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Luo J, Wang T, Yang K, Wang X, Xu R, Gong H, Zhang X, Wang J, Yang R, Gao P, Ma Y, Jiao L. Endovascular therapy versus medical treatment for symptomatic intracranial artery stenosis. Cochrane Database Syst Rev 2023; 2:CD013267. [PMID: 36738471 PMCID: PMC9897029 DOI: 10.1002/14651858.cd013267.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Intracranial artery stenosis (ICAS) is an arterial narrowing in the brain that can cause stroke. Endovascular therapy (ET) and conventional medical treatment (CMT) may prevent recurrent ischaemic stroke caused by ICAS. However, there is no consensus on the best treatment for people with ICAS. OBJECTIVES To evaluate the safety and efficacy of endovascular therapy plus conventional medical treatment compared with conventional medical treatment alone for the management of symptomatic intracranial artery stenosis. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, four other databases, and three trials registries on 16 August 2022. We contacted study authors and researchers when we required additional information. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing ET plus CMT with CMT alone for the treatment of symptomatic ICAS. ET modalities included angioplasty alone, balloon-mounted stent, and angioplasty followed by placement of a self-expanding stent. CMT included antiplatelet therapy in addition to control of risk factors such as hypertension, hyperlipidaemia, and diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently screened the records to select eligible RCTs, then extracted data from them. We resolved any disagreements through discussion, reaching consensus decisions among the full team. We assessed risk of bias and applied the GRADE approach to assess the certainty of the evidence. The primary outcome was death by any cause or non-fatal stroke of any type within three months of randomisation. Secondary outcomes included all-cause death or non-fatal stroke of any type occurring more than three months after randomisation, ipsilateral stroke, transient ischaemic attack, ischaemic stroke, haemorrhagic stroke, death, restenosis, dependency, and health-related quality of life. MAIN RESULTS We included four RCTs with 989 participants who had symptomatic ICAS, with an age range of 18 to 85 years. We identified two ongoing RTCs. All trials had high risk of performance bias, as it was impossible to blind participants and personnel to the intervention. Three trials were terminated early. One trial was at high risk of attrition bias because of substantial loss to follow-up after one year and a high proportion of participants transferring from ET to CMT. The certainty of evidence ranged from low to moderate; we downgraded for imprecision. Compared to CMT alone, ET plus CMT probably increases the risk of short-term death or stroke (risk ratio (RR) 2.93, 95% confidence interval (CI) 1.81 to 4.75; 4 RCTs, 989 participants; moderate certainty), short-term ipsilateral stroke (RR 3.26, 95% CI 1.94 to 5.48; 4 RCTs, 989 participants; moderate certainty), short-term ischaemic stroke (RR 2.24, 95% CI 1.30 to 3.87; 4 RCTs, 989 participants; moderate certainty), and long-term death or stroke (RR 1.49, 95% CI 1.12 to 1.99; 4 RCTs, 970 participants; moderate certainty). Compared to CMT alone, ET plus CMT may increase the risk of short-term haemorrhagic stroke (RR 13.49, 95% CI 2.59 to 70.15; 4 RCTs, 989 participants; low certainty), short-term death (RR 5.43, 95% CI 1.21 to 24.40; 4 RCTs, 989 participants; low certainty), and long-term haemorrhagic stroke (RR 7.81, 95% CI 1.43 to 42.59; 3 RCTs, 879 participants; low certainty). It is unclear if ET plus CMT compared with CMT alone has an effect on the risk of short-term transient ischaemic attack (RR 0.79, 95% CI 0.30 to 2.07; 3 RCTs, 344 participants; moderate certainty), long-term transient ischaemic attack (RR 1.05, 95% CI 0.50 to 2.19; 3 RCTs, 335 participants; moderate certainty), long-term ipsilateral stroke (RR 1.78, 95% CI 1.00 to 3.17; 4 RCTs, 970 participants; moderate certainty), long-term ischaemic stroke (RR 1.56, 95% CI 0.77 to 3.16; 4 RCTs, 970 participants; moderate certainty), long-term death (RR 1.61, 95% CI 0.77 to 3.38; 4 RCTs, 951 participants; moderate certainty), and long-term dependency (RR 1.51, 95% CI 0.93 to 2.45; 4 RCTs, 947 participants; moderate certainty). No subgroup analyses significantly modified the effect of ET plus CMT versus CMT alone. The trials included no data on restenosis or health-related quality of life. AUTHORS' CONCLUSIONS This review provides moderate-certainty evidence that ET plus CMT compared with CMT alone increases the risk of short-term stroke and death in people with recent symptomatic severe ICAS. This effect was still apparent at long-term follow-up but appeared to be due to the early risks of ET; therefore, there may be no clear difference between the interventions in terms of their effects on long-term stroke and death. The impact of delayed ET intervention (more than three weeks after a qualifying event) warrants further study.
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Affiliation(s)
- Jichang Luo
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Kun Yang
- Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xue Wang
- Medical Library of Xuanwu Hospital, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ran Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Haozhi Gong
- China International Neuroscience Institute (China-INI), Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Jie Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Renjie Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Peng Gao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
- Department of Interventional Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Caton MT, Mark IT, Narsinh KH, Baker A, Cooke DL, Hetts SW, Dowd CF, Halbach VV, Higashida RT, Ko NU, Chung SA, Amans MR. Endovascular Therapy for Intracranial Giant Cell Arteritis : Systematic Review, Technical Considerations and the Effect of Intra-arterial Calcium Channel Blockers. Clin Neuroradiol 2022; 32:1045-1056. [PMID: 35503467 PMCID: PMC9744710 DOI: 10.1007/s00062-022-01171-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/06/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Giant cell arteritis (GCA) is a systemic vasculitis that may cause ischemic stroke. Rarely, GCA can present with aggressive intracranial stenoses, which are refractory to medical therapy. Endovascular treatment (EVT) is a possible rescue strategy to prevent ischemic complications in intracranial GCA but the safety and efficacy of EVT in this setting are not well-described. METHODS A systematic literature review was performed to identify case reports and series with individual patient-level data describing EVT for intracranial GCA. The clinical course, therapeutic considerations, and technique of seven endovascular treatments in a single patient from the authors' experience are presented. RESULTS The literature review identified 9 reports of 19 treatments, including percutaneous transluminal angioplasty (PTA) with or without stenting, in 14 patients (mean age 69.6 ± 6.3 years). Out of 12 patients 8 (66.7%) with sufficient data had > 1 pre-existing cardiovascular risk factor. All patients had infarction on MRI while on glucocorticoids and 7/14 (50%) progressed despite adjuvant immunosuppressive agents. Treatment was PTA alone in 15/19 (78.9%) cases and PTA + stent in 4/19 (21.1%). Repeat treatments were performed in 4/14 (28.6%) of patients (PTA-only). Non-flow limiting dissection was reported in 2/19 (10.5%) of treatments. The indications, technical details, and results of PTA are discussed in a single illustrative case. We report the novel use of intra-arterial calcium channel blocker infusion (verapamil) as adjuvant to PTA and as monotherapy, resulting in immediate improvement in cerebral blood flow. CONCLUSION Endovascular treatment, including PTA with or without stenting or calcium channel blocker infusion, may be effective therapies in medically refractory GCA with intracranial stenosis.
