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Pini R, Faggioli G, Lodato M, Campana F, Vacirca A, Gallitto E, Gargiulo M. Medical and interventional outcome of dissection of the cervical arteries: Systematic review and meta-analysis. J Vasc Surg 2024; 80:913-921.e13. [PMID: 38636608 DOI: 10.1016/j.jvs.2024.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/29/2024] [Accepted: 04/10/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE The management of cervical artery dissections (CADs) is poorly standardized given the scarce number of prospective studies comparing medical and interventional approach to CAD. The aim of the present study is to perform a systematic review and meta-analysis of studies on the treatments of CAD. METHODS Systematic review and meta-analysis (pre-registered on PROSPERO [CRD42022297512] are performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses [PRISMA] guidelines searching in three different databases [PubMed, Embase and Cochrane Database]) of studies on medical or interventional approach to CAD. Only prospective studies were selected to reduce the risk of bias for the primary meta-analysis. Secondarily, retrospective studies were also included. The aim was to assess the rate of stroke and of stroke/death/bleeding (major or intracranial) by Der Simonian-Laird weights of random effects model. RESULTS After screening 456 articles, 6 prospective and 22 retrospective studies were identified. Two randomized controlled trials and five retrospective studies comparing antiplatelet (APT) vs oral anticoagulant therapy (OAC) for CAD were identified, as well as four prospective and 17 retrospective single-arm studies evaluating stenting for CAD. In the meta-analysis of randomized controlled trials comparing APT vs OAC, 444 patients were considered, and a borderline significant association was identified in terms of stroke/death in the APT vs OAC groups (odds ratio [OR], 5.6; 95% confidence interval [CI], 0.94-33.38; P = .06; I2 = 0%). No differences were found for the stroke/death/bleeding outcome (OR, 1.25; 95% CI, 0.19-8.18; P = .81; I2 = 0%) between the two treatments. In the meta-analysis including also retrospective studies, overall risk of bias was considered "serious," and 4104 patients were included with no differences in APT vs OAC for stroke (OR, 1.06; 95% CI, 0.53-2.11; P = .29; I2 = 18%); no other comparisons were possible. The pooled meta-analysis of prospective studies on stenting for CAD included four series, for a total of 68 patients, in whom stenting was adopted primarily after failed medical therapy or after traumatic dissection. The pooled rate of stroke/death was 7% (95% CI, 3%-17%; I2 = 0%). The analysis of moderators identified a significant inverse association between the percentage of traumatic dissection and a reduction in postoperative stroke (Y = -1.60-2.02X; P = .03). The pooled rate of the composite endpoint of stroke/death/ or major bleeding was 8% (95% CI, 3%-18%; I2 = 0%). Secondarily, the meta-analysis also included 17 retrospective studies with overall 457 patients and showed a 2.1% pooled rate of stroke/death (95% CI, 1.0%-3.3%; I2 = 0%) and 3.2% stroke/death/bleeding (95% CI, 1.8%-4.7%; I2 = 0%). CONCLUSIONS Few prospective studies on CAD treatment are present in literature. APT and OAC seem to have similar efficacy in reducing the recurrence of stroke after CAD. No definitive conclusion can be drawn for stenting, due to the low number of studies available. More prospective studies are necessary to evaluate its potential additional value over medical therapy alone in the early phase after CAD.
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Affiliation(s)
- Rodolfo Pini
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy.
| | - Marcello Lodato
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Federica Campana
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Andrea Vacirca
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Enrico Gallitto
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Mauro Gargiulo
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
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Han JW, Lee JI, Hwangbo L. [Endovascular Treatment for Head and Neck Trauma]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:792-808. [PMID: 37559799 PMCID: PMC10407061 DOI: 10.3348/jksr.2023.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/09/2023] [Accepted: 07/08/2023] [Indexed: 08/11/2023]
Abstract
Trauma to the head and neck region can have serious consequences for vital organs such as the brain, and injuries to blood vessels can cause permanent neurological damage or even death. Thus, prompt treatment of head and neck vessels is crucial. Although the level of evidence is moderate, an increasing amount of research indicates that endovascular treatments can be a viable alternative to traditional surgery or medical management. Embolization or reconstructive endovascular procedures can significantly improve patient outcomes. This article provides an overview of various endovascular options available for specific clinical scenarios, along with examples of cases in which they were employed.
