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Mekonnen EA, Tekle WG, Desai SK, Hassan AE. Angioplasty And stenting For symptomatic intracranial atherosclerotic disease: How I Do It. Interv Neuroradiol 2023; 29:459-465. [PMID: 35331035 PMCID: PMC10399498 DOI: 10.1177/15910199221090430] [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: 01/15/2022] [Accepted: 03/06/2022] [Indexed: 11/16/2022] Open
Abstract
Intracranial atherosclerotic disease (ICAD) is a common cause of acute ischemic stroke. ICAD has a high rate of recurrent ischemic stroke despite recommended adequate medical treatment. Endovascular treatment of ICAD has been controversial due to high periprocedural complication in historic randomized clinical trials (RCTs). Recently, a multicenter prospective study of stent placement in patients with high grade intracranial stenosis that evaluated safety and efficacy of Balloon-mounted stents (BMS) in symptomatic ICAD showed low rates of periprocedural stroke (5.6%) than the SAMMPRIS (14.7%) and VISSIT (21.4%) trials. This review highlights the recent evolution of endovascular therapy for symptomatic ICAD.
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Affiliation(s)
- Ermias A. Mekonnen
- Department of Neuroscience, Valley Baptist Medical Center, Harlingen, TX, USA
| | - Wondwossen G. Tekle
- Department of Neuroscience, Valley Baptist Medical Center, Harlingen, TX, USA
- Department of Neurology, School of Medicine, University of Texas Rio Grande Valley, Edinburg, TX, USA
| | - Sohum K. Desai
- Department of Neuroscience, Valley Baptist Medical Center, Harlingen, TX, USA
- Department of Neurology, School of Medicine, University of Texas Rio Grande Valley, Edinburg, TX, USA
| | - Ameer E. Hassan
- Department of Neuroscience, Valley Baptist Medical Center, Harlingen, TX, USA
- Department of Neurology, School of Medicine, University of Texas Rio Grande Valley, Edinburg, TX, USA
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2
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Palmisciano P, Hoz SS, Algburi HA, Ventre G, Street S, Agyeman N, Robinson MW, Smith MS, Shirani P, Grossman AW, Prestigiacomo CJ. Percutaneous transluminal angioplasty and/or stenting for the treatment of basilar artery stenosis: a systematic review and meta-analysis. Neuroradiology 2023; 65:985-1000. [PMID: 36881121 DOI: 10.1007/s00234-023-03124-x] [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: 10/09/2022] [Accepted: 01/14/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE Basilar artery stenosis (BAS) carries high morbidity and mortality, with variable outcomes after endovascular treatments. We systematically reviewed the literature on percutaneous transluminal angioplasty and/or stenting (PTAS) for BAS. METHODS PubMed, EMBASE, Web-of-Science, Scopus, and Cochrane were searched upon the PRISMA guidelines to include prospective/retrospective cohort studies describing PTAS for BAS. Pooled rates of intervention-related complications and outcomes were analyzed with random-effect model meta-analyses. RESULTS We included 25 retrospective cohort studies comprising 1016 patients. All patients were symptomatic, presenting with transient ischemic attack or ischemic stroke. BAS frequently involved the middle basilar artery (51.4%), mostly classified as Mori-B (57.4%). PTAS for BAS was indicated in severe (≥ 50-70%), symptomatic BAS refractory to dual antiplatelet therapy. Patients underwent angioplasty (95.5%) and/or stenting (92.2%), preferably using Wingspan or Apollo stents. Median baseline BAS was 81% (range, 53-99%), while median post-intervention BAS was 13% (0-75%). Actuarial rates of successful intervention and "good" final outcome were 100% (95% CI: 100-100%) and 89% (95% CI: 85-93%). Intervention-related recurrent ischemic stroke occurred in 85 patients (8.3%) with actuarial rates of 5% (95% CI: 4-7%), differentiated into perforator (5.4%), in-stent (2.6%), and embolic (0.4%). Actuarial rates of intervention-related dissection, restenosis, and death were 0% (95% CI: 0-0%), 1% (95% CI: 0-1%), and 0% (95% CI: 0-2%). CONCLUSION Elective PTAS appears to be safe and effective in selected patients with medically refractory, severe, symptomatic, and non-acute BAS. Different stent types and angioplasty-assisted procedures should be considered based on specific clinico-radiological characteristics of the lesions. Future randomized controlled trials are required to corroborate these findings.
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Affiliation(s)
- Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45229, USA
| | - Samer S Hoz
- Department of Neurosurgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45229, USA
| | | | - Giancarlo Ventre
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Seth Street
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nana Agyeman
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael W Robinson
- Department of Neurosurgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45229, USA
| | - Matthew S Smith
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Peyman Shirani
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Aaron W Grossman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Charles J Prestigiacomo
- Department of Neurosurgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45229, USA.
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Anagnostakou V, Ughi GJ, Puri AS, Gounis MJ. Optical Coherence Tomography for Neurovascular Disorders. Neuroscience 2021; 474:134-144. [PMID: 34126186 DOI: 10.1016/j.neuroscience.2021.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 06/03/2021] [Accepted: 06/06/2021] [Indexed: 11/26/2022]
Abstract
Diagnosis of cerebrovascular disease includes vascular neuroimaging techniques such as computed tomography (CT) angiography, magnetic resonance (MR) angiography (with or without use of contrast agents) and catheter digital subtraction angiography (DSA). These techniques provide mostly information about the vessel lumen. Vessel wall imaging with MR seeks to characterize cerebrovascular pathology, but with resolution that is often insufficient for small lesions. Intravascular imaging techniques such as ultrasound and optical coherence tomography (OCT), used for over a decade in the peripheral circulation, is not amendable to routine deployment in the intracranial circulation due to vessel caliber and tortuosity. However, advances in OCT technology including the probe profile, stiffness and unique distal rotation solution, holds the promise for eventual translation of OCT into the clinical arena. As such, it is apropos to review this technology and present the rationale for utilization of OCT in the cerebrovasculature.
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Affiliation(s)
- Vania Anagnostakou
- University of Massachusetts Medical School, Radiology, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, United States
| | - Giovanni J Ughi
- University of Massachusetts Medical School, Radiology, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, United States
| | - Ajit S Puri
- University of Massachusetts Medical School, Radiology, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, United States
| | - Matthew J Gounis
- University of Massachusetts Medical School, Radiology, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, United States.
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Pham BN, Phan HT, Nguyen TQ, Nguyen TH. A Case of Successful Intravenous Thrombolysis Bridged with Repeated Endovascular Treatment in Acute Basilar Artery Occlusion. Case Rep Neurol 2021; 12:34-40. [PMID: 33505270 DOI: 10.1159/000507752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 04/03/2020] [Indexed: 11/19/2022] Open
Abstract
Acute basilar artery occlusion (BAO) is a neurological emergency that has a high rate of mortality and poor functional outcome. Endovascular therapy (ET) is the gold standard therapy for large vessel occlusion stroke of the anterior circulation. Whether ET can also be effectively and safely performed in early recurrent large vessel occlusion, especially in BAO, is unclear. We describe a case of successful recanalization and independent functional outcome of a BAO patient treated with intravenous thrombolysis combined with repeated ET. The patients was a 32-year-old man with a history of heavy smoking and drinking who presented to the Emergency Department with dizziness and hypertension, and progressed over the next 13 h to left hemiparesis and mild dysarthria with an NIHSS score of 7. CT angiography demonstrated occlusion of the proximal basilar artery (BA). Intravenous alteplase was given followed by ET. The first intervention failed and over the next 8 h, the patient's NIHSS score increased to 12. A second attempt with balloon angioplasty managed to reconstitute arterial blood flow with a severe residual stenosis of the proximal BA. Subsequently, the patient progressed into deep coma with reocclusion of the BA demonstrated on transcranial Doppler. A third intervention with emergent stenting resulted in complete recanalization of the BA and excellent neurological recovery. This patient received three endovascular treatments within 24 h due to reocclusion of the BA and achieved good outcomes. In conclusion, repeated ET for early recurrent BAO is feasible in carefully selected patients.
