Radiología.

2017;59(3):218---225

www.elsevier.es/rx

ORIGINAL ARTICLE

Intracranial stents in the endovascular treatment of

acute ischemic stroke夽
F. Delgado Acosta a,∗ , E. Jiménez Gómez a , I. Bravo Rey a , F.A. Bravo Rodríguez b ,
J.J. Ochoa Sepúlveda b , R. Oteros Fernández a

a
Servicio de Radiología, Hospital Reina Sofía de Córdoba, Spain
b
Servicio de Neurología, Hospital Reina Sofía de Córdoba, Spain

Received 20 August 2016; accepted 30 January 2017

KEYWORDS Abstract
Ischemic cerebral Objective: To evaluate the efficacy and safety of intracranial stenting as a rescue therapy after
stroke; failed mechanical thrombectomy in patients with acute ischemic stroke.
Thrombectomy; Material and methods: We retrospectively studied 42 patients treated with intracranial sten-
Treatment; ting after failed mechanical thrombectomy between December 2008 and January 2016. We
Stents compared outcomes before and after the incorporation of stentrievers. We assessed the degree
of recanalization in the carotid and basilar territories (modified TIMI score), prognostic fac-
tors, and outcome (modified Rankin scale at 3 months). Safety was evaluated in function of the
appearance of symptomatic intracranial hemorrhage (SICH).
Results: Median NIHSS was 17 in patients with carotid territory strokes and 26 in those with ver-
tebrobasilar territory strokes. Median time from onset of symptoms to treatment was 225 min in
carotid territory strokes and 390 min in vertebrobasilar territory strokes. A total of 10 patients
underwent intravenous fibrinolytic therapy before treatment with stentrievers. Two patients
developed SICH; both had undergone intravenous fibrinolytic therapy (p = 0.0523). Recanaliza-
tion was effective in 30 (71.4%) in the entire series: in 7 (50%) of 14 patients treated before
the incorporation of stentrievers and in 23 (82.1%) of 28 treated after the incorporation of
stentrievers (p = 0.0666). Outcome at 3 months was good in 2 (14.3%) patients in the earlier
group and in 14 (50%) patients in the later group (p = 0.042). We found significant associations
between recanalization and outcome (p = 0.0415) and between shorter time to treatment and
outcome (p = 0.002). Outcome was good in 14 (48.3%) of the 29 patients with carotid territory
strokes and in 2 (15.4%) of the 13 patients with vertebrobasilar territory strokes (p = 0.078).

夽
Please cite this article as: Delgado Acosta F, Jiménez Gómez E, Bravo Rey I, Bravo Rodríguez FA, Ochoa Sepúlveda JJ, Oteros Fernández
R. Uso del stent intracraneal en el tratamiento endovascular en agudo del ictus. Radiología. 2017;59:218---225.
∗ Corresponding author.

E-mail address: fdelgado.neuro@gmail.com (F. Delgado Acosta).

2173-5107/© 2017 SERAM. Published by Elsevier España, S.L.U. All rights reserved.
Intracranial stents in the endovascular treatment of acute stroke 219

Conclusions: Intracranial stenting is the rescue treatment when the usual treatment fails. Sten-
trievers must be used to eliminate the clot burden before stenting. In our study, antiplatelet
treatment did not seem to increase the risk of SICH except in patients with prior intravenous
fibrinolytic therapy.
© 2017 SERAM. Published by Elsevier España, S.L.U. All rights reserved.

