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Safety and efficacy of balloon angioplasty in symptomatic intracranial stenosis: A systematic review and meta-analysis. J Neuroradiol 2020; 47:27-32. [DOI: 10.1016/j.neurad.2019.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/16/2019] [Accepted: 02/27/2019] [Indexed: 11/18/2022]
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Sauvageau E, Ecker RD, Levy EI, Hanel RA, Guterman LR, Hopkins LN. Recent advances in endoluminal revascularization for intracranial atherosclerotic disease. Neurol Res 2013; 27 Suppl 1:S89-94. [PMID: 16197832 DOI: 10.1179/016164105x35486] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
More than 750,000 strokes occur annually in the United States. Of these, 8-10% are due to intracranial atherosclerosis. Less than 50% of patients with strokes from intracranial atherosclerosis will have a transient ischemic attack. For those patients with symptomatic intracranial atherosclerosis, the prognosis is poor; and the recent Warfarin-Aspirin Symptomatic Intracranial Stenosis (WASID) trial results have demonstrated the high risk of warfarin without clear benefit. Intracranial angioplasty and stenting is emerging as a viable and effective treatment alternative for patients with symptomatic intracranial stenosis. Advances in stent design, endovascular wires, and catheters and balloons are allowing endovascular surgeons to safely treat intracranial atherosclerosis. Wider clinical experience has led to refinement of patient selection and endoluminal techniques. Drug eluting-stents have the promise of decreasing the risk of restenosis. In this review, the most recent clinical, laboratory, and technical details for the treatment of intracranial angioplasty and stenting are discussed.
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Affiliation(s)
- Eric Sauvageau
- Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, State University of New York, University at Buffalo, Buffalo, New York 14209-1194, USA
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Hassan AE, Akbar U, Chaudhry SA, Tekle WG, Tummala RP, Rodriguez GJ, Qureshi AI. Rate and prognosis of patients under conscious sedation requiring emergent intubation during neuroendovascular procedures. AJNR Am J Neuroradiol 2013; 34:1375-9. [PMID: 23370474 DOI: 10.3174/ajnr.a3385] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Neuroendovascular procedures are performed with the patient under conscious sedation (local anesthesia) in varying numbers of patients in different institutions, though the risk of unplanned conversion to general anesthesia is poorly characterized. Our aim was to ascertain the rate of failure of conscious sedation in patients undergoing neuroendovascular procedures and compare the in-hospital outcomes of patients who were converted from conscious sedation to general anesthesia with those whose procedures were initiated with general anesthesia. MATERIALS AND METHODS All patients who had an endovascular procedure initiated under general anesthesia or conscious sedation were identified through a prospective data base maintained at 2 comprehensive stroke centers. Patient clinical and procedural characteristics, in-hospital deaths, and favorable outcomes (modified Rankin Scale score, 0-2) at discharge were ascertained. RESULTS Nine hundred seven endovascular procedures were identified, of which 387 were performed with the patient under general anesthesia, while 520 procedures were initiated with conscious sedation. Among procedures initiated with intent to be performed under conscious sedation, 9 (1.7%) procedures required emergent conversion to general anesthesia. Favorable clinical outcome and in-hospital mortality in patients requiring emergent conversion from conscious sedation to general anesthesia and in those with procedures initiated with general anesthesia were not statistically different (42% versus 50%, P = .73 and 17% versus 13%, P = 1.00, respectively). CONCLUSIONS In our study, there was a very low rate of conscious sedation failure and associated adverse outcomes among patients undergoing neuroendovascular procedures. Proper patient selection is important if procedures are to be performed with the patient under conscious sedation. Limitations of the methodology used in our study preclude us from offering specific recommendations regarding when to use a specific anesthetic protocol.
