1
|
Wegener S, Baron JC, Derdeyn CP, Fierstra J, Fromm A, Klijn CJM, van Niftrik CHB, Schaafsma JD. Hemodynamic Stroke: Emerging Concepts, Risk Estimation, and Treatment. Stroke 2024; 55:1940-1950. [PMID: 38864227 DOI: 10.1161/strokeaha.123.044386] [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] [Indexed: 06/13/2024]
Abstract
Ischemic stroke can arise from the sudden occlusion of a brain-feeding artery by a clot (embolic), or local thrombosis. Hemodynamic stroke occurs when blood flow does not sufficiently meet the metabolic demand of a brain region at a certain time. This discrepancy between demand and supply can occur with cerebropetal arterial occlusion or high-grade stenosis but also arises with systemic conditions reducing blood pressure. Treatment of hemodynamic stroke is targeted toward increasing blood flow to the affected area by either systemically or locally enhancing perfusion. Thus, blood pressure is often maintained above normal values, and extra-intracranial flow augmentation bypass surgery is increasingly considered. Still, current evidence supporting the superiority of pressure or flow increase over conservative measures is limited. However, methods assessing hemodynamic impairment and identifying patients at risk of hemodynamic stroke are rapidly evolving. Sophisticated models incorporating clinical and imaging factors have been suggested to aid patient selection. In this narrative review, we provide current state-of-the-art knowledge about hemodynamic stroke, tools for assessment, and treatment options.
Collapse
Affiliation(s)
- Susanne Wegener
- Department of Neurology (S.W.), University Hospital Zurich (USZ) and University of Zurich (UZH), Switzerland
- Clinical Neurocenter Zurich and Neuroscience Center Zurich (ZNZ), Switzerland (S.W., J.F., C.H.B.v.N.)
| | - Jean Claude Baron
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Université Paris Cité, Inserm U1266, FHU NeuroVasc, France (J.C.B.)
| | - Colin P Derdeyn
- Department of Radiology and Medical Imaging, University of Virginia School of Medicine, Charlottesville (C.P.D.)
| | - Jorn Fierstra
- Department of Neurosurgery (J.F., C.H.B.v.N.), University Hospital Zurich (USZ) and University of Zurich (UZH), Switzerland
- Clinical Neurocenter Zurich and Neuroscience Center Zurich (ZNZ), Switzerland (S.W., J.F., C.H.B.v.N.)
| | - Annette Fromm
- Department of Neurology, Haukeland University Hospital, Bergen, Norway (A.F.)
| | - Catharina J M Klijn
- Department of Neurology at Radboud University Nijmegen, the Netherlands (C.J.M.K.)
| | - Christiaan Hendrik Bas van Niftrik
- Department of Neurosurgery (J.F., C.H.B.v.N.), University Hospital Zurich (USZ) and University of Zurich (UZH), Switzerland
- Clinical Neurocenter Zurich and Neuroscience Center Zurich (ZNZ), Switzerland (S.W., J.F., C.H.B.v.N.)
| | - Joanna D Schaafsma
- Division of Neurology, Department of Medicine (JDS) and Division of Neuroradiology, Department of Medical Imaging, University Health Network, Toronto, Canada (DJM, DMM) (J.D.S.)
| |
Collapse
|
2
|
Chen KS, Khawaja A, Xu E, Mekary RA, Vaitkevicius H, Aziz-Sultan A, Du R, Patel NJ. Changes in inpatient brain arteriovenous malformation management in the United States following the ARUBA trial: analysis of an interrupted time series design. Clin Neurol Neurosurg 2024; 242:108293. [PMID: 38728853 DOI: 10.1016/j.clineuro.2024.108293] [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: 11/07/2023] [Revised: 01/31/2024] [Accepted: 04/18/2024] [Indexed: 05/12/2024]
Abstract
The November 2013 online publication of ARUBA, the first multi-institutional randomized controlled trial for unruptured brain arteriovenous malformations (AVMs), has sparked over 100 publications in protracted debates METHODS: This study sought to examine inpatient management patterns of brain AVMs from 2009 to 2016 and observe if changes in U.S. inpatient management were attributable to the ARUBA publication using interrupted time series of brain AVM studies from the National Inpatient Sample data 2009-2016. Outcomes of interest were use of embolization, surgery, combined embolization and microsurgery, radiotherapy, and observation during that admission. An interrupted time series design compared management trends before and after ARUBA. Segmented linear regression analysis tested for immediate and long-term impacts of ARUBA on management. RESULTS: Elective and asymptomatic patient admissions declined 2009-2016. In keeping with the ARUBA findings, observation for unruptured brain AVMs increased and microsurgery decreased. However, embolization, radiosurgery, and combined embolization and microsurgery also increased. For ruptured brain AVMs, treatment modality trends remained positive with even greater rates of observation, embolization, and combined embolization and microsurgery occurring after ARUBA (data on radiosurgery were scarce). None of the estimates for the change in trends were statistically significant. CONCLUSIONS: The publication of ARUBA was associated with a decrease in microsurgery and increase in observation for unruptured brain AVMs in the US. However, inpatient radiotherapy, embolization, and combined embolization and surgery also increased, suggesting trends moved counter to ARUBA's conclusions. This analysis suggested that ARUBA had a small impact as clinicians rejected ARUBA's findings in managing unruptured brain AVMs.
Collapse
Affiliation(s)
- Karen S Chen
- Department of Radiology and Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 470, Houston, TX 77030, USA
| | - Ayaz Khawaja
- Department of Neurology, New York University Health and Hospitals, Bellevue, 462 First Ave, New York, NY 10016, USA
| | - Edward Xu
- Department of Radiology and Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 470, Houston, TX 77030, USA
| | - Rania A Mekary
- Department of Social and Administrative Sciences, School of Pharmacy, MCPHS University, 179 Longwood Ave, Boston, MA 02115, USA; Computational Neuroscience Outcomes Center at Harvard, Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Henri Vaitkevicius
- Marinus Pharmaceuticals, 5 Radnor Corporate Center, 100 Matsonford Rd, Suite 500, Radnor, PA 19087, USA
| | - Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Nirav J Patel
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.
| |
Collapse
|
3
|
Mulcahy M, Presti AL, Veken JPVD, Steinfort B, Assaad N. Staged Common and External Carotid Artery Stenting Followed by Superficial Temporal Artery to Middle Cerebral Artery Bypass. J Neurol Surg A Cent Eur Neurosurg 2024; 85:412-416. [PMID: 35453160 DOI: 10.1055/a-1832-3158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery for internal carotid artery (ICA) occlusive disease necessarily requires sufficient external carotid artery (ECA) blood flow. Surgical bypass is therefore precluded if there is common carotid artery (CCA) occlusion. Here we present two such cases: one patient had a CCA occlusion and the other had an ICA occlusion and ECA stenosis. Both had failed medical management, and were therefore treated with angioplasty and stenting of the ECA, followed by STA-MCA bypass. We describe the clinical and radiologic outcomes of these cases, and remark on the potential pitfalls associated with this novel approach.
Collapse
Affiliation(s)
- Michael Mulcahy
- Sydney Medical School, the University of Sydney, Camperdown NSW, Sydney, New South Wales, Australia
| | - Anna Lo Presti
- Department of Neurosurgery, Macquarie University, Sydney, New South Wales, Australia
| | | | - Brendan Steinfort
- Department of Radiology, Macquarie University, Sydney, New South Wales, Australia
| | - Nazih Assaad
- Department of Neurosurgery, Macquarie University, Sydney, New South Wales, Australia
| |
Collapse
|
4
|
Darsaut TE, Rheaume AR, Chagnon M, Raymond J. The use and abuse of survival analysis and Kaplan-Meier curves in surgical trials. Neurochirurgie 2024; 70:101567. [PMID: 38761639 DOI: 10.1016/j.neuchi.2024.101567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 04/30/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Survival analysis based on Cox regression and Kaplan-Meier curves, initially devised for oncology trials, have frequently been used in other contexts where fundamental statistical assumptions (such as a constant hazard ratio) are not satisfied. This is almost always the case in trials that compare surgery with medical management. METHODS We review a trial that compared extracranial-intracranial bypass surgery (EC-IC bypass) with medical management (MM) of patients with symptomatic occlusion of the carotid or middle cerebral artery, where it was claimed that surgery was of no benefit. We discuss a hypothetical study and review other neurovascular trials which have also used survival analysis to compare results. RESULTS The trial comparing EC-IC bypass and MM did not satisfy the fundamental proportional hazard assumption necessary for valid analyses. This was also the case for two prior EC-IC bypass trials, as well as for other landmark neurovascular studies, such as the trials comparing endarterectomy with MM for carotid stenoses, or for the trial that compared intervention and MM for unruptured brain arteriovenous malformations. While minor deviations may have little effect on large trials, it may be impossible to show the benefits of surgery when trial size is small and deviations large. CONCLUSION Survival analyses are inappropriate in RCTs comparing surgery with conservative management, unless survival is calculated after the postoperative period. Alternative ways to compare final clinical outcomes, using for example a fixed follow-up period, should be planned for preventive surgical trials that compare intervention with conservative management.
Collapse
Affiliation(s)
- Tim E Darsaut
- University of Alberta Hospital, Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Alan R Rheaume
- University of Alberta Hospital, Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistics, University of Montreal, Montreal, Quebec, Canada
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
| |
Collapse
|
5
|
Chung Y, Nam SM, Lee SH, Kim K, Kang HS, Kim JE, Cho WS. Surgical Outcomes of Low-Flow Bypass Surgery in Intracranial Atherosclerotic Steno-Occlusive Diseases. Neurosurgery 2024:00006123-990000000-01155. [PMID: 38690884 DOI: 10.1227/neu.0000000000002972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/10/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The role of bypass surgery in intracranial atherosclerotic steno-occlusive diseases (ICADs) remains controversial. We aimed to analyze the surgical outcomes of bypass surgery in patients with the ICADs in a single tertiary institution. METHODS Among 1018 cases of low-flow bypass surgery between 2003 and 2022, 215 patients with the ICAD refractory to medical treatment were finally enrolled in this study. Clinical and radiological outcomes were retrospectively evaluated, with survival analyses. RESULTS All strokes, cerebral infarctions, and intracranial hemorrhages occurred in 12.1% (n = 26), 9.8% (n = 21), and 2.3% (n = 5), respectively, during the clinical follow-up of 54.6 ± 47.6 months (range, 0.6-237.8 months). Among all stroke events, 84.6% (n = 22) occurred within 30 postoperative days. The 2-year and 5-year cumulative risks of all strokes were 12.1% each. The mean modified Rankin Scale scores were 1.6 ± 1.1 (range, 0-5) preoperatively and 0.8 ± 1.2 (range, 0-6) at last (P < .01). The patency of direct bypass was 99.1% (n = 213) just before discharge and 96.3% (n = 184 of 191 patients with available tests) at the last angiographic follow-up of 27.0 ± 27.3 months (range, 2.3-97.3 months). All the patients with available data (n = 190) showed hemodynamic improvement on acetazolamide-challenged single-photon emission computed tomography with 99mTc-hexamethylpropyleneamine oxime during the follow-up of 38.6 ± 36.7 months (range, 2.3-158.6 months). CONCLUSION Low-flow bypass surgery showed acceptable treatment outcomes in the prevention of recurrent stroke.
