1. Iwata T, Mori T, Tajiri H, Uesugi T, Nakazaki M
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,
Kamakura City,　Japan
Thank you Mr Chairmen.
We would like to present our experiences of Angioplasty and Stenting for the Internal Carotid or Middle Cerebral Artery Occlusion in a Subacute Stroke Stage in Deteriorating Patients due to the Internal Border Zone Infarcts

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.
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.
Sseveral 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.
The internal border zone (IBZ) means the perforating 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
This figure shows typical features of IBZ and CBZ infarcts on CT scans. Upper line shows the IBZ, indicating infarcts in the territory of perforating arteries.
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:

5. Patients (1) Acute ischemic stroke patients
Period: Jan 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
Inclusive criteria for retrospective analysis were
Acute ischemic stroke Patients
who were admitted between Jan and Dec 2008,
within 72 hours from onset.
Emergency MRA on admission showed the ICA or MCA occlusion and DWIs showed no extensive infarcts in the ICA or MCA territory.

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.
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.
The patients were severely disabled on the 7th day. Therefore, some patients hoped to undergo endovascular recanalization even in a subacute stage to improve their outcome, but others did not because of high risk and no evidence.

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
We evaluated these features and compared them between two groups.
Compared between two groups.

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

10. Results (2) Group E Group C p Value (n=6) (n=11) NIHSS on admission,
median, (IR) ( ) 6 (4-9.5) NS
NIHSS on the 7th day,
median, (IR) 13 ( ) ( ) NS
NIHSS on discharge,
median, (IR) 7 ( ) ( ) NS
mRS on discharge
median, (IR) (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) **
There were no differences　during　the　hospitalization between two groups,　but　3-month　mRS　was　brtter　in　endovascular　group.

11. Case (the MCA Occlusion)
A 63-year-old woman was admitted to our institution,
since her right-sided hemiparesis deteriorated over 60 hours.
We show you a case.
A 63-year-old woman was admitted to our institution on the 2nd day of stroke, since her right-sided hemiparesis deteriorated over 40 hours.

12. CT and MRI on admission (3rd day)
63-yo-female CT
T2WI
DWI
CT scans and MR images showed infarcts were limited in the left insula and corona radiata.

13. MRI and MRA on admission
PWI (time-intensity curve)
Left MCA territory
The left middle cerebral artery was not visualized on MRAs and PWI suggested decrease of CBF in the left MCA territory.

14. Treatment and clinical course
She took dual antiplatelets agents. However, her neurological symptoms deteriorated day by day.
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
Diagnostic carotid angiography showed total occlusion of the left middle cerebral artery.
A-P view
Lateral view

16. Left MCA occlusion Estimated length of the occlusion M1
On angiograms, peripheral branch of the left MCA was probably opacified via collateral circulation and we estimated the length of the occlusion was about 10 mm on angiograms. I believed that I was able to recanalize the left MCA with balloon angioplasty.
Probable peripheral branch of the MCA
opacified via collateral circulation

17. The NIHSS score rose up to 30. CT scans showed the IBZ infarcts.
CT scans (8th day)
The NIHSS score rose up to 30.
CT scans showed the IBZ infarcts.
On the 8th day, she was severely disabled, but CT scans showed her infarcts were limited in the insula and corona radiata only, indicating the internal border zone (IBZ) infarcts.

18. Balloon Angioplasty for the Left MCA Occlusion (9th day)
Synchro-14S 300cm
Gateway 2.0mm×12mm
On the 9th day, we performed balloon angioplasty for total occlusion of the left MCA. We were successful in advancing a guide-wire into the distal branch of the left MCA, and occlusion site was dilated with a balloon.
Total occlusion
of the Left MCA
AP view

19. Successful balloon angioplasty (9th day)
The left MCA was recanalized successfully on the 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
Just before endovascular treatment, her NIHSS socre was 30 but 4 days later it improved to 18. Three months later her ADL was improved and mRS was 3. She was able to talk, sit independently and eat oraly then.

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 .
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 .