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Affiliation(s)
- A E Hassan
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, MN 55455,
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4
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Don't Hurt My Brain … It's My Second Favorite Organ. JACC Cardiovasc Interv 2013; 6:392-3. [DOI: 10.1016/j.jcin.2013.01.133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Accepted: 01/18/2013] [Indexed: 11/22/2022]
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Badawi RA, White CJ, Collins TJ, Jenkins JS, Reilly JP, Grise MA, McMullan PW, Ramee SR. Elective percutaneous intervention for intracranial atherosclerotic stenoses by interventional cardiologists. Catheter Cardiovasc Interv 2012; 80:121-7. [DOI: 10.1002/ccd.23439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 10/13/2011] [Indexed: 11/10/2022]
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Li J, Zhao ZW, Gao GD, Cheng JM. Wingspan stenting with modified predilation for symptomatic middle cerebral artery stenosis. Catheter Cardiovasc Interv 2011; 78:286-93. [PMID: 20824757 DOI: 10.1002/ccd.22755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Accepted: 07/20/2010] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Our purpose was to assess the feasibility, safety, and effectiveness of a modified predilation for middle cerebral artery (MCA) stenosis. BACKGROUND Wingspan stenting of MCA remains a technical challenge, and rates of residual stenosis and restenosis must be lowered. METHODS A series of 48 patients with symptomatic MCA stenosis greater than 50% and refractory to medical therapy underwent Wingspan stenting with different balloon/artery ratios before (group 1, Boston guidelines predilation) or after (group 2, modified predilation) July of 2008. Technical success, periprocedural complications, recurrent symptoms, and restenosis were assessed retrospectively, and risk factors for restenosis were analyzed using logistic regression. RESULTS Successful stenting occurred in 48 of 49 (98%) lesions. Primary endpoints within 30 days included one (2.12%) minor stroke and two (4.26%) transient ischemic attacks. Stenoses were reduced from 77.11% ± 10.09% to 27.50% ± 6.91% in group 1 versus from 72.56% ± 10.46% to 8.20% ± 5.41% in group 2. A total of 43 patients were followed up for 12.92 ± 5.08 months, and recurrent stroke or transient ischemic attack occurred in two (4.65%) patients. Vessels were followed with transcranial Doppler (43 vessels), angiography (23 vessels), or computed tomographic angiography (one vessel). The restenosis rate was 8 of 18 (44%) in group 1 and 3 of 25 (12%) in group 2. Restenosis was associated with residual stenosis and diabetes. CONCLUSIONS Wingspan stenting for symptomatic MCA stenosis can be performed with high success and low complication rates, and modified predilation with the Gateway balloon can reduce the rates of residual stenosis and restenosis.
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Affiliation(s)
- Jian Li
- Department of Interventional Neuroradiology and Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shanxi, China
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9
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Chamczuk AJ, Ogilvy CS, Snyder KV, Ohta H, Siddiqui AH, Hopkins LN, Levy EI. Elective stenting for intracranial stenosis under conscious sedation. Neurosurgery 2011; 67:1189-93; discussion 1194. [PMID: 20871450 DOI: 10.1227/neu.0b013e3181efbcac] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Elective stenting for intracranial stenosis is under study as an effective means of reducing stroke risk. At most institutions, these procedures are performed and monitored after the induction of general anesthesia. OBJECTIVE To report our success with elective intracranial stenting and angioplasty performed in conscious patients after the administration of mild sedatives and local anesthetic agents. METHODS We retrospectively evaluated data from 66 patients who underwent elective intracranial stenting for atherosclerosis. Sixty-one procedures were performed under local anesthesia with mild sedation; 3 were performed under general anesthesia, and 2 were converted from local to general anesthesia during the procedure. Intraprocedural neurological changes were monitored and led to reevaluation of technique, immediate reimaging, modifying the endovascular procedure itself, or possibly mandating conversion to general anesthesia. RESULTS Thirty-nine anterior and 27 posterior circulation stenotic segments were treated. Angiographic success was achieved in 95.5% of patients with an overall reduction in stenosis of 75.5 to 22.3%. Percutaneous angioplasty and stenting were used in 58 cases; 8 patients were treated with stenting alone. Three patients (4.9%) developed neurological deficits mandating alteration or adjustment of endovascular technique or immediate postoperative management to avoid permanent sequelae. A total of 8 periprocedural complications occurred, 2 of which resulted in permanent neurological deficit. The overall mortality rate was 3.2%. CONCLUSIONS Stenting of intracranial atherosclerosis performed under conscious sedation is associated with complication rates and effectiveness similar to historical rates for general anesthesia. Conscious sedation confers the additional benefit of continuous neurological assessment during the procedure.