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Affiliation(s)
| | - Hoang Thi Phan
- 115 People's Hospital, Ho Chi Minh City, Vietnam.,Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Thang Huy Nguyen
- 115 People's Hospital, Ho Chi Minh City, Vietnam.,Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
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5
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Kim J, Ban SP, Kim YD, Kwon OK. Long-term outcomes of drug-eluting stent implantation in patients with symptomatic extra- and intracranial atherosclerotic stenoses. J Cerebrovasc Endovasc Neurosurg 2020; 22:216-224. [PMID: 33050686 PMCID: PMC7820269 DOI: 10.7461/jcen.2020.e2020.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/23/2020] [Indexed: 12/04/2022] Open
Abstract
Objective Implantation of drug-eluting stents (DES) for extra- and intracranial atherosclerotic stenoses is an emerging topic. It has the potential benefit of preventing recurrent stroke with a reduced rate of in-stent restenosis (ISR). Methods Patients who underwent extra- or intracranial stenting using DES in a single institution were retrospectively reviewed with long-term angiographic and clinical follow-up data. Results Twenty-one patients, 9 (42.9%) with extracranial lesions and 12 (57.1%) with intracranial lesions, were included. The most common symptom was cerebral infarction (71.4%), followed by vertebrobasilar insufficiency (19.1%) and transient ischemic attack (9.5%). All patients achieved technical success, with the mean degree of stenosis of 85.9±6.3% before the procedure and 19.5±5.9% after the procedure. All patients showed clinical improvement and no symptomatic recurrence was reported during the mean clinical follow-up period of 45.5±8.9 months. The significant ISR was observed in one patient (4.8%) during the mean radiological follow-up period of 42.8±10.0 months. Conclusions Implantation of drug-eluting stents for symptomatic extra- and intracranial atherosclerotic stenoses is feasible and has the potential benefit of reducing the rate of ISR.
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Affiliation(s)
- Junhyung Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Bundang, Korea
| | - Seung Pil Ban
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Bundang, Korea
| | - Young Deok Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Bundang, Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Bundang, Korea
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Nakashima T, Kojima T, Hatano N, Takasu S, Fuse Y, Seki Y. Long-Term Effects on Preventing Stroke after Endovascular Treatment or Bypass Surgery for Intracranial Arterial Stenosis. J Stroke Cerebrovasc Dis 2019; 28:1107-1112. [PMID: 30639144 DOI: 10.1016/j.jstrokecerebrovasdis.2018.12.039] [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: 10/31/2018] [Revised: 12/11/2018] [Accepted: 12/27/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Intracranial arterial stenosis (ICAS) is an important cause of ischemic stroke worldwide due to its higher risk of recurrence with medical therapy. Although some large randomized studies failed to show the superiority of surgical treatment compared with medical therapy, the results of medical therapy are not sufficient. There are patients who still benefit from surgical treatment. This retrospective analysis aimed to evaluate the long-term efficacy of surgical therapy with percutaneous transluminal angioplasty and/or stenting (PTA/PTAS) or extracranial-intracranial (EC/IC) bypass surgery for patients with ICAS. METHODS Between October 2005 and December 2016, 55 ICAS patients were treated with PTA/PTAS or EC-IC bypass surgery. Their electronic medical records were retrospectively reviewed and analyzed. The primary outcome was all adverse events beyond 30 days after a revascularization procedure. RESULTS We performed 21 cases (35%) of PTA, 4 cases (7%) of PTAS, and 34 cases (58%) of EC-IC bypass surgery and the median follow-up duration was 66 months (range 1-144 months). The occurrence rate of the primary outcome was 10.2% and only 1 patient (1.8%) experienced ipsilateral disabling ischemic stroke beyond 30 days. The long-term functional independent survival rate was 83.6%. CONCLUSIONS We demonstrated a long-term favorable outcome of combined surgical intervention for ICAS patients with PTA/PTAS and EC-IC bypass surgery, and the result was better than previously reported outcomes of medical therapy. Additional multicenter studies are required to draw firm conclusions on the efficacy of reduction of recurrent stroke in patients with ICAS.
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Affiliation(s)
- Takuma Nakashima
- Department of Neurosurgery, Tosei General Hospital, Aichi, Japan.
| | - Takao Kojima
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Japan
| | - Norikazu Hatano
- Department of Stroke Medicine, Kawashima Hospital, Aichi, Japan
| | - Syuntaro Takasu
- Department of Neurosurgery, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Yutaro Fuse
- Department of Neurosurgery, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
| | - Yukio Seki
- Department of Neurosurgery, Japanese Red Cross Nagoya Daini Hospital, Aichi, Japan
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Yu W, Jiang WJ. Stenting for intracranial stenosis: potential future for the prevention of disabling or fatal stroke. Stroke Vasc Neurol 2018; 3:140-146. [PMID: 30294469 PMCID: PMC6169606 DOI: 10.1136/svn-2018-000158] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/20/2018] [Accepted: 05/24/2018] [Indexed: 01/01/2023] Open
Abstract
Intracranial stenosis is a common cause of ischaemic strokes, in particular, in the Asian, African and Hispanic populations. The randomised multicentre study Stenting and Aggressive Medical Management for the Prevention of Recurrent stroke in Intracranial Stenosis (SAMMPRIS) showed 14.7% risk of stroke or death in the stenting group versus 5.8% in the medical group at 30 days, and 23% in the stenting group versus 15% in the medical group at a median follow-up of 32.4 months. The results demonstrated superiority of medical management over stenting and have almost put the intracranial stenting to rest in recent years. Of note, 16 patients (7.1%) in the stenting group had disabling or fatal stroke within 30 days mostly due to periprocedural complications as compared with 4 patients (1.8%) in the medical group. In contrast, 5 patients (2.2%) in the stenting group and 14 patients (6.2%) in the medical group had a disabling or fatal stroke beyond 30 days, indicating significant benefit of stenting if periprocedural complications can be reduced. Recently, the results of the Chinese Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis trial and the Wingspan Stent System Post Market Surveillance Study (WEAVE trial) showed 2%-2.7% periprocedural complications. It is time to evaluate the role of intracranial stenting for the prevention of disabling or fatal stroke.
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Affiliation(s)
- Wengui Yu
- Department of Neurology, University of California, Irvine, California, USA
| | - Wei-Jian Jiang
- New Era Stroke Care and Research Institute, The Rocket Force General Hospital, Beijing, China
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8
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Luo J, Wang T, Gao P, Krings T, Jiao L. Endovascular Treatment of Intracranial Atherosclerotic Stenosis: Current Debates and Future Prospects. Front Neurol 2018; 9:666. [PMID: 30186219 PMCID: PMC6110852 DOI: 10.3389/fneur.2018.00666] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/25/2018] [Indexed: 11/13/2022] Open
Abstract
Intracranial atherosclerotic stenosis (ICAS) is a common cause of transient ischemic attack (TIA) and ischemic stroke. Endovascular treatment, including balloon angioplasty alone, balloon-mounted stents, and self-expandable stent placement with or without prior angioplasty, is an alternative to medical treatment for the prevention of recurrent TIA or ischemic stroke in patients with ICAS. Although the SAMMPRIS and VISSIT trials supported medical management alone against endovascular treatments, both randomized controlled trials (RCT) were criticized due to flaws relating to patient-, intervention-, and operator-related factors. In this review, we discuss the current debate regarding these aspects and suggest approaches to solve current controversies in the future. In our opinion, endovascular treatment in carefully selected patients, individualized choice of endovascular treatment subtypes, and an experienced multidisciplinary team managing the patient in the pre-, peri- and post-procedural period have the potential to provide safe and efficious treatment of patients with symptomatic ICAS.