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Wen D, Chen Y, Zhu W, Peng Z, Ma L. Cerebral hemorrhage after thrombolysis in stroke patients with unruptured intracranial aneurysms: a systemic review and meta-analysis. J Neurol 2023; 270:1931-1944. [PMID: 36547715 DOI: 10.1007/s00415-022-11533-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/10/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND For ischemic stroke patients with concomitant unruptured aneurysm, intravenous thrombolysis therapy (IVT) remains a disputable decision. We hence performed a meta-analysis to identify the related brain hemorrhage rate of unruptured aneurysms and the risk ratio for their rupture comparing to stroke patients who do not have aneurysms. METHODS A comprehensive search was conducted to identify the studies from the online database from 2000 to September 1st, 2022. Cohort studies were included and assessed by Newcastle-Ottawa Scale (NOS) for quality. The research procedures were subjected to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Fixed-effects model was used based on the heterogeneity tests. RESULTS In 10 eligible studies, 7238 ischemic stroke patients were screened, a total of 302 patients with 348 aneurysms were included. 10 studies were eligible for ICH rate analysis, 8 for SAH rate analysis and 7 for risk ratio of stroke patients with unruptured aneurysms. The pooled any ICH rate was 16% (95% CI 11-21%), symptomatic ICH rate was 4% (95% CI 1-7%, I2 = 0.00%, p = 0.90), and 0% (95% CI 0-1%) for aneurysm-related ICH. Subarachnoid hemorrhage was as low as 2% (95% CI 0-5%), while 0% (95% CI 0-2%) directly related to the aneurysm rupture. The risk ratio of ICH in stroke patients with aneurysms was 1.18 (95% CI 0.79-1.77). Additionally, the hemorrhage rate difference was not evident between saccular and fusiform aneurysms due to a lack of details. CONCLUSIONS IVT is unlikely to induce hemorrhage of pre-existing unruptured aneurysms in stroke patients. Further randomized control studies are warranted to validate these conclusions.
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Affiliation(s)
- Dingke Wen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yuqi Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Wei Zhu
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zongjun Peng
- Department of Neurosurgery, Sichuan Friendship Hospital, Chengdu, 610000, Sichuan, China.
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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Kargiotis O, Psychogios K, Safouris A, Spiliopoulos S, Karapanayiotides T, Bakola E, Mantatzis M, Dardiotis E, Ellul J, Giannopoulos S, Magoufis G, Tsivgoulis G. Diagnosis and treatment of acute isolated proximal internal carotid artery occlusions: a narrative review. Ther Adv Neurol Disord 2022; 15:17562864221136335. [PMID: 36437850 PMCID: PMC9685148 DOI: 10.1177/17562864221136335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/16/2022] [Indexed: 07/27/2023] Open
Abstract
The clinical manifestations of proximal (extracranial) internal carotid artery occlusions (pICAOs) may range from asymptomatic to acute, large, and devastating ischemic strokes. The etiology and pathophysiology of the occlusion, intracranial collateral status and patient's premorbid status are among the factors determining the clinical presentation and outcome of pICAOs. Rapid and accurate diagnosis is crucial and may be assisted by the combination of carotid and transcranial duplex sonography, or a computed tomography/magnetic resonance angiography (CTA/MRA). It should be noted that with either imaging modalities, the discrimination of a pseudo-occlusion of the extracranial internal carotid artery (ICA) from a true pICAO may not be straightforward. In the absence of randomized data, the management of acute, symptomatic pICAOs remains individualized and relies largely on expert opinion. Administration of intravenous thrombolysis is reasonable and probably beneficial in the settings of acute ischemic stroke with early presentation. Unfortunately, rates of recanalization are rather low and acute interventional reperfusion therapies emerge as a potentially powerful therapeutic option for patients with persistent and severe symptoms. However, none of the pivotal clinical trials on mechanical thrombectomy for acute ischemic stroke randomized patients with isolated extracranial large vessel occlusions. On the contrary, several lines of evidence from non-randomized studies have shown that acute carotid endarterectomy, or endovascular thrombectomy/stenting of the ICA are feasible and safe, and pοtentially beneficial. The heterogeneity in the pathophysiology and clinical presentation of acute pICAOs renders patient selection for an acute interventional treatment a complicated decision-making process. The present narrative review will outline the pathophysiology, clinical presentation, diagnostic challenges, and possible treatment options for pICAOs.