PALABRAS CLAVE Uso del stent intracraneal en el tratamiento endovascular en agudo del ictus
Infarto cerebral;
Resumen
Trombectomía;
Objetivo: Valorar la eficacia y seguridad del stent intracraneal (SI) como rescate tras el fallo
Tratamiento;
de la trombectomía mecánica en el ictus isquémico agudo.
Stents
Material y métodos: Revisión retrospectiva de 42 pacientes (diciembre de 2008-enero de 2016)
con SI como rescate. Comparamos la evolución antes y tras incorporar los stentrievers. Val-
oramos el grado de recanalización en territorio carotídeo y basilar (escala TICIm), factores
pronósticos y evolución (escala mRS a los 3 meses). El grado de seguridad se valoró por la
aparición de hemorragia sintomática intracraneal (HSI).
Resultados: La mediana del NIHSS en territorio carotídeo fue 17 y en posterior 26. La mediana
del tiempo desde la clínica hasta el tratamiento en territorio carotídeo fue de 225 minutos,
y en vertebrobasilar, de 390 minutos. Un total de 10 pacientes fueron tratados con fibrinólisis
intravenosa (FIV) antes de usar stentrievers. Hubo dos casos con HSI, ambos con FIV previa
(p = 0,0523). La recanalización fue efectiva en 30 (71,42%), 7 de 14 antes de los stentrievers y
23 de 28 (82,14%) tras ello (p = 0,0666). Dos pacientes mostraron buena evolución a 3 meses en
el primer grupo y 14 en el segundo (p = 0,042). La asociación fue estadísticamente significativa
entre recanalización y evolución (p = 0,0415) y entre menor tiempo del tratamiento y evolución
(p = 0,002). Un total de 14 de 29 pacientes en territorio carotídeo y 2 de 13 en posterior tuvieron
buena evolución (p = 0,078).
Conclusiones: El SI es un método de rescate si el tratamiento habitual falla. Antes hay que usar
stentriever para eliminar la carga de trombos. En nuestro estudio, la antiagregación no parece
incrementar el riesgo hemorrágico excepto en pacientes con FIV previa.
© 2017 SERAM. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.

Introduction Material and methods

After the appearance of randomized multicenter trials Patients

that confirmed the effectiveness and safety of mechani-
cal thrombectomy in the management of acute strokes, the We retrospectively reviewed our prospectively collected
stentriever system has been recommended as the first-line database of patients with intracranial vessel occlusion
therapy for the management of acute strokes occurring in treated in our center from December 2008 through January,
the anterior circulation due to large vessel occlusions.1---5 2016. A total of 42 patients were implanted with one IS after
Still, thrombectomies that use the stentriever system do not mechanical thrombectomy failure. Informed consent was
achieve successful recanalizations in 20---30% of the cases6 obtained from all patients (or their families). Since this was
(in the modified Thrombolysis In Cerebral Ischemia [mTICI] a retrospective study conducted in our center, the explicit
perfusion scale grade indicator, grades 2b or 3 are consid- approval from the ethics committee was not required.
ered effective outcomes). Placing a permanent intracranial Selection to consider the administration of intra-arterial
stent (IS) has been suggested as a bail out method under therapy is based on image modalities. All patients admitted
these circumstances. The goal of our study was proving that at the hospital under stroke code underwent one computed
the use of IS as a bail out method is safe and achieves tomography (CT) scan without contrast, one brain perfusion
an effective neurological recovery in a large number of scan, and one computed tomography angiography (CTA) in
patients. order to rule out the existence of large vessel occlusion.
220 F. Delgado Acosta et al.

