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Abdollahifard S, Yousefi O, Kamran H, Mowla A. Balloon-mounting stent for intracranial arterial stenosis: A comprehensive and comparative systematic review and meta-analysis. Interv Neuroradiol 2022:15910199221100620. [PMID: 35549530 PMCID: PMC10399500 DOI: 10.1177/15910199221100620] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION As one of the major causes of acute ischemic stroke, intracranial arterial stenosis necessitates an intervention that ranges from medical treatment to balloon angioplasty and stenting. Self-expandable stents (SES) and balloon-mounted stents (BMS) are two types of stents and their comparative efficacy and safety for intracranial stenosis are not well established. METHODS Studies that investigate balloon-mounted stenting for intracranial stenosis were extracted from PubMed, Scopus, and Cochrane library. We sought to gather data on the success rate, change in mean arterial stenosis, and complications such as minor and major stroke and death (MMD), symptomatic intracranial hemorrhage, myocardial infarction, all-cause mortality, and in-stent re-stenosis. RESULTS 3049 patients from 35 studies were included in this study. 20 studies investigated BMS alone and others compared BMS with SES. BMS was significantly more effective in reducing the degree of stenosis compared to SES (Difference in mean -5.953, CI 95% -7.727 to -4.179), had less complications compared to SES such as MMD (8.5% vs. 11.2%) and less in-stent re-stenosis (18.6% vs. 19.6%), but patients with SES experienced a lower rate of all-cause mortality(1.7% vs. 4.1%). CONCLUSION Intracranial stenting with BMS is more effective in reducing the degree of stenosis and has lower rates of complications when compared to SES.
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Affiliation(s)
- Saeed Abdollahifard
- Research center for neuromodulation and pain, Shiraz, Iran.,Student research committee, 48435Shiraz University of Medical Sciences, Shiraz, Iran
| | - Omid Yousefi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, 48435Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hooman Kamran
- Student research committee, 48435Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, 5116University of Southern California (USC), Los Angeles, CA, USA
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John S, Thompson NR, Lesko T, Papesh N, Obuchowski N, Tomic D, Wisco D, Khawaja Z, Uchino K, Man S, Cheng-Ching E, Toth G, Masaryk T, Ruggieri P, Modic M, Hussain MS. Cost Analysis of the Addition of Hyperacute Magnetic Resonance Imaging for Selection of Patients for Endovascular Stroke Therapy. INTERVENTIONAL NEUROLOGY 2017; 6:183-190. [PMID: 29118795 DOI: 10.1159/000472158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background and Purpose Patient selection is important to determine the best candidates for endovascular stroke therapy. In application of a hyperacute magnetic resonance imaging (MRI) protocol for patient selection, we have shown decreased utilization with improved outcomes. A cost analysis comparing the pre- and post-MRI protocol time periods was performed to determine if the previous findings translated into cost opportunities. Materials and Methods We retrospectively identified individuals considered for endovascular stroke therapy from January 2008 to August 2012 who were ≤8 h from stroke symptoms onset. Patients prior to April 30, 2010 were selected based on results of the computed tomography/computed tomography angiography alone (pre-hyperacute), whereas patients after April 30, 2010 were selected based on results of MRI (post-hyperacute MRI). Demographic, outcome, and financial information was collected. Log-transformed average daily direct costs were regressed on time period. The regression model included demographic and clinical covariates as potential confounders. Multiple imputation was used to account for missing data. Results We identified 267 patients in our database (88 patients in pre-hyperacute MRI period, 179 in hyperacute MRI protocol period). Patient length of stay was not significantly different in the hyperacute MRI protocol period as compared to the pre-hyperacute MRI period (10.6 vs. 9.9 days, p < 0.42). The median of average daily direct costs was reduced by 24.5% (95% confidence interval 14.1-33.7%, p < 0.001). Conclusions Use of the hyperacute MRI protocol translated into reduced costs, in addition to reduced utilization and better outcomes. MRI selection of patients is an effective strategy, both for patients and hospital systems.
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Affiliation(s)
- Seby John
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicolas R Thompson
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA.,Neurological Institute Center for Outcomes Research and Evaluation, Cleveland Clinic, Cleveland, Ohio, USA
| | - Terry Lesko
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nancy Papesh
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nancy Obuchowski
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dan Tomic
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dolora Wisco
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Zeshaun Khawaja
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shumei Man
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Esteban Cheng-Ching
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gabor Toth
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Thomas Masaryk
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul Ruggieri
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Modic
- Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Abstract
Angioplasty and stenting for intracranial atherosclerotic stenosis (ICAS) are a last resort for patients with high-grade intracranial stenosis with multiple ischemic events unresponsive to medical therapy. Medical management, consisting of aggressive risk factor control and dual antiplatelet therapy, is superior to angioplasty and stenting for the prevention of future stroke. Future studies of angioplasty and stenting in this population are important, as the stroke risk on medical therapy is 12 % at 1 year and post-procedure stroke rates are similar to rates with medical treatment. There are many issues that will need to be resolved for stenting to offer any benefit, however. Procedural risks of hemorrhagic and ischemic stroke are unacceptably high. High-risk subgroups, potentially based on hemodynamic factors, will need to be identified for future interventional trials. Nevertheless, it is still reasonable to consider angioplasty and stenting for selected patients with multiple recurrent events despite aggressive medical management, but benefits are unclear at this time.