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Affiliation(s)
- M. Travis Caton
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Ian T. Mark
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Kazim H. Narsinh
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Amanda Baker
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Daniel L. Cooke
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Steven W. Hetts
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Christopher F. Dowd
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Van V. Halbach
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Randall T. Higashida
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
| | - Nerissa U. Ko
- Department of Neurology, University of California, San Francisco, USA
| | - Sharon A. Chung
- Department of Medicine, Division of Rheumatology, University of California, San Francisco, USA
| | - Matthew R. Amans
- Department of Radiology and Biomedical Imaging, Interventional Neuroradiology Section, University of California San Francisco, 505 Parnassus Ave, Room L349, 94143 San Francisco, CA USA
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Hurford R, Rothwell PM. Prevalence, prognosis, and treatment of atherosclerotic intracranial stenosis in Caucasians. Int J Stroke 2021; 16:248-264. [PMID: 33270537 PMCID: PMC8044631 DOI: 10.1177/1747493020974461] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/16/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intracranial atherosclerotic stenosis is a highly prevalent cause of stroke worldwide with important ethnic disparities. Widely considered to be a common cause of stroke in Asian and Afro-Caribbean populations, relatively less is known about the burden and significance of intracranial atherosclerotic stenosis in Caucasians. AIMS We aim to highlight recent insights and advances into the prevalence, prognosis, and treatment of symptomatic and asymptomatic atherosclerotic intracranial atherosclerotic stenosis in Caucasian patients. SUMMARY OF REVIEW We identified 48 articles studying intracranial atherosclerotic stenosis in Caucasian patients with ischemic stroke or transient ischemic attack. Most studies were on hospital-based cohorts of consecutive patients and half were graded as "fair" quality. There was significant variation between studies in the definition of intracranial atherosclerotic stenosis and in the imaging modalities used to detect intracranial atherosclerotic stenosis. Overall, 12.1% of Caucasian patients were found to have any intracranial atherosclerotic stenosis, 6.4% symptomatic intracranial atherosclerotic stenosis and 11.1% asymptomatic intracranial atherosclerotic stenosis, with higher rates at older ages. In studies reporting prognosis, there were 61 and 10 same-territory ischemic strokes in 1000 person-years in patients with symptomatic and asymptomatic intracranial atherosclerotic stenosis, respectively. Percutaneous stenting and angioplasty have not proven superior to intensive medical management in patients with symptomatic intracranial atherosclerotic stenosis. CONCLUSIONS Intracranial atherosclerotic stenosis has previously been neglected as a cause of stroke in Caucasians but is highly prevalent at older ages and frequently discovered with the growing use of noninvasive angiography. Intensive medical therapy is the treatment of choice, but there is a need to develop novel treatments or therapeutic approaches to lower the risk of stroke in higher risk patients.
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Affiliation(s)
- Robert Hurford
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Peter M Rothwell
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Wang T, Luo J, Wang X, Yang K, Jadhav V, Gao P, Ma Y, Zhao N, Jiao L. Endovascular therapy versus medical treatment for symptomatic intracranial artery stenosis. Cochrane Database Syst Rev 2020; 8:CD013267. [PMID: 32789891 PMCID: PMC7437396 DOI: 10.1002/14651858.cd013267.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Intracranial atherosclerotic stenosis (ICAS) is an arterial narrowing in the brain that can cause stroke. Endovascular therapy and medical management may be used to prevent recurrent ischaemic stroke caused by ICAS. However, there is no consensus on the best treatment for people with ICAS. OBJECTIVES To compare the safety and efficacy of endovascular therapy (ET) plus conventional medical treatment (CMT) with CMT alone for the management of symptomatic ICAS. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (30 August 2019), Cochrane Central Register of Controlled Trials (CENTRAL: to 30 August 2019), MEDLINE Ovid (1946 to 30 August 2019), Embase Ovid (1974 to 30 August 2019), Scopus (1960 to 30 August 2019), Science Citation Index Web of Science (1900 to 30 July 2019), Academic Source Complete EBSCO (ASC: 1982 to 30 July 2019), and China Biological Medicine Database (CBM: 1978 to 30 July 2019). We also searched the following trial registers: ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and Stroke Trials Registry. We also contacted trialists and researchers where additional information was required. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing ET plus CMT with CMT alone for the treatment of symptomatic ICAS. ET modalities included angioplasty alone, balloon-mounted stent, and angioplasty followed by placement of a self-expanding stent. CMT included antiplatelet therapy in addition to control of risk factors such as hypertension, hyperlipidaemia, and diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently screened trials to select potentially eligible RCTs and extracted data. Any disagreements were resolved by discussing and reaching consensus decisions with the full team. We assessed risk of bias and applied the GRADE approach to assess the quality of the evidence. The primary outcome was death of any cause or non-fatal stroke of any type within three months of randomisation. Secondary outcomes included any-cause death or non-fatal stroke of any type more than three months of randomisation, ipsilateral stroke, type of recurrent event, death, restenosis, dependency, and health-related quality of life. MAIN RESULTS We included three RCTs with 632 participants who had symptomatic ICAS with an age range of 18 to 85 years. The included trials had high risks of performance bias and other potential sources of bias due to the impossibility of blinding of the endovascular intervention and early termination of the trials. Moreover, one trial had a high risk of attrition bias because of the high rate of loss of one-year follow-up and the high proportion of participants transferred from endovascular therapy to medical management. The quality of evidence ranged from low to moderate, downgraded for imprecision. Compared to CMT, ET probably results in a higher rate of 30-day death or stroke (risk ratio (RR) 3.07, 95% confidence interval (CI) 1.80 to 5.24; 3 RCTs, 632 participants, moderate-quality evidence), 30-day ipsilateral stroke (RR 3.54, 95% CI 1.98 to 6.33; 3 RCTs, 632 participants, moderate-quality evidence), 30-day ischaemic stroke (RR 2.52, 95% CI 1.37 to 4.62; 3 RCTs, 632 participants, moderate-quality evidence), and 30-day haemorrhagic stroke (RR 15.53, 95% CI 2.10 to 115.16; 3 RCTs, 632 