The intra-arterial therapy was suggested only to patients microcatheter and the intermediate catheter in order to
with NIHSS score ≥4 as assessed by the neurologists on call choose the length of the stent that would eventually be
in our hospital (7 physicians with an experience between used. In all cases, one Enterprise-type catheter (Codman
30 and 2 years) and with an ASPECTS (Alberta Stroke Pro- Neurovascular, Raynham, MA USA) was used that would later
gram Early CT) score >4 in the carotid territory.4 In order to be released using the digital subtraction technique after
make the decision on this or that therapy, the results from vessel repletion with contrast as the guidewire (‘‘road map-
image modalities on the ischemic penumbra compared to ping’’). When stenosis was confirmed after releasing the
the infarct core we not taken into consideration. stent, such stenosis was dilated using a Gateway balloon
(Stryker, Fremont, CA, USA) with careful balloon inflation. In
the very first patients, clopidogrel 300 mg and aspirin 300 mg
Procedure were used as antiaggregant agents administered orally or
through one nasogastric tube. Starting October, 2013 (22
In our center, the use of intra-arterial therapy has changed patients), one 0.1 mg/kg bolus dose of IV abciximab was
throughout the years. At the beginning, the intra-arterial used as the only antiaggregant agent prior to initiating the
therapy was used when the IV therapy was counter indi- procedure.
cated or when no improvement could be confirmed after No stent was used as a temporal bypass whatsoever.
the use of the r-TPA (tissue plasminogen activator). During After the procedure, one complete neurological exam
the last years, the intra-arterial therapy has been admin- was conducted, the patient was transferred to the neuroin-
istered in large vessel occlusions as the first-line therapy, tensive care unit, and one CT scan was performed 24 h after
being the IV therapy administered only until the interven- symptom onset. In the presence of clinical impairment, one
tional neuroradiology unit was ready to take care of the new control CT scan was performed. Then, 100 mg of aspi-
patient. rina, and 75 mg of clopidogrel were prescribed orally for
In our hospital, the stentriever system was available from one (1) year, and after this time, 100 mg of aspirin were
the 2nd quarter of 2011. Until that date, the IS was only used prescribed for life.
in cases of pharmacological treatment failure and/or use of
the Penumbra system (Penumbra, Oakland, CA, USA). After
the introduction of the stentriever system, the IS was placed Statistical analysis
only when there was no recanalization after four (4) passes
of the mechanical system, or in the presence of underlying The clinical characteristics, the location of the occlusion,
stenoses. The IS was used in the carotid territory if less than the time elapsed from symptom onset until hospital arrival,
8 h had passed since the patient suffered his/her stroke, the time elapsed from symptom onset until recanaliza-
while in the basilar territory, the IS was used even 24 h after tion, the use of drugs like urokinase or glycoprotein IIb/IIIa
symptom onset. In cases of fluctuating or progressive clinical inhibitors (GPI), and complications during treatment were
