrhagic complications.





Background


Each year approximately 795,000 patients will experience a new or recurrent stroke with approximately 610,000 of these as first occurrences. In compiled assessments 87% were ischemic, 10% intracerebral hemorrhages, and 3% subarachnoid hemorrhages (SAHs). The main goal in treating ischemic stroke patients is to restore cerebral perfusion as fast and safely as possible given that roughly 2 million neurons die per minute after vessel occlusion without recanalization. Intravenous tissue plasminogen activator (IV tPA) may successfully recanalize about 30% of occlusions but has only a 10% to 15% efficacy in large vessel occlusions, namely those involving the internal carotid artery (ICA), proximal middle cerebral artery (MCA), or basilar artery (BA). IV tPA has not demonstrated efficacy in thrombus lengths above 8 mm, and reocclusions of the involved vascular segment may also occur. The recent multicenter MR CLEAN, ESCAPE, and EXTEND IA trials demonstrated that for large vessel occlusions, mechanical thrombectomy with stent retrievers had the highest recanalization rates in the anterior circulation and were superior to medical management with IV tPA. Additionally, good neurologic outcomes (mRS ≤2 at 90 days) were demonstrated in 40% to 60% of patients according to the TREVO trial. However, these benefits come with the potentially devastating complication of intracranial hemorrhage.




Endovascular Thrombectomy Complications


Although the total rate of complications is below 5%, endovascular treatments carry risks related to vascular access at the groin site, along with device- or procedure-related complications such as stent retriever detachment, arterial dissection, carotid-cavernous fistula, or vessel perforation. Additional complications may be related to arterial-related infarct or ischemic complications such as reocclusion, vessel vasospasm, or reperfusion injuries that may progress to devastating parenchymal hemorrhages. Rare medical complications of the procedure include contrast-induced nephropathy at a rate of 1.5%.



Surgical Rewind

My Worst Case


A 58-year-old man presented with National Institutes of Health (NIH) Stroke Scale 19 and an occlusion of the left M2 superior division on computed tomography (CT) angiography. CT perfusion suggested salvageable penumbra in the distribution of the occlusion. He received IV tPA without improvement in his neurologic examination and subsequently underwent uneventful and successful thrombectomy with a thrombolysis in cerebral infarction (TICI) 3 recanalization. While in the ICU he had elevated blood pressures postprocedurally and had a significant neurologic decline. CT head demonstrated a devastating intraparenchymal reperfusion hemorrhage. After a discussion with his family, they elected to withdraw care.









Hemorrhagic Complications


The risk of hemorrhagic transformation of an acute ischemic stroke without any intervention is nearly 0.6%, whereas intraarterial pharmacologic treatments and mechanical interventions increase this risk to 15.4% and 10%, respectively. After revascularization of an occluded vessel, the vasculature distal to the occlusion may show dilations or “luxury perfusion” that can be visualized on angiograms because the vessel has been maximally dilated to maintain cerebral perfusion secondary to autoregulation. It has been postulated that these dilated vessels in the salvageable ischemic penumbra are less tolerant of higher pressures, suggesting a higher vulnerability for damage and resultant hemorrhage. It has been noted when using intraoperative transcranial Doppler that increased blood flow and decreased pulsatility distal to the stent retriever device were seen. Given this knowledge, transient aggressive postoperative blood pressure control could help prevent hemorrhage after mechanical thrombectomy with a blood pressure reduction of 25% to 30% from preoperative baseline.


The majority of patients with intracranial hemorrhage after thrombectomy remain asymptomatic with a 2% to 15% reported rate of symptomatic hemorrhages. Decompressive craniectomy for hemorrhage or malignant cerebral edema has also been reported in up to 15% of patients after thrombectomy, and both symptomatic hemorrhage and need for craniectomy were associated with poor outcome.




Subarachnoid Hemorrhagic Complications


The occurrence of peri-interventional subarachnoid hemorrhage has been reported in 5% to 16% of cases, whereas angiographically detectable vessel perforations were reported at a rate of 0% to 3%, meaning that the majority of peri-interventional SAH is likely due to angiographically occult perforations. The majority of these perithrombectomy SAH cases are asymptomatic but were found to have a higher chance of developing asymptomatic intraparenchymal hemorrhage within the first 24 hours after recanalization, according to a retrospective case control study (57% vs 0%, P = 0.018). Apart from true SAH, sulcal hyperdensities that resemble SAH may be seen on postinterventional CTs in 3.5% to 16.2% of stroke interventions secondary to either small vessel perforation or, more commonly, mechanical destruction of the endothelial integrity during thrombectomy and seepage of contrast. The chances of developing SAH increase with a longer time interval between clinical onset and recanalization, an extensive procedure time, and a higher number of recanalization attempts.



Red Flags





  • Tortuous vascular anatomy



  • Vessel wall calcifications



  • Difficulty navigating microwires or microcatheters past thrombus



  • tPA administration before thrombectomy



  • Poorly controlled blood pressure peri- and postintervention



  • Stasis or nonfilling of distal vasculature






Intracranial Vascular Perforation


Perforation of a vessel is a rare occurrence during thrombectomy, although its mechanisms, risk factors, outcomes, and rescue approaches have not been well described in the literature. It is usually related to micro-guidewire manipulation making a 29- to 30-gauge hole (about 0.014 in. or 0.09 mm ), which is usually self-sealing if it occurs in a nondiseased vessel. The sequela of this will depend on the location of the perforation in the vessel (subarachnoid space vs intraparenchymal), duration of bleeding, and rate of bleeding. Most of the time, the microwire perforation will be identified by extravasation seen on microcatheter injection beyond the vessel occlusion before the stent retriever is inserted. When this occurs, it is typically wise to forgo thrombectomy so that the occluded vessel will prevent hemorrhage from the small vessel perforation. When this is not possible, or if extravasation persists, treatment may require occlusion of the vessel over the hole or just proximal to it with a small coil or the use of Onyx embolization material. Intraprocedural vessel perforation during stent retriever thrombectomy cases occurred in 1.0% with most perforations occurring at distal locations. Mortality during hospitalization and at 3 months were 56% and 63%, respectively, whereas 25% of patients achieved good functional outcome at 90 days postprocedure.

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Jun 29, 2019 | Posted by in NEUROSURGERY | Comments Off on Procedure-Related Complications: Stroke

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