Collapse
Affiliation(s)
- Yuwhan Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | | | | | | | | | | | | |
Collapse
|
6
|
Pelz DM, Fox AJ, Spence JD, Lownie SP. Carotid Stenosis and Stroke: Historical Perspectives Leading to Current Challenges. Can J Neurol Sci 2024:1-6. [PMID: 38465386 DOI: 10.1017/cjn.2024.40] [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: 03/12/2024]
Abstract
The carotid artery is unique; it is the only vessel to bifurcate into a bulb larger than itself. The history of its anatomic description, understanding of its pathophysiology and evolution of its imaging are relevant to current controversies regarding measurement of stenosis, surgical/endovascular therapies and medical management of carotid stenosis in stroke prevention. Treatment decisions on millions of symptomatic and asymptomatic patients are routinely based on information from clinical trials from over 30 years ago. This article briefly summarizes the highlights of past research in key areas and discuss how they led to current challenges of diagnosis and treatment.
Collapse
Affiliation(s)
- David M Pelz
- Department of Medical Imaging, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | | | - J David Spence
- Neurology and Clinical Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, London, ON, Canada
| | - Stephen P Lownie
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, NS, Canada
- Schulich School of Medicine and Dentistry, Western University, Halifax, NS, Canada
| |
Collapse
|
7
|
Baron JC. Predicting Stroke Recurrence in Occlusive Disease Using Noninvasive Quantitative Mapping of Cerebrovascular Reserve. Stroke 2024; 55:622-624. [PMID: 38328925 DOI: 10.1161/strokeaha.124.046235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Affiliation(s)
- Jean-Claude Baron
- Department of Neurology, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences, FHU NeuroVasc, France. Université Paris Cité, Institut de Psychiatrie et Neurosciences de Paris, Inserm U1266, France
| |
Collapse
|
8
|
Degollado-García J, Casas-Martínez MR, Mejia BRF, Balcázar-Padrón JC, Rodríguez-Rubio HA, Nathal E. Internal maxillary artery (IMax) - middle cerebral artery bypass in a patient with bilateral atherosclerotic carotid occlusion: A technical case report. J Cerebrovasc Endovasc Neurosurg 2024; 26:51-57. [PMID: 37997040 PMCID: PMC10995475 DOI: 10.7461/jcen.2023.e2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/21/2023] [Accepted: 05/12/2023] [Indexed: 12/06/2023] Open
Abstract
Since the first description of the possible utilization of the internal maxillary artery for bypass surgery, there are some reports of its use in aneurysm cases; however, there is no information about the possible advantages of this type of bypass for cerebral ischemic disease. We present a 77-year-old man with a history of diabetes, hypertension, systemic atherosclerosis, and two acute myocardial infarctions with left hemiparesis. Imaging studies reported total occlusion of the right internal carotid artery and 75% occlusion on the left side, with an old opercular infarction and repeated transient ischemic attacks in the right middle cerebral artery territory despite medical treatment. After a consensus, we decided to perform a bypass from the internal maxillary artery to the M2 segment of the middle cerebral artery using a radial artery graft. After performing the proximal anastomosis, the calculated graft's free flow was 216 ml/min. Subsequently, after completing the bypass, the patency was confirmed with fluorescein videoangiography and intraoperative Doppler. Postoperatively, imaging studies showed improvement in the perfusion values and the hemiparesis from 3/5 to 4+/5. The patient was discharged one week after the operation, with a modified Rankin scale of 1, without added deficits. The use of revascularization techniques in steno-occlusive disease indicates a select group of patients that may benefit from this procedure. In addition, internal maxillary artery bypass has provided a safe option for large areas of ischemia that cannot be supplied with a superficial temporal artery - middle cerebral artery bypass.
Collapse
Affiliation(s)
- Javier Degollado-García
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Martin R. Casas-Martínez
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Bill Roy Ferrufino Mejia
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Juan C. Balcázar-Padrón
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Héctor A. Rodríguez-Rubio
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| | - Edgar Nathal
- Vascular Neurosurgery Department, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City, Mexico
| |
Collapse
|
9
|
van Niftrik CHB, Sebök M, Germans MR, Halter M, Pokorny T, Stumpo V, Bellomo J, Piccirelli M, Pangalu A, Katan M, Wegener S, Tymianski M, Kulcsár Z, Luft AR, Fisher JA, Mikulis DJ, Regli L, Fierstra J. Increased Risk of Recurrent Stroke in Symptomatic Large Vessel Disease With Impaired BOLD Cerebrovascular Reactivity. Stroke 2024; 55:613-621. [PMID: 38328926 DOI: 10.1161/strokeaha.123.044259] [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: 06/19/2023] [Accepted: 12/11/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Impaired cerebrovascular reactivity (CVR) has been correlated with recurrent ischemic stroke. However, for clinical purposes, most CVR techniques are rather complex, time-consuming, and lack validation for quantitative measurements. The recent adaptation of a standardized hypercapnic stimulus in combination with a blood-oxygenation-level-dependent (BOLD) magnetic resonance imaging signal as a surrogate for cerebral blood flow offers a potential universally comparable CVR assessment. We investigated the association between impaired BOLD-CVR and risk for recurrent ischemic events. METHODS We conducted a retrospective analysis of patients with symptomatic cerebrovascular large vessel disease who had undergone a prospective hypercapnic-challenged BOLD-CVR protocol at a single tertiary stroke referral center between June 2014 and April 2020. These patients were followed up for recurrent acute ischemic events for up to 3 years. BOLD-CVR (%BOLD signal change per mm Hg CO2) was calculated on a voxel-by-voxel basis. Impaired BOLD-CVR of the affected (ipsilateral to the vascular pathology) hemisphere was defined as an average BOLD-CVR, falling 2 SD below the mean BOLD-CVR of the right hemisphere in a healthy age-matched reference cohort (n=20). Using a multivariate Cox proportional hazards model, the association between impaired BOLD-CVR and ischemic stroke recurrence was assessed and Kaplan-Meier survival curves to visualize the acute ischemic stroke event rate. RESULTS Of 130 eligible patients, 28 experienced recurrent strokes (median, 85 days, interquartile range, 5-166 days). Risk factors associated with an increased recurrent stroke rate included impaired BOLD-CVR, a history of atrial fibrillation, and heart insufficiency. After adjusting for sex, age group, and atrial fibrillation, impaired BOLD-CVR exhibited a hazard ratio of 10.73 (95% CI, 4.14-27.81; P<0.001) for recurrent ischemic stroke. CONCLUSIONS Among patients with symptomatic cerebrovascular large vessel disease, those exhibiting impaired BOLD-CVR in the affected hemisphere had a 10.7-fold higher risk of recurrent ischemic stroke events compared with individuals with nonimpaired BOLD-CVR.
Collapse
Affiliation(s)
- Christiaan H B van Niftrik
- Department of Neurosurgery (C.H.B.v.N., M.S., M.R.G., M.H., V.S., J.B., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
| | - Martina Sebök
- Department of Neurosurgery (C.H.B.v.N., M.S., M.R.G., M.H., V.S., J.B., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
| | - Menno R Germans
- Department of Neurosurgery (C.H.B.v.N., M.S., M.R.G., M.H., V.S., J.B., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
| | - Matthias Halter
- Department of Neurosurgery (C.H.B.v.N., M.S., M.R.G., M.H., V.S., J.B., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
| | - Thomas Pokorny
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Department of Neurology (T.P., M.K., S.W., A.R.L.), University Hospital of Zürich, University of Zürich, Switzerland
| | - Vittorio Stumpo
- Department of Neurosurgery (C.H.B.v.N., M.S., M.R.G., M.H., V.S., J.B., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
| | - Jacopo Bellomo
- Department of Neurosurgery (C.H.B.v.N., M.S., M.R.G., M.H., V.S., J.B., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
| | - Marco Piccirelli
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Department of Neurology (M.P., A.P., Z.K.), University Hospital of Zürich, University of Zürich, Switzerland
| | - Athina Pangalu
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Department of Neurology (M.P., A.P., Z.K.), University Hospital of Zürich, University of Zürich, Switzerland
| | - Mira Katan
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Department of Neurology (T.P., M.K., S.W., A.R.L.), University Hospital of Zürich, University of Zürich, Switzerland
| | - Susanne Wegener
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Department of Neurology (T.P., M.K., S.W., A.R.L.), University Hospital of Zürich, University of Zürich, Switzerland
| | - Michael Tymianski
- Division of Neurosurgery, Toronto Western Hospital (M.T., J.F.), University of Toronto, ON, Canada
| | - Zsolt Kulcsár
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Department of Neurology (M.P., A.P., Z.K.), University Hospital of Zürich, University of Zürich, Switzerland
| | - Andreas R Luft
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Department of Neurology (T.P., M.K., S.W., A.R.L.), University Hospital of Zürich, University of Zürich, Switzerland
| | - Joseph A Fisher
- Institute of Medical Science (J.A.F.), University of Toronto, ON, Canada
- Department of Anesthesia and Pain Management (J.A.F.), University Health Network, Toronto, ON, Canada
| | - David J Mikulis
- Joint Department of Medical Imaging and Functional Neuroimaging Laboratory (D.J.M.), University Health Network, Toronto, ON, Canada
| | - Luca Regli
- Department of Neurosurgery (C.H.B.v.N., M.S., M.R.G., M.H., V.S., J.B., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery (C.H.B.v.N., M.S., M.R.G., M.H., V.S., J.B., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Clinical Neuroscience Center (C.H.B.v.N., M.S., M.R.G., M.H., T.P., V.S., J.B., M.P., A.P., M.K., S.W., Z.K., A.R.L., L.R., J.F.), University Hospital of Zürich, University of Zürich, Switzerland
- Division of Neurosurgery, Toronto Western Hospital (M.T., J.F.), University of Toronto, ON, Canada
| |
Collapse
|
10
|
Huang B, Huang C, Alok K, Chen AY. Superficial Temporal Artery-to-Middle Cerebral Artery Bypass in Ischemic Stroke With Blood Pressure-Dependent Symptoms. Cureus 2024; 16:e56236. [PMID: 38618338 PMCID: PMC11016294 DOI: 10.7759/cureus.56236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2024] [Indexed: 04/16/2024] Open
Abstract
The efficacy of extracranial-intracranial (EC-IC) bypass in preventing ischemic stroke progression and recurrence is controversial. As per the current hypothesis, EC-IC bypass is most beneficial for patients with persistent hemodynamic insufficiency. Hence, various approaches have been used to evaluate hemodynamic insufficiency, including repeated single photon emission CT (SPECT) imaging or continuous monitoring of cerebral flow with transcranial Doppler ultrasound (TCD). However, both modalities are time- and resource-intensive. In this report, we discuss how EC-IC bypass turned out to be beneficial for a patient presenting with blood pressure-dependent severe aphasia and right hemiparesis due to middle cerebral artery (MCA) occlusion that failed thrombectomy. CT perfusion (CTP) scan at admission demonstrated a persistent volume of delayed perfusion without core infarct. Following the superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass, the patient's National Institute of Health Stroke Scale (NIHSS) score improved from 12 to 1. Ischemic penumbra, as seen on CTP imaging, also improved after the STA-MCA bypass. Our case suggests that persistent volume of delayed perfusion and blood pressure-dependent neurological deficits can be used in tandem as selection criteria for EC-IC bypass.