manifestations, time starting running from the moment the all analyzed. The NIHSS score was assessed before the
patient was asymptomatic for the last time. procedure. The outcome was assessed based on the Throm-
All of our patients undergo one CT scan twenty-four (24) bolysis in Cerebral Infarction modified (TICIm) perfusion
hours after symptom onset. scale grade indicator:4 grade 0---absence of recanalization,
The procedure was conducted in one neuroangiography grade 1---minimal distal reprfusion, grade 2---reperfusion of
ward with biplane digital subtraction angiography capabili- the territory to be treated <50%, grade 2b---reperfusion
ties (Axiom Artis, Siemens, Munich, Germany). Patients were >50% of the territory to be treated, and grade 3---complete
managed by three (3) interventional neuro-radiologists with reperfusion. Grades 2b and 31 were considered effective
25, 11, and 4 years of experience. The percutaneous access recanalization.
was achieved through catheterization of the femoral artery Safety was assessed by the presence, or not, of symp-
using one 7F introducer sheath, 80 cm (Super Arrow-Flex tomatic intracranial hemorrhages defined as four or more
sheath introducer, Reading, PA, USA). Prior to the treat- points scored in the NIHSS score due to hematoma diagnosed
ment, one diagnostic arteriography was conducted in order in the CT scan after the surgery.1
to assess the colateralization provided by non-occluded ves- The modified Rankin scale (mRS) score was assessed both
sels. Once the vessel occlusion was confirmed, treatment 1 and 3 months after treatment. The progression of the
was initiated with one Navien-type intermediate catheter disease was categorized as good (mRS 0---2), or poor (mRS
(Medtronic, Irvine, CA, USA) that was advanced until the 3---6).4
cavernous carotid artery or distal vertebtral artery depend- Statistical assessment was estimated using Microsoft
ing on the location of the occlusion. As the first-line therapy, Excel V.2010. The outcomes of the carotid and ver-
the Penumbra system (Penumbra, Oakland, CA, USA) was tebrobasilar territories were assessed separately, while
used before the 2nd semester of 2011, and then the sten- the same separate assessment was estimated in patients
triever system Trevo (Stryker, Fremont, CA, USA) from that treated before the introduction of the stentriever sys-
date onwards. When these methods failed, or in presence of tem in our center and in patients treated after that
intracranial stenosis, one Rapid Transit-type microcatheter moment. The Fisher’s test was used to assess the asso-
(Codman Neurovascular, Raynham, MA, USA), or Prowler ciation among dichotomous categorical variables, and the
Select Plus microcatheter (Codman Neurovascular, Rayn- Student’s t-test was used to make comparisons among
ham, MA, USA) was placed while being assisted by the continuous variables of normal distribution. The interpre-
Synchro 14 microwire (Stryker Neurovascular, Fremont, CA, tation of data was conducted by the two most experienced
USA). One arteriography was performed both through the neuro-radiologists.
Intracranial stents in the endovascular treatment of acute stroke 221

Table 1 Demographic data, management times, and risk factors.