participants, low-quality evidence). ET was also likely associated with a worse outcome in one-year death or stroke (RR 1.69, 95% CI 1.21 to 2.36; 3 RCTs, 632 participants, moderate-quality evidence), one-year ipsilateral stroke (RR 2.28, 95% CI 1.52 to 3.42; 3 RCTs, 632 participants, moderate-quality evidence), one-year ischaemic stroke (RR 2.07, 95% CI 1.37 to 3.13; 3 RCTs, 632 participants, moderate-quality evidence), and one-year haemorrhagic stroke (RR 10.13, 95% CI 1.31 to 78.51; 2 RCTs, 521 participants, low-quality evidence). There were no significant differences between ET and CMT in 30-day transient ischaemic attacks (TIA) (RR 0.52, 95% CI 0.11 to 2.35, P = 0.39; 2 RCTs, 181 participants, moderate-quality evidence), 30-day death (RR 5.53, 95% CI 0.98 to 31.17, P = 0.05; 3 RCTs, 632 participants, low-quality evidence), one-year TIA (RR 0.82, 95% CI 0.32 to 2.12; 2 RCTs, 181 participants, moderate-quality evidence), one-year death (RR 1.20, 95% CI 0.50 to 2.86, P = 0.68; 3 RCTs, 632 participants, moderate-quality evidence), and one-year dependency (RR 1.90, 95% CI 0.91 to 3.97, P = 0.09; 3 RCTs, 613 participants, moderate-quality evidence). No data on restenosis and health-related quality of life for meta-analysis were available from the included trials. Two RCTs are ongoing. AUTHORS' CONCLUSIONS This systematic review provides moderate-quality evidence showing that ET, compared with CMT, in people with recent symptomatic severe intracranial atherosclerotic stenosis probably does not prevent recurrent stroke and appears to carry an increased hazard. The impact of delayed ET intervention (more than three weeks after a qualifying event) is unclear and may warrant further study.
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Affiliation(s)
- Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jichang Luo
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xue Wang
- Medical Library of Xuanwu Hospital, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kun Yang
- Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Vikram Jadhav
- Neurosciences, Essentia Health, St Mary's Medical Center, Duluth, Minnesota, USA
- Neurosciences, Stroke and Cerebrovascular, CentraCare Health System, St Cloud, Minnesota, USA
| | - Peng Gao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Na Zhao
- Department of Anesthesiology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Wang T, Yang K, Luo J, Gao P, Ma Y, Wang Y, Li L, Liu Y, Feng Y, Wang X, Jiao L. Outcomes after stenting for symptomatic intracranial arterial stenosis: a systematic review and meta-analysis. J Neurol 2019; 267:581-590. [PMID: 30612142 DOI: 10.1007/s00415-018-09176-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/26/2018] [Accepted: 12/27/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Stenting is a common endovascular therapy for symptomatic intracranial arterial stenosis (ICAS). We sought to update the evaluation of global short-term safety and long-term efficacy outcomes after stenting for symptomatic ICAS and explore their distributional characteristics. METHODS Major databases including Cochrane Library, MEDLINE, EMBASE were systematically searched from January 1st, 2005, for RCTs and observational studies which reported short- and long-term outcomes after stenting for symptomatic ICAS. Each outcome was pooled with meta-analysis and the impacts of study location, publication time, and other population characteristics were further assessed by the univariate and multivariate Poisson regression analyses. RESULTS A total of 8408 patients were identified in 92 studies from 16 countries across five WHO regions. The estimated rate of short-term stroke or death was 6.68% (95% CI 5.60-8.36%), and the rate of long-term stroke or death was 4.43% (95% CI 2.61-6.60%). After adjustment of age, sex, study location, preprocedual stenosis, publication period and study design, multivariate regression analysis showed that the rate of short-term stroke or death was different between Western and Eastern countries (10.27% versus 5.52%, p = 0.018). The rates of short-term, stroke, ischemic stroke and long-term death were also significantly higher in Western compared to Eastern countries. CONCLUSION This systematic review provided the worldwide profile of short- and long-term outcomes of stenting for symptomatic ICAS. The generally acceptable outcomes indicate that stenting may still be feasible in selected patients. Regional disparity calls for more cautious decisions and future studies.
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Affiliation(s)
- Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China
| | - Jichang Luo
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Peng Gao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Yabing Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Long Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Yiran Liu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China.
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Hussain M, Datta N, Cheng Z, Dornbos D, Bashir A, Sultan I, Mehta T, Shweikeh F, Mazaris P, Lee N, Nouh A, Geng X, Ding Y. Spanning from the West to East: An Updated Review on Endovascular Treatment of Intracranial Atherosclerotic Disease. Aging Dis 2017; 8:196-202. [PMID: 28400985 PMCID: PMC5362178 DOI: 10.14336/ad.2016.0807] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 08/07/2016] [Indexed: 12/25/2022] Open
Abstract
Ischemic stroke is a major cause of morbidity and mortality, incurring significant cost. Intracranial atherosclerotic disease (ICAD) accounts for 10-15% of ischemic stroke in Western societies, but is an underlying pathology in up to 54% of ischemic strokes in Asian populations. ICAD has largely been treated with medical management, although a few studies have examined outcomes following endovascular treatment. Our objective was to summarize the major trials that have been performed thus far in regard to the endovascular treatment of ICAD and to provide direction for future management of this disease process. Systematic review of the literature from 1966 to 2015, was conducted in regard to intracranial angioplasty and stenting. Studies were analyzed from PubMed, American Heart Association and Society of Neurointerventional Surgery databases. SAMMPRIS and VISSIT are the only randomized controlled trials from which Western guidelines of intracranial stenting have been derived, which have displayed the superiority of medical management. However, pooled reviews of smaller studies and other nonrandomized trials have shown better outcomes with endovascular therapy in select patient subsets, such as intracranial vertebrobasilar stenosis or in the presence of robust collaterals. Suboptimal cases, including longer lesions, bifurcations and significant tortuosity tend to fair better with medical management. Medical management has been shown to be more efficacious with less adverse outcomes than endovascular therapy. However, the majority of studies on endovascular management included a diverse patient population without ideal selection criteria, resulting in higher adverse outcomes. Population analyses and selective utilization of endovascular therapy have shown that the treatment may be superior to other management in select patients.