Collapse
Affiliation(s)
| | | | - Khaled Alok
- Neurosurgery, Northwell Health, Manhasset, USA
| | | |
Collapse
|
11
|
Elder TA, White TG, Woo HH, Siddiqui AH, Nunna R, Siddiq F, Esposito G, Chang D, Gonzalez NR, Amin-Hanjani S. Future of Endovascular and Surgical Treatments of Atherosclerotic Intracranial Stenosis. Stroke 2024; 55:344-354. [PMID: 38252761 DOI: 10.1161/strokeaha.123.043634] [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] [Indexed: 01/24/2024]
Abstract
Intracranial atherosclerotic disease and resultant intracranial stenosis is a global leading cause of stroke, and poses an ongoing treatment challenge. Among patients with intracranial stenosis, those with hemodynamic compromise are at high risk for recurrent stroke despite medical therapy and risk factor modification. Revascularization of the hypoperfused territory is the most plausible treatment strategy for these high-risk patients, yet surgical and endovascular therapies have not yet shown to be sufficiently safe and effective in randomized controlled trials. Advances in diagnostic and therapeutic technologies have led to a resurgence of interest in surgical and endovascular treatment strategies, with a growing body of evidence to support their further evaluation in the treatment of select patient populations. This review outlines the current and emerging endovascular and surgical treatments and highlights promising future management strategies.
Collapse
Affiliation(s)
- Theresa A Elder
- University Hospitals Cleveland Medical Center/Case Western Reserve University School of Medicine, OH (T.A.E., S.A.-H.)
| | - Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY (T.G.W., H.H.W.)
| | - Henry H Woo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY (T.G.W., H.H.W.)
| | - Adnan H Siddiqui
- Departments of Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, NY (A.H.S.)
| | - Ravi Nunna
- Department of Neurological Surgery, University of Missouri School of Medicine, Columbia (R.N., F.S.)
| | - Farhan Siddiq
- Department of Neurological Surgery, University of Missouri School of Medicine, Columbia (R.N., F.S.)
| | - Giuseppe Esposito
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Switzerland (G.E.)
| | - Daniel Chang
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (D.C., N.R.G.)
| | - Nestor R Gonzalez
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA (D.C., N.R.G.)
| | - Sepideh Amin-Hanjani
- University Hospitals Cleveland Medical Center/Case Western Reserve University School of Medicine, OH (T.A.E., S.A.-H.)
| |
Collapse
|
12
|
Salih M, Mallick A, Rai HH, Nwajei F, Cappuzzo JM, Snyder K, Ogilvy CS. Percutaneous transluminal angioplasty or stenting of petrous and cavernous internal carotid artery stenosis - a systematic review. J Neuroradiol 2024; 51:82-88. [PMID: 37364744 DOI: 10.1016/j.neurad.2023.06.005] [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: 05/03/2022] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 06/28/2023]
Abstract
Percutaneous transluminal angioplasty (PTA) and stenting have been used for the treatment of internal carotid artery (ICA) stenosis over the past two decades. A systematic review was performed to understand the efficacy of PTA and/or stenting for petrous and cavernous ICA stenosis. In total, 151 patients (mean age 64.9) met criteria for analysis, 117 (77.5%%) were male and 34 (22.5%) were female. Of the 151 patients, 35 of them (23.2%) had PTA, and 116 (76.8%) had endovascular stenting. Twenty-two patients had periprocedural complications. There was no significant difference in the complication rates between the PTA (14.3%) and stent (14.7%) groups. Distal embolism was the most common periprocedural complication. Average clinical follow up for 146 patients was 27.3 months. Eleven patients (7.5%) out of 146 had retreatment. The treatment of petrous and cavernous ICA with PTA and stenting has relatively significant procedure related complication rates and adequate long-term patency.
Collapse
Affiliation(s)
- Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street Boston, Boston, MA 02215, United States
| | - Akashleena Mallick
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street Boston, Boston, MA 02215, United States
| | | | - Felix Nwajei
- Boston Medical Center, Boston, MA, United States
| | | | - Kenneth Snyder
- University at Buffalo Neurosurgery, Buffalo, NY, United States
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street Boston, Boston, MA 02215, United States.
| |
Collapse
|
13
|
Hoh BL, Chimowitz MI. Focused Update on Intracranial Atherosclerosis: Introduction, Highlights, and Knowledge Gaps. Stroke 2024; 55:305-310. [PMID: 38252758 PMCID: PMC10832349 DOI: 10.1161/strokeaha.123.045513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Affiliation(s)
- Brian L Hoh
- Department of Neurosurgery, University of Florida (B.L.H.)
| | - Marc I Chimowitz
- Department of Neurology, Medical University of South Carolina (M.I.C.)
| |
Collapse
|
14
|
de Havenon A, Turan TN. Past, Present, and Future of Intracranial Atherosclerosis Treatment. Stroke 2024; 55:471-473. [PMID: 38152957 PMCID: PMC10842205 DOI: 10.1161/strokeaha.123.044270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Affiliation(s)
- Adam de Havenon
- Department of Neurology, Yale University School of Medicine, New Haven, CT (A.d.H.)
| | - Tanya N Turan
- Department of Neurology, Medical University of South Carolina, Charleston (T.N.T.)
| |
Collapse
|
15
|
Dunn L, Wang Y, Kass-Hout T, Chiu D. Randomized Secondary Prevention Trials in Participants With Symptomatic Intracranial Atherosclerotic Stenosis. Stroke 2024; 55:324-334. [PMID: 38252760 PMCID: PMC11008430 DOI: 10.1161/strokeaha.123.043632] [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] [Indexed: 01/24/2024]
Abstract
Intracranial atherosclerotic stenosis is a prevalent cause of ischemic stroke worldwide. Its association with silent cerebral infarcts and its contribution to cognitive impairment and dementia emphasize the critical need for disease prevention and effective management strategies. Despite extensive research on secondary stroke prevention treatment over the past several decades, intracranial atherosclerotic stenosis continues to exhibit a notably higher recurrent stroke rate compared with other causes. This review focuses on randomized secondary prevention trials involving antithrombotic therapy, endovascular treatment, open surgical therapy, and remote ischemic conditioning. It aims to provide an insightful overview of the major findings from each trial and their implications for future research efforts.
Collapse
Affiliation(s)
- Lauren Dunn
- Department of Neurology, Ochsner Health System, New Orleans, LA
| | - Yan Wang
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | | | - David Chiu
- Department of Neurology, Houston Methodist Hospital, Houston, TX
| |
Collapse
|
16
|
Kuffer AF, Golub D, Dehdashti AR. Editorial: Clinical experience of open cerebral revascularization (bypass surgery) for the management of ischemic or hemorrhagic stroke. Front Neurol 2024; 14:1354100. [PMID: 38239319 PMCID: PMC10794517 DOI: 10.3389/fneur.2023.1354100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 01/22/2024] Open
Affiliation(s)
- Alexander F. Kuffer
- Northwell Health Neurosurgery, North Shore University Hospital, Manhasset, NY, United States
| | | | - Amir R. Dehdashti
- Northwell Health Neurosurgery, North Shore University Hospital, Manhasset, NY, United States
| |
Collapse
|
17
|
Radu RA, Cagnazzo F, Schiphorst AT, Machi P, Dargazanli C, Lefevre PH, Gascou G, Costalat V. A proposed modern standardized technical approach for symptomatic chronic carotid total occlusion management. Interv Neuroradiol 2024:15910199231224006. [PMID: 38166519 DOI: 10.1177/15910199231224006] [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: 01/04/2024] Open
Abstract
Chronic carotid total occlusion (CCTO) is a known cause of ischemic stroke and transient ischemic attack. Symptomatic CCTO is associated with up to 30% risk of recurrent ischemic stroke, despite optimal medical treatment. Notably, a randomized controlled trial reported that previous surgical management did not improve the overall prognosis of these patients. Endovascular treatment of CCTO has been proposed as a feasible strategy to re-establish cerebral perfusion in symptomatic patients. However, its use is controversial and not supported by evidence from randomized clinical trials. Recently, a meta-analysis reported a reasonably high procedural success without an excess periprocedural complication rate, but several steps are needed before the procedure is mature enough to be tested in randomized controlled trials. This review highlights the developments in the endovascular recanalization of CCTO and emphasizes key steps towards standardizing the procedure.
Collapse
Affiliation(s)
- Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Department of Clinical Neurosciences, "Carol Davila" University of Medicine and Pharmacy Bucharest, Bucharest, Romania
- Departments of Neurology and Interventional Radiology, University Emergency Hospital Bucharest, Bucharest, Romania
| | - Federico Cagnazzo
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Adrien Ter Schiphorst
- Department of Neurology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Paolo Machi
- Department of Neuroradiology, Geneva University Hospital, Geneva, Switzerland
| | - Cyril Dargazanli
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Pierre-Henri Lefevre
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Gregory Gascou
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| |
Collapse
|
18
|
Darsaut TE, Raymond J. Extracranial-Intracranial Bypass in Patients With Symptomatic Artery Occlusion. JAMA 2023; 330:2396. [PMID: 38147098 DOI: 10.1001/jama.2023.21999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
Affiliation(s)
- Tim E Darsaut
- Division of Neurosurgery, University of Alberta, Edmonton, Canada
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| |
Collapse
|
19
|
Khaw AV, Thiessen JD, St. Lawrence K, Pandey SK. The Quest of Characterizing Hemodynamic Failure in Patients With Cerebrovascular Disease. J Am Heart Assoc 2023; 12:e032657. [PMID: 38084748 PMCID: PMC10863759 DOI: 10.1161/jaha.123.032657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/24/2023] [Indexed: 12/20/2023]
Affiliation(s)
- Alexander V. Khaw
- Department of Clinical Neurosciences, Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
- Lawson Health Research InstituteLondonOntarioCanada
- Department of Medical Biophysics, Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
| | - Jonathan D. Thiessen
- Lawson Health Research InstituteLondonOntarioCanada
- Department of Medical Biophysics, Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
- Department of Medical Imaging, Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
| | - Keith St. Lawrence
- Lawson Health Research InstituteLondonOntarioCanada
- Department of Medical Biophysics, Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
- Department of Medical Imaging, Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
| | - Sachin K. Pandey
- Department of Medical Imaging, Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
| |
Collapse
|
20
|
Tan BY, Zheng Y, Lim MJR, Koh YY, Tan YK, Goh C, Myint MZ, Sia CH, Tan J, Nor FEM, Soon B, Chan BP, Leow AS, Ho JS, Yeo LL, Sharma VK. Comparison of short-term outcomes between patients with extracranial carotid and/or intracranial atherosclerotic disease. Clin Neurol Neurosurg 2023; 235:108024. [PMID: 37922680 DOI: 10.1016/j.clineuro.2023.108024] [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: 06/07/2023] [Revised: 09/16/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To directly compare the 90-day outcomes of patients with symptomatic intracranial atherosclerotic disease (ICAD), extracranial carotid atherosclerotic disease (ECAD), and ICAD with concomitant ECAD. METHODS From 2017-2021, patients who had (1) a transient ischemic attack or ischemic stroke within 30 days of admission as evaluated by a stroke neurologist and (2) ipsilateral ICAD and/or ECAD were prospectively enrolled. The cohort was divided into three groups: ICAD, ECAD, and ICAD with concomitant ECAD. The primary outcome assessed was 90-day ischemic stroke recurrence. Secondary outcomes included 90-day myocardial infarction (MI), all-cause mortality, and major adverse cardiovascular events (MACE, including cardiovascular death, nonfatal MI, and/or nonfatal ischemic stroke). RESULTS Of 371 patients included in the analysis, 240 (64.7%) patients had ICAD only, 93 (25.0%) patients had ECAD only, and 38 (10.3%) patients had ICAD with concomitant ECAD. On multivariate time-to-event analysis adjusting for potential confounders and with ICAD as the reference comparator, the risk of 90-day clinical outcomes was highest among patients with ICAD and concomitant ECAD, with adjusted hazard ratios of 4.54 (95% CI=1.45, 14.2; p = 0.006), 9.32 (95% CI=1.58, 54.8; p = 0.014), and 8.52 (95% CI=3.54, 20.5; p < 0.001) for 90-day ischemic stroke, MI, and MACE, respectively. CONCLUSIONS Patients with ICAD and concomitant ECAD have a poorer prognosis and are at significantly higher risk for 90-day ischemic stroke, MI, and MACE. Further research should focus on the evaluation of coronary atherosclerotic disease and more intensive medical therapy in this population.