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Affiliation(s)
- Jichang Luo
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Peng Gao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Timo Krings
- UHN Joint Department of Medical Imaging Division of Neuroradiology, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Cao J, Xuan J, Chen R, Zhu X, Shao H, Chao X, Zhi F, Shao N, Peng Y. Intra-Arterial Treatment for Patients with Severe Acute Vertebrobasilar Occlusion: A Single-Center Retrospective Study. J Stroke Cerebrovasc Dis 2017; 26:2376-2382. [PMID: 28666803 DOI: 10.1016/j.jstrokecerebrovasdis.2017.05.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/08/2017] [Accepted: 05/17/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Recently, favorable outcomes from several randomized controlled trials of rapid endovascular treatment for acute ischemic stroke has emerged. OBJECTIVE The aim of this retrospective study is to present our clinical experience in severe acute vertebrobasilar occlusion (AVBO) using intra-arterial treatment (IAT). METHODS Twenty patients with ischemic stroke in the vertebrobasilar circulation treated by IAT between March 2011 and December 2014 were included. We retrospectively assessed National Institutes of Health Stroke Scale (NIHSS) score on admission and at discharge, Thrombolysis in Cerebral Infarction (TICI) scale, and clinical outcome using modified Rankin scale (mRs) at 90 days, and causes of stroke were prospectively assessed. RESULTS The mean NIHSS score on admission was 26.4 ± 7.9 (range 9-33) points. The mean time from symptom onset to revascularization was 349.5 ± 124.0 (range 201-579) minutes. Successful recanalization (TICI ≥2b) was achieved in 19 (95.0%) patients. The mean NIHSS score at discharge was 5.7 ± 9.0 (range 0-30) points. A favorable clinical outcome (mRS ≤2) was observed in 12 (60.0%) patients at 90 days and mortality was 25.0% (n = 5). CONCLUSION IAT for AVBO provides high rate of recanalization, favorable clinical outcome, and improved survival.
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Affiliation(s)
- Jie Cao
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu, China; Modern Medical Research Center, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Jinggang Xuan
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu, China
| | - Ronghua Chen
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu, China
| | - Xucheng Zhu
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu, China
| | - Huaming Shao
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu, China
| | - Xiaofeng Chao
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu, China
| | - Feng Zhi
- Modern Medical Research Center, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China.
| | - Naiyuan Shao
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu, China.
| | - Ya Peng
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu, China; Modern Medical Research Center, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China.
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Wajima D, Aketa S, Nakagawa I, Masui K, Yonezawa T, Enami T, Nishida F, Nakase H. Effectiveness of Intracranial Percutaneous Transluminal Angioplasty or Stenting for Atherosclerotic Vertebrobasilar Artery Occlusion in the Acute Phase of Ischemic Stroke. World Neurosurg 2016; 97:253-260. [PMID: 27729300 DOI: 10.1016/j.wneu.2016.09.106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 09/22/2016] [Accepted: 09/26/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Although short-term clinical outcomes after basilar artery stent placement have been reported previously, effectiveness of intracranial stenting for vertebrobasilar artery occlusion in the acute phase of ischemic stroke is unclear. METHODS We clinically investigated 8 patients with intracranial percutaneous transluminal angioplasty (PTA) or stenting as our protocol for symptomatic atherosclerotic vertebrobasilar artery occlusion (age range, 54-80 years; mean age, 69 ± 11 years; 6 men and 2 women) who were admitted to our hospital between August 2013 and December 2015. RESULTS Two patients underwent PTA of the vertebrobasilar artery 2-5 months before stent placement. The other 6 patients underwent intracranial stenting just after PTA. Within the first 30 days after vertebrobasilar artery stent placement, 2 ischemic stroke complications affected patients. Ischemic complications were significantly associated with prestent lesion lumen greater than 0.5 mm. The modified Rankin Scale score and clinical outcome were significantly associated with complications. Clinical outcomes correlate with ischemic complications and vertebrobasilar anatomy. CONCLUSIONS Stent angioplasty may be a reasonably good treatment option for patients with technically favorable lesions, especially in vertebrobasilar atherosclerotic occlusion with medically or PTA only refractory symptoms. Despite a significant complication rate, most of our patients experienced good to excellent clinical outcomes and were free of vertebrobasilar ischemia at late midterm follow-up.
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Affiliation(s)
- Daisuke Wajima
- Department of Neurosurgery, Nara Medical University, Kashihara City, Japan; Department of Neurosurgery, Osaka Police Hospital, Osaka City, Japan.
| | - Shuta Aketa
- Department of Neurosurgery, Osaka Police Hospital, Osaka City, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Kashihara City, Japan
| | - Katsuya Masui
- Department of Neurosurgery, Osaka Police Hospital, Osaka City, Japan
| | - Taiji Yonezawa
- Department of Neurosurgery, Osaka Police Hospital, Osaka City, Japan
| | - Tomomi Enami
- Department of Neurology, Osaka Police Hospital, Osaka City, Japan
| | - Fukuko Nishida
- Department of Neurology, Osaka Police Hospital, Osaka City, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Kashihara City, Japan
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11
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Chen Z, Liu AF, Chen H, Yuan C, He L, Zhu Y, Guan M, Jiang WJ, Zhao X. Evaluation of basilar artery atherosclerotic plaque distribution by 3D MR vessel wall imaging. J Magn Reson Imaging 2016; 44:1592-1599. [PMID: 27249041 DOI: 10.1002/jmri.25296] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Basilar artery (BA) atherosclerosis is an important cause of perforator stroke in the brainstem due to plaque involvement of the perforator ostia in BA dorsal or lateral walls. Therefore, to acquire information on plaque distribution is important to better understand and prevent the perforator stroke. This study aimed to comprehensively evaluate BA plaque distribution with 3D magnetic resonance imaging (MRI) vessel wall imaging. MATERIALS AND METHODS Consecutive patients with cerebrovascular symptoms and stenosis or irregular luminal surface of BA were recruited and underwent BA 3D proton density-weighted volume isotropic turbo spin echo acquisition (VISTA) imaging at 3T. The cross-sectional and longitudinal distribution of BA plaque were analyzed with a custom-developed tool. RESULTS In all, 85 BA plaques were detected in 61 recruited patients. For cross-sectional distribution, the prevalence of plaque involvement in the ventral, left, dorsal, and right quadrant of BA wall was 74.1%, 70.6%, 67.1%, and 62.4%, respectively. Of the 85 plaques, 17.7% involved one quadrant and 82.3% involved two or more quadrants. The most severe plaque region was more commonly situated at lateral walls (66.1%) as compared to ventral (23.2%, P < 0.001) and dorsal walls (10.6%, P < 0.001). Longitudinally, plaques were more frequently found to occur at BA segment distal than proximal to anterior inferior cerebellar artery (AICA) (63.5% vs. 36.5%). CONCLUSION Taking advantage of 3D MR vessel wall imaging, BA plaques were found to more likely affect lateral walls and form in BA distal to AICA, where most perforators originate, suggesting that it might be useful to characterize BA plaque distribution before aggressive treatment for prevention of perforator stroke. J. Magn. Reson. Imaging 2016;44:1592-1599.
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Affiliation(s)
- Zhensen Chen
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
| | - Ao-Fei Liu
- New Era Stroke Care and Research Institute, General Hospital of the PLA Rocket Force, Beijing, China
| | - Huijun Chen
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
| | - Chun Yuan
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China.,Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Le He
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
| | - Yandong Zhu
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
| | - Maobin Guan
- Department of Radiology, Yangzhou First People's Hospital, Yangzhou, China
| | - Wei-Jian Jiang
- New Era Stroke Care and Research Institute, General Hospital of the PLA Rocket Force, Beijing, China
| | - Xihai Zhao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
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Silber T, Ziemann U, Ernemann U, Bischof F. Analysis of periinterventional complications of intracranial angioplasty and stenting: A single center experience. Eur J Radiol 2014; 83:2190-2195. [DOI: 10.1016/j.ejrad.2014.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 08/27/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Toni Silber
- Center of Neurology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Ulf Ziemann
- Center of Neurology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Ulrike Ernemann
- Department of Diagnostic and Interventional Neuroradiology, University of Tübingen, Germany
| | - Felix Bischof
- Center of Neurology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Germany.