Before the 2nd After the 2nd semester p value
semester of 2011 of 2011
Number of patients 14 (33.33%) 28 (66.66%)
Women 4 (28.57%) 8 (28.57%) 1.0000
NIHSS mean score on presentation 21.5 18 0.0708
Median of ASPECTS mean score of carotid cases 7 8 0.0196
treated
Relation between anterior/posterior cases treated 7/7 (50%) 22/6 (78.57%) 0.0821
Mean time from symptom onset until the 240 min 270 min 0.6675
initiation of intra-arterial therapy
Mean time from symptom onset until successful 420 min 365 min 0.1063
recanalization
Use of the Penumbra system 7 (50%) 0 (0%) 0.0001
Use of angioplasty 8 (57.14%) 13 (46.43%) 0.7442
Symptomatic swelling 1 (7.14%) 1 (3.57%) 1.0000
Active smoker 3 (21.43%) 9 (32.14%) 0.7186
Arterial hypertension 10 (71.43%) 14 (50%) 0.3214
Diabetes 6 (42.86%) 10 (35.71%) 0.7418
Dyslipemia 4 (28.57%) 11 (39.29%) 0.7337
Myocardial ischemia 2 (14.29%) 2 (7.14%) 0.5902
NIHSS: National Institute of Health Stroke Scale; ASPECTS: Alberta Stroke Program Early CT Score.

Results patients after the 2nd semester of 2011). The antiaggregant

drugs used before the 2nd semester of 2011 were: double
This study included 42 patients---12 women and 30 males, antiaggregation in 9 patients, IV abciximab and double anti-
with an average age of 61 years old (interquartile range-IQR aggregation in 4 patients, and only IV abxicimab in 1 case.
53---72), from December, 2008 through January, 2016. The After the 2nd semester of 2011, only IV abciximab was used
mean NIHSS score of the 29 patients with carotid territory in 19 patients, double antiaggregation in 4 patients, abcix-
affected was 17 (IQR 13.5---21), while in the 13 cases with imab and double antiaggregation in 2 patients, while 3 had
vertebrobasilar territory affected the mean NIHSS score was been previously antiaggregated.
26 (IQR 11.5---31). These were the locations of occlusions: 12 In two cases (4.76%) there was presence of one symp-
in the basilar trunk, 1 in the right vertebrobasilar junction, tomatic hematoma (one located in the anterior territory and
14 in the distal internal carotid artery, and 15 in the middle the other one in the posterior territory). These two cases
cerebral artery (M1). Table 1 shows other demographic data. had been previously treated with IVF (intravenous fibrino-
The ASPECTS mean score of the carotid territory was lysis). The other 8 cases treated with IVF did not show the
7 (IQR 6---8.5). The mean time from symptom onset until presence of any symptomatic hemorrhages. No patient with-
the initiation of intra-arterial therapy was 225 min (IQR out IVF therapy suffered from any symptomatic hemorrhages
150---270) in the carotid territory, and 390 min in the verte- (two tailed Fisher’s test p = 0.0523).
brobasilar territory (IQR 257---1575). Only three (3) patients In the evolution of behavior and neural control, among
were already receiving antiaggregant agents---aspirin. Ten the group of patients treated before the 1st semester of
(10) patients received IVT only (two before the 2nd semester 2011, only 1 patient showed good progression of the dis-
of 2011). ease after 1 month, compared with the 11 patients who
The mean time spent in the ward until recanalization were treated from that date onwards (two tailed Fisher’s
could be achieved was 98 min (IQR 63.75---170) in the anterior test, p = 0.0361). After 3 months, there was good pro-
territory and 112.5 min (IQR 77---143.75) in the posterior ter- gression of the disease in the first group of 2 patients
ritory. Effective recanalization was achieved in 30 patients (14.28%), while in the group of patients treated after
(71.42%), in 7 out of 14 patients (50%) before the use of sten- the 2nd semester of 2011, there was good progression of
trievers, and in 23 out of 28 patients (82.14%) after the use the disease in 14 patients (50%) (two tailed Fisher’s test,
of stentrievers (two tailed Fisher’s test p = 0.0666). Overall, p = 0.042).
in the carotid territory, good recanalization was achieved in Overall, after 3 months there was good progression of the
20 out of 29 patients (68.9%) (Fig. 1), while in the territory disease in 38.09% of the cases. Sixteen (16) (38.09%) deaths
of posterior circulation, good recanalization was achieved were reported: 9 out of 29 cases (31.03%) located in the
in 10 out of 13 patients (76.9%) (Fig. 2). anterior territory, and 7 out of 13 cases (53.84%) located in
Twenty-one (21) angioplasties were performed (2 before the posterior territory (Table 2).
placing the stent and 19 after releasing the stent). There was a significant statistical correlation between a
Intra-arterial urokinase was used in 12 patients (in 8 good degree of recanalization and a good clinical progression
patients after the introduction of stentrievers and in 4 of the disease (two tailed Fisher’s test, p = 0.0415).
222 F. Delgado Acosta et al.