Collapse
Affiliation(s)
- Benjamin Yq Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Ying Ying Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ying Kiat Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Claire Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - May Zin Myint
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Cardiology, National University Health System, Singapore
| | - Jaclyn Tan
- Division of Neurosurgery, National University Health System, Singapore
| | | | - Betsy Soon
- Department of Diagnostic Imaging, National University Health System, Singapore
| | - Bernard Pl Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Aloysius St Leow
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Jamie Sy Ho
- Department of Medicine, National University Health System, Singapore
| | - Leonard Ll Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Vijay Kumar Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| |
Collapse
|
21
|
Yan S, Feng H, Ma L, Xu JC, Han HJ, Huang HE, Tan HQ, Fang C. Predictors of successful endovascular recanalization in patients with symptomatic nonacute intracranial large artery occlusion. BMC Neurol 2023; 23:376. [PMID: 37858051 PMCID: PMC10585922 DOI: 10.1186/s12883-023-03424-y] [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: 04/19/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Endovascular recanalization in patients with symptomatic nonacute intracranial large artery occlusion (ILAO) has been reported to be feasible, but technically challenging. This study aimed to determine the predictors of successful endovascular recanalization in patients with symptomatic nonacute ILAO. METHODS The outcomes of endovascular recanalization attempts performed in 70 consecutive patients showing symptomatic nonacute ILAO with hemodynamic cerebral ischemia between January 2016 to December 2022 were reviewed. Potential variables, including clinical and radiological characteristics related to technical success, were collected. Univariate analysis and multivariate logistic regression were performed to identify predictors of successful recanalization for nonacute ILAO. RESULTS Technically successful recanalization was achieved in 57 patients (81.4%). The periprocedural complication rate was 21.4% (15 of 70), and the overall 30-day morbidity and mortality rates were 7.1% (5 of 70) and 2.9% (2 of 70), respectively. Univariate analysis showed that successful recanalization was associated with occlusion duration, stump morphology, occlusion length, slow distal antegrade flow sign, and the presence of bridging collateral vessels. Multivariate analysis showed that occlusion duration ≤ 3 months (odds ratio [OR]: 22.529; 95% confidence interval [CI]: 1.636-310.141), tapered stump (OR: 7.498; 95% CI: 1.533-36.671), and occlusion length < 10 mm (OR: 7.049; 95% CI: 1.402-35.441) were independent predictive factors for technical success of recanalization. CONCLUSIONS Occlusion duration ≤ 3 months, tapered stump, and occlusion length < 10 mm were independent positive predictors of technical success of endovascular recanalization for symptomatic nonacute ILAO. These findings may help predict the likelihood of successful recanalization in patients with symptomatic nonacute ILAO and also provide a reference for the selection of appropriate patients. Further prospective and multicenter studies are required to validate our findings.
Collapse
Affiliation(s)
- Shuo Yan
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China
| | - Hao Feng
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China
| | - Lin Ma
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China
| | - Ji-Chong Xu
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China
| | - Hong-Jie Han
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China
| | - Hong-En Huang
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China
| | - Hua-Qiao Tan
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China.
| | - Chun Fang
- Department of Interventional Radiology, Tongji Hospital, Tongji University School of Medicine, No. 389, Xin Chun Road, Shanghai, 200065, China
| |
Collapse
|
22
|
Ahmed R, Maqsood H, Bains RS, Gulraiz A, Kamal M. Intracranial atherosclerotic disease: current management strategies. Ann Med Surg (Lond) 2023; 85:4903-4908. [PMID: 37811034 PMCID: PMC10552953 DOI: 10.1097/ms9.0000000000001145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/01/2023] [Indexed: 10/10/2023] Open
Abstract
A stroke due to underlying intracranial large artery occlusion, which is atherosclerotic in nature, is known as intracranial atherosclerotic disease (ICAD). It is important to recognize that ischaemic stroke due to ICAD differs from extracranial disease and other stroke aetiologies and requires a nuanced approach. It is a significant cause of stroke worldwide, and severe symptomatic ICAD can present challenges from a therapeutic standpoint, including recurrent ischaemic stroke despite optimal management. Furthermore, exploring the underlying pathophysiological mechanisms responsible for the disease may be necessary while considering treatment options. This narrative review aims to provide an all-encompassing overview of this disease. Epidemiology and clinical pathophysiology will be explored in detail. The findings of large clinical trials will serve as a guide to finding the most optimized management strategies. Another critical question that arises is the treatment of acute ischaemic stroke due to large vessel occlusion with underlying intracranial atherosclerosis, is the treatment and clinical diagnosis the same as for other aetiologies of stroke (i.e. extracranial disease and nonvalvular atrial fibrillation)? Consequently, secondary prevention of patients with ischaemic stroke or transient ischaemic attack will be divided into medical therapy, risk factor control, and endovascular and surgical treatment options.
Collapse
Affiliation(s)
| | | | | | | | - Meraj Kamal
- BP Koirala Institute of Health Sciences, Dharan-18, Nepal
| |
Collapse
|
23
|
Kuo CH, Tu TH, Chen KT. Editorial: Advanced technological applications in neurosurgery. Front Surg 2023; 10:1277997. [PMID: 37744725 PMCID: PMC10512053 DOI: 10.3389/fsurg.2023.1277997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/25/2023] [Indexed: 09/26/2023] Open
Affiliation(s)
- Chao-Hung Kuo
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tsung-Hsi Tu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ko-Ting Chen
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Neurosurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Neuroscience Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| |
Collapse
|
24
|
Chaturvedi S, Simard JM. Extracranial-Intracranial Bypass Surgery for Stroke Prevention. JAMA 2023; 330:697-698. [PMID: 37606685 DOI: 10.1001/jama.2023.11166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Affiliation(s)
- Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore
| | - J Marc Simard
- Department of Neurological Surgery, University of Maryland School of Medicine, Baltimore
| |
Collapse
|
25
|
Ma Y, Wang T, Wang H, Amin-Hanjani S, Tong X, Wang J, Tong Z, Kuai D, Cai Y, Ren J, Wang D, Duan L, Maimaitili A, Hang C, Yu J, Bai X, Powers WJ, Derdeyn CP, Wu Y, Ling F, Gu Y, Jiao L. Extracranial-Intracranial Bypass and Risk of Stroke and Death in Patients With Symptomatic Artery Occlusion: The CMOSS Randomized Clinical Trial. JAMA 2023; 330:704-714. [PMID: 37606672 PMCID: PMC10445185 DOI: 10.1001/jama.2023.13390] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 06/29/2023] [Indexed: 08/23/2023]
Abstract
Importance Prior trials of extracranial-intracranial (EC-IC) bypass surgery showed no benefit for stroke prevention in patients with atherosclerotic occlusion of the internal carotid artery (ICA) or middle cerebral artery (MCA), but there have been subsequent improvements in surgical techniques and patient selection. Objective To evaluate EC-IC bypass surgery in symptomatic patients with atherosclerotic occlusion of the ICA or MCA, using refined patient and operator selection. Design, Setting, and Participants This was a randomized, open-label, outcome assessor-blinded trial conducted at 13 centers in China. A total of 324 patients with ICA or MCA occlusion with transient ischemic attack or nondisabling ischemic stroke attributed to hemodynamic insufficiency based on computed tomography perfusion imaging were recruited between June 2013 and March 2018 (final follow-up: March 18, 2020). Interventions EC-IC bypass surgery plus medical therapy (surgical group; n = 161) or medical therapy alone (medical group; n = 163). Medical therapy included antiplatelet therapy and stroke risk factor control. Main Outcomes and Measures The primary outcome was a composite of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years after randomization. There were 9 secondary outcomes, including any stroke or death within 2 years and fatal stroke within 2 years. Results Among 330 patients who were enrolled, 324 patients were confirmed eligible (median age, 52.7 years; 257 men [79.3%]) and 309 (95.4%) completed the trial. For the surgical group vs medical group, no significant difference was found for the composite primary outcome (8.6% [13/151] vs 12.3% [19/155]; incidence difference, -3.6% [95% CI, -10.1% to 2.9%]; hazard ratio [HR], 0.71 [95% CI, 0.33-1.54]; P = .39). The 30-day risk of stroke or death was 6.2% (10/161) in the surgical group and 1.8% (3/163) in the medical group, and the risk of ipsilateral ischemic stroke beyond 30 days through 2 years was 2.0% (3/151) and 10.3% (16/155), respectively. Of the 9 prespecified secondary end points, none showed a significant difference including any stroke or death within 2 years (9.9% [15/152] vs 15.3% [24/157]; incidence difference, -5.4% [95% CI, -12.5% to 1.7%]; HR, 0.69 [95% CI, 0.34-1.39]; P = .30) and fatal stroke within 2 years (2.0% [3/150] vs 0% [0/153]; incidence difference, 1.9% [95% CI, -0.2% to 4.0%]; P = .08). Conclusions and Relevance Among patients with symptomatic ICA or MCA occlusion and hemodynamic insufficiency, the addition of bypass surgery to medical therapy did not significantly change the risk of the composite outcome of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years. Trial Registration ClinicalTrials.gov Identifier: NCT01758614.