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Affiliation(s)
| | | | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus,
Greece
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
- Aktios Rehabilitation Center, Koropi,
Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional
Radiology Unit, ‘Attikon’ University General Hospital, Athens, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of
Medicine, Faculty of Health Sciences, AHEPA University General Hospital,
Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Bakola
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
| | - Michail Mantatzis
- Department of Radiology, Interventional
Neuroradiology Unit, AHEPA University General Hospital, Aristotle University
of Thessaloniki, Thessaloniki, Greece
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital
of Larissa, School of Medicine, University of Thessaly, Larissa,
Greece
| | - John Ellul
- Department of Neurology, University General
Hospital of Patras, Patras, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
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Bontinis V, Antonopoulos CN, Bontinis A, Koutsoumpelis A, Zymvragoudakis V, Rafailidis V, Giannopoulos A, Stoiloudis P, Ktenidis K. A systematic review and meta-analysis of carotid artery stenting for the treatment of cervical carotid artery dissection. Eur J Vasc Endovasc Surg 2022; 64:299-308. [PMID: 35961627 DOI: 10.1016/j.ejvs.2022.07.048] [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] [Received: 03/02/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of carotid artery stenting for the treatment of extracranial carotid artery dissection (CAD). DATA SOURCES Systematic review using Medline, Scopus, EMBASE and Cochrane Library. REVIEW METHODS A systematic search was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) statement. Data from the eligible studies were extracted and meta-analyzed. Primary endpoints included postoperative mortality, cerebrovascular events (CE) and modified Rankin Score for neurologic disability (mRS) at 90 days. We performed subgroup analyses between stenting of spontaneous and traumatic CAD, primary stenting versus stenting after failed medical therapy (FMT) and stenting of CAD in the presence of tandem occlusions versus stenting of isolated extracranial CAD. RESULTS Twenty-four studies with 1,224 patients were included. Pooled post-operative mortality, CE and mRS 0-2 rates were 1.71% (95%CI:0.83-2.80), 6.45% (95%CI:2.80-11.10) and 76.13% (95%CI:64.15-86.50), respectively. The pooled stroke rate was 2.16% (95%CI:0.0-6.64). Spontaneous versus traumatic CAD mortality rates were 3.20% (95%CI:1.80-4.88) and 0.00% (95%CI:0.00-1.59) while CE rates were 14.26% (95%CI:6.28-24.36) and 1.64% (95%CI:0.0-6.08). Primary stenting and stenting after FMT mortality rates were 0.63% (95%CI:0.0-5.63) and 0.0% (95%CI:0.0-2.24), while CE rates were 5.02% (95%CI:0.38-12.63) and 3.33% (95%CI:0.12-9.03). Mortality rates for tandem occlusions and isolated extracranial CAD were 5.62% (95%CI:1.76-10.83) and 0.23% (95%CI:0.0-1.88) respectively, while CE rates were 15.28% (95%CI:6.23-26.64) and 1.88% (95%CI:0.23-4.51). The methodological index for non-randomized studies (MINORS) score was 8.66 (low). CONCLUSION Both primary stenting and stenting of spontaneous CAD yielded unfavorable results regarding stent thrombosis and stroke rates. Conversely, stenting following FMT displayed acceptable mortality and complication rates corroborating the use of stenting in the setting of CAD as a second line treatment. Due to the low quality of the included studies, definite conclusions cannot be drawn necessitating further research.
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Affiliation(s)
- Vangelis Bontinis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece.
| | - Constantine N Antonopoulos
- Department of Vascular Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Alkis Bontinis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Andreas Koutsoumpelis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Vassilios Zymvragoudakis
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Vasileios Rafailidis
- Department of Radiology, Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Argirios Giannopoulos
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Panagiotis Stoiloudis
- 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki
| | - Kiriakos Ktenidis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
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Farouk M, Sato K, Matsumoto Y, Tominaga T. Endovascular Treatment of Internal Carotid Artery Dissection Presenting with Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2020; 29:104592. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/23/2019] [Accepted: 12/03/2019] [Indexed: 01/18/2023] Open
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Non-traumatic cervical artery dissection and ischemic stroke: A narrative review of recent research. Clin Neurol Neurosurg 2019; 187:105561. [DOI: 10.1016/j.clineuro.2019.105561] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 10/02/2019] [Accepted: 10/06/2019] [Indexed: 12/19/2022]
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Ishigami D, Ota T. Spontaneous Bilateral Cervical Internal Carotid Artery Dissection Treated with Simultaneous Bilateral Carotid Artery Stenting: A Case Report. NMC Case Rep J 2019; 6:71-74. [PMID: 31417834 PMCID: PMC6692600 DOI: 10.2176/nmccrj.cr.2018-0257] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 12/19/2018] [Indexed: 11/20/2022] Open
Abstract
Spontaneous cervical internal carotid artery dissection (CICAD) is occasionally treated with conservative management, mainly using antithrombotics. However, we have to consider emergency interventions for bilateral CICAD occurring simultaneously and accompanied by progressive cerebral ischemia. A 46-year-old woman was brought to our hospital with a complaint of left-handed clumsiness, blurred vision in the left eye, and right hemiplegia. Acute cerebral infarction in bilateral cerebral hemispheres was evident on brain magnetic resonance imaging. Bilateral internal carotid arteries were barely visible on time-of-flight magnetic resonance angiography. Subsequent cerebral angiography demonstrated that cervical internal carotid arteries on both sides were tapered off immediately after the bifurcations, indicating CICAD. Despite management with intravenous antithrombotic agents and hydration, neurological status gradually deteriorated. After insertion of a transvenous temporary pacemaker, we performed simultaneous bilateral carotid artery stenting (sbCAS) 3 days after admission. The patient first suffered slight right-sided hemiplegia and hoarseness, but symptoms resolved after rehabilitation, and modified Rankin Scale was 0 as of 2 years after the procedure. Bilateral CICAD causes severe insufficiency of cerebral blood flow, and symptoms often persist even after administration of antithrombotic agents. In such refractory cases, early intervention should be considered, and sbCAS can be safely performed. During the procedure, a transvenous temporary pacemaker maintains hemodynamic stability and might be a favorable option.