Figure 1 (A) Left middle cerebral occlusion at its origin. (B) Stentriever in cerebral media. Due to its failure, a stent is placed
(arrows proximal and distal of the stent; C), achieving recovery of flow. (D) Final control.

While assessing both the progression and location of the was good in 2 out of 13 patients treated (two tailed Fisher’s
injury, we saw that the progression of the disease was good test p = 0.078).
in the carotid territory of 14 out of the 29 patients treated, In the overall series, when we compared time from symp-
and in the basilar territory, the progression of the disease tom onset until achieving good progression of the disease

Figure 2 (A) Occlusion of the basilar artery in its lower third. After stent-fail, stents are placed. (B) End result (arrows proximal
and distal of the stent).
Intracranial stents in the endovascular treatment of acute stroke 223

Table 2 Progression of the disease in anterior and posterior circulation at 3 months.

mRS 0 mRS 1 mRS 2 mRS3 mRS 4 mRS 5 mRS 6
Anterior circulation 6(20.69%) 5(17.24%) 3(10.34%) 3(10.34%) 2(6.90%) 1(3.45%) 9(31.03%)
Posterior circulation 0 2(15.38%) 0 0 1(7.69%) 3(23.08%) 7(53.84%)
Clinical progression at 3 months in both territories. mRS: modified Rankin scale.

Table 3 Comparison between series published and our study.

Number of mRS at 3 Symptomatic Localization
patients months ≤2 hemorrhage
Sung et al.7 10 60% 5% M2
Dumont TM et al.8 13 38.43%a 7.69% Anterior and posterior circulation
Xavier AR et al.9 12 58% 8.33% Anterior and posterior circulation
Linfante et al.10 19 42% 16% Anterior and posterior circulation
Kansara et al.11 12 66.6% 0% Posterior circulation
Gao et al.12 13 46.2% 0% Posterior circulation
Seo et al.13 10 70% 0% Anterior and posterior circulation
Baek et al.6 17 35.3% 11.8% Anterior circulation
Our series 42 38.09% 4.76% Anterior and posterior circulation
a mRS (modified Rankin scale) monthly assessment.

using the method of the Student’s t-test, we saw a p = 0.002 or the consistency of the coil is such that makes it stick to
(statistically significant) that confirmed that the sooner we the walls and not be apprehended by the stentriever sys-
start the treatment, the better the progression of the dis- tem, which in turn forces the recanalization of many passes
ease will be. with the corresponding possibility of clot fragmentation and
While assessing prognostic factors associated with good appearance of emboli in previously nonoccluded vessels.8
clinical progressions of the disease, we confirmed that The use of the angioplasty after the release of the stent
the progression of the disease in smokers was better than can be complicated since, on some occasions, the stent
the progression of the disease in non-smokers (two tailed Enterprise distal guide wire is lost when trying to per-
Fisher’s test p = 0.0324), and that hypertension (two tailed form the catheterization of the vessel through the stent
Fisher’s test p = 0.0590) and diabetes (two tailed Fisher’s lumen area using the microcatheter. It is advisable to always
test p = 0.0557) were poor prognostic factors. Other factors advance the guide wire as distally as possible so that the
such as prior heart coronary disease or dyslipidemia did not microcatheter can easily navigate though the stent lumen
show any tendencies that would eventually be statistically area. The need to perform the angioplasty in 45.23% of the
associated with the progression of the disease. case shows the low radial strength of this stent.8
Table 3 shows a comparison between our results and those The use of the angioplasty without stent can be an option
from other series published. in patients with high risk of bleeding, yet despite the fact
that using this technique associates a greater number of re-
thrombosis and dissections. However, it can be used in very
Discussion tortuous cases where the stent cannot be released,12 which
is an exceptional situation when using the stent Enterprise.
Our study shows that the use of stents is an appropriate The SARIS trial15 (The Stent-Assisted Recanalization in
method when the stentriever system will not facilitate an Acute Ischemic Stroke) is the very first prospective trial
effective recanalization. This endorses all those multicenter approved by the FDA (Food and Drug Administration) for the
randomized trials that confirm that one effective recanal- management of acute strokes of the middle cerebral artery
ization plus the stentriever system and IVF in patients in using the stents Neuroform or Wingspan. Twenty (20) adults
whom this therapy is indicated promotes a better progres- with an average NIHSS score of 14 were treated before the
sion of the disease than in those patients treated with IVF 6 h prior to symptom onset. All patients showed complete
only.1---5 or partial recanalizations (TIMI 2 = 40%, TIMI 3 = 60%). These
The advantage of using one self-expandable stent is that outcomes are far better than our own outcomes, even if we
it minimizes the trauma inflicted on the vessel wall, since only chose patients treated after implementing the sten-
it adapts itself to the shape and diameter of the injured triever systems. This can be partially explained because we
artery.7 The use of the stent Enterprise for the manage- treated patients with affectation of the posterior territory
ment of acute strokes has been endorsed by several authors of >6 h duration, and because in our series the use of the
following failure of mechanical methods.14 stent was a bail out method when other methods failed.
The stentriever system fails to extract the coil for two We also have a lower degree of recanalization, which might
reasons basically: whether there is an underlying stenosis, explain why our clinical outcomes at three (3) months are
224 F. Delgado Acosta et al.