Collapse
Affiliation(s)
- Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Haibo Wang
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing, China
| | - Sepideh Amin-Hanjani
- Cerebrovascular and Skull Base Surgery, Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Xiaoguang Tong
- Department of Neurosurgery, Huanhu Hospital, Tianjin, China
| | - Jiyue Wang
- Department of Neurosurgery, Liaocheng People’s Hospital, Shandong First Medical University and Shandong Academy of Medical Sciences, Liaocheng City, Shandong, China
| | - Zhiyong Tong
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Dong Kuai
- Department of Neurosurgery, The Affiliated Cardiovascular Hospital of Shanxi Medical University and Shanxi Cardiovascular Hospital (Institute), Taiyuan, Shanxi, China
| | - Yiling Cai
- Department of Neurology, Strategic Support Force Medical Center, Beijing, China
| | - Jun Ren
- Department of Neurosurgery, The Second Hospital of Lan Zhou University, Lan Zhou, China
| | - Donghai Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, China
- Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Lian Duan
- Department of Neurosurgery, The First Medical Center of Chinese People’s Liberation Army (PLA) General Hospital, HaiDian District, Beijing, China
| | - Aisha Maimaitili
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Xinshi District, Urumqi, Xinjiang,China
| | - Chunhua Hang
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Neurosurgical Institute of Nanjing University, Nanjing University Medical School, Nanjing, China
| | - Jiasheng Yu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - William J. Powers
- Department of Neurology, Duke University School of Medicine, Duke South, Durham, North Carolina
| | - Colin P. Derdeyn
- Departments of Radiology and Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Feng Ling
- Department of Neurosurgery and Interventional Neuroradiology, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Fudan University, National Center for Neurological Disorders, Shanghai, China
| | - Liqun Jiao
- Department of Neurosurgery and Interventional Neuroradiology, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| |
Collapse
|
26
|
Turpin J, Lynch DG, White T, Shah KA, Yang K, Katz JM, Dehdashti AR. Hyperperfusion syndrome after superficial temporal artery-middle cerebral artery bypass for non-moyamoya steno-occlusive disease. J Stroke Cerebrovasc Dis 2023; 32:107222. [PMID: 37384979 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/11/2023] [Accepted: 06/13/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Stroke is a major cause of morbidity and mortality worldwide, and intracranial stenoses increase the risk for stroke. Superficial temporal artery to middle cerebral artery bypass can be beneficial in selected patients with non-moyamoya steno-occlusive disease, however data is limited regarding the postoperative occurrence of hyperperfusion syndrome in this population. This case series describes the outcomes and complications, including hyperperfusion, in these patients who underwent bypass. METHODS This is a retrospective review of bypass procedures done for medically refractory intracranial stenosis at a single institution by a single surgeon between 2014 and 2021. RESULTS 30 patients underwent 33 bypass procedures for unequivocal non-moyamoya steno-occlusive disease. All patients had immediate bypass patency on post-operative day one. Major perioperative complications (9%) included one stroke and two cases of hyperperfusion syndrome. Minor perioperative complications (12%) included two seizures, one superficial wound infection and one deep vein thrombosis. Modified Rankin Score improved in 20 patients (74%), worsened in one patient (4%), and remained stable in seven patients (22%) at the last follow up. Twenty-three patients (85%) had scores ≤ 2. The recurrent stroke rate was 3% at 30 days and 7% at two years. The bypass patency rate at one year was 87.5%. CONCLUSION In this series, bypass for patients with medically refractory non-moyamoya steno-occlusive disease was well tolerated and effective, with overall favorable outcomes. The occurrence of hyperperfusion syndrome is rare but significant and should be considered in post-operative management of this population.
Collapse
Affiliation(s)
- Justin Turpin
- Donald and Barbera Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Daniel G Lynch
- Donald and Barbera Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Timothy White
- Donald and Barbera Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Kevin A Shah
- Donald and Barbera Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Kaiyun Yang
- Department of Neurosurgery, Community Health Partners, Fresno, CA, USA.
| | - Jeffrey M Katz
- North Shore University Hospital Department of Vascular Neurology, Manhasset, NY, USA.
| | - Amir R Dehdashti
- Donald and Barbera Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| |
Collapse
|
27
|
Lin CJ, Chung CP, Liao NC, Chen PL, Chi NF, Lai YJ, Tang CW, Wu CH, Chang FC, Luo CB, Fay LY, Lin CF, Chou CH, Lee TH, Lee JT, Jeng JS, Lee IH. The 2023 Taiwan Stroke Society Guidelines for the management of patients with intracranial atherosclerotic disease. J Chin Med Assoc 2023; 86:697-714. [PMID: 37341526 DOI: 10.1097/jcma.0000000000000952] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, especially in Asian populations, which has a high risk of recurrent stroke and cardiovascular comorbidities. The present guidelines aim to provide updated evidence-based recommendations for diagnosis and management of patients with ICAD. Taiwan Stroke Society guideline consensus group developed recommendations for management of patients with ICAD via consensus meetings based on updated evidences. Each proposed class of recommendation and level of evidence was approved by all members of the group. The guidelines cover six topics, including (1) epidemiology and diagnostic evaluation of ICAD, (2) nonpharmacological management of ICAD, (3) medical therapy for symptomatic ICAD, (4) endovascular thrombectomy and rescue therapy for acute ischemic stroke with underlying ICAD, (5) endovascular interventional therapy for postacute symptomatic intracranial arterial stenosis, and (6) surgical treatment of chronic symptomatic intracranial arterial stenosis. Intensive medical treatment including antiplatelet therapy, risk factor control, and life style modification are essential for patients with ICAD.
Collapse
Affiliation(s)
- Chun-Jen Lin
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chih-Ping Chung
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Nien-Chen Liao
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Po-Lin Chen
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Nai-Fang Chi
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yen-Jun Lai
- Radiology Department, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Chih-Wei Tang
- Neurology Department and Stroke Center, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Chia-Hung Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Li-Yu Fay
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chun-Fu Lin
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chung-Hsing Chou
- Neurology Department, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Jiunn-Tay Lee
- Neurology Department, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Jiann-Shing Jeng
- Department of Neurology and Stroke Center, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - I-Hui Lee
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| |
Collapse
|
28
|
Darsaut TE, Raymond J. 'It is not the answer which enlightens, but the question'. Neurochirurgie 2023; 69:101446. [PMID: 37178487 DOI: 10.1016/j.neuchi.2023.101446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023]
Affiliation(s)
- T E Darsaut
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440 112 St NW, Edmonton, Alberta, Canada
| | - J Raymond
- Department of Radiology, Service of Neuroradiology, centre hospitalier de l'université de Montréal (CHUM), room D03.5462b, Montreal, H2X 0C1 Quebec, Canada.
| |
Collapse
|
29
|
Kim NC, Sangwon KL, Raz E, Shapiro M, Rutledge C, Nelson PK, Riina HA, Nossek E. Early Experience of Surgical Planning for STA-MCA Bypass Using Virtual Reality. World Neurosurg 2023; 174:e44-e52. [PMID: 36906090 DOI: 10.1016/j.wneu.2023.02.113] [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: 01/17/2023] [Revised: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND The superficial temporal artery (STA)-to-middle cerebral artery (MCA) bypass requires precise preoperative planning, and 3-dimensional virtual reality (VR) models have recently been used to optimize planning of STA-MCA bypass. In the present report, we have described our experience with VR-based preoperative planning of STA-MCA bypass. METHODS Patients from August 2020 to February 2022 were analyzed. For the VR group, using 3-dimensional models from the patients' preoperative computed tomography angiograms, VR was used to locate the donor vessels, potential recipient, and anastomosis sites and plan the craniotomy, which were referenced throughout surgery. Computed tomography angiograms or digital subtraction angiograms were used to plan the craniotomy for the control group. The procedure time, bypass patency, craniotomy size, and postoperative complication rates were assessed. RESULTS The VR group included 17 patients (13 women; age, 49 ± 14 years) with Moyamoya disease (76.5%) and/or ischemic stroke (29.4%). The control group included 13 patients (8 women; age, 49 ± 12 years) with Moyamoya disease (92.3%) and/or ischemic stroke (7.3%). For all 30 patients, the preoperatively planned donor and recipient branches were effectively translated intraoperatively. No significant difference were found in the procedure time or craniotomy size between the 2 groups. Bypass patency was 94.1% for the VR group (16 of 17) and 84.6% for the control group (11 of 13). No permanent neurological deficits occurred in either group. CONCLUSIONS Our early experience has shown that VR can serve as a useful, interactive preoperative planning tool by enhancing visualization of the spatial relationship between the STA and MCA without compromising the surgical results.
Collapse
Affiliation(s)
- Nora C Kim
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Karl L Sangwon
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Eytan Raz
- Department of Radiology, NYU Langone Health, New York, New York, USA
| | - Maksim Shapiro
- Department of Radiology, NYU Langone Health, New York, New York, USA
| | - Caleb Rutledge
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Peter K Nelson
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA; Department of Radiology, NYU Langone Health, New York, New York, USA
| | - Howard A Riina
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA; Department of Radiology, NYU Langone Health, New York, New York, USA
| | - Erez Nossek
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA.
| |
Collapse
|
30
|
Rennert RC, Brandel MG, Budohoski KP, Twitchell S, Fredrickson VL, Grandhi R, Couldwell WT. Influence of Patient and Technical Variables on Combined Direct and Indirect Cerebral Revascularization: Case Series. Oper Neurosurg (Hagerstown) 2023; 24:610-618. [PMID: 36786755 DOI: 10.1227/ons.0000000000000618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/05/2022] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Cerebral bypass for flow augmentation is an important technique for selected neurosurgical patients, with multiple techniques used (direct, indirect, or combined). OBJECTIVE To assess the impact of patient and technical variables on direct and indirect bypass flow after combined revascularization. METHODS This was a retrospective, single-institution review of patients undergoing direct superficial temporal artery-to-middle cerebral artery bypass with indirect encephaloduro-myosynangiosis for moyamoya disease and steno-occlusive cerebrovascular disease over a 2-year period. We evaluated the effect of baseline patient characteristics, preoperative imaging characteristics, and operative variables on direct and indirect patency grades. RESULTS Twenty-six hemispheres (8 moyamoya disease and 18 steno-occlusive cerebrovascular disease) in 23 patients were treated with combined revascularization. The mean patient age was 53.4 ± 19.1 years. Direct bypass patency was 96%. Over a mean follow-up of 8.3 ± 5.4 months, there were 3 strokes in the treated hemispheres (11.5%). The mean modified Rankin Scale score improved from 1.3 ± 1.1 preoperatively to 0.7 ± 0.8 postoperatively. Preservation of the nondonor superficial temporal artery branch was associated with a lower direct bypass grade ( P < .01), whereas greater mean time to maximum perfusion (Tmax)> 4 and >6 seconds and mismatch volumes were associated with higher direct bypass grades ( P < .05). Tmax >4-second volume inversely predicted indirect bypass patency. CONCLUSION Patient and technical variables may influence the relative contributions of the direct and indirect components of combined revascularizations.