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Affiliation(s)
- Mohammed Hussain
- 1Department of Neurology, University of Connecticut, Farmington, CT 06030, USA
| | - Neil Datta
- 1Department of Neurology, University of Connecticut, Farmington, CT 06030, USA
| | - Zhe Cheng
- 2Department of Neurology, Luhe Hospital, Capital Medical University, Beijing 101149, China
| | - David Dornbos
- 3Department of Neurological Surgery, The Ohio State University Wexner Medical Center, OH 43210, USA
| | - Asif Bashir
- 4Department of Neurosurgery, Seton Hall University, South Orange, NJ 07079, USA
| | - Ibrahim Sultan
- 5Department of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Tapan Mehta
- 1Department of Neurology, University of Connecticut, Farmington, CT 06030, USA
| | - Faris Shweikeh
- 6Department of Surgery, University of Arizona, Tucson, AZ 85724, USA
| | - Paul Mazaris
- 1Department of Neurology, University of Connecticut, Farmington, CT 06030, USA
| | - Nora Lee
- 1Department of Neurology, University of Connecticut, Farmington, CT 06030, USA
| | - Amre Nouh
- 1Department of Neurology, University of Connecticut, Farmington, CT 06030, USA
| | - Xiaokun Geng
- 2Department of Neurology, Luhe Hospital, Capital Medical University, Beijing 101149, China; 7Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48236, USA
| | - Yuchuan Ding
- 7Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48236, USA
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7
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Banerjee C, Chimowitz MI. Stroke Caused by Atherosclerosis of the Major Intracranial Arteries. Circ Res 2017; 120:502-513. [PMID: 28154100 PMCID: PMC5312775 DOI: 10.1161/circresaha.116.308441] [Citation(s) in RCA: 257] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/16/2016] [Accepted: 11/17/2016] [Indexed: 11/16/2022]
Abstract
Our goal in this review is to discuss the pathophysiology, diagnosis, and treatment of stroke caused by atherosclerosis of the major intracranial arteries. References for the review were identified by searching PubMed for related studies published from 1955 to June 2016 using search terms intracranial stenosis and intracranial atherosclerosis. Reference sections of published randomized clinical trials and previously published reviews were searched for additional references. Intracranial atherosclerotic disease is a highly prevalent cause of stroke that is associated with a high risk of recurrent stroke. It is more prevalent among blacks, Hispanics, and Asians compared with whites. Diabetes mellitus, hypertension, metabolic syndrome, smoking, hyperlipidemia, and a sedentary lifestyle are the major modifiable risk factors associated with intracranial atherosclerotic disease. Randomized clinical trials comparing aggressive management (dual antiplatelet treatment for 90 days followed by aspirin monotherapy and intensive management of vascular risk factors) with intracranial stenting plus aggressive medical management have shown medical management alone to be safer and more effective for preventing stroke. As such, aggressive medical management has become the standard of care for symptomatic patients with intracranial atherosclerotic disease. Nevertheless, there are subgroups of patients who are still at high risk of stroke despite being treated with aggressive medical management. Future research should aim to establish clinical, serological, and imaging biomarkers to identify high-risk patients, and clinical trials evaluating novel therapies should be focused on these patients.
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Affiliation(s)
- Chirantan Banerjee
- From the Department of Neurology, Stroke Division, Medical University of South Carolina, Charleston
| | - Marc I Chimowitz
- From the Department of Neurology, Stroke Division, Medical University of South Carolina, Charleston.
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Gao P, Wang D, Zhao Z, Cai Y, Li T, Shi H, Wu W, He W, Yin L, Huang S, Zhu F, Jiao L, Ji X, Qureshi AI, Ling F. Multicenter Prospective Trial of Stent Placement in Patients with Symptomatic High-Grade Intracranial Stenosis. AJNR Am J Neuroradiol 2016; 37:1275-80. [PMID: 26869472 DOI: 10.3174/ajnr.a4698] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/16/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE On the basis of the high 1-month stroke and/or death (14.7%) rates associated with stent placement in the Stenting versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis trial, modifications in patient selection and procedural aspects for intracranial stent placement have been recommended. We performed a multicenter prospective single-arm trial to determine whether such modifications would result in lower rates of periprocedural stroke and/or death. MATERIALS AND METHODS The study enrolled patients with recent transient ischemic attack or ischemic stroke (excluding perforator ischemic events) related to high-grade (70%-99% in severity) stenosis of a major intracranial artery. Patients were treated by using angioplasty and self-expanding stents 3 weeks after the index ischemic event at 1 of the 10 high-volume centers in China. An independent neurologist ascertained the occurrence of any stroke and/or death within 1 month after the procedure. RESULTS A total of 100 consecutive patients were recruited. The target lesions were located in the middle cerebral artery (M1) (n = 38, 38%), intracranial internal carotid artery (n = 17, 17%), intradural vertebral artery (n = 18, 18%), and basilar artery (n = 27, 27%). The technical success rate of stent deployment with residual stenosis of <50% was 100%. The overall 1-month stroke and/or death rate was 2% (95% confidence interval, 0.2%-7.0%). Two ischemic strokes occurred in the pontine region (perforator distribution) in patients following angioplasty and stent placement for basilar artery stenosis. CONCLUSIONS The results of this prospective multicenter study demonstrated that modifications in patient selection and procedural aspects can substantially reduce the 1-month stroke and/or death rate following intracranial stent placement.