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Affiliation(s)
- Andrea J Chamczuk
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University New York, Buffalo, New York, USA
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Interventional Neuroradiologic Therapy of Atherosclerotic Disease and Vascular Malformations. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10061-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Sugg RM, Jackson AS, Holloway W, Martin CO, Akhtar N, Rymer M. Is mechanical embolectomy performed in nonanesthetized patients effective? AJNR Am J Neuroradiol 2010; 31:1533-5. [PMID: 20395385 DOI: 10.3174/ajnr.a2091] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In centers performing endovascular treatment for patients with AIS, there is variability in placing patients under general anesthesia. Nonanesthetized patients might move during the procedure leading to complications and prolonging the time to revascularization due to lack of cooperation. However, general anesthesia can lead to a delay of the procedure, an inability to assess the patient during the procedure, and fluctuations of blood pressure. Our center does not routinely either use general anesthesia or sedate patients. We report our experience with nonanesthetized patients undergoing emergent mechanical embolectomy. MATERIALS AND METHODS We performed a retrospective analysis of 66 consecutive patients enrolled in the MERCI Registry at our center from June 2007 to June 2009. A univariate statistical analysis was performed by using the Fisher exact test for categoric variables and the Student t test for continuous variables in comparing use of general anesthesia with nonanesthetized patient demographics, procedural times, procedural complications, good outcome, and mortality. RESULTS Nine patients (13.6%) were placed under general anesthesia, and 57 (86.4%) were awake. Higher baseline NIHSS scores and older age were statistically associated with general anesthesia. No significant difference occurred between groups in the time to groin puncture or procedural times. Revascularization rates were 77% for general anesthesia patients and 70% for nonanesthetized patients (P = .331). The nonanesthetized group had better outcomes, but we did not control these outcomes for other factors. Complications were much more frequent in the general anesthesia patients (22%) than in the nonanesthetized patients (3.5%) (P = .0288). CONCLUSIONS Performing mechanical embolectomy in nonanesthetized patients at our institution does not prolong procedure time, decrease revascularization rates, increase complication rates, or decrease good outcome. Mechanical embolectomy in nonanesthetized patients is effective and should be considered an option in the treatment of the patient with AIS.
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Affiliation(s)
- R M Sugg
- Saint Luke's Hospital, Kansas City, Missouri, USA.
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Siddiq F, Memon MZ, Vazquez G, Safdar A, Qureshi AI. COMPARISON BETWEEN PRIMARY ANGIOPLASTY AND STENT PLACEMENT FOR SYMPTOMATIC INTRACRANIAL ATHEROSCLEROTIC DISEASE. Neurosurgery 2009; 65:1024-33; discussion 1033-4. [PMID: 19934961 DOI: 10.1227/01.neu.0000360138.54474.52] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
To compare the short- and long-term rates of stroke-and/or-death associated with primary angioplasty alone and angioplasty with stent placement using a meta-analysis of published studies. Both primary angioplasty alone and angioplasty with stent placement have been proposed as treatment strategies for symptomatic intracranial atherosclerotic disease to reduce the risk of stroke-and/or-death with best medical treatment alone. However, it remains unclear which of these endovascular techniques offers the best risk reduction.
METHODS
We identified pertinent studies published between January 1980 and May 2008 using a search on PubMed and Cochrane libraries, supplemented by a review of bibliographies of selected publications. The incidences of stroke-and/or-death were estimated for each report and pooled for both angioplasty alone and angioplasty with stent placement at 1 month and 1 year postintervention and then compared using a random-effects model. The association of year of publication and 1-year incidence of stroke-and/or-death was analyzed with meta-regression.
RESULTS
After applying our selection criteria, we included 69 studies (33 primary angioplasty-alone studies [1027 patients] and 36 studies of angioplasty with stent placement [1291 patients]) in the analysis. There were a total of 91 stroke-and/or-deaths reported in the angioplasty-alone–treated group (8.9%; 95% confidence interval [CI], 7.1%–10.6%), compared with 104 stroke-and/or-deaths in the angioplasty-with-stent–treated group (8.1%; 95% CI, 6.6%–9.5%) during a 1-month period (relative risk [RR], 1.1; P = 0.48). The pooled incidence of 1-year stroke-and/or-death in patients treated with angioplasty alone was 19.7% (95% CI, 16.6%–23.5%), compared with 14.2% (95% CI, 11.9%–16.9%) in the angioplasty-with-stent–treated patients (RR, 1.39; P = 0.009). The incidence of technical success was 79.8% (95% CI, 74.7%–84.8%) in the angioplasty-alone group and 95% (95% CI, 93.4%–96.6%) in the angioplasty-with-stent–treated group (RR, 0.84; P < 0.0001). The pooled restenosis rate was 14.2% (95% CI, 11.8–16.6%) in the angioplasty-alone group, as compared with 11.1% (95% CI, 9.2%–13.0%) in the angioplasty-with-stent–treated group (RR, 1.28; P = 0.04). There was no effect of the publication year of the studies on the risk of stroke-and/or-death.