Collapse
Affiliation(s)
- Robert C Rennert
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Michael G Brandel
- Department of Neurological Surgery, University of California San Diego, San Diego, California, USA
| | - Karol P Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Spencer Twitchell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Vance L Fredrickson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
31
|
Nguyen VN, Motiwala M, Parikh K, Miller LE, Barats M, Nickele CM, Inoa V, Elijovich L, Goyal N, Hoit DA, Arthur AS, Morcos JJ, Khan NR. Extracranial-Intracranial Cerebral Revascularization for Atherosclerotic Vessel Occlusion: An Updated Systematic Review of the Literature. World Neurosurg 2023; 173:199-207.e8. [PMID: 36758795 DOI: 10.1016/j.wneu.2023.02.003] [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: 12/22/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Atherosclerotic steno-occlusive cerebrovascular disease includes extracranial carotid occlusive and intracranial atherosclerotic disease. Despite the negative findings in Carotid Occlusion Surgery Study (COSS), many large centers continue to report favorable results for revascularization surgery in select groups of patients. The aim of our study was to perform an updated systematic review to investigate the role of revascularization surgery for atherosclerotic steno-occlusive patients in the modern era. METHODS Five independent reviewers performed Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided literature searches in October 2022 to identify articles reporting clinical outcomes in adult patients undergoing bypass for atherosclerotic steno-occlusive disease. Primary endpoints used were perioperative and long-term ischemic strokes, intracerebral hemorrhage, bypass patency, and favorable clinical outcomes. Study quality was evaluated with Newcastle-Ottawa, JADAD, and the Oxford Center for Evidence-Based Medicine scales. RESULTS A total of 6709 articles were identified in the initial search. Of these articles, 50 met the inclusion criteria and were included in the systematic review. A notable increase in the proportion of articles published over the past 10 years was observed. There were 6046 total patients with 4447 bypasses performed over the period from 1978 to 2022. The average length of follow-up was 2.75 ± 2.71 years. The average Newcastle-Ottawa was 6.23 out of 9 stars. There was a significant difference in perioperative stroke (odds ratio [OR], 0.65 [0.48-0.87]; P = 0.004), long-term ischemia (OR, 0.32 [0.23-0.44]; P < 0.0001), overall ischemia (OR, 0.36 [0.28-0.44]; P < 0.0001), and favorable outcomes (OR, 3.63 [2.84-4.64]; P < 0.0001) when comparing pre-COSS to post-COSS time frames in favor of post-COSS. CONCLUSIONS Based on a systematic review of 50 articles, the existing literature indicates that long-term stroke rates and favorable outcomes for surgical revascularization for steno-occlusive disease have improved over time and are lower than previously reported. Improved patient selection, perioperative care, and surgical techniques may contribute to improved outcomes.
Collapse
Affiliation(s)
- Vincent N Nguyen
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA
| | - Mustafa Motiwala
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA
| | - Kara Parikh
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA
| | - L Erin Miller
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA
| | - Michael Barats
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA
| | - Christopher M Nickele
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA; Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee, USA
| | - Violiza Inoa
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA; University of Tennessee Health Sciences Center Department of Neurology, Memphis, Tennessee, USA; Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee, USA
| | - Lucas Elijovich
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA; University of Tennessee Health Sciences Center Department of Neurology, Memphis, Tennessee, USA; Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee, USA
| | - Nitin Goyal
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA; University of Tennessee Health Sciences Center Department of Neurology, Memphis, Tennessee, USA; Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee, USA
| | - Daniel A Hoit
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA; Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee, USA
| | - Adam S Arthur
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA; Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee, USA
| | - Jacques J Morcos
- University of Miami Department of Neurosurgery, Miami, Florida, USA
| | - Nickalus R Khan
- University of Tennessee Health Sciences Center Department of Neurosurgery, Memphis, Tennessee, USA; Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee, USA.
| |
Collapse
|
32
|
Imamura H, Sakai N, Sakai C, Hasegawa Y, Hyodo A, Iihara K, Minematsu K, Ogasawara K. Japanese Postmarket Surveillance of Percutaneous Transluminal Angioplasty and Wingspan Stenting for Intracranial Atherosclerotic Disease. World Neurosurg 2023; 173:e48-e54. [PMID: 36716851 DOI: 10.1016/j.wneu.2023.01.093] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/22/2023] [Accepted: 01/23/2023] [Indexed: 01/30/2023]
Abstract
BACKGROUND The Wingspan stent system was approved as a rescue device for angioplasty of intracranial atherosclerotic disease (ICAD) in 2012. We conducted the government-recommended Japanese Postmarket Surveillance of Percutaneous Transluminal Angioplasty and Wingspan Stenting for Intracranial Atherosclerotic Disease to monitor Wingspan safety and performance. METHODS In this open-label, single-arm study at 76 centers in Japan, ICAD subjects were treated with the Wingspan stent between 2014 and 2016. Efficacy end points were successful stent deployment and technical success, defined as stenosis improvement to <50%. Safety end points were ischemic stroke, modified Rankin Scale and National Institutes of Health Stroke Scale scores, adverse events, and mortality. Subjects were considered treated outside of current recommendations if not already receiving antithrombotics or if percutaneous transluminal angioplasty and stenting occurred within 7 days of onset. RESULTS The safety cohort included 305 subjects (mean age: 68.7 + 9.6; 83.3% male). Four subjects were removed due to being out of contract. Therefore, 301 subjects were included (mean age: 68.7 ± 9.7; 84.1% male). Successful stent placement was 96.7%. Technical success was observed in 86.8% of lesions. At 1 year, the rate of restenosis was 15.7%, ischemic stroke was 3.9%, and any stroke was 7.9%. Functionally independent outcome (modified Rankin Scale: 0-2) was 88.9% and mortality 3.0%. Significantly more serious adverse events occurred in subjects treated outside of current recommendations (17.9%) versus subjects treated per current recommendations (8.8%) (P = 0.045). CONCLUSIONS Endovascular treatment using the Wingspan stent for ICAD is safe and effective in the Japanese population.
Collapse
Affiliation(s)
- Hirotoshi Imamura
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Chiaki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Akio Hyodo
- Department of Neurosurgery, Dokkyo Medical University Saitama Hospital, Koshigaya, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Iwate, Japan
| |
Collapse
|
33
|
Speranza G, Harish K, Rockman C, Gordon R, Sadek M, Jacobowitz G, Chang H, Garg K, Maldonado TS. The Natural History of Carotid Artery Occlusions Diagnosed on Duplex Ultrasound. Ann Vasc Surg 2023; 91:1-9. [PMID: 36574830 DOI: 10.1016/j.avsg.2022.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 11/07/2022] [Accepted: 11/28/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND There is a paucity of literature on the natural history of extracranial carotid artery occlusion (CAO). This study reviews the natural history of this patient cohort. METHODS This single-institution retrospective analysis studied patients with CAO diagnosed by duplex ultrasound between 2010 and 2021. Patients were identified by searching our office-based Intersocietal Accreditation Commission accredited vascular laboratory database. Imaging and clinical data were obtained via our institutional electronic medical record. Outcomes of interest included ipsilateral stroke, attributable neurologic symptoms, and ipsilateral intervention after diagnosis. RESULTS The full duplex database consisted of 5,523 patients who underwent carotid artery duplex examination during the study period. The CAO cohort consisted of 139 patients; incidence of CAO was 2.5%. Mean age at diagnosis was 69.7 years; 31.4% were female. Hypertension (72.7%), hyperlipidemia (64.7%), and prior smoking (43.9%) were the most common comorbid conditions. Of the CAO cohort, 61.3% (n = 85) of patients were asymptomatic at diagnosis; 38.8% (n = 54) were diagnosed after a stroke or transient ischemic attack occurring within 6 months prior to diagnosis, with 21.6% occurring ipsilateral to the CAO and 10.1% occurring contralateral to the CAO. 7.2% (n = 10) had unclear symptoms or laterality at presentation. Of the CAO cohort, 95 patients (68.3%) had duplex imaging follow-up (mean 42.7 ± 31.3 months). Of those with follow-up studies, 7 patients (5.0%) developed subsequent stroke ipsilateral to the CAO with mean occurrence 27.8 ± 39.0 months postdiagnosis. In addition, 5 patients (3.6%) developed other related symptoms, including global hypoperfusion (2.4%) and transient ischemic attack (1.2%). Of those, 95 patients with follow-up duplex ultrasound imaging, 6 (4.3%) underwent eventual ipsilateral intervention, including carotid endarterectomy (n = 4), transfemoral carotid artery stent (n = 1), and carotid bypass (n = 1), with mean occurrence 17.7 ± 23.7 months postdiagnosis. The aggregate rate of ipsilateral cerebrovascular accident, attributable neurologic symptoms, or ipsilateral intervention was 11.5%. Of 95 patients with follow-up duplex ultrasound imaging, 5 underwent subsequent duplex studies demonstrating ipsilateral patency, resulting in a 5.3% discrepancy rate between sequential duplex studies. All 6 patients undergoing intervention received periprocedural cross-sectional imaging (magnetic resonance angiography or computed tomography angiography). In 5 of these 6 patients, cross-sectional demonstrated severe stenosis rather than CAO, disputing prior duplex ultrasound findings. CONCLUSIONS In this large, institutional cohort of patients with a CAO diagnosis on duplex ultrasound, a clinically meaningful subset of patients experienced cerebrovascular accident, related symptoms, or intervention. We also found a notable rate of temporal duplex discrepancies among patients with CAO diagnoses and discrepancies between CAO diagnosis per duplex ultrasound and findings on cross-sectional imaging for those patients who underwent intervention. These results suggest that use of a single duplex ultrasound as a sole diagnostic tool in CAO may not be sufficient and that physicians should consider close duplex ultrasound surveillance of these patients, potentially in conjunction with additional confirmatory imaging modalities. Further investigation into optimal workup and surveillance protocols for CAO is needed.
Collapse
Affiliation(s)
| | - Keerthi Harish
- New York University Grossman School of Medicine, New York, NY
| | - Caron Rockman
- New York University Grossman School of Medicine, New York, NY
| | - Ryan Gordon
- Department of General Surgery, ChristianaCare, Wilmington, DE
| | - Mikel Sadek
- New York University Grossman School of Medicine, New York, NY
| | | | - Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Thomas S Maldonado
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY.
| |
Collapse
|
34
|
Nuerlanbieke H, Niyazi A, Wu Q, Yuan Y, Habudele Z, Dun X, Wei R, Aisha A. Efficacy of modified EDAS combined with a superficial temporal fascia attachment-dural reversal surgery for the precise treatment of ischemic cerebrovascular disease. Front Surg 2023; 10:1087311. [PMID: 37066009 PMCID: PMC10090302 DOI: 10.3389/fsurg.2023.1087311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/15/2023] [Indexed: 03/31/2023] Open
Abstract
ObjectiveTo investigate the potential therapeutic benefits of Modified EDAS combined with superficial temporal fascia attachment-dural reversal surgery for the treatment of ischemic cerebrovascular disease.MethodsRetrospective analysis was made on the clinical data of 33 patients with ischemic cerebrovascular disease, who were admitted to the Neurological Diagnosis and Treatment Center of the Second Affiliated Hospital of Xinjiang Medical University from December 2019 to June 2021. All patients were treated with Modified EDAS combined with superficial temporal fascia attachment-dural reversal surgery. At 3 months after operation, the outpatient department rechecked the patient's head CT perfusion imaging (CTP) to understand the intracranial cerebral blood flow perfusion. The DSA of the patient's head was re-examined 6 months after operation to observe the establishment of collateral circulation. The improved Rankin Rating Scale (mRS) score was used to evaluate the good prognosis rate of patients at 6 months after surgery. The mRS score ≤2 was defined as good prognosis.ResultsThe preoperative cerebral blood flow (CBF), local blood flow peak time (rTTP), and local mean transit time (rMTT) of 33 patients were 28.235 ml/(100 g·min), 17.702 s, 9.796 s, respectively. At 3 months after surgery, CBF, rTTP, and rMTT were 33.743 ml/(100 g·min), 15.688, and 8.100 s, respectively, with significant differences (P < 0.05). At 6 months after operation, the establishment of extracranial and extracranial collateral circulation was observed in all patients by re-examination of head DSA. At 6 months after operation, the good prognosis rate was 81.8%.ConclusionThe Modified EDAS combined with superficial temporal fascia attachment-dural reversal surgery is safe and effective in the treatment of ischemic cerebrovascular disease, which can significantly increase the establishment of collateral circulation in the operation area and improve the prognosis of patients.
Collapse
Affiliation(s)
- Hanati Nuerlanbieke
- Department of Neurosurgery, The 2th Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Ailiyaer Niyazi
- Department of Neurosurgery, The 2th Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Qinfen Wu
- Department of Neurosurgery, The 2th Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Neurological Disorder Research, Urumqi, China
- Correspondence: Qinfen Wu Yang Yuan
| | - Yang Yuan
- Department of Neurosurgery, The 2th Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Neurological Disorder Research, Urumqi, China
- Correspondence: Qinfen Wu Yang Yuan
| | - Zanghaer Habudele
- Xinjiang Key Laboratory of Neurological Disorder Research, Urumqi, China
| | - Xiaoyi Dun
- Xinjiang Medical University, Urumqi, China
| | - RuRui Wei
- Department of Neurosurgery, The 2th Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Neurological Disorder Research, Urumqi, China
| | - Abudula Aisha
- Department of Neurosurgery, The 2th Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Neurological Disorder Research, Urumqi, China
| |
Collapse
|
35
|
Xia J, Gao H, Zhang K, Gao B, Li T, Wang Z. Effects of endovascular recanalization on symptomatic non-acute occlusion of intracranial arteries. Sci Rep 2023; 13:4550. [PMID: 36941301 PMCID: PMC10027893 DOI: 10.1038/s41598-023-31313-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 03/09/2023] [Indexed: 03/23/2023] Open
Abstract
To investigate the effect and safety of recanalization surgery for non-acute occlusion of large intracranial arteries and factors affecting clincial outcomes. Patients with non-acute occlusion of internal carotid artery (ICA), middle cerebral artery (MCA), and vertebrobasilar artery (VBA) treated with recanalization were retrospectively enrolled. The clinical and angiographic data were analyzed. 177 patients were enrolled, including 67 patients with intracranial ICA occlusion, 52 with MCA occlusion, and 58 with VBA occlusion. Successful recanalization was achieved in 152 (85.9%) patients. Complications occurred in 15 patients (8.5%). Followed up for 3-7 months, the 90 day mRS was significantly improved compared with that before the procedure. Among 152 patients with successful recanalization, eight patients experienced reocclusion (5.3%), and 11 patients experienced restenosis (7.2%). Successful recanalization was significantly (P < 0.05) associated with occlusion duration, calcification or angulation of the occluded segment. Complications were significantly (P < 0.05) associated with location of occlusion, hyperlipidemia, and patients' height. Restentosis or reocclusion at follow-up was significantly (P < 0.05) associated with complications and mRS at 90 days. The significant (P < 0.05) independent risk factors were angulation and calcification for successful recanalization, hyperlipidemia for complications, and mRS at 90 days for restenosis or reocclusion at follow-up. Recanalization surgery may be a safe and effective approach for patients with non-acute symptomatic occlusion of large intracranial arteries, and factors significantly independently associated with successful recanalization, periprocedural complications and restenosis or reocclusion after surgery have been identified for future reference to improve clinical outcomes.
Collapse
Affiliation(s)
- Jinchao Xia
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University and Henan University, 7 Weiwu Road, Zhengzhou, 450000, Henan, China
| | - Huili Gao
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University and Henan University, 7 Weiwu Road, Zhengzhou, 450000, Henan, China
| | - Kun Zhang
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University and Henan University, 7 Weiwu Road, Zhengzhou, 450000, Henan, China
| | - Bulang Gao
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University and Henan University, 7 Weiwu Road, Zhengzhou, 450000, Henan, China
| | - Tianxiao Li
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University and Henan University, 7 Weiwu Road, Zhengzhou, 450000, Henan, China
| | - Ziliang Wang
- Stroke Center, Henan Provincial People's Hospital, Zhengzhou University and Henan University, 7 Weiwu Road, Zhengzhou, 450000, Henan, China.
| |
Collapse
|
36
|
Jo H, Lee SU, Jeong HG, Kim YD, Kim T, Sunwoo L, Ban SP, Bang JS, Kwon O, Oh CW. Long-term outcomes and quantitative radiologic analysis of extracranial-intracranial bypass for hemodynamically compromised chronic large artery occlusive disease. Sci Rep 2023; 13:3717. [PMID: 36879127 PMCID: PMC9988922 DOI: 10.1038/s41598-023-30874-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
This study aimed to demonstrate the effectiveness of nonemergent extracranial-to-intracranial bypass (EIB) in symptomatic chronic large artery atherosclerotic stenosis or occlusive disease (LAA) through quantitative analysis of computed tomography perfusion (CTP) parameters using RAPID software. We retrospectively analyzed 86 patients who underwent nonemergent EIB due to symptomatic chronic LAA. CTP data obtained preoperatively, immediately postoperatively (PostOp0), and 6 months postoperatively (PostOp6M) after EIB were quantitatively analyzed through RAPID software, and their association with intraoperative bypass flow (BF) was assessed. The clinical outcomes, including neurologic state, incidence of recurrent infarction and complications, were also analyzed. The time-to-maximum (Tmax) > 8 s, > 6 s and > 4 s volumes decreased significantly at PostOp0 and up through PostOp6M (preoperative, 5, 51, and 223 ml (median), respectively; PostOp0, 0, 20.25, and 143 ml, respectively; PostOp6M, 0, 7.5, and 148.5 ml, respectively; p < 0.001, p < 0.001, and p < 0.001, respectively). The postoperative improvement in the Tmax > 6 s and > 4 s volumes was significantly correlated with the BF at PostOp0 and PostOp6M (PostOp0, r = 0.367 (p = 0.001) and r = 0.275 (p = 0.015), respectively; PostOp6M r = 0.511 (p < 0.001) and r = 0.391 (p = 0.001), respectively). The incidence of recurrent cerebral infarction was 4.7%, and there were no major complications that produced permanent neurological impairment. Nonemergent EIB under strict operation indications can be a feasible treatment for symptomatic, hemodynamically compromised LAA patients.
Collapse
Affiliation(s)
- Hyunjun Jo
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea.
| | - Han-Gil Jeong
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea.,Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Young-Deok Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Leonard Sunwoo
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Oki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, Gyeonggi-do, Korea
| |
Collapse
|
37
|
Raymond J, Rheaume AR, Olijnyk L, Lecaros NE, Darsaut TE. Understanding the difference between theory and practice: The extracranial-intracranial bypass trials in prevention of ischemic stroke. Neurochirurgie 2023; 69:101407. [PMID: 36689827 DOI: 10.1016/j.neuchi.2023.101407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Patients with atherosclerotic carotid or middle cerebral artery occlusions suffer ischemic events that might theoretically be preventable with a surgical extracranial-intracranial bypass, but theory by itself does not justify surgical interventions. METHODS We review landmark randomized trials on EC-IC bypass surgery for the treatment of ischemic stroke in patients with atherosclerotic stenoses or occlusions. RESULTS The initial EC-IC bypass trial from 1985 did not show any clinical benefit from surgery. The carotid occlusion surgery study (COSS) performed more than 20 years later included only patients highly selected to potentially benefit from bypass by using modern perfusion studies. While EC-IC bypasses were successfully created and they did improve cerebral perfusion, the COSS study also failed to show any clinical benefit to the participating patients. CONCLUSION Neurosurgical interventions must not only work in theory; they must improve patient outcomes in real practice.
Collapse
Affiliation(s)
- J Raymond
- Department of radiology, Service of neuroradiology, Centre hospitalier de l'université de Montréal (CHUM), Montréal, Québec, Canada.
| | - A R Rheaume
- Division of neurosurgery, Department of surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - L Olijnyk
- Department of radiology, Service of neuroradiology, Centre hospitalier de l'université de Montréal (CHUM), Montréal, Québec, Canada
| | - N E Lecaros
- Department of radiology, Service of neuroradiology, Centre hospitalier de l'université de Montréal (CHUM), Montréal, Québec, Canada
| | - T E Darsaut
- Division of neurosurgery, Department of surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| |
Collapse
|
38
|
Raymond J, Olijnyk L, Lecaros NE, Rheaume AR, Darsaut TE. When successful surgery may not be beneficial to patients. Neurochirurgie 2023; 69:101406. [PMID: 36706512 DOI: 10.1016/j.neuchi.2023.101406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 01/26/2023]
Affiliation(s)
- J Raymond
- Centre hospitalier de l'université de Montreal, Montreal, Canada.
| | - L Olijnyk
- Centre hospitalier de l'université de Montreal, Montreal, Canada
| | - N E Lecaros
- Centre hospitalier de l'université de Montreal, Montreal, Canada
| | - A R Rheaume
- Division of neurosurgery, department of surgery, university of Alberta hospital, Mackenzie health sciences centre, Edmonton, Alberta, Canada
| | - T E Darsaut
- Division of neurosurgery, department of surgery, university of Alberta hospital, Mackenzie health sciences centre, Edmonton, Alberta, Canada
| |
Collapse
|
39
|
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.