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Affiliation(s)
- P Gao
- From the Department of Neurosurgery (P.G., F.Z., L.J., X.J., F.L.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - D Wang
- Department of Neurosurgery (D.W.), Beijing Hospital of the Ministry of Health, Beijing, China
| | - Z Zhao
- Department of Neurosurgery (Z.Z.), Tangdu Hospital, the Fourth Military Medical University, Xi'an, Shaanxi Province, China
| | - Y Cai
- Department of Neurology (Y.C.), the 306 Hospital of the People's Liberation Army, Beijing, China
| | - T Li
- Department of Intervention (T.L.), Henan Provincial People's Hospital, Zhengzhou, Henan Province, China
| | - H Shi
- Department of Neurosurgery (H.S.), the 1st Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - W Wu
- Department of Neurology (W.W.), Qilu Hospital of Shandong University, Ji'nan, Shandong Province, China
| | - W He
- Department of Neurosurgery (W.H.), the 2nd Affiliated Hospital of Guangzhou Medical College, Guangzhou, Guangdong Province, China
| | - L Yin
- Department of Neurosurgery (L.Y.), Tianjin Huanhu Hospital, Tianjin, China
| | - S Huang
- Department of Neurosurgery (S.H.), Guangdong Province Hospital of Traditional Chinese Medicine, Guangzhou, Guangdong Province, China
| | - F Zhu
- From the Department of Neurosurgery (P.G., F.Z., L.J., X.J., F.L.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - L Jiao
- From the Department of Neurosurgery (P.G., F.Z., L.J., X.J., F.L.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - X Ji
- From the Department of Neurosurgery (P.G., F.Z., L.J., X.J., F.L.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - A I Qureshi
- Zeenat Qureshi Stroke Institute (A.I.Q.), St. Cloud, Minnesota
| | - F Ling
- From the Department of Neurosurgery (P.G., F.Z., L.J., X.J., F.L.), Xuanwu Hospital, Capital Medical University, Beijing, China
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9
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Davis MC, Deveikis JP, Harrigan MR. Clinical Presentation, Imaging, and Management of Complications due to Neurointerventional Procedures. Semin Intervent Radiol 2015; 32:98-107. [PMID: 26038618 DOI: 10.1055/s-0035-1549374] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Neurointervention is a rapidly evolving and complex field practiced by clinicians with backgrounds ranging from neurosurgery to radiology, neurology, cardiology, and vascular surgery. New devices, techniques, and clinical applications create exciting opportunities for impacting patient care, but also carry the potential for new iatrogenic injuries. Every step of every neurointerventional procedure carries risk, and a thorough appreciation of potential complications is fundamental to maximizing safety. This article presents the most frequent and dangerous iatrogenic injuries, their presentation, identification, prevention, and management.
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Affiliation(s)
- Matthew C Davis
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - John P Deveikis
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark R Harrigan
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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10
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Gao P, Zhao Z, Wang D, Wu J, Cai Y, Li T, Wu W, Shi H, He W, Zhu F, Jiao L, Ling F. China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis (CASSISS): A new, prospective, multicenter, randomized controlled trial in China. Interv Neuroradiol 2015; 21:196-204. [PMID: 25934656 DOI: 10.1177/1591019915581778] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Patients with symptomatic stenosis of intradural arteries are at high risk for subsequent stroke. Since the SAMMPRIS trial, stenting is no longer recommended as primary treatment; however, the results of this trial, its inclusion criteria and its center selection received significant criticism and did not appear to reflect our experience regarding natural history nor treatment complications rate. As intracranial atherosclerosis (ICAS) is the most common cause for stroke in Asian countries, we are hereby proposing a refined prospective, randomized, multicenter study in an Asian population with strictly defined patient and participating center inclusion criteria. METHODS The China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis (CASSISS) trial is an ongoing, government-funded, prospective, multicenter, randomized trial. It recruits patients with recent TIA or stroke caused by 70%-99% stenosis of a major intracranial artery. Patients with previous stroke related to perforator ischemia will not be included. Only high-volume centers with a proven track record will enroll patients as determined by a lead-in phase. Patients will be randomized (1:1) to best medical therapy alone or medical therapy plus stenting. Primary endpoints are any stroke or death within 30 days after enrollment or after any revascularization procedure of the qualifying lesion during follow-up, or stroke in the territory of the symptomatic intracranial artery beyond 30 days. The CASSISS trial will be conducted in eight sites in China with core imaging lab review at a North American site and aims to have a sample size of 380 participants (stenting, 190; medical therapy, 190). Recruitment is expected to be finished by December 2016. Patients will be followed for at least three years. The trial is scheduled to complete in 2019. CONCLUSION In the proposed trial, certain shortcomings of SAMMPRIS including patient and participating center selection will be addressed. The present manuscript outlines the rationale and design of the study. We estimate that this trial will allow for a critical reappraisal of the role of intracranial stenting for selected patients in high-volume centers.
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Affiliation(s)
- Peng Gao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China
| | - Zhenwei Zhao
- Department of Neurosurgery, Tangdu Hospital, the Fourth Military Medical University, China
| | - Daming Wang
- Department of Neurosurgery, Beijing Hospital of the Ministry of Health, China
| | - Jian Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, China
| | - Yiling Cai
- Department of Neurology, the 306 Hospital of PLA, China
| | - Tianxiao Li
- Department of Intervention, Henan Provincial People's Hospital, China
| | - Wei Wu
- Department of Neurology, Qilu Hospital of Shandong University, China
| | - Huaizhang Shi
- Department of Neurosurgery, The 1st Affiliated Hospital of Harbin Medical University, China
| | - Weiwen He
- Department of Neurology, The 2nd Affiliated Hospital of Guangzhou Medical College, China
| | - Fengshui Zhu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China
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Abstract
Patients with symptomatic intracranial atherosclerotic disease have a high risk of recurrent stroke, and secondary prevention in these patients remains a challenge. Aggressive medical management of vascular risk factors is safe and effective for most high risk patients, but the role of endovascular and surgical therapies still remain uncertain. Future studies may identify novel therapeutic strategies for patients with intracranial atherosclerotic disease, but aggressive risk factor control remains the mainstay of evidenced-based treatment at this time.