CONCLUSION
Risk of 1-year stroke-and/or-death and rate of angiographic restenosis may be lower in symptomatic intracranial atherosclerosis patients treated by angioplasty with stent placement compared with patients treated by angioplasty alone.
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Affiliation(s)
- Farhan Siddiq
- Department of Neurosurgery and Neurology, Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota(Siddiq)
| | | | - Gabriela Vazquez
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota
| | - Adnan Safdar
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota
| | - Adnan I. Qureshi
- Department of Neurosurgery and Neurology, Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota(Siddiq)
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Schumacher HC, Meyers PM, Higashida RT, Derdeyn CP, Lavine SD, Nesbit GM, Sacks D, Rasmussen P, Wechsler LR. Reporting standards for angioplasty and stent-assisted angioplasty for intracranial atherosclerosis. J Vasc Interv Radiol 2009; 20:S451-73. [PMID: 19560032 DOI: 10.1016/j.jvir.2009.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2008] [Revised: 10/27/2008] [Accepted: 11/04/2008] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND AND PURPOSE Intracranial cerebral atherosclerosis causes ischemic stroke in a significant number of patients. Technological advances over the past 10 years have enabled endovascular treatment of intracranial atherosclerotic stenosis. The number of patients treated with angioplasty or stent-assisted angioplasty for this condition is increasing. Given the lack of universally accepted definitions, the goal of this document is to provide consensus recommendations for reporting standards, terminology, and written definitions when reporting clinical and radiological evaluation, technique, and outcome of endovascular treatment using angioplasty or stent-assisted angioplasty for stenotic and occlusive intracranial atherosclerosis. SUMMARY OF REPORT This article was written under the auspices of Joint Writing Group of the Technology Assessment Committee, Society of NeuroInterventional Surgery, Society of Interventional Radiology; Joint Section on Cerebrovascular Neurosurgery of the American Association of Neurological Surgeons and Congress of Neurological Surgeons; and the Section of Stroke and Interventional Neurology of the American Academy of Neurology. A computerized search of the National Library of Medicine database of literature (PubMed) from January 1997 to December 2007 was conducted with the goal to identify published endovascular cerebrovascular interventional data in stenotic intracranial atherosclerosis that could be used as benchmarks for quality assessment. We sought to identify those risk adjustment variables that affect the likelihood of success and complications. This document offers the rationale for different clinical and technical considerations that may be important during the design of clinical trials for endovascular treatment of intracranial stenotic and occlusive atherosclerosis. Included in this guidance document are suggestions for uniform reporting standards for such trials. These definitions and standards are primarily intended for research purposes; however, they should also be helpful in clinical practice and applicable to all publications. CONCLUSION In summary, the definitions proposed represent recommendations for constructing useful research data sets. The intent is to facilitate production of scientifically rigorous results capable of reliable comparisons between and among similar studies. In some cases, the definitions contained here are recommended by consensus of a panel of experts in this writing group for consistency in reporting and publication. These definitions should allow different groups to publish results that are directly comparable.
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Affiliation(s)
- H Christian Schumacher
- Saul R. Korey Department of Neurology, Division of Vascular Neurology and Neurocritical Care, Albert Einstein College of Medicine, Bronx, NY, USA
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Schumacher HC, Meyers PM, Higashida RT, Derdeyn CP, Lavine SD, Nesbit GM, Sacks D, Rasmussen P, Wechsler LR. Reporting Standards for Angioplasty and Stent-Assisted Angioplasty for Intracranial Atherosclerosis. Stroke 2009; 40:e348-65. [PMID: 19246710 DOI: 10.1161/strokeaha.108.527580] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Intracranial cerebral atherosclerosis causes ischemic stroke in a significant number of patients. Technological advances over the past 10 years have enabled endovascular treatment of intracranial atherosclerotic stenosis. The number of patients treated with angioplasty or stent-assisted angioplasty for this condition is increasing. Given the lack of universally accepted definitions, the goal of this document is to provide consensus recommendations for reporting standards, terminology, and written definitions when reporting clinical and radiological evaluation, technique, and outcome of endovascular treatment using angioplasty or stent-assisted angioplasty for stenotic and occlusive intracranial atherosclerosis.