worse. Unlike the SARIS trial, we used the stent Enterprise; intracranial stenoses that in time grow worse while giving
it is pure speculation that the difference reported in the rise to the appearance of collaterals; these patients usually
progression of the disease had anything to do with the type show thrombosis on a previous stenosis with good pial vessel
of stent used. The stent Enterprise makes navigation eas- compensation, which is why collaterality is greater, allowing
ier than the stent Wingspan, and it is easier to release than longer tolerance times to cerebral ischemia and eventually
other types of stent like the Solitaire.10 better progression of the disease.
The SAMMPRIS trial16 (Stenting vs Aggressive Medical Although not statistically significant, the two (2) negative
Management for Preventing Recurrent Stroke in Intracra- prognostic factors were arterial hypertension and diabetes;
nial Stenosis) showed that medical therapy is better than it is possible that a larger number of patients reached a more
endovascular therapy for secondary prevention purposes of conclusive statistical value.
a new stroke occurring in patients with intracranial stenoses. Despite the use of double antiaggregation, in our series
These data cannot be generalized and applied to our series, we observed a low frequency of symptomatic hemorrhages.
since we are dealing with the acute phase of a stroke in This finding is highly variable in the specialized literature,
patients in whom the usual therapy failed.12 with some series showing similar or better results than
Initially, in our study, we used the aspiration system ours,7,8,11---13 and other series showing a much higher inci-
Penumbra, and the trial of the same name17 showed good dence of symptomatic hemorrhages.10,21 For the moment,
progression of the disease in only 25% of the patients at 3 we do not have an explanation for this. Even though we
months. This is consistent with the poor results reported in used several antiaggregation methods, many of our patients
our first patients, since in the vast majority of patients the were treated with low doses of IV abciximab (0.1 mg/kg)
stent was used whenever the system Penumbra failed. Since through one single bolus. Either this route of administration
then, several authors have claimed that new catheters like or this dose are not usually mentioned in our reference at
stents ACE (Penumbra, Alameda, California, USA),18 or Sofia the end of this paper; whether there is an association with
(MicroVention Inc, Tustin, CA, USA)19 allow fast and effec- the appearance of the hemorrhage as a complication is pure
tive recanalizations, yet these data are still to be confirmed speculation, and the low incidence of stent placement for
by one randomized multicenter trial. Even so, most authors the management of acute strokes makes it difficult to think
using the aspiration system, also use stentriever systems of one prospective trial that would confirm whether there
before placing the IS --- a position backed by our series. really is an association between the different methods of
In our study, disease progression at 3 months is worse antiaggregation and the appearance of symptomatic hem-
than the disease progression reported by other studies such orrhages. Although not statistically significant, there was
as Sung et al.’s study7 (even though in this case, manage- a tendency toward more symptomatic hemorrhages in the
ment was assessed in M2 occlusions only), or Kansara et al.’s group previously treated with IVF as reported in the medi-
study11 that shows a series of patients with basilar occlusions cal literature.11 This should make us even more accurate
and good progression of the disease in 66% of the patients when monitoring blood pressure, the type and dose of anti-
(even though some patients were selected using diffusion- aggregant agents used in this group of patients, and when it
weighted imaging (DWI) and perfusion-weighted imaging comes to assessing the risk-benefit ratio of our therapy.
(PWI), or Seo’s study13 (even though these were ongoing The main limitation of our study is that it is a multicenter
or fluctuating strokes without the need to use first sten- retrospective study, which somehow justifies the relatively
trievers, hence patients had better prognosis), but similar small number of patients treated (even though it stands as
to the disease progression reported in the studies conducted one of the longest series) and the heterogeneous popula-
by Baek,6 Dumont,8 Xavier,9 Linfante,10 or Gao.12 In Baek’s tion. It is really difficult to be absolutely positive that the
study,6 2 groups of patients in whom recanalization therapy occlusion is due to stenosis or a blood clot. The use of a
failed were compared: the 1st group with stent implantation stent requires the long-term follow-up of the stent patency
and the 2nd group without it; comparison showed better pro- with the use of double antiaggregation for, at least, six (6)
gression of the disease in stent implanted-patients. Since an months. Unfortunately, no diagnostic method exists that is
alternative to the failing different thrombectomy methods capable of assessing moderate or minimum degrees of intra-
used today is necessary (around 20%1---5 ), the use of intracra- stent stenosis, so in many cases, assessing the effectiveness
nial devices stands as an easy, alternative method that has of the stent has a direct influence on the clinical progression
better results than the natural evolution of an occluded of the disease.
large intracranial vessel, which in turn shows how necessary In sum, the use of IS is one bail out method when the rou-
recanalization is in the management of acute strokes as the tine recanalization technique has failed. Before placing one
first step toward the satisfactory recovery of patients.6 stent it is advisable to use the stentriever system following
In our series, the stent was used when other methods the recommendations produced by clinical trials1---5 in order
failed, or in the presence of underlying stenosis associated to reduce the load of thrombi. In our study, antiaggregation
to the blood clot. What this does is delay the procedure, did not seem to increase hemorrhagic risk except in patients
which can in turn lead to worse results than the results previously treated with IVF.
recently published in other trials.1---5
Also, in our series, there are patients with an intention-
to-treat (ITT) beyond 8 h, above all, in the basilar territory Ethical responsibilities
that, as is well known, has worse prognosis.20
When it comes to prognostic factors, the apparent pro- Protection of people and animals. The authors declare that
tection derived from smoking may have spurious results. It no experiments with human beings or animals have been
is well known that smoking promotes the appearance of performed while conducting this investigation.
Intracranial stents in the endovascular treatment of acute stroke 225