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Affiliation(s)
- Tanya N Turan
- MUSC Stroke Program, Suite 501, Harborview Office Tower, 19 Hagood Ave, Charleston, SC, 29425, USA,
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12
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Gupta A, Desai MM, Kim N, Bulsara KR, Wang Y, Krumholz HM. Trends in intracranial stenting among medicare beneficiaries in the United States, 2006-2010. J Am Heart Assoc 2013; 2:e000084. [PMID: 23588099 PMCID: PMC3647283 DOI: 10.1161/jaha.113.000084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background It is uncertain how intracranial stenting (ICS) has been adopted nationally during a period characterized by a restrictive payment policy by the Centers for Medicare & Medicaid Services, humanitarian device exemption approval by the Food and Drug Administration, and insufficient evidence of effectiveness. We sought to determine the trends in rates of ICS use and associated outcomes in the United States. Methods and Results From 65 211 328 Medicare Fee‐for‐Service beneficiaries hospitalized between 2006 and 2010 in acute care hospitals in the United States, we included patients with ICD‐9‐CM procedure codes for intracranial angioplasty and stenting, excluding those with a principal discharge diagnosis code of cerebral aneurysm or subarachnoid hemorrhage. We report operative rates per 1 000 000 person‐years and outcomes including 30‐day and 1‐year mortality rates. There were 838 ICS procedures performed among Fee‐for‐Service beneficiaries. The overall hospitalization rate for ICS increased significantly from ≈1 per 1 000 000 person‐years (n=35 procedures) in 2006 to 9 per 1 000 000 person‐years (n=258 procedures) in 2010 (P=0.0090 for trend). Procedure rates were higher in men than in women, and were highest among patients aged 75 to 84 years and lowest among those ≥85 years. The 30‐day mortality rate increased from 2.9% (95% CI, 0.1 to 15.3) to 12.9% (95% CI, 9.0 to 17.6), P=0.1294 for trend, and the 1‐year mortality rate increased from 14.7% (95% CI, 5.0 to 31.1) to 19.5% (95% CI, 14.9 to 24.9), P=0.0101; however, the annual changes were not significant after adjustment. Conclusions ICS utilization in the United States has modestly increased during a period of inadequate supportive evidence. Humanitarian device exemption and a restrictive payment policy appear to have caused slow adoption of the technology.
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Affiliation(s)
- Aakriti Gupta
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT 06510, USA
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13
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Abdihalim MM, Hassan AE, Qureshi AI. Off-label use of drugs and devices in the neuroendovascular suite. AJNR Am J Neuroradiol 2013; 34:2054-63. [PMID: 23518356 DOI: 10.3174/ajnr.a3447] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
SUMMARY The off-label use of drugs and devices in neuroendovascular procedures is common. Neurointerventionalists should be well aware of the level of evidence available in support of the off-label use of drugs and devices in their practice and some of the potential adverse events associated with them. These uses are categorized as I or II if they have been evaluated as primary or ancillary interventions in prospective trials/registries of neuroendovascular procedures and III if they were evaluated in case series. Category IV use is based on evaluation as primary or ancillary interventions in prospective trials/registries of non-neuroendovascular procedures. Physicians are allowed to use off-label drugs and procedures if there is strong evidence that they are beneficial for the patient. The neurointerventional professional societies agree that off-label use of drugs and devices is an important part of the specialty, but practicing providers should base their decisions on sound evidence when using such drugs and devices.
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14
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Mohammadian R, Pashapour A, Sharifipour E, Mansourizadeh R, Mohammadian F, Taher Aghdam AA, Mousavi M, Dadras F. A Comparison of Stent Implant versus Medical Treatment for Severe Symptomatic Intracranial Stenosis: A Controlled Clinical Trial. Cerebrovasc Dis Extra 2012; 2:108-20. [PMID: 23599702 PMCID: PMC3567882 DOI: 10.1159/000344004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Atherosclerotic stenosis of the major intracranial arteries is the most common cause of ischemic stroke. There are limited treatments for severe intracranial stenosis, and stent placement versus medical treatment remains controversial. The aim of this study was to compare functional outcomes of these two modalities in patients with severe symptomatic intracranial stenosis. Methods At a single center, between 2008 and 2011, patients with angiographically demonstrated severe (70–90%) symptomatic intracranial atherosclerosis were divided into two groups: group A, which received only medical treatment, and group B, which underwent endovascular stent implant treatment. The severity and location of the stenosis was determined by digital subtraction angiography and the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial criteria in all patients. The exclusion criteria were: specific causes other than atherosclerosis, such as artery dissection, fibromuscular dysplasia, vasculitis, radiation and intracranial hemorrhage, focal neurological deficit that did not correlate to internal carotid artery or middle cerebral artery stenosis. All procedures were done under light anesthesia. Technical success was defined as the reduction of stenosis to <30% with complete enveloping of the lesion after the procedure. Early and late adverse events and functional outcomes were compared between the groups using the modified Rankin Scale (mRS). Results Overall, 63 patients (29 in group A and 34 in group B) were evaluated and followed for a mean period of 15.22 months (range 6–25). The technical success rate was 97% in a total of 34 stents in 34 patients. There was no difference between the early (within 30 days) adverse event rates of the two groups. The median follow-up duration for the stent implant patients was 15 months (range 6–25), and for the medically treated cohort it was 14 months (range 8–25). The re-stenosis rate was 5.8% and the total number of late (>30 days) adverse events, including stroke, myocardial infarction and death, was 1 (2.9%) and 6 (20.7%) in the stent implant and medical groups, respectively (p = 0.042). The stent implant group had significantly better favorable functional outcomes according to the mRS than the medical group (93.9 vs. 63.0%). The cumulative secondary adverse event-free survival was significantly lower in the stent implant group. Conclusion Stent implants can be considered more durable and safe for patients with symptomatic severe stenosis of the internal carotid artery or middle cerebral artery, despite optimal medical therapy. Randomized, multicenter trials are required to confirm these results.
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Affiliation(s)
- Rezao Mohammadian
- Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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15
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Tang CW, Chang FC, Chern CM, Lee YC, Hu HH, Lee IH. Stenting versus medical treatment for severe symptomatic intracranial stenosis. AJNR Am J Neuroradiol 2011; 32:911-6. [PMID: 21393399 DOI: 10.3174/ajnr.a2409] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intracranial atherosclerosis is especially prevalent in Asians, but intracranial stent placement and medical treatment for severe intracranial stenosis are controversial. Thus, we compared long-term outcomes of these 2 therapeutic approaches in an Asian population. MATERIALS AND METHODS Patients with angiographically proved severe (≥70%) symptomatic intracranial atherosclerosis, with or without stent placement, were retrospectively reviewed at a single center between 2002 and 2009, with adjustments for age, sex, vascular risk factors, degree of baseline stenosis, and baseline functional status. RESULTS Of the 114 patients followed from 3 to 36 months (mean, 17.3 months) after initial diagnosis, 53 received 56 stents in addition to medical treatment (stent-placement group), and 61 matched patients received only medical treatment (medical group). Total clinical events, including stroke, TIA, and vascular death, were 12 (22.6%) and 15 (24.6%) in the stent-placement and medical groups, respectively (P = .99). The stent-placement group had significantly better functional outcomes than the medical group (94.3% versus 78.7% for mRS scores of 0-3, P = .045). Most events in the stent-placement group occurred within the first week of the periprocedural period (17.0%) as minor embolic or perforator infarctions, and the rate of events decreased thereafter (5.7%, P = .07). Stent placement over the perforator-rich MCA and BA independently predicted periprocedural events on multivariate regression analysis. In the medical group, events increased in frequency (21.7%) and severity with time. CONCLUSIONS Although the total ischemic event rate was similar in the 2 groups during a 3-year follow-up, the stent-placement group had a more favorable functional outcome despite minor periprocedural strokes.