Summary of Report—
This article was written under the auspices of Joint Writing Group of the Technology Assessment Committee, Society of NeuroInterventional Surgery, Society of Interventional Radiology; Joint Section on Cerebrovascular Neurosurgery of the American Association of Neurological Surgeons and Congress of Neurological Surgeons; and the Section of Stroke and Interventional Neurology of the American Academy of Neurology. A computerized search of the National Library of Medicine database of literature (PubMed) from January 1997 to December 2007 was conducted with the goal to identify published endovascular cerebrovascular interventional data in stenotic intracranial atherosclerosis that could be used as benchmarks for quality assessment. We sought to identify those risk adjustment variables that affect the likelihood of success and complications. This document offers the rationale for different clinical and technical considerations that may be important during the design of clinical trials for endovascular treatment of intracranial stenotic and occlusive atherosclerosis. Included in this guidance document are suggestions for uniform reporting standards for such trials. These definitions and standards are primarily intended for research purposes; however, they should also be helpful in clinical practice and applicable to all publications.
Conclusion—
In summary, the definitions proposed represent recommendations for constructing useful research data sets. The intent is to facilitate production of scientifically rigorous results capable of reliable comparisons between and among similar studies. In some cases, the definitions contained here are recommended by consensus of a panel of experts in this writing group for consistency in reporting and publication. These definitions should allow different groups to publish results that are directly comparable.
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Affiliation(s)
- H Christian Schumacher
- Saul R Korey Department of Neurology, Division of Vascular Neurology and Neurocritical Care, Albert Einstein College of Medicine, Bronx, NY, USA
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Mazighi M, Abou-Chebl A. Management of symptomatic intracranial arterial stenosis: endovascular therapy. Curr Atheroscler Rep 2006; 8:298-303. [PMID: 16822395 DOI: 10.1007/s11883-006-0007-y] [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: 12/19/2022]
Abstract
Patients with symptomatic intracranial stenosis are at high risk of subsequent stroke despite the use of antithrombotic agents or surgical management. Although endovascular therapy appears to promise therapeutic solutions, the reported high peri-procedural adverse event rate limits the widespread use of this technique. In the past few years, the morbidity and mortality associated with intracranial angioplasty and stenting have decreased with the development of new intracranial specific devices. The most recent prospective studies on intracranial stenting have been nothing more than registries of patients with symptomatic intracranial stenosis of 50% or greater who have failed medical therapy. However, no randomized controlled data exist on the comparison between endovascular therapy and medical treatment. There are new data identifying factors associated with a higher risk of stroke in medically treated patients. These findings will help to define a high-risk patient population on whom the initial controlled trials will be conducted.
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Affiliation(s)
- Mikael Mazighi
- Department of Neurology, S 90, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Ecker RD, Levy EI, Sauvageau E, Hanel RA, Hopkins LN. Current Concepts in the Management of Intracranial Atherosclerotic Disease. Neurosurgery 2006; 59:S210-8; discussion S3-13. [PMID: 17053605 DOI: 10.1227/01.neu.0000237326.06732.aa] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
MEDICALLY REFRACTORY, SYMPTOMATIC intracranial atherosclerotic disease has a poor prognosis. Based on the results of the Warfarin-Aspirin Symptomatic Intracranial Disease study, the risk of ipsilateral stroke at 1.8 years is between 13 and 14% in patients with symptomatic intracranial atherosclerosis. Synergistic advances in intracranial angioplasty and stenting, modern neuroimaging techniques, and periprocedural and postprocedural antithrombotic regimens are creating new models for the diagnosis and successful endovascular treatment of intracranial stenosis. In this article, the most recent clinical developments and concepts for the diagnosis and endovascular treatment of intracranial atherosclerotic disease are discussed.
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Affiliation(s)
- Robert D Ecker
- Department of Neurosurgery,School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 14209, USA
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Abou-Chebl A, Krieger DW, Bajzer CT, Yadav JS. Intracranial angioplasty and stenting in the awake patient. J Neuroimaging 2006; 16:216-23. [PMID: 16808823 DOI: 10.1111/j.1552-6569.2006.00043.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Endovascular treatment for intracranial atherosclerosis is evolving, but complications remain an issue. Most interventions are performed under general anesthesia, preventing intraprocedural clinical evaluations. We describe our approach to intracranial angioplasty and stenting, using local rather than general anesthesia, and intraprocedural neurological assessment. METHODS We prospectively collected procedural and outcome information on all patients undergoing intracranial angioplasty and stenting. Patients underwent interventions under local anesthesia with mild intravenous sedation or analgesia only if needed. Intraoperative neurological evaluations were performed, and symptomatology was used to guide the interventional technique. RESULTS Forty-eight arteries in 40 patients with a mean age of 65.2 years were treated. Thirty-two anterior and 16 posterior circulation segments were treated. Technical success was achieved in 100% of patients with reduction of the mean pretreatment stenosis from 85 +/- 8.6% to 7 +/- 10.1%. Stents were deployed in 40 segments; five patients were treated with drug-eluting stents. The cobalt-chromium coronary stents were the easiest to deliver. Thirty-seven patients were treated under local anesthesia and, of those, 61.4% experienced intraprocedural symptoms that led to some alteration of the interventional technique. Headache was the most common symptom, and, when persistent, it heralded the occurrence of subarachnoid hemorrhage. There were seven total neurological complications, but only five (10.5%) led to permanent morbidity (4 strokes) or mortality (1 death). CONCLUSIONS Intracranial angioplasty and stenting can be successfully performed using coronary techniques and equipment including drug-eluting stents. Local anesthesia permits neurological evaluations and often leads to the adjustment of the interventional technique, potentially making the procedure safer.
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Affiliation(s)
- Alex Abou-Chebl
- Department of Neurology, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Abstract
BACKGROUND Intracranial artery stenosis causes up to 10% of all ischaemic strokes. The rate of recurrent vascular ischaemic events is very high. Angioplasty with or without stent placement is a feasible procedure to dilate the vessel affected. However, its safety and efficacy have not been systematically studied. OBJECTIVES To determine the efficacy and safety of angioplasty combined with best medical treatment compared with best medical treatment alone in patients with acute ischaemic stroke or transient ischaemic attack (TIA) resulting from intracranial artery stenosis for preventing recurrent ischaemic strokes, death, and vascular events. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched March 2006). In addition we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2006), MEDLINE (1966 to March 2006), EMBASE (1980 to February 2006) and Science Citation Index (1945 to March 2006). To identify further published, unpublished and ongoing trials we searched reference lists of relevant articles and contacted authors and experts in the field. SELECTION CRITERIA Randomised or otherwise controlled studies comparing best medical care plus angioplasty of the intracranial cerebral arteries, with or without stent placement, with best medical care alone. Studies were only included if data for clinical significant endpoints such as recurrent ischaemic stroke, haemorrhagic stroke and death were available. DATA COLLECTION AND ANALYSIS Two review authors selected trials for inclusion, and independently assessed trial quality and extracted data. Calculation of relative treatment effects with subgroup analysis was done if possible. MAIN RESULTS No randomised controlled trials were found. There were 79 articles of interest consisting of open-label case series with three or more cases. The safety profile of the procedure showed an overall perioperative rate of stroke of 7.9% (95% confidence intervals (CI) 5.5% to 10.4%), perioperative death of 3.4% (95% CI 2.0% to 4.8%), and perioperative stroke or death of 9.5% (95% CI 7.0% to 12.0%). No comments can be made on the effectiveness of the procedure. AUTHORS' CONCLUSIONS At present there is insufficient evidence to recommend angioplasty with or without stent placement in routine practice for the prevention of stroke in patients with intracranial artery stenosis. The descriptive studies show that the procedure is feasible although carries a significant morbidity and mortality risk. Evidence from randomised controlled trials is needed to assess the safety of angioplasty and its effectiveness in preventing recurrent stroke.
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Affiliation(s)
- S Cruz-Flores
- Saint Louis University School of Medicine, Department of Neurology, 3635 Vista Avenue, St. Louis, Missouri 63110, USA.
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Alberts MJ, Latchaw RE, Selman WR, Shephard T, Hadley MN, Brass LM, Koroshetz W, Marler JR, Booss J, Zorowitz RD, Croft JB, Magnis E, Mulligan D, Jagoda A, O'Connor R, Cawley CM, Connors JJ, Rose-DeRenzy JA, Emr M, Warren M, Walker MD. Recommendations for Comprehensive Stroke Centers. Stroke 2005; 36:1597-616. [PMID: 15961715 DOI: 10.1161/01.str.0000170622.07210.b4] [Citation(s) in RCA: 400] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
To develop recommendations for the establishment of comprehensive stroke centers capable of delivering the full spectrum of care to seriously ill patients with stroke and cerebrovascular disease. Recommendations were developed by members of the Brain Attack Coalition (BAC), which is a multidisciplinary group of members from major professional organizations involved with the care of patients with stroke and cerebrovascular disease.