Data confidentiality. The authors confirm that in this article the Enterprise vascular reconstruction device: early results. J
there are no data from patients. NeuroIntervent Surg. 2014;6:363---72.
9. Xavier AR, Tiwari A, Purain N, Rayes M, Pandey P, Kansara A,
Right to privacy and informed consent. The authors con- et al. Safety and efficacy of intracranial stenting for acute
firm that in this article there are no data from patients. ischemic stroke beyond 8 h of symptom onset. J NeuroIntervent
Surg. 2012;4:94---100.
10. Linfante I, Samaniego EA, Geisbüsch P, Dabus G. Self-
Authors expandable stents in the treatment of acute ischemic
stroke refractory to current thrombectomy devices. Stroke.
1. Manager of the integrity of the study: FDA. 2011;42:2636---8.
2. Study Idea: FDA, ROF. 11. Kansara A, Pandey P, Tiwari A, Rayes M, Narayanan S,
Xavier AR. Stenting of acute and subacute intracranial ver-
3. Study Design: FDA, ROF.
tebrobasilar arterial occlusive lesions. J NeuroIntervent Surg.
4. Data Mining: FDA, EJG, IBR, FBR, JJOS, ROF.
2012;4:274---80.
5. Data Analysis and Interpretation: FDA, ROF. 12. Gao F, Lo WT, Sun X, Mo DP, Ma N, Miao ZR. Combined use
6. Statistical Analysis: FDA, IBR, ROF. of mechanical thrombectomy with angioplasty and stenting
7. Reference: FDA, EJG, IBR. for acute basilar occlusions with underlying severe intracranial
8. Writing: FDA. vertebrobasilar stenosis: preliminary experience from a single
9. Critical review of the manuscript with intellectually rel- Chinese center. Am J Neuroradiol. 2015;36:1947---52.
evant remarks: FDA, EJG, IBR, FBR, JJOS, ROF. 13. Seo WK, Oh K, Suh SI, Seol HY. Intracranial stenting as a rescue
10. Approval of final version: FDA, EJG, IBR, FBR, JJOS, ROF. therapy in patients with stroke-in-evolution. J Stroke Cere-
brovasc Dis. 2016;25:1411---6.
14. Kulcsár Z, Bonvin C, Lovblad KO, Gory B, Yilmaz H, Sztajzel R,
Conflicts of interests et al. Use of the Enterprise intracranial stent for revasculariza-
tion of large vessel occlusions in acute stroke. Clin Neuroradiol.
The authors declare no conflict of interests associated with 2010;20:54---60.
this article whatsoever. 15. Levy EI, Siddiqui AH, Crumlish A, Snyder KV, Hauck EF, Fiorella
DJ, et al. First Food and Drug Administration-approved prospec-
tive trial of primary intracranial stenting for acute stroke: SARIS
References (stent-assisted recanalization in acute ischemic stroke). Stroke.
2009;40:3552---6.
1. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira 16. Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D,
A, et al. Thrombectomy within 8 hours after symptom onset in Lane BF, et al. Stenting versus aggressive medical therapy for
ischemic stroke. N Engl J Med. 2015;372:2296---306. intracranial arterial stenosis. N Engl J Med. 2011;365:993---1003.
2. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, 17. Penumbra Pivotal Stroke Trial Investigators. The penumbra piv-
et al. Stent-retriever thrombectomy after intravenous t-PA vs. otal stroke trial: safety and effectiveness of a new generation of
t-PA alone in stroke. N Engl J Med. 2015;372:2285---95. mechanical devices for clot removal in intracranial large vessel
3. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton occlusive disease. Stroke. 2009;40:2761---8.
J, et al. Randomized assessment of rapid endovascular treat- 18. Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A,
ment of ischemic stroke. N Engl J Med. 2015;372:1019---30. et al. ADAPT FAST study: a direct aspiration first pass tech-
4. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma nique for acute stroke thrombectomy. J NeuroIntervent Surg.
HF, Yoo AJ, et al. A randomized trial of intraarterial treatment 2014;6:260---4.
for acute ischemic stroke. N Engl J Med. 2015;372:11---20. 19. Kabbasch C, Möhlenbruch M, Stampfl S, Mpotsaris A, Behme D,
5. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Liebig T. First-line lesional aspiration in acute stroke thrombec-
Yassi N, et al. Endovascular therapy for ischemic stroke with tomy using a novel intermediate catheter: initial experiences
perfusion-imaging selection. N Engl J Med. 2015;372:1009---18. with the SOFIA. Interv Neuroradiol. 2016;22:333---9.
6. Baek JH, Kim BM, Kim DJ, Heo JH, Nam HS, Yoo J. Stenting 20. Delgado Acosta F, Jiménez Gómez E, de Asís Bravo Rodríguez
as a rescue treatment after failure of mechanical thrombec- F, Oteros Fernández R, Ochoa Sepúlveda JJ. Técnicas de
tomy for anterior circulation large artery occlusion. Stroke. recanalización vertebrobasilar antes de la introducción de las
2016;47:2360---3. endoprótesis recuperadoras: la reapertura no es sinónimo de
7. Sung SM, Lee TH, Lee SW, Cho HJ, Park KH, Jung DS. Emergent buena evolución. Radiologia. 2014;56:44---51.
intracranial stenting for acute M2 occlusion of middle cerebral 21. Dorado L, Castaño C, Millán M, Aleu A, de la Ossa NP, Gomis
artery. Clin Neurol Neurosurg. 2014;119:110---5. M, et al. Hemorrhagic risk of emergent endovascular treatment
8. Dumont TM, Natarajan SK, Eller JL, Mocco J, Kelly WH Jr, Sny- plus stenting in patients with acute ischemic stroke. J Stroke
der KV, et al. Primary stenting for acute ischemic stroke using Cerebrovasc Dis. 2013;22:1326---31.