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Affiliation(s)
- C-W Tang
- Department of Neurology, Suao Veterans Hospital, Yilan County, Taiwan
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16
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Short JL, Majid A, Hussain SI. Endovascular treatment of symptomatic intracranial atherosclerotic disease. Front Neurol 2011; 1:160. [PMID: 21359195 PMCID: PMC3040367 DOI: 10.3389/fneur.2010.00160] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 12/27/2010] [Indexed: 12/21/2022] Open
Abstract
Symptomatic intracranial atherosclerotic disease (ICAD) is responsible for approximately 10% of all ischemic strokes in the United States. The risk of recurrent stroke may be as high as 35% in patient with critical stenosis >70% in diameter narrowing. Recent advances in medical and endovascular therapy have placed ICAD at the forefront of clinical stroke research to optimize the best medical and endovascular approach to treat this important underlying stroke etiology. Analysis of symptomatic ICAD studies lead to the question that whether angioplasty and/or stenting is a safe, suitable, and efficacious therapeutic strategy in patients with critical stenoses that are deemed refractory to medical management. Most of the currently available data in support of angioplasty and/or stenting in high risk patients with severe symptomatic ICAD is in the form of case series and randomized trial results of endovascular therapy versus medical treatment are awaited. This is a comprehensive review of the state of the art in the endovascular approach with angioplasty and/or stenting of symptomatic ICAD.
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Affiliation(s)
- Jody L. Short
- Department of Neurology, Michigan State UniversityEast Lansing, MI, USA
- Sparrow Hospital Neurovascular SectionLansing, MI, USA
| | - Arshad Majid
- Department of Neurology, Michigan State UniversityEast Lansing, MI, USA
- Sparrow Hospital Neurovascular SectionLansing, MI, USA
| | - Syed I. Hussain
- Department of Neurology, Michigan State UniversityEast Lansing, MI, USA
- Sparrow Hospital Neurovascular SectionLansing, MI, USA
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17
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Lanfranconi S, Bersano A, Branca V, Ballabio E, Isalberti M, Papa R, Candelise L. Stenting for the treatment of high-grade intracranial stenoses. J Neurol 2010; 257:1899-908. [PMID: 20602237 DOI: 10.1007/s00415-010-5633-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Revised: 05/21/2010] [Accepted: 06/11/2010] [Indexed: 12/01/2022]
Abstract
To date, evidence to recommend endovascular treatment in patients with intracranial stenoses is lacking. Recently, the introduction of self-expanding stents (Wingspan Stent System) aroused considerable expectations in their employ for stroke prevention. We report a single-center experience of percutaneous transluminal angioplasty and stenting in a series of consecutive patients with intracranial stenoses and compare the safety and performance of balloon-mounted stents versus self-expanding stent systems (Wingspan). Thirty-four patients with 39 severe (>70%) intracranial stenoses were treated during a 6-year period. An independent stroke neurologist collected data about intra and periprocedural complications and short-term outcome. We considered as endpoint measures (1) any 30-day stroke or death (2) any major 30-day complication and (3) procedure technical success. Technical success was achieved in all patients. No vessel dissection or ruptures were observed. The 30-day stroke/death rate was 17.9%. Five ischemic strokes in the territory of treated vessels and two intracranial hemorrhages occurred respectively within 24 h and 5 days after endovascular treatment. Three (17.6%) patients of Wingspan treated group and four (18.2%) of the patients treated with different stent systems had unfavorable outcome. Our study confirms that endovascular treatment can be performed with a high technical success rate, even though the safety of these devices has still to be demonstrated.
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Affiliation(s)
- S Lanfranconi
- Centro Dino Ferrari, Università degli Studi di Milano, Milan, Italy
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18
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Kurre W, Chapot R, du Mesnil de Rochemont R, Berkefeld J. Intracranial stenting in atherosclerotic disease—recent results and challenges to face. Neuroradiology 2010; 52:633-44. [DOI: 10.1007/s00234-010-0678-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2009] [Accepted: 03/02/2010] [Indexed: 10/19/2022]
Affiliation(s)
- Wiebke Kurre
- Department of Neuroradiology, Alfried-Krupp-Krankenhaus, Alfried Krupp Strasse 21, 45131, Essen, Germany.
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19
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Berkefeld J, Zanella FE. Intracranial stenting of atherosclerotic stenoses: current status and perspectives. ACTA ACUST UNITED AC 2009; 19:38-44. [PMID: 19636677 DOI: 10.1007/s00062-009-8039-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Accepted: 01/15/2009] [Indexed: 10/20/2022]
Abstract
The purpose of this review article is to give an overview of the current development of intracranial stenting for treatment of atherosclerotic stenoses. Natural history and methods for diagnostic imaging are described as basis for the indication for endovascular treatment. Target group are patients with high-grade symptomatic stenoses > 70%. Technical standards for the use of self-expanding and balloon-expandable stents are reported together with the results of clinical case series. It seems to be difficult to drop acute complication rates (procedure-related stroke and death during the first 30 days) reliably from current levels of around 10% to values < 6%, which are more acceptable for a prophylactic procedure for the prevention of stroke. High restenosis rates up to 30% in the 1st year raised concerns about long-term efficacy. Further technical developments and improved criteria for patient selection are necessary to make intracranial stenting safer and more effective before a randomized trial (stent vs. medical treatment) may prove superiority of the endovascular approach.
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Affiliation(s)
- Joachim Berkefeld
- Department of Neuroradiology, Johann Wolfgang Goethe University, Frankfurt/Main, Germany.
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20
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Khatri R, Gomez CR, Qureshi AI. Interventional neuroimaging. Neurol Clin 2008; 27:109-37, viii. [PMID: 19055977 DOI: 10.1016/j.ncl.2008.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Interventional neuroimaging procedures are becoming more effective and safer. This article discusses the therapeutic benefits of endovascular procedures for commonly encountered clinical situations in cerebrovascular disease and brain tumors and then briefly discusses the advances in interventional neuroimaging modalities. Each topic is subdivided into prevalence/natural course, techniques/interventions, summary of clinical trials, and current guidelines/recommendations from professional organizations, whenever applicable.
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Affiliation(s)
- Rakesh Khatri
- Zeenat Qureshi Stroke Research Center, Minnesota Stroke Initiative, University of Minnesota, Minneapolis, MN 55455, USA.
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21
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Treatment of symptomatic high-grade intracranial stenoses with the balloon-expandable Pharos stent: initial experience. Neuroradiology 2008; 50:701-8. [DOI: 10.1007/s00234-008-0394-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2008] [Accepted: 03/27/2008] [Indexed: 10/22/2022]
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22
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Puetz V, Gahn G, Becker U, Mucha D, Mueller A, Weir NU, Wiedemann B, von Kummer R. Endovascular therapy of symptomatic intracranial stenosis in patients with impaired regional cerebral blood flow or failure of medical therapy. AJNR Am J Neuroradiol 2008; 29:273-80. [PMID: 17989370 DOI: 10.3174/ajnr.a0829] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Symptomatic intracranial stenoses have a high risk for a recurrent stroke if treated medically. Although angioplasty and stent placement are proposed treatment options, data on longer-term outcome are limited. MATERIALS AND METHODS We analyzed all endovascular procedures on symptomatic intracranial stenosis at our institution from January 1998 to December 2005. We retrospectively assigned patients to group A (symptoms despite antithrombotic therapy) or group B (impaired regional cerebral blood flow [rCBF]). Primary outcome events were periprocedural major complications or recurrent ischemic strokes in the territory of the treated artery. We used the Kaplan-Meier method to calculate survival probabilities. RESULTS The procedural technical success rate was 92% (35/38) with periprocedural major complications in 4 cases (10.5%; group A [8.3%, 2/24], group B [14.3%, 2/14]). Median (range) follow-up for the 33 patients with technically successful procedures was 21 (0-72) months. Recurrent ischemic strokes occurred in 15% (3/20) of patients in group A and 0% (0/13) of patients in group B. Overall, there were 21% (7/33) primary outcome events (group A [25%, 5/20], group B [15%, 2/13]). There was a nonsignificant trend for better longer-term survival free of a major complication or recurrent stroke in patients with impaired rCBF compared with patients who were refractory to medical therapy treatment (Kaplan-Meier estimate 0.85 [SE 0.10] vs 0.72 [SE 0.11] at 2 years, respectively). CONCLUSION Interventional treatment of symptomatic intracranial stenosis carries significant risk for complications and recurrent stroke in high-risk patients. The observation that patients with impaired rCBF may have greater longer-term benefit than medically refractory deserves further study.
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Affiliation(s)
- V Puetz
- Department of Neurology, Dresden Stroke Center,University of Technology, Dresden, Germany.
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23
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Zaidat OO, Klucznik R, Alexander MJ, Chaloupka J, Lutsep H, Barnwell S, Mawad M, Lane B, Lynn MJ, Chimowitz M. The NIH registry on use of the Wingspan stent for symptomatic 70-99% intracranial arterial stenosis. Neurology 2008; 70:1518-24. [PMID: 18235078 DOI: 10.1212/01.wnl.0000306308.08229.a3] [Citation(s) in RCA: 247] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial showed that patients with symptomatic 70% to 99% intracranial arterial stenosis are at particularly high risk of ipsilateral stroke on medical therapy: 18% at 1 year (95% CI = 3% to 24%). The Wingspan intracranial stent is another therapeutic option but there are limited data on the technical success of stenting and outcome of patients with 70% to 99% stenosis treated with a Wingspan stent. METHODS Sixteen medical centers enrolled consecutive patients treated with a Wingspan stent in this registry between November 2005 and October 2006. Data on stenting indication, severity of stenosis, technical success (stent placement across the target lesion with <50% residual stenosis), follow-up angiography, and outcome were collected. RESULTS A total of 129 patients with symptomatic 70% to 99% intracranial stenosis were enrolled. The technical success rate was 96.7%. The mean pre and post-stent stenoses were 82% and 20%. The frequency of any stroke, intracerebral hemorrhage, or death within 30 days or ipsilateral stroke beyond 30 days was 14.0% at 6 months (95% CI = 8.7% to 22.1%). The frequency of >or=50% restenosis on follow-up angiography was 13/52 (25%). CONCLUSION The use of a Wingspan stent in patients with severe intracranial stenosis is relatively safe with high rate of technical success with moderately high rate of restenosis. Comparison of the event rates in high-risk patients in Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) vs this registry do not rule out either that stenting could be associated with a substantial relative risk reduction (e.g., 50%) or has no advantage compared with medical therapy. A randomized trial comparing stenting with medical therapy is needed.
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Affiliation(s)
- O O Zaidat
- Associate Medical College of Wisconsin/Froedtert Hospital, 9200 W Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Rabia K, Khoo E. Recurrent stroke: what have we learnt? MALAYSIAN FAMILY PHYSICIAN : THE OFFICIAL JOURNAL OF THE ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA 2007; 2:70-3. [PMID: 25606084 PMCID: PMC4170336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Stroke is the third leading cause of death, a major cause of disability in adults, and is frequently more disabling than fatal. With a decline in mortality from initial cerebral infarction and an increase in the life expectancy of the population, the number of patients with recurrent stroke and ensuing cardiovascular events will become greater. Thus it is important to find out those patients at high risk of stroke recurrence. This case report illustrates the process of recurrent stroke and the resulting disabilities and morbidities in a 42-year- old man. The role of integrated stroke rehabilitation programme is described.
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Fussell D, Schumacher HC, Meyers PM, Higashida RT. Mechanical interventions to treat acute stroke. Curr Neurol Neurosci Rep 2007; 7:21-7. [PMID: 17217850 DOI: 10.1007/s11910-007-0017-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The approach to stroke therapy has historically been limited due to the existence of relatively few treatment options and the necessity for action within 3 hours of symptom onset. As neuroimaging technology advances, fertile new ground is revealed for novel therapies. Recently, a number of exciting mechanical systems have been developed with potential efficacy even hours after cerebrovascular occlusion: endovascular clot disruption, endovascular clot extraction, and angioplasty with stenting are currently under study, with promising initial results. With more options, each with greater effectiveness in a particular clinical scenario, the physician is now better equipped than ever to treat acute ischemic stroke successfully.
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Affiliation(s)
- David Fussell
- Doris and Stanley Tananbaum Stroke Center, Neurological Institute of New York, New York, NY 10032, USA
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Affiliation(s)
- Ming Liu
- Stroke Clinical Research Unit, Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China.
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