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Endovascular treatment of severe acute basilar artery occlusion. J Clin Neurosci 2014; 22:195-8. [PMID: 25443091 DOI: 10.1016/j.jocn.2014.05.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 05/04/2014] [Indexed: 11/23/2022]
Abstract
Severe acute basilar artery occlusion (BAO) has a high mortality rate but as yet no effective treatment has been developed. This study aimed to evaluate the feasibility and safety of combined mechanical thrombectomy, intra-arterial thrombolysis, and emergent stent placement for patients with severe acute BAO. Eighteen patients who were unconscious after confirmed onset of BAO and who were given arterial interventional treatment from March 2011 to June 2013 at our department were included in this study. The mean age was 59.56 years (range: 31-76 years) and patients were in a critical physical condition upon admission, and had a mean National Institutes of Health Stroke Scale (NIHSS) score of 25.94 (range: 18-35). All patients were treated with mechanical thrombectomy, 10 of whom received mechanical thrombectomy only. Of the others, eight were also treated with intra-arterial thrombolysis, three were treated with emergent stent placement, and 17 were treated with recanalization with an achieved recanalized rate of 94.4%. The average number of passes through the stent was 1.5 (range: 1-3) and five patients died (27.8%). Thirteen patients survived, and the mean NIHSS score was 6.54 (range: 0-16). Seven patients showed a modified Rankin Scale score ⩽ 2, and the rate of good prognoses was 38.9%. In the treatment of patients with severe acute BAO, intra-arterial mechanical thrombectomy combined with thrombolysis or stent placement are effective strategies to restore blood flow and preserve life, and these strategies have a low incidence of complications.
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Sorkin GC, Dumont TM, Eller JL, Mokin M, Snyder KV, Levy EI, Siddiqui AH, Hopkins LN. Cerebrovascular neurosurgery in evolution: the endovascular paradigm. Neurosurgery 2014; 74 Suppl 1:S191-7. [PMID: 24402487 DOI: 10.1227/neu.0000000000000222] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Endovascular technique represents an important, minimally invasive approach to treating cerebrovascular disease. In this article, we discuss the origins of endovascular neurosurgery as a discipline in the context of important technical milestones, evidence-based medicine, and future cerebrovascular neurosurgical training. Cerebrovascular neurosurgery has seen a steady, convergent evolution toward the surgeon capable of seamless incorporation of open and endovascular approaches to any complex vascular disease affecting the central nervous system. Neurosurgery must assume the leadership role in the multidisciplinary neurovascular team.
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Affiliation(s)
- Grant C Sorkin
- Departments of *Neurosurgery, §Radiology, and ¶Neurology, School of Medicine and Biomedical Sciences, and ‖Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York; ‡Department of Neurosurgery, Gates Vascular Institute, Kaleida Health Buffalo, New York; #Jacobs Institute, Buffalo, New York
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15
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Given CA, Ramsey CN, Attizzani GF, Jones MR, Brooks WH, Bezerra HG, Costa MA. Optical coherence tomography of the intracranial vasculature and Wingspan stent in a patient. J Neurointerv Surg 2014; 7:e22. [DOI: 10.1136/neurintsurg-2014-011114.rep] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2014] [Indexed: 12/21/2022]
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16
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Given CA, Ramsey CN, Attizzani GF, Jones MR, Brooks WH, Bezerra HG, Costa MA. Optical coherence tomography of the intracranial vasculature and Wingspan stent in a patient. BMJ Case Rep 2014; 2014:bcr-2014-011114. [PMID: 24835808 DOI: 10.1136/bcr-2014-011114] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 67-year-old man with medically refractory vertebrobasilar insufficiency and short segment occlusions of the intracranial vertebral arteries was treated with angioplasty and stent placement. Fifteen hours after the procedure the patient developed symptoms of posterior fossa ischemia and repeat angiography showed thrombus formation within the stent which was treated with thrombolytic and aggressive antiplatelet therapy. Angiography revealed lysis of the clot, but concerns regarding the mechanism of the thrombotic phenomenon prompted frequency-domain optical coherence tomography (FDOCT) assessment. FDOCT provided excellent visualization of the stent and vessel wall interactions, as well as excluding residual flow-limiting stenosis, obviating the need for further intervention. The potential utility of FDOCT in the evaluation of intracranial atherosclerotic disease and additional intracranial applications are discussed.
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Affiliation(s)
- Curtis Alden Given
- Neurosurgical Associates, Baptist Health Lexington, Lexington, Kentucky, USA
| | - Christian Norman Ramsey
- Neurosurgical Associates, Baptist Health Lexington, Lexington, Kentucky, USA Department of Neurosurgery, Baptist Health Lexington, Lexington, Kentucky, USS
| | | | - Michael R Jones
- Department of Cardiology, Baptist Health Lexington, Lexington, Kentucky, USA
| | - William H Brooks
- Neurosurgical Associates, Baptist Health Lexington, Lexington, Kentucky, USA Department of Neurosurgery, Baptist Health Lexington, Lexington, Kentucky, USS
| | - Hiram G Bezerra
- Department of Cardiology, Case Western University, Cleveland, Ohio, USA
| | - Marco A Costa
- Department of Cardiology, Case Western University, Cleveland, Ohio, USA
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17
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Role of bypass surgery and balloon occlusion test for the endovascular management of fusiform dissecting aneurysms. Report of two cases. ACTA NEUROCHIRURGICA. SUPPLEMENT 2014; 119:43-8. [PMID: 24728631 DOI: 10.1007/978-3-319-02411-0_7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Fusiform intracranial aneurysm is one of the most difficult pathologies to treat. The role and efficacy of recent advanced endovascular technique and conventional bypass surgery are discussed.
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Derdeyn CP, Fiorella D, Lynn MJ, Rumboldt Z, Cloft HJ, Gibson D, Turan TN, Lane BF, Janis LS, Chimowitz MI. Mechanisms of stroke after intracranial angioplasty and stenting in the SAMMPRIS trial. Neurosurgery 2013; 72:777-95; discussion 795. [PMID: 23328689 DOI: 10.1227/neu.0b013e318286fdc8] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Enrollment in the stenting and aggressive medical management for the prevention of stroke in intracranial stenosis (SAMMPRIS) trial was halted owing to higher-than-expected 30-day stroke rates in the stenting arm. Improvement in periprocedural stroke rates from angioplasty and stenting for intracranial atherosclerotic disease (ICAD) requires an understanding of the mechanisms of these events. OBJECTIVE To identify the types and mechanisms of periprocedural stroke after angioplasty and stenting for ICAD. METHODS Patients who experienced a hemorrhagic or ischemic stroke or a cerebral infarct with temporary signs within 30 days of attempted angioplasty and stenting in SAMMPRIS were identified. Study records, including case report forms, procedure notes, and imaging were reviewed. Strokes were categorized as ischemic or hemorrhagic. Ischemic strokes were categorized as perforator territory, distal embolic, or delayed stent thrombosis. Hemorrhagic strokes were categorized as subarachnoid or intraparenchymal. Causes of hemorrhage (wire perforation, vessel rupture) were recorded. RESULTS Three patients had an ischemic stroke after diagnostic angiography. Two of these strokes were unrelated to the procedure. Twenty-one patients had an ischemic stroke (n = 19) or cerebral infarct with temporary signs (n = 2) within 30 days of angioplasty and stenting. Most (n = 15) were perforator territory and many of these occurred after angiographically successful angioplasty and stenting of the basilar artery (n = 8). Six patients experienced a subarachnoid hemorrhage (3 from wire perforation) and 7 had a delayed intraparenchymal hemorrhage. CONCLUSION Efforts at reducing complications from angioplasty and stenting for ICAD must focus on reducing the risks of regional perforator infarction, delayed intraparenchymal hemorrhage, and wire perforation.
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Affiliation(s)
- Colin P Derdeyn
- Mallinckrodt Institute of Radiology, Department of Neurology, Washington University School of Medicine, St Louis, Missouri, USA.
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Derdeyn CP, Fiorella D, Chimowitz MI. In reply: Is there a contribution of anesthesia to the outcome of the SAMMPRIS trial? Neurosurgery 2013; 74:E235-6. [PMID: 24149979 DOI: 10.1227/neu.0000000000000227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Colin P Derdeyn
- St. Louis, Missouri Stony Brook, New York Charleston, South Carolina
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20
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Boulos AS, Agner C, Deshaies EM. Preliminary evidence supporting the safety of drug-eluting stents in neurovascular disease. Neurol Res 2013; 27 Suppl 1:S95-102. [PMID: 16197833 DOI: 10.1179/016164105x35459] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Restenosis is a significant complication of stent placement. With coronary revascularization, drug-eluting stents have significantly decreased the incidence of in-stent stenosis and, therefore, the morbidity of the procedure. Restenosis is potentially a significant problem for neurovascular disease. We therefore report our institutional experience on the use of drug-eluting stents for the management of cerebrovascular insufficiency. METHODS Over a period of 2 years, 19 patients underwent extra- and intracranial drug-eluting stent placement for intra- and extracranial atherosclerotic disease. There were 12 males and seven females aged between 36 and 83 years old (mean 65). Thirteen heparin, three rapamycin, and three taxus-coated stents were placed. There were five intracranial internal carotid arteries, two intracranial vertebral arteries, three mid-basilar, six of vertebral artery origin and three middle cerebral artery stents utilized. No complications occurred. RESULTS There was one case of re-stenosis associated with recurrent symptoms requiring repeat drug eluting stent placement. No other patients have developed new or recurrent neurological symptoms. Five of six vertebral artery origin stents were placed with distal protection to prevent embolic complications. CONCLUSION Intracranial and extracranial drug-eluting stent placement appears to be a safe alternative to the medical management of atherosclerotic disease of the vertebrobasilar and carotid systems. However, further randomized studies are needed to examine the effectiveness and safety of this procedure.
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Affiliation(s)
- Alan S Boulos
- Department of Surgery, Division of Neurosurgery, Albany Medical Center, Albany, New York 12208, USA.
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21
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You SH, Jo SM, Kim YJ, Lee JH, Jo KD, Park WS. Pre- and Post-Angioplasty Perfusion CT with Acetazolamide Challenge in Patients with Unilateral Cerebrovascular Stenotic Disease. J Korean Neurosurg Soc 2013; 54:280-8. [PMID: 24294450 PMCID: PMC3841269 DOI: 10.3340/jkns.2013.54.4.280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 07/19/2013] [Accepted: 09/30/2013] [Indexed: 11/27/2022] Open
Abstract
Objective Perfusion computed tomography (PCT) has the ability to measure quantitative value and produce maps of mean transit time (MTT), cerebral blood flow (CBF), and cerebral blood volume (CBV). We assessed cerebral hemodynamics by using these parameters and acetazolamide (ACZ) challenge for pre- and post-procedural evaluation in patients with unilateral cerebrovascular stenotic disease. Methods Thirty patients underwent pre-procedural PCT with ACZ challenge, and 24 patients (80%) was conducted follow up PCT after angioplasty with same protocol. The mean MTT, CBF, and CBV were measured and compared in both middle cerebral arterial (MCA) territories before and after ACZ challenge. Hemispheric ratio and percent change after ACZ challenge were calculated before and after angioplasty. Results The mean stenosis rate was 76.6%. Significant increases in MTT (32.6%, p=0.000) and significant decreases in CBF (-14.2%, p=0.000) were found in stenotic side MCA territories. After ACZ challenge, there were significant changes in MTT (37.4%, p=0.000), CBF (-13.1%, p=0.000), and CBV (-10.5%, p=0.001) in pre-procedural perfusion study. However, no significant increases were found in MTT, or decreases in CBF and CBV in post-procedural study. There were no significant changes after ACZ challenge also. In addition, the degrees of these changes (before and after ACZ challenge) were highly correlated with the stenotic degrees in pre-procedural perfusion study. Conclusion PCT with ACZ challenge appears to be a useful tool to assess the cerebral perfusion status especially in patients with unilateral symptomatic stenotic disease.
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Affiliation(s)
- Seung-Hoon You
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Sung-Min Jo
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Young-June Kim
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jong-Hyeog Lee
- Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Kwang-Deog Jo
- Department of Neurology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Woong-Sub Park
- Department of Preventive Medicine, College of Medicine, Gwandong University, Gangneung, Korea
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Chavent A, Kazemi A, Voguet C, Osseby GV, Palova E, Ricolfi F. Endovascular treatment of symptomatic intracranial atheromatous stenosis: a single center study of 21 consecutive cases. J Neuroradiol 2012; 39:332-41. [PMID: 23174303 DOI: 10.1016/j.neurad.2012.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Revised: 02/04/2012] [Accepted: 02/17/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This retrospective single-center study evaluated the technical success as well as the periprocedural and long-term complications of angioplasty with stenting of symptomatic intracranial atheromatous stenosis. PATIENTS AND METHODS From January 2005 to December 2010, 21 patients were treated by angioplasty with stent implantation for symptomatic atheromatous intracranial stenosis greater or equal to 50% at least 7 days after a stroke. RESULTS The median population age was 65 years (range: 41-88 years), and 76% (16/21) of the candidates had a history of transient ischemic attack (TIA) or stroke before the event qualifying them for an endovascular procedure. In addition, 86% (18/21) were taking antithrombotic medication at the time of the qualifying event. Technical success was obtained in all cases. The periprocedural stroke or death rate was 9.5% (2/21), and there was no other stroke or death after 30 days during the mean follow-up of 1.4 years. CONCLUSION Endovascular treatment of symptomatic intracranial atherothrombotic stenosis can lead to severe complications, particularly during the periprocedural period, but it also represents the only alternative treatment for patients who fail with medical therapy. Future studies need to focus on improvement of periprocedural complications. Essentially, this should include more rigorous selection of candidates as well as a better understanding of the pathophysiological mechanism(s) of the ischemic phenomenon related to stenosis.
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Affiliation(s)
- A Chavent
- Service de neuroradiologie, hôpital Bocage, CHU de Dijon, 2, boulevard Maréchal-De-Lattre-De-Tassigny, 21079 Dijon, France.
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23
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Kattah JC, Nair D, Talkad A, Wang DZ, Fraser K. A case of vestibular and oculomotor pathology from bilateral AICA watershed infarcts treated with basilar artery stenting. Clin Neurol Neurosurg 2012; 115:1098-101. [PMID: 22921038 DOI: 10.1016/j.clineuro.2012.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 07/06/2012] [Accepted: 08/06/2012] [Indexed: 10/28/2022]
Affiliation(s)
- Jorge C Kattah
- Department of Neurology, The Illinois Neurologic Institute, University of Illinois College of Medicine, Peoria, IL, USA.
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Vellimana AK, Ford AL, Lee JM, Derdeyn CP, Zipfel GJ. Symptomatic intracranial arterial disease: incidence, natural history, diagnosis, and management. Neurosurg Focus 2012; 30:E14. [PMID: 21631215 DOI: 10.3171/2011.3.focus1138] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Symptomatic intracranial arterial disease is associated with a high rate of recurrent ischemic events. The management of this condition is controversial, with some advocating medical therapy as a sole means of treatment and others recommending endovascular therapy in addition to best medical management. In rare cases, surgical intervention is considered. A thorough review of the available literature was performed, and treatment recommendations based on these data are provided.
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Affiliation(s)
- Ananth K Vellimana
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Shi M, Wang S, Zhu H, Feng J, Wu J. Emergent stent placement following intra-arterial thrombolysis for the treatment of acute basilar artery occlusion. J Clin Neurosci 2011; 19:152-4. [PMID: 22169507 DOI: 10.1016/j.jocn.2011.03.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2011] [Revised: 03/27/2011] [Accepted: 03/29/2011] [Indexed: 11/28/2022]
Abstract
Acute basilar artery occlusion (BAO) is a condition producing high rates of morbidity and mortality. Intravenous thrombolysis or intra-arterial thrombolysis are therapeutic options; however, the clinical outcomes remain poor. The purpose of the present study was to evaluate feasibility, safety, and efficacy of emergency stent placement following intra-arterial thrombolysis for patients with acute BAO. Thirty-six consecutive patients were treated for acute BAO using intra-arterial therapy from September 2004 to October 2009. Nine patients, with a Glasgow Coma Scale (GCS) score ranging from 8 to 12, underwent emergency stent placement following inadequate revascularization after thrombolysis. Neurological status prior to treatment was evaluated using the GCS score. Modified Rankin Scale (mRS) scores at 90 days post-treatment were used to assess functional outcome and we reviewed clinical records for frequency of procedure-related complications. Stents were deployed at the target lesion in all patients. Successful revascularization was achieved in eight of nine (88.9%) patients (residual stenosis <50%). The median GCS score prior to thrombolysis was 9 (range: 6-12) and prior to stent placement was 10 (range: 8-12). Four patients (44.4%) achieved good outcomes as determined by the mRS scale (0-2 at 90 days). Mortality was 33.3% in all procedures with one patient (11.1%) experiencing acute intrastent thrombus formation. No patient developed symptomatic intracerebral hemorrhage. Data from our small case series demonstrates that emergency stent placement following intra-arterial thrombolysis is a feasible treatment for patients with acute BAO and may reduce mortality and prevent re-occlusion of the basilar artery.
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Affiliation(s)
- MingChao Shi
- Department of Neurology, The First Bethune Hospital of Jilin University, Jilin University, 71 Xinmin Street, Changchun 130021, China
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Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, Janis LS, Lutsep HL, Barnwell SL, Waters MF, Hoh BL, Hourihane JM, Levy EI, Alexandrov AV, Harrigan MR, Chiu D, Klucznik RP, Clark JM, McDougall CG, Johnson MD, Pride GL, Torbey MT, Zaidat OO, Rumboldt Z, Cloft HJ. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med 2011; 365:993-1003. [PMID: 21899409 PMCID: PMC3552515 DOI: 10.1056/nejmoa1105335] [Citation(s) in RCA: 1241] [Impact Index Per Article: 95.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Atherosclerotic intracranial arterial stenosis is an important cause of stroke that is increasingly being treated with percutaneous transluminal angioplasty and stenting (PTAS) to prevent recurrent stroke. However, PTAS has not been compared with medical management in a randomized trial. METHODS We randomly assigned patients who had a recent transient ischemic attack or stroke attributed to stenosis of 70 to 99% of the diameter of a major intracranial artery to aggressive medical management alone or aggressive medical management plus PTAS with the use of the Wingspan stent system. The primary end point was stroke or death within 30 days after enrollment or after a revascularization procedure for the qualifying lesion during the follow-up period or stroke in the territory of the qualifying artery beyond 30 days. RESULTS Enrollment was stopped after 451 patients underwent randomization, because the 30-day rate of stroke or death was 14.7% in the PTAS group (nonfatal stroke, 12.5%; fatal stroke, 2.2%) and 5.8% in the medical-management group (nonfatal stroke, 5.3%; non-stroke-related death, 0.4%) (P=0.002). Beyond 30 days, stroke in the same territory occurred in 13 patients in each group. Currently, the mean duration of follow-up, which is ongoing, is 11.9 months. The probability of the occurrence of a primary end-point event over time differed significantly between the two treatment groups (P=0.009), with 1-year rates of the primary end point of 20.0% in the PTAS group and 12.2% in the medical-management group. CONCLUSIONS In patients with intracranial arterial stenosis, aggressive medical management was superior to PTAS with the use of the Wingspan stent system, both because the risk of early stroke after PTAS was high and because the risk of stroke with aggressive medical therapy alone was lower than expected. (Funded by the National Institute of Neurological Disorders and Stroke and others; SAMMPRIS ClinicalTrials.gov number, NCT00576693.).
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Affiliation(s)
- Marc I Chimowitz
- Department of Neurosciences, Medical University of South Carolina, Charleston, SC 29425, USA.
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Chamczuk AJ, Ogilvy CS, Snyder KV, Ohta H, Siddiqui AH, Hopkins LN, Levy EI. Elective stenting for intracranial stenosis under conscious sedation. Neurosurgery 2011; 67:1189-93; discussion 1194. [PMID: 20871450 DOI: 10.1227/neu.0b013e3181efbcac] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Elective stenting for intracranial stenosis is under study as an effective means of reducing stroke risk. At most institutions, these procedures are performed and monitored after the induction of general anesthesia. OBJECTIVE To report our success with elective intracranial stenting and angioplasty performed in conscious patients after the administration of mild sedatives and local anesthetic agents. METHODS We retrospectively evaluated data from 66 patients who underwent elective intracranial stenting for atherosclerosis. Sixty-one procedures were performed under local anesthesia with mild sedation; 3 were performed under general anesthesia, and 2 were converted from local to general anesthesia during the procedure. Intraprocedural neurological changes were monitored and led to reevaluation of technique, immediate reimaging, modifying the endovascular procedure itself, or possibly mandating conversion to general anesthesia. RESULTS Thirty-nine anterior and 27 posterior circulation stenotic segments were treated. Angiographic success was achieved in 95.5% of patients with an overall reduction in stenosis of 75.5 to 22.3%. Percutaneous angioplasty and stenting were used in 58 cases; 8 patients were treated with stenting alone. Three patients (4.9%) developed neurological deficits mandating alteration or adjustment of endovascular technique or immediate postoperative management to avoid permanent sequelae. A total of 8 periprocedural complications occurred, 2 of which resulted in permanent neurological deficit. The overall mortality rate was 3.2%. CONCLUSIONS Stenting of intracranial atherosclerosis performed under conscious sedation is associated with complication rates and effectiveness similar to historical rates for general anesthesia. Conscious sedation confers the additional benefit of continuous neurological assessment during the procedure.
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Affiliation(s)
- Andrea J Chamczuk
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University New York, Buffalo, New York, USA
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Wingspan stent for high-grade symptomatic vertebrobasilar artery atherosclerotic stenosis. Cardiovasc Intervent Radiol 2011; 35:268-78. [PMID: 21516376 DOI: 10.1007/s00270-011-0163-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Accepted: 04/07/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE This study was designed to present the treatment outcomes with Wingspan stent angioplasty of high-grade intracranial vertebrobasilar artery (VBA) stenosis in symptomatic patients. METHODS Between 2007 and 2010, the records of 30 patients with 31 intracranial high-grade VBA stenoses (all ≥ 70%) who underwent elective stenting due to the failure of medical therapy were retrospectively reviewed. Clinical evaluation was performed based on the modified Rankin scale and the National Institutes of Health Stroke Scale. RESULTS In all cases, the stent deployment was technically successful. The mean stenosis decreased significantly from 82.28 ± 8.02% (range, 72-99%) to 11.18 ± 7.28% (range, 0-25%) after stent-assisted angioplasty (P < 0.05). Periprocedure complications occurred in 3 (10%) of 30 patients; there were 2 cases of perforator strokes and 1 case of transient flow insufficiency with stent overlap. Clinical follow-up (mean, 17.81 ± 11.49 months; range, 5-40 months) was available for 27 patients, and angiographic follow-up (mean, 9.95 ± 5.74 months, range, 5-20 months) was available for 19 patients. Only one case demonstrated recurrent symptoms with restenosis (≥ 50%). There were no recurrent ischemic events and no cases of restenosis in the other patients. CONCLUSIONS According to our data, the Wingspan stent for symptomatic intracranial VBA stenoses is a safe and efficacious treatment alternative in cases with recurrent symptoms despite medical therapy. However, the improvement of outcome requires the reduction in the rate of procedure-related complications and long-term outcomes still have to be demonstrated.
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10 questions about intracranial atherosclerotic stenosis. Neurologist 2011; 16:400-5. [PMID: 21150394 DOI: 10.1097/nrl.0b013e3181e52b8c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intracranial atherosclerotic disease is one of the most common causes of stroke worldwide, yet treatment for this disease is still uncertain. This article discusses challenges in the diagnosis and treatment of intracranial stenosis by posing 10 commonly asked questions about this disease.
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30
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Interventional Neuroradiologic Therapy of Atherosclerotic Disease and Vascular Malformations. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10061-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Kurre W, Chapot R, du Mesnil de Rochemont R, Berkefeld J. Intracranial stenting in atherosclerotic disease—recent results and challenges to face. Neuroradiology 2010; 52:633-44. [DOI: 10.1007/s00234-010-0678-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2009] [Accepted: 03/02/2010] [Indexed: 10/19/2022]
Affiliation(s)
- Wiebke Kurre
- Department of Neuroradiology, Alfried-Krupp-Krankenhaus, Alfried Krupp Strasse 21, 45131, Essen, Germany.
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Endovascular recanalization of acute intracranial vertebrobasilar artery occlusion using local fibrinolysis and additional balloon angioplasty. Neuroradiology 2010; 52:361-70. [PMID: 20119683 DOI: 10.1007/s00234-010-0658-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2009] [Accepted: 01/05/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Vertebrobasilar artery occlusion (VBO) produces high mortality and morbidity due to low recanalization rate utilization in endovascular therapy. The use of percutaneous transluminal angioplasty (PTA) to improve recanalization rate additional to local intra-arterial fibrinolysis (LIF) was investigated in this study. Results obtained following recanalization therapy in acute intracranial VBO are reported. METHODS Eighteen consecutive patients with acute VBO underwent LIF with or without PTA, from August 2000 to May 2006. Eight patients were treated using LIF alone, and ten required additional PTA. Rate of recanalization, neurological status before treatment, and clinical outcomes were evaluated. RESULTS Of 18 patients, 17 achieved recanalization. One procedure-related complication of subarachnoid hemorrhage occurred. Overall survival rate was 94.4% at discharge. Seven patients achieved good outcomes [modified Rankin scale (mRS) 0-2], and the other 11 had poor outcomes (mRS 3-6). Five of six patients who scored 9-14 on the Glasgow Coma Scale (GCS) before treatment displayed good outcomes, whereas ten of 12 patients who scored 3-8 on the GCS showed poor outcomes. GCS prior to treatment showed a statistically significant correlation to outcomes (p < 0.05). Moreover, the National Institutes of Health Stroke Scale (NIHSS) before treatment correlated well with mRS (correlation coefficient 0.487). No statistical difference between the good and poor outcome groups was observed for the duration of symptoms, age, etiology, and occlusion site. CONCLUSIONS Endovascular recanalization can reduce mortality and morbidity of acute VBO. Good GCS and NIHSS scores prior to treatment can predict the efficacy of endovascular recanalization.
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Mocco J, Darkhabani Z, Levy EI. Pharos neurovascular intracranial stent: elective use for a symptomatic stenosis refractory to medical therapy. Catheter Cardiovasc Interv 2009; 74:642-6. [PMID: 19496116 DOI: 10.1002/ccd.22054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The Warfarin-Aspirin Symptomatic Intracranial Disease study investigators demonstrated that medically managed patients with symptomatic intracranial stenosis experience a 7-11% annual stroke risk. Early treatment efforts utilized balloon-mounted coronary stents, which provided excellent angiographic results (postprocedure stenoses <10%), versus percutaneous transluminal angioplasty (PTA) alone (40%). However, the rigidity of balloon-mounted coronary stents provided limited access to the tortuous cerebrovasculature. Self-expanding stents became available for intracranial stenosis treatment in 2002. With increased flexibility, immediate results were encouraging (approximately 30% residual stenosis). However, midterm results have demonstrated disappointingly high rates of restenosis. To address these issues, the Pharos Neurovascular Stent System (Pharos, Micrus Endovascular, San Jose, CA) was developed. The Pharos is a balloon-expandable stent mounted on a rapid-exchange PTA catheter especially designed for intracranial endovascular applications. Utilizing the Pharos, we obtained an outstanding angiographic result (0% residual stenosis), with no associated morbidity. The patient was discharged home on postprocedure day 1 and remained symptom-free, with no in-stent stenosis, 3 months later. Our experience with the Pharos supports early literature suggesting that this stent may be a valuable treatment option for patients with medically refractory intracranial stenosis.
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Affiliation(s)
- J Mocco
- Department of Neurosurgery, Toshiba Stroke Research Center, University at Buffalo, State University of New York, Buffalo, NY, USA
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Siddiq F, Memon MZ, Vazquez G, Safdar A, Qureshi AI. COMPARISON BETWEEN PRIMARY ANGIOPLASTY AND STENT PLACEMENT FOR SYMPTOMATIC INTRACRANIAL ATHEROSCLEROTIC DISEASE. Neurosurgery 2009; 65:1024-33; discussion 1033-4. [PMID: 19934961 DOI: 10.1227/01.neu.0000360138.54474.52] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
To compare the short- and long-term rates of stroke-and/or-death associated with primary angioplasty alone and angioplasty with stent placement using a meta-analysis of published studies. Both primary angioplasty alone and angioplasty with stent placement have been proposed as treatment strategies for symptomatic intracranial atherosclerotic disease to reduce the risk of stroke-and/or-death with best medical treatment alone. However, it remains unclear which of these endovascular techniques offers the best risk reduction.
METHODS
We identified pertinent studies published between January 1980 and May 2008 using a search on PubMed and Cochrane libraries, supplemented by a review of bibliographies of selected publications. The incidences of stroke-and/or-death were estimated for each report and pooled for both angioplasty alone and angioplasty with stent placement at 1 month and 1 year postintervention and then compared using a random-effects model. The association of year of publication and 1-year incidence of stroke-and/or-death was analyzed with meta-regression.
RESULTS
After applying our selection criteria, we included 69 studies (33 primary angioplasty-alone studies [1027 patients] and 36 studies of angioplasty with stent placement [1291 patients]) in the analysis. There were a total of 91 stroke-and/or-deaths reported in the angioplasty-alone–treated group (8.9%; 95% confidence interval [CI], 7.1%–10.6%), compared with 104 stroke-and/or-deaths in the angioplasty-with-stent–treated group (8.1%; 95% CI, 6.6%–9.5%) during a 1-month period (relative risk [RR], 1.1; P = 0.48). The pooled incidence of 1-year stroke-and/or-death in patients treated with angioplasty alone was 19.7% (95% CI, 16.6%–23.5%), compared with 14.2% (95% CI, 11.9%–16.9%) in the angioplasty-with-stent–treated patients (RR, 1.39; P = 0.009). The incidence of technical success was 79.8% (95% CI, 74.7%–84.8%) in the angioplasty-alone group and 95% (95% CI, 93.4%–96.6%) in the angioplasty-with-stent–treated group (RR, 0.84; P < 0.0001). The pooled restenosis rate was 14.2% (95% CI, 11.8–16.6%) in the angioplasty-alone group, as compared with 11.1% (95% CI, 9.2%–13.0%) in the angioplasty-with-stent–treated group (RR, 1.28; P = 0.04). There was no effect of the publication year of the studies on the risk of stroke-and/or-death.
CONCLUSION
Risk of 1-year stroke-and/or-death and rate of angiographic restenosis may be lower in symptomatic intracranial atherosclerosis patients treated by angioplasty with stent placement compared with patients treated by angioplasty alone.
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Affiliation(s)
- Farhan Siddiq
- Department of Neurosurgery and Neurology, Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota(Siddiq)
| | | | - Gabriela Vazquez
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota
| | - Adnan Safdar
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota
| | - Adnan I. Qureshi
- Department of Neurosurgery and Neurology, Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota(Siddiq)
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Schumacher HC, Meyers PM, Higashida RT, Derdeyn CP, Lavine SD, Nesbit GM, Sacks D, Rasmussen P, Wechsler LR. Reporting standards for angioplasty and stent-assisted angioplasty for intracranial atherosclerosis. J Vasc Interv Radiol 2009; 20:S451-73. [PMID: 19560032 DOI: 10.1016/j.jvir.2009.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2008] [Revised: 10/27/2008] [Accepted: 11/04/2008] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND AND PURPOSE Intracranial cerebral atherosclerosis causes ischemic stroke in a significant number of patients. Technological advances over the past 10 years have enabled endovascular treatment of intracranial atherosclerotic stenosis. The number of patients treated with angioplasty or stent-assisted angioplasty for this condition is increasing. Given the lack of universally accepted definitions, the goal of this document is to provide consensus recommendations for reporting standards, terminology, and written definitions when reporting clinical and radiological evaluation, technique, and outcome of endovascular treatment using angioplasty or stent-assisted angioplasty for stenotic and occlusive intracranial atherosclerosis. SUMMARY OF REPORT This article was written under the auspices of Joint Writing Group of the Technology Assessment Committee, Society of NeuroInterventional Surgery, Society of Interventional Radiology; Joint Section on Cerebrovascular Neurosurgery of the American Association of Neurological Surgeons and Congress of Neurological Surgeons; and the Section of Stroke and Interventional Neurology of the American Academy of Neurology. A computerized search of the National Library of Medicine database of literature (PubMed) from January 1997 to December 2007 was conducted with the goal to identify published endovascular cerebrovascular interventional data in stenotic intracranial atherosclerosis that could be used as benchmarks for quality assessment. We sought to identify those risk adjustment variables that affect the likelihood of success and complications. This document offers the rationale for different clinical and technical considerations that may be important during the design of clinical trials for endovascular treatment of intracranial stenotic and occlusive atherosclerosis. Included in this guidance document are suggestions for uniform reporting standards for such trials. These definitions and standards are primarily intended for research purposes; however, they should also be helpful in clinical practice and applicable to all publications. CONCLUSION In summary, the definitions proposed represent recommendations for constructing useful research data sets. The intent is to facilitate production of scientifically rigorous results capable of reliable comparisons between and among similar studies. In some cases, the definitions contained here are recommended by consensus of a panel of experts in this writing group for consistency in reporting and publication. These definitions should allow different groups to publish results that are directly comparable.
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Affiliation(s)
- H Christian Schumacher
- Saul R. Korey Department of Neurology, Division of Vascular Neurology and Neurocritical Care, Albert Einstein College of Medicine, Bronx, NY, USA
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Schumacher HC, Meyers PM, Higashida RT, Derdeyn CP, Lavine SD, Nesbit GM, Sacks D, Rasmussen P, Wechsler LR. Reporting Standards for Angioplasty and Stent-Assisted Angioplasty for Intracranial Atherosclerosis. Stroke 2009; 40:e348-65. [PMID: 19246710 DOI: 10.1161/strokeaha.108.527580] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Intracranial cerebral atherosclerosis causes ischemic stroke in a significant number of patients. Technological advances over the past 10 years have enabled endovascular treatment of intracranial atherosclerotic stenosis. The number of patients treated with angioplasty or stent-assisted angioplasty for this condition is increasing. Given the lack of universally accepted definitions, the goal of this document is to provide consensus recommendations for reporting standards, terminology, and written definitions when reporting clinical and radiological evaluation, technique, and outcome of endovascular treatment using angioplasty or stent-assisted angioplasty for stenotic and occlusive intracranial atherosclerosis.
Summary of Report—
This article was written under the auspices of Joint Writing Group of the Technology Assessment Committee, Society of NeuroInterventional Surgery, Society of Interventional Radiology; Joint Section on Cerebrovascular Neurosurgery of the American Association of Neurological Surgeons and Congress of Neurological Surgeons; and the Section of Stroke and Interventional Neurology of the American Academy of Neurology. A computerized search of the National Library of Medicine database of literature (PubMed) from January 1997 to December 2007 was conducted with the goal to identify published endovascular cerebrovascular interventional data in stenotic intracranial atherosclerosis that could be used as benchmarks for quality assessment. We sought to identify those risk adjustment variables that affect the likelihood of success and complications. This document offers the rationale for different clinical and technical considerations that may be important during the design of clinical trials for endovascular treatment of intracranial stenotic and occlusive atherosclerosis. Included in this guidance document are suggestions for uniform reporting standards for such trials. These definitions and standards are primarily intended for research purposes; however, they should also be helpful in clinical practice and applicable to all publications.
Conclusion—
In summary, the definitions proposed represent recommendations for constructing useful research data sets. The intent is to facilitate production of scientifically rigorous results capable of reliable comparisons between and among similar studies. In some cases, the definitions contained here are recommended by consensus of a panel of experts in this writing group for consistency in reporting and publication. These definitions should allow different groups to publish results that are directly comparable.
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Affiliation(s)
- H Christian Schumacher
- Saul R Korey Department of Neurology, Division of Vascular Neurology and Neurocritical Care, Albert Einstein College of Medicine, Bronx, NY, USA
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Gröschel K, Schnaudigel S, Pilgram SM, Wasser K, Kastrup A. A systematic review on outcome after stenting for intracranial atherosclerosis. Stroke 2009; 40:e340-7. [PMID: 19182081 DOI: 10.1161/strokeaha.108.532713] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND PURPOSE Angioplasty and stenting is increasingly being used for the treatment of intracranial stenoses. Based on a literature search (01/1998 to 04/2008) we sought to determine the immediate and long-term outcomes, as well as the durability of this procedure. SUMMARY OF REVIEW We identified 31 studies dealing with 1177 procedures, which had mainly been performed in patients with a symptomatic (98%) intracranial high-grade stenosis (mean: 78+/-7%) at high technical success rates (median: 96%; interquartile range [IQR]: 90% to 100%). The periprocedural minor or major stroke and death rates ranged from 0% to 50% with a median of 7.7% (IQR: 4.4% to 14.3%). Periprocedural complications were significantly higher in the posterior versus the anterior circulation (12.1%, versus 6.6%, P<0.01, odds ratio [OR]: 1.94, 95% confidence interval [CI]: 1.21 to 3.10), but did not differ between patients treated with a balloon-mounted (n=906) versus those who had been treated with a self-expandable stent (n=271; 9.5% versus 7.7%, P=0.47, OR: 1.15, CI:0.76 to 2.05). Restenosis >50% occurred more frequently after the use of a self-expandable stent (16/92; 17.4%, mean follow-up time: 5.4 months) than a balloon-mounted stent (61/443; 13.8%, mean follow-up time: 8.7 months; P<0.001, log-rank test). CONCLUSIONS Although intracranial stenting appears to be feasible, adverse events vary widely. Against the background of the results of this review yielding a high rate of restenoses and no clear impact of new stent devices on outcome, the widespread application of intracranial stenting outside the setting of randomized trials and in inexperienced centers currently does not seem to be justified.
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Affiliation(s)
- Klaus Gröschel
- Department of Neurology, University of Göttingen, Göttingen, Germany
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38
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Seifert T, Augustin M, Klein GE, Horner S, Niederkorn K, Fazekas F. Symptomatic stenosis of the vertebrobasilar arteries: results of extra- and intracranial stent-PTA. Eur J Neurol 2009; 16:31-6. [DOI: 10.1111/j.1468-1331.2008.02297.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Endovascular recanalization for subacute symptomatic intracranial arterial occlusion: A report of two cases. Clin Neurol Neurosurg 2008; 110:1058-63. [DOI: 10.1016/j.clineuro.2008.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2008] [Accepted: 07/13/2008] [Indexed: 11/20/2022]
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40
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Chiam PTL, Mocco J, Samuelson RM, Siddiqui AH, Hopkins LN, Levy EI. Retrograde angioplasty for basilar artery stenosis: bypassing bilateral vertebral artery occlusions. J Neurosurg 2008; 110:427-30. [PMID: 19012478 DOI: 10.3171/2008.7.jns08436] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Basilar artery angioplasty with or without stenting is an emerging and promising treatment for vertebrobasilar insufficiency that is refractory to medical therapy. The usual approach is via a transfemoral route, with access directly through the vertebral artery (VA). An approach from the anterior circulation via the posterior communicating artery has been reported for optimal stent positioning and deployment across basilar apex aneurysms. No similar technique has been reported for treatment of midbasilar stenosis. The authors report a case of severe symptomatic basilar stenosis in which both VAs were occluded. The only option was to perform retrograde basilar angioplasty via the posterior communicating artery. This useful technique should be part of the armamentarium for the percutaneous treatment of symptