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Pini R, Faggioli G, Lodato M, Campana F, Vacirca A, Gallitto E, Gargiulo M. Medical and interventional outcome of dissection of the cervical arteries: Systematic review and meta-analysis. J Vasc Surg 2024; 80:913-921.e13. [PMID: 38636608 DOI: 10.1016/j.jvs.2024.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/29/2024] [Accepted: 04/10/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE The management of cervical artery dissections (CADs) is poorly standardized given the scarce number of prospective studies comparing medical and interventional approach to CAD. The aim of the present study is to perform a systematic review and meta-analysis of studies on the treatments of CAD. METHODS Systematic review and meta-analysis (pre-registered on PROSPERO [CRD42022297512] are performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses [PRISMA] guidelines searching in three different databases [PubMed, Embase and Cochrane Database]) of studies on medical or interventional approach to CAD. Only prospective studies were selected to reduce the risk of bias for the primary meta-analysis. Secondarily, retrospective studies were also included. The aim was to assess the rate of stroke and of stroke/death/bleeding (major or intracranial) by Der Simonian-Laird weights of random effects model. RESULTS After screening 456 articles, 6 prospective and 22 retrospective studies were identified. Two randomized controlled trials and five retrospective studies comparing antiplatelet (APT) vs oral anticoagulant therapy (OAC) for CAD were identified, as well as four prospective and 17 retrospective single-arm studies evaluating stenting for CAD. In the meta-analysis of randomized controlled trials comparing APT vs OAC, 444 patients were considered, and a borderline significant association was identified in terms of stroke/death in the APT vs OAC groups (odds ratio [OR], 5.6; 95% confidence interval [CI], 0.94-33.38; P = .06; I2 = 0%). No differences were found for the stroke/death/bleeding outcome (OR, 1.25; 95% CI, 0.19-8.18; P = .81; I2 = 0%) between the two treatments. In the meta-analysis including also retrospective studies, overall risk of bias was considered "serious," and 4104 patients were included with no differences in APT vs OAC for stroke (OR, 1.06; 95% CI, 0.53-2.11; P = .29; I2 = 18%); no other comparisons were possible. The pooled meta-analysis of prospective studies on stenting for CAD included four series, for a total of 68 patients, in whom stenting was adopted primarily after failed medical therapy or after traumatic dissection. The pooled rate of stroke/death was 7% (95% CI, 3%-17%; I2 = 0%). The analysis of moderators identified a significant inverse association between the percentage of traumatic dissection and a reduction in postoperative stroke (Y = -1.60-2.02X; P = .03). The pooled rate of the composite endpoint of stroke/death/ or major bleeding was 8% (95% CI, 3%-18%; I2 = 0%). Secondarily, the meta-analysis also included 17 retrospective studies with overall 457 patients and showed a 2.1% pooled rate of stroke/death (95% CI, 1.0%-3.3%; I2 = 0%) and 3.2% stroke/death/bleeding (95% CI, 1.8%-4.7%; I2 = 0%). CONCLUSIONS Few prospective studies on CAD treatment are present in literature. APT and OAC seem to have similar efficacy in reducing the recurrence of stroke after CAD. No definitive conclusion can be drawn for stenting, due to the low number of studies available. More prospective studies are necessary to evaluate its potential additional value over medical therapy alone in the early phase after CAD.
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Affiliation(s)
- Rodolfo Pini
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy.
| | - Marcello Lodato
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Federica Campana
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Andrea Vacirca
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Enrico Gallitto
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
| | - Mauro Gargiulo
- Department of Vascular Surgery, DIMEC, University of Bologna, Policlinico Sant' Orsola Malpighi, Bologna, Italy
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Bontinis V, Antonopoulos CN, Bontinis A, Koutsoumpelis A, Zymvragoudakis V, Rafailidis V, Giannopoulos A, Stoiloudis P, Ktenidis K. A systematic review and meta-analysis of carotid artery stenting for the treatment of cervical carotid artery dissection. Eur J Vasc Endovasc Surg 2022; 64:299-308. [PMID: 35961627 DOI: 10.1016/j.ejvs.2022.07.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of carotid artery stenting for the treatment of extracranial carotid artery dissection (CAD). DATA SOURCES Systematic review using Medline, Scopus, EMBASE and Cochrane Library. REVIEW METHODS A systematic search was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) statement. Data from the eligible studies were extracted and meta-analyzed. Primary endpoints included postoperative mortality, cerebrovascular events (CE) and modified Rankin Score for neurologic disability (mRS) at 90 days. We performed subgroup analyses between stenting of spontaneous and traumatic CAD, primary stenting versus stenting after failed medical therapy (FMT) and stenting of CAD in the presence of tandem occlusions versus stenting of isolated extracranial CAD. RESULTS Twenty-four studies with 1,224 patients were included. Pooled post-operative mortality, CE and mRS 0-2 rates were 1.71% (95%CI:0.83-2.80), 6.45% (95%CI:2.80-11.10) and 76.13% (95%CI:64.15-86.50), respectively. The pooled stroke rate was 2.16% (95%CI:0.0-6.64). Spontaneous versus traumatic CAD mortality rates were 3.20% (95%CI:1.80-4.88) and 0.00% (95%CI:0.00-1.59) while CE rates were 14.26% (95%CI:6.28-24.36) and 1.64% (95%CI:0.0-6.08). Primary stenting and stenting after FMT mortality rates were 0.63% (95%CI:0.0-5.63) and 0.0% (95%CI:0.0-2.24), while CE rates were 5.02% (95%CI:0.38-12.63) and 3.33% (95%CI:0.12-9.03). Mortality rates for tandem occlusions and isolated extracranial CAD were 5.62% (95%CI:1.76-10.83) and 0.23% (95%CI:0.0-1.88) respectively, while CE rates were 15.28% (95%CI:6.23-26.64) and 1.88% (95%CI:0.23-4.51). The methodological index for non-randomized studies (MINORS) score was 8.66 (low). CONCLUSION Both primary stenting and stenting of spontaneous CAD yielded unfavorable results regarding stent thrombosis and stroke rates. Conversely, stenting following FMT displayed acceptable mortality and complication rates corroborating the use of stenting in the setting of CAD as a second line treatment. Due to the low quality of the included studies, definite conclusions cannot be drawn necessitating further research.
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Affiliation(s)
- Vangelis Bontinis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece.
| | - Constantine N Antonopoulos
- Department of Vascular Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Alkis Bontinis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Andreas Koutsoumpelis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Vassilios Zymvragoudakis
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Vasileios Rafailidis
- Department of Radiology, Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Argirios Giannopoulos
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Panagiotis Stoiloudis
- 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki
| | - Kiriakos Ktenidis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
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Fernández García A, Jiménez Zapata HD, de Lera Alfonso MC, Sánchez Fernández C, Jiménez Arribas P, Rodríguez Arias CA. Decompressive Craniectomy in Pregnant Women. J Neurol Surg A Cent Eur Neurosurg 2021; 83:210-213. [PMID: 34077979 DOI: 10.1055/s-0041-1726108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Malignant middle cerebral artery (MCA) infarction warranting decompressive craniectomy (DC) is unusual in the population younger than 40 years. Specifically, only a few cases affecting pregnant women have been described in the literature. We present the case of a 39-year-old woman in the 24th week of pregnancy who suffered a right malignant MCA infarction that eventually required DC. The patient delivered a healthy baby and underwent a second surgery for cranioplasty 7 months later. We present both this case and a review of the literature, including all cases of DC in pregnant women published to date.
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Befera N, Griffin AS, Hauck EF. Endovascular repair of an acute symptomatic carotid artery dissection through the false dissecting carotid lumen. Interv Neuroradiol 2018; 25:51-53. [PMID: 30189757 DOI: 10.1177/1591019918798154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 48-year-old woman presented with an acute ischemic stroke (National Institutes of Health Stroke Scale (NIHSS) 21) six hours after symptom onset. Workup revealed a left cervical internal carotid artery (ICA) occlusive dissection, which was emergently reconstructed with a flow-diverting stent. A routine Duplex scan one hour later suggested reocclusion of the ICA, confirmed by angiography. The true lumen of the ICA could not be accessed and therefore the "false lumen" of the ICA dissection was entered proximally. The true lumen and ultimately the flow-diverting stent were accessed via the false lumen. In analogy to the subintimal arterial flossing with antegrade-retrograde intervention technique described for peripheral vascular disease, several stents were placed in telescoping fashion from the true common carotid lumen through the "false dissecting" lumen of the proximal ICA into the distal true lumen. The stent construct remained patent, and the patient recovered clinically to an NIHSS of 1.
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Affiliation(s)
- Nicholas Befera
- Duke University Medical Center, Department of Radiology, Durham, NC, USA
| | - Andrew S Griffin
- Duke University Medical Center, Department of Radiology, Durham, NC, USA
| | - Erik F Hauck
- Duke University Medical Center, Department of Radiology, Durham, NC, USA
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Murata K, Yamauchi S, Kaneshiro Y, Urano Y, Yamagata K, Takami T. A novel technique to visualize true lumen in endovascular treatment of the occlusive carotid dissection and the usefulness of external-internal carotid collateral channel. Interv Neuroradiol 2018; 24:533-539. [PMID: 29788812 DOI: 10.1177/1591019918776915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Dissection of the internal carotid artery (ICA) can cause occlusion or severe stenosis and is known to be one of the major causes of ischemic stroke in the young. Endovascular treatment is one of the useful options for carotid dissections, but passing the guidewire through the occlusion (lesion-cross) and confirmation of the true lumen are sometimes difficult. Case presentation A 40-year-old right-handed man complaining of dysarthria and gait disturbance consulted our hospital. Magnetic resonance imaging and angiography revealed right ICA dissection. Because of worsening symptoms with conservative treatment, we performed endovascular treatment. Prior to the lesion-cross, a microcatheter was navigated to the third segment of the internal maxillary artery and a balloon-guiding catheter was navigated to the proximal ICA. Under balloon occlusion of the ICA, superselective angiography via the ipsilateral maxillary artery and slow evacuation from the balloon-guiding catheter were performed. Thereafter, the course of the true lumen was clearly visualized, and we were able to navigate another microcatheter without difficulty. Subsequently, angioplasty and stent placement were successfully accomplished. Conclusion We presented a case of ICA dissection and demonstrated a novel technique for a safe lesion-cross for occlusive ICA dissection.
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Affiliation(s)
- Keiji Murata
- 1 Department of Neurosurgery, Shimada Municipal Hospital, Shimada, Japan
| | - Shigeru Yamauchi
- 1 Department of Neurosurgery, Shimada Municipal Hospital, Shimada, Japan
| | - Yuta Kaneshiro
- 1 Department of Neurosurgery, Shimada Municipal Hospital, Shimada, Japan
| | - Yumiko Urano
- 1 Department of Neurosurgery, Shimada Municipal Hospital, Shimada, Japan
| | | | - Toshihiro Takami
- 3 Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Zussman BM, Gross BA, Ares WJ, Kenmuir CL, Weiner GM, Panczykowski DM, Jadhav AP, Jovin TG, Jankowitz BT. Stent Reconstruction of Carotid Tonsillar Loop Dissection Using Telescoping Peripheral Stents. INTERVENTIONAL NEUROLOGY 2018; 7:189-195. [PMID: 29719557 DOI: 10.1159/000486457] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 12/19/2017] [Indexed: 01/05/2023]
Abstract
Background Endovascular treatment options for internal carotid artery (ICA) dissection with tandem intracranial occlusion are evolving. We report 2 cases of stent reconstruction of carotid loop dissections. Methods Two patients with symptomatic ICA dissections of true 360° tonsillar loops and tandem intracranial occlusions were treated with manual aspiration thrombectomy (MAT) and telescoping Zilver self-expanding peripheral stents. Patient demographics, clinical presentations, endovascular techniques, and clinical outcomes were reviewed. Results In both cases, MAT achieved modified Treatment in Cerebral Ischemia scale 2B reperfusion, and complete endovascular reconstruction of the dissected extracranial loop was performed. Both patients had improved pre- to postintervention National Institutes of Health Stroke Scale scores (16 to 0 and 14 to 0), and both had modified Rankin scale scores of 1 at 3-month follow-up. Conclusions Stent reconstruction of complex cerebrovascular anatomy is increasingly feasible with advancements in stent technology and catheter support system design. This technique may be of use to neuroendovascular surgeons who encounter variant ICA anatomy.
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Affiliation(s)
- Benjamin M Zussman
- Neurosurgery Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Neurosurgery Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - William J Ares
- Neurosurgery Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Cynthia L Kenmuir
- Neurology Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gregory M Weiner
- Neurosurgery Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David M Panczykowski
- Neurosurgery Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ashutosh P Jadhav
- Neurology Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tudor G Jovin
- Neurology Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian T Jankowitz
- Neurosurgery Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Bhaskar S, Stanwell P, Cordato D, Attia J, Levi C. Reperfusion therapy in acute ischemic stroke: dawn of a new era? BMC Neurol 2018; 18:8. [PMID: 29338750 PMCID: PMC5771207 DOI: 10.1186/s12883-017-1007-y] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 12/14/2017] [Indexed: 12/14/2022] Open
Abstract
Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging-based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes.
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Affiliation(s)
- Sonu Bhaskar
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Peter Stanwell
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Dennis Cordato
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
| | - John Attia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
- Centre for Clinical Epidemiology & Biostatistics, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW Australia
| | - Christopher Levi
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
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