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von Schoenfeldt P, Krützelmann A, Bußmeyer M, Mpotsaris A, Rosenkranz M, Fiehler J, Weber W, Buhk JH. Elective treatment of intracranial stenosis with the balloon-expandable Pharos Vitesse stent: 30-day stroke rate and complications. J Neurointerv Surg 2014; 7:188-93. [PMID: 24510379 DOI: 10.1136/neurintsurg-2013-011019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE Analysis of procedural results and 30-day outcome after intracranial angioplasty and stenting (ICAS) with the balloon-expandable Pharos Vitesse stent system in carefully selected high-risk patients in two high-volume neurovascular centers. MATERIALS AND METHODS 92 patients scheduled for elective ICAS using Pharos Vitesse between August, 2008 and August, 2011 were included. All patients showed high-grade intracranial stenosis and recurrent ischemic events despite best medical treatment at that time. The stroke rates and complications were divided into procedural and 30-day short-term events. RESULTS Successful stent placement was achieved in all but one patient. Ischemic procedural complications occurred in three subjects. 30-Day complications and strokes were seen in four patients: two minor ischemic strokes, one fatal hemorrhage and one non-stroke-related death. Overall, strokes occurred in 6 out of 92 patients (6.5%, 95% CI 3.0% to 13.5%). The total stroke and death rate was 7.6% (95% CI 3.7% to 14.9%). No significant correlation with previously reported risk factors could be found, although a higher rate of ischemic strokes (four out of five) in the posterior circulation was recorded. CONCLUSIONS In patients with intracranial stenosis who experience recurrent ischemic events despite best medical treatment, ICAS, using the balloon-expandable Pharos Vitesse stent, may still be considered as an individual treatment option in high-volume neurovascular centers.
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Affiliation(s)
| | - Anna Krützelmann
- Department of Neurology, University Medical Center Hamburg Eppendorf (UKE), Hamburg, Germany
| | | | - Anastasios Mpotsaris
- Department of Radiology and Neuroradiology, University Cologne, Cologne, Germany
| | | | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg Eppendorf (UKE), Hamburg, Germany
| | - Werner Weber
- Department of Radiology and Neuroradiology, Klinikum Vest, Recklinghausen, Germany
| | - Jan-Hendrik Buhk
- Department of Neuroradiology, University Medical Center Hamburg Eppendorf (UKE), Hamburg, Germany
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Levy EI, Rahman M, Khalessi AA, Beyer PT, Natarajan SK, Hartney ML, Fiorella DJ, Hopkins LN, Siddiqui AH, Mocco J. Midterm clinical and angiographic follow-up for the first Food and Drug Administration-approved prospective, Single-Arm Trial of Primary Stenting for Stroke: SARIS (Stent-Assisted Recanalization for Acute Ischemic Stroke). Neurosurgery 2011; 69:915-20; discussion 920. [PMID: 21552168 DOI: 10.1227/neu.0b013e318222afd1] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Although early data demonstrate encouraging angiographic results following intracranial stent deployment for acute ischemic stroke, longer-term follow-up is necessary to evaluate the clinical outcomes, as well as the durability of angiographic results. OBJECTIVE We report 6-month clinical and radiologic follow-up data of the 20 patients prospectively enrolled in the Stent-Assisted Recanalization in acute Ischemic Stroke (SARIS) trial. METHODS Twenty patients were prospectively enrolled to receive self-expanding intra-arterial stents as first-line therapy for acute ischemic stroke treatment. Patients were scheduled for follow-up 6-months after treatment for clinical evaluation (modified Rankin Scale [mRS] score obtained by a trained certified research nurse/nurse practitioner) and repeat cerebral angiography. Angiographic interpretation was performed by an independent adjudicator. RESULTS At 6 months, the mRS score was ≤3 in 60% of patients (n = 12) and was ≤2 in 55% of patients (n = 11). Mortality at the 6-month follow-up was 35% (n = 7). Follow-up angiography was performed for 85% (11 of 13) of surviving patients. All patients undergoing angiographic follow-up demonstrated Thrombolysis in Myocardial Infarction 3 flow on digital subtraction angiography or stent patency on computed tomographic angiography. None of the patients demonstrated evidence of in-stent stenosis (≥50% vessel narrowing). CONCLUSION The midterm angiographic and clinical results following intracranial stent deployment for acute ischemic stroke are encouraging. Further study of primary stent-for-stroke treatment is warranted.
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Affiliation(s)
- Elad I Levy
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, NY, USA.
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