Summary of Review—
A comprehensive literature search was conducted from 1966 through December 2004 using Medline and Pub Med. Articles with information about clinical trials, meta-analyses, care guidelines, scientific guidelines, and other relevant clinical and research reports were examined and graded using established evidence-based medicine approaches for therapeutic and diagnostic modalities. Evidence was also obtained from a questionnaire survey sent to leaders in cerebrovascular disease. Members of BAC reviewed literature related to their field and graded the scientific evidence on the various diagnostic and treatment modalities for stroke. Input was obtained from the organizations represented by BAC. BAC met on several occasions to review each specific recommendation and reach a consensus about its importance in light of other medical, logistical, and financial factors.
Conclusions—
There are a number of key areas supported by evidence-based medicine that are important for a comprehensive stroke center and its ability to deliver the wide variety of specialized care needed by patients with serious cerebrovascular disease. These areas include: (1) health care personnel with specific expertise in a number of disciplines, including neurosurgery and vascular neurology; (2) advanced neuroimaging capabilities such as MRI and various types of cerebral angiography; (3) surgical and endovascular techniques, including clipping and coiling of intracranial aneurysms, carotid endarterectomy, and intra-arterial thrombolytic therapy; and (4) other specific infrastructure and programmatic elements such as an intensive care unit and a stroke registry. Integration of these elements into a coordinated hospital-based program or system is likely to improve outcomes of patients with strokes and complex cerebrovascular disease who require the services of a comprehensive stroke center.
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Affiliation(s)
- Mark J Alberts
- Northwestern University Medical School, 710 N Lake Shore Dr, Room 1420, Chicago, IL 60611, USA.
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Engh JA, Levy EI, Howington JU, Guterman LR. Intracranial angioplasty and stenting: modern approaches to revascularization for atherosclerotic disease. Neurosurg Clin N Am 2005; 16:297-308, ix. [PMID: 15694162 DOI: 10.1016/j.nec.2004.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Johnathan A Engh
- Department of Neurosurgery, University of Pittsburgh, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
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21
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Schumacher HC, Khaw AV, Meyers PM, Gupta R, Higashida RT. Intracranial Revascularization Therapy: Angioplasty and Stenting. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2004; 6:193-198. [PMID: 15096310 DOI: 10.1007/s11936-996-0013-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Depending on the population studied, intracranial atherosclerosis accounts for 10% to 29% of ischemic brain events. A significant number of patients with intracranial atherosclerosis continue to suffer from repeated strokes or transient ischemic attacks despite optimal medical management. In selected patients, intracranial angioplasty with or without stenting is a promising treatment option. Patient selection, careful periprocedural medical management, and a highly skilled neuroendovascular interventionalist are required in order to perform the procedure with an acceptable risk.
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Affiliation(s)
- H. Christian Schumacher
- Neuroendovascular Service, Departments of Radiology and Neurological Surgery, Columbia and Cornell University Medical Centers, Neurological Institute
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22
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Boulos AS, Levy EI, Bendok BR, Kim SH, Qureshi AI, Guterman LR, Hopkins LN. Evolution of Neuroendovascular Intervention: A Review of Advancement in Device Technology. Neurosurgery 2004; 54:438-52; discussion 452-3. [PMID: 14744291 DOI: 10.1227/01.neu.0000103672.96785.42] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2002] [Accepted: 10/08/2003] [Indexed: 11/19/2022] Open
Abstract
Abstract
NEUROENDOVASCULAR SURGERY IS a rapidly evolving field. Each year, numerous improvements are made in the endovascular surgeon's armamentarium. This evolution in technology, which is occurring at a dizzying pace, addresses many of the current limitations of neuroendovascular approaches. The potential to improve the outcomes of our patients is tremendous, particularly because one of the most common and most devastating neurological disorders, ischemic stroke, remains largely untreated. This article presents several of the new technologies that are currently being investigated or are under development and have the potential to lead to major advances in endovascular approaches for the treatment of intracranial and extracranial diseases.
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Affiliation(s)
- Alan S Boulos
- Department of Neurosurgery and Toshiba Stroke Research Center, University at Buffalo, State University of New York, 3 Gates Circle, Buffalo, NY 14209-1194, USA
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Schumacher HC, Khaw AV, Meyers PM, Gupta R, Higashida RT. Intracranial Angioplasty and Stent Placement for Cerebral Atherosclerosis. J Vasc Interv Radiol 2004; 15:S123-32. [PMID: 15101521 DOI: 10.1097/01.rvi.0000107488.61085.8f] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Intracranial atherosclerotic stenoses have been estimated to account for 8%-10% of all ischemic strokes. A substantial number of patients fail the best medical treatment, which includes control of vascular risk factors and administration of antithrombotics (platelet-active drugs or warfarin), statins, and angiotensin-converting enzyme inhibitors. In these patients, angioplasty with stent placement is one reasonable treatment option for preventing massive ischemic stroke. Herein, we discuss basic pathophysiologic concepts and their effect on endovascular revascularization procedures.
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Affiliation(s)
- H Christian Schumacher
- Doris and Stanley Tananbaum Stroke Center, Neurological Institute, New York-Presbyterian Hospital, College of Physicians & Surgeons, Columbia University, 710 West 168th Street, New York, NY 10032, USA
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24
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Levy EI, Kim SH, Bendok BR, Boulos AS, Xavier AR, Yahia AM, Qureshi AI, Guterman LR, Hopkins LN. Interventional Neuroradiologic Therapy. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50087-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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25
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Han PP, Albuquerque FC, Ponce FA, MacKay CI, Zabramski JM, Spetzler RF, McDougall CG. Percutaneous intracranial stent placement for aneurysms. J Neurosurg 2003; 99:23-30. [PMID: 12854739 DOI: 10.3171/jns.2003.99.1.0023] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intracranial stent placement combined with coil embolization is an emerging procedure for the treatment of intracranial aneurysms. The authors report their results using intracranial stents for the treatment of intracranial aneurysms. METHODS A prospectively maintained database was reviewed to identify all patients with intracranial aneurysms that were treated with intracranial stents. Ten lesions, including eight broad-based aneurysms and two dissecting aneurysms, were treated in 10 patients. Four lesions were located in the cavernous segment of the internal carotid artery, two at the vertebrobasilar junction, two at the basilar trunk, one at the basilar apex, and one in the intracranial vertebral artery. Attempts were made to place stents in 13 patients, but in three the stents could not be delivered. Altogether, intracranial stents were placed in 10 patients for 10 lesions. Results that were determined to be satisfactory angiographically were achieved in all 10 lesions. Two patients suffered permanent neurological deterioration related to stent placement. In two patients, the aneurysm recurred after stent-assisted coil embolization. In one case of recurrence a second attempt at coil embolization was successful, whereas in the second case of recurrence parent vessel occlusion was required and well tolerated. CONCLUSIONS Intracranial stents can be a useful addition to coil embolization by providing mechanical, hemodynamic, and visual benefits in the treatment of complex, broad-based aneurysms.
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Affiliation(s)
- Patrick P Han
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013-4496, USA
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26
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Martínez-Rodrigo J, Agramunt-Lerma M, Poyatos C, Taberner-Andrés P, Lonjedo-Vicent E, Ruiz-Guanter A. Colocación de endoprótesis vascular sin dilatación previa en estenosis intracraneal de la carótida interna. A propósito de un caso. ANGIOLOGIA 2003. [DOI: 10.1016/s0003-3170(03)74786-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Stroke is the most common life-threatening neurologic disease and the leading cause of serious long-term disability. The advent of new treatment options for selected patients suffering ischemic stroke (such as systemic administration of tissue plasminogen activator or catheter-guided intra-arterial thrombolysis), the structural reorganization of patient care facilities into stroke units, and interdisciplinary cerebrovascular centers have broadened the scope of possible therapeutic interventions in the acute and post-acute phase after cerebral ischemia. This review summarizes currently available and recommended treatment modalities for acute ischemic stroke from an interdisciplinary perspective, including medical, neurointerventional, and neurosurgical therapies.
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Affiliation(s)
- C Stapf
- The Neurological Institute, Columbia University College of Physicians and Surgeons, 710 West 168th Street, New York, New York 10032, USA
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