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Affiliation(s)
- Daiichiro Ishigami
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
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Befera N, Griffin AS, Hauck EF. Endovascular repair of an acute symptomatic carotid artery dissection through the false dissecting carotid lumen. Interv Neuroradiol 2018; 25:51-53. [PMID: 30189757 DOI: 10.1177/1591019918798154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 48-year-old woman presented with an acute ischemic stroke (National Institutes of Health Stroke Scale (NIHSS) 21) six hours after symptom onset. Workup revealed a left cervical internal carotid artery (ICA) occlusive dissection, which was emergently reconstructed with a flow-diverting stent. A routine Duplex scan one hour later suggested reocclusion of the ICA, confirmed by angiography. The true lumen of the ICA could not be accessed and therefore the "false lumen" of the ICA dissection was entered proximally. The true lumen and ultimately the flow-diverting stent were accessed via the false lumen. In analogy to the subintimal arterial flossing with antegrade-retrograde intervention technique described for peripheral vascular disease, several stents were placed in telescoping fashion from the true common carotid lumen through the "false dissecting" lumen of the proximal ICA into the distal true lumen. The stent construct remained patent, and the patient recovered clinically to an NIHSS of 1.
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Affiliation(s)
- Nicholas Befera
- Duke University Medical Center, Department of Radiology, Durham, NC, USA
| | - Andrew S Griffin
- Duke University Medical Center, Department of Radiology, Durham, NC, USA
| | - Erik F Hauck
- Duke University Medical Center, Department of Radiology, Durham, NC, USA
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Bricout N, Nouri N, Henon H, Estrade L, Boustia F, Leclerc X. Compliant balloon angioplasty for the treatment of internal carotid artery dissection. Interv Neuroradiol 2018; 25:47-50. [PMID: 30165775 DOI: 10.1177/1591019918796490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This report describes the innovative management of a severe haemodynamic stroke related to an occlusive extracranial internal carotid artery dissection. Intravenous thrombolysis combined with endovascular treatment were undertaken on the basis of a total mismatch profile (National Institutes of Health stroke scale (NIHSS) score of 27 and infarct volume on diffusion-weighted imaging of 0 mL). Balloon angioplasty using a long and compliant balloon microcatheter allowed complete recovery of the intracranial blood flow. The patient showed dramatic clinical improvement (day 1, NIHSS 5) and favourable functional outcome (day 90, modified Rankin scale score 2). Day 90 follow-up brain magnetic resonance imaging revealed no ischaemic change and magnetic resonance angiography assessed the patency of the internal carotid artery.
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Affiliation(s)
- Nicolas Bricout
- 1 Department of Interventional Neuroradiology, University of Lille, CHU Lille, Lille, France
| | - Nasreddine Nouri
- 1 Department of Interventional Neuroradiology, University of Lille, CHU Lille, Lille, France
| | - Hilde Henon
- 2 Department of Vascular Neurology, Stroke Unit, University of Lille, CHU Lille, Lille, France
| | - Laurent Estrade
- 1 Department of Interventional Neuroradiology, University of Lille, CHU Lille, Lille, France
| | - Fakhreddine Boustia
- 1 Department of Interventional Neuroradiology, University of Lille, CHU Lille, Lille, France
| | - Xavier Leclerc
- 1 Department of Interventional Neuroradiology, University of Lille, CHU Lille, Lille, France
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