Collapse
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
| |
Collapse
|
40
|
Surgical Management of Intracranial Atherosclerotic Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023. [DOI: 10.1007/s11936-022-00974-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
41
|
Abdelgadir J, Haskell-Mendoza AP, Magno AR, Suarez AD, Antwi P, Raghavan A, Nelson P, Yang LZ, Jung SH, Zomorodi AR. Revisiting flow augmentation bypass for cerebrovascular atherosclerotic vaso-occlusive disease: Single-surgeon series and review of the literature. PLoS One 2023; 18:e0285982. [PMID: 37205640 DOI: 10.1371/journal.pone.0285982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/07/2023] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVE Despite advances in the nonsurgical management of cerebrovascular atherosclerotic steno-occlusive disease, approximately 15-20% of patients remain at high risk for recurrent ischemia. The benefit of revascularization with flow augmentation bypass has been demonstrated in studies of Moyamoya vasculopathy. Unfortunately, there are mixed results for the use of flow augmentation in atherosclerotic cerebrovascular disease. We conducted a study to examine the efficacy and long term outcomes of superficial temporal artery to middle cerebral artery (STA-MCA) bypass in patients with recurrent ischemia despite optimal medical management. METHODS A single-institution retrospective review of patients receiving flow augmentation bypass from 2013-2021 was conducted. Patients with non-Moyamoya vaso-occlusive disease (VOD) who had continued ischemic symptoms or strokes despite best medical management were included. The primary outcome was time to post-operative stroke. Time from cerebrovascular accident to surgery, complications, imaging results, and modified Rankin Scale (mRS) scores were aggregated. RESULTS Twenty patients met inclusion criteria. The median time from cerebrovascular accident to surgery was 87 (28-105.0) days. Only one patient (5%) had a stroke at 66 days post-op. One (5%) patient had a post-operative scalp infection, while 3 (15%) developed post-operative seizures. All 20 (100%) bypasses remained patent at follow-up. The median mRS score at follow up was significantly improved from presentation from 2.5 (1-3) to 1 (0-2), P = .013. CONCLUSIONS For patients with high-risk non-Moyamoya VOD who have failed optimal medical therapy, contemporary approaches to flow augmentation with STA-MCA bypass may prevent future ischemic events with a low complication rate.
Collapse
Affiliation(s)
- Jihad Abdelgadir
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Aden P Haskell-Mendoza
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Amanda R Magno
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Alexander D Suarez
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Prince Antwi
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Alankrita Raghavan
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Patricia Nelson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Lexie Zidanyue Yang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sin-Ho Jung
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Ali R Zomorodi
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| |
Collapse
|
42
|
Nguyen VN, Parikh K, Motiwala M, Moore KA, Miller LE, Barats M, Sorenson JM, Michael LM, Arthur AS, Khan NR. Far Lateral Craniotomy, Occipital Artery-Posterior Inferior Cerebellar Artery Bypass, and Trapping of a Ruptured Dissecting Fusiform Right Vertebral Artery Aneurysm Involving the Posterior Inferior Cerebellar Artery Origin: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e39-e40. [PMID: 36227210 DOI: 10.1227/ons.0000000000000425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/16/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Vincent N Nguyen
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kara Parikh
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Mustafa Motiwala
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kenneth A Moore
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - L Erin Miller
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Michael Barats
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jeffrey M Sorenson
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, Semmes Murphey Neurologic & Spine Institute, Memphis, Tennessee, USA
| | - L Madison Michael
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, Semmes Murphey Neurologic & Spine Institute, Memphis, Tennessee, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, Semmes Murphey Neurologic & Spine Institute, Memphis, Tennessee, USA
| | - Nickalus R Khan
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, Semmes Murphey Neurologic & Spine Institute, Memphis, Tennessee, USA
| |
Collapse
|
43
|
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.
Collapse
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
| | | | | |
Collapse
|
44
|
Wu J, Fang C, Wei L, Liu Y, Xu H, Wang X, Yuan L, Wu X, Xu Y, Zhang A. Spotlight on clinical strategies of Chronic Internal Carotid Artery Occlusion: Endovascular interventions and external-intracarotid bypasses compared to conservative treatment. Front Surg 2022; 9:971066. [PMID: 36425889 PMCID: PMC9679017 DOI: 10.3389/fsurg.2022.971066] [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: 06/16/2022] [Accepted: 10/18/2022] [Indexed: 10/11/2023] Open
Abstract
Chronic internal carotid artery occlusion (CICAO) has high prevalence and incidence rates, and patients with CICAO can be completely asymptomatic, experience a devastating stroke or die. It is important to note that CICAO causes cerebrovascular accidents. Currently, the external carotid-internal carotid (EC-IC) bypass technique is used to treat CICAO. However, many clinical studies showed that EC-IC bypass was not beneficial for many patients with CICAO. Meanwhile, endovascular intervention treatment options for CICAO are evolving, and an increasing number of patients are undergoing endovascular intervention therapy. Accordingly, a review comparing both techniques is warranted. For this review, we searched PubMed and collected relevant case study reports comparing endovascular interventional therapy and internal and external cervical bypass surgeries to provide strategies for clinical treatment.
Collapse
Affiliation(s)
- Junnan Wu
- Department of Emergency, Dongyang Hospital Affiliated to Wenzhou Medical University, Jinhua, China
| | - Chaoyou Fang
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lingying Wei
- Department of Emergency, Dongyang Hospital Affiliated to Wenzhou Medical University, Jinhua, China
| | - Yibo Liu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Shanghai, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Houshi Xu
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Shanghai, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Ling Yuan
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoya Wu
- Department of Emergency, Dongyang Hospital Affiliated to Wenzhou Medical University, Jinhua, China
| | - Yuanzhi Xu
- Department of Neurosurgery, Huashan Hospital, School of Medicine, Fudan University, Shanghai, China
| | - Anke Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Shanghai, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| |
Collapse
|
45
|
Zhang Z, Pan C, McBride D, Wu Z, Zhang G, Chen D, Zhang JH, Tang Z. Progress in the treatment of chronic intracranial large artery occlusion: Time for large, randomized trials? BRAIN HEMORRHAGES 2022. [DOI: 10.1016/j.hest.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
|
46
|
Khan NR, Elarjani T, Jamshidi AM, Lu VM, Silva MA, Richardson A, Harrington T, Valdes T, Campo N, Krementz N, Asdaghi N, Sur N, Londono EM, Malik AM, Koch S, Romano J, Morcos JJ. Direct Bypass Surgery for Moyamoya and Steno-occlusive Vasculopathy: Clinical Outcomes, Intraoperative Blood Flow Analysis, Long-term Follow-up, and Long-term Bypass Patency in a Single Surgeon Case Series of 162 Procedures. World Neurosurg 2022; 168:e500-e517. [DOI: 10.1016/j.wneu.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
|
47
|
Chronic remote ischaemic conditioning in patients with symptomatic intracranial atherosclerotic stenosis (the RICA trial): a multicentre, randomised, double-blind sham-controlled trial in China. Lancet Neurol 2022; 21:1089-1098. [DOI: 10.1016/s1474-4422(22)00335-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/10/2022] [Accepted: 07/26/2022] [Indexed: 11/06/2022]
|
48
|
Ghannam MM, Davies JM. Application of Big Data in Vascular Neurosurgery. Neurosurg Clin N Am 2022; 33:469-482. [DOI: 10.1016/j.nec.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
49
|
Srinivasan VM, Rahmani R, Labib MA, Lang MJ, Catapano JS, Graffeo CS, Lawton MT. Evolution in Cerebrovascular Bypass. Neurosurg Clin N Am 2022; 33:383-402. [DOI: 10.1016/j.nec.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
|
50
|
Lefevre E, Ganau M, Zaed I, de Macedo Machado-Filho G, Scibilia A, Mallereau CH, Bresson D, Todeschi J, Cebula H, Proust F, Vignes JL, Masquelet AC, Facca S, Livernaux P, Alfieri A, Ramos TCM, Magaldi M, Bruno C, Chibbaro S. Learning curve and influencing factors of performing microsurgical anastomosis: a laboratory prospective study. Neurosurg Rev 2022; 45:3271-3280. [PMID: 36066661 DOI: 10.1007/s10143-022-01856-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/28/2022] [Accepted: 08/27/2022] [Indexed: 11/29/2022]
Abstract
Despite being a critical component of any cerebrovascular procedure, acquiring skills in microsurgical anastomosis is challenging for trainees. In this context, simulation models, especially laboratory training, enable trainees to master microsurgical techniques before performing real surgeries. The objective of this study was to identify the factors influencing the learning curve of microsurgical training. A prospective observational study was conducted during a 7-month diploma in microsurgical techniques carried out in the anatomy laboratory of the school of surgery. Training focused on end-to-end (ETE) and end-to-side (ETS) anastomoses performed on the abdominal aorta, vena cava, internal carotid and jugular vein, femoral artery and vein, caudal artery, etc. of Wistar strain rats under supervision of 2 expert anatomical trainers. Objective and subjective data were collected after each training session. The 44 microsurgical trainees enrolled in the course performed 1792 anastomoses (1577 ETE, 88%, vs. 215 ETS, 12%). The patency rate of 41% was independent from the trainees' surgical background and previous experience. The dissection and the temporary clamping time both significantly decreased over the months (p < 0.001). Technical mistakes were independently associated with thrombosis of the anastomoses, as assessed by the technical mistakes score (p < 0.01). The training duration (in weeks) at time of each anastomosis was the only significant predictor of permeability (p < 0.001). Training duration and technical mistakes constituted the two major factors driving the learning curve. Future studies should try and investigate other factors (such as access to wet laboratory, dedicated fellowships, mentoring during early years as junior consultant/attending) influencing the retention of surgical skills for our difficult and challenging discipline.
Collapse
Affiliation(s)
- Etienne Lefevre
- Department of Neurosurgery, University Hospital "Pitié-Salpêtrière", Paris, France
| | - Mario Ganau
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| | - Ismail Zaed
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France.
| | | | - Antonino Scibilia
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| | - Charles-Henry Mallereau
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| | - Damien Bresson
- Department of Neurosurgery, University Hospital "Henri Mondor", Créteil, France
| | - Julien Todeschi
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| | - Helene Cebula
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| | - Francois Proust
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| | - Jean-Luc Vignes
- Microsurgery Laboratory of "Assistance Publique Hopitaux Paris", Fer a moulin, Paris, France
| | - Alain-Charles Masquelet
- Microsurgery Laboratory of "Assistance Publique Hopitaux Paris", Fer a moulin, Paris, France.,Department of Orthopedics, University Hospital "Saint-Antoine", Paris, France
| | - Sybille Facca
- Department of Orthopedics (Hand Surgery Unit), University Hospital "Hautepierre II", Strasbourg, France
| | - Philippe Livernaux
- Department of Orthopedics (Hand Surgery Unit), University Hospital "Hautepierre II", Strasbourg, France
| | - Alex Alfieri
- Department of Neurosurgery, Winterthur Hospital, Winterthur, Switzerland
| | - Taise Cruz Mosso Ramos
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| | - Marcelo Magaldi
- Department of Neurosurgery, "Hospital das Clinicas", Belo Horizonte, Brazil
| | - Carmen Bruno
- Neurosurgery Department, Bonomo Hospital, Andria, Italy
| | - Salvatore Chibbaro
- Department of Neurosurgery, University Hospital "Hautepierre", 1, Av. Moliere, 67098, Strasbourg, France
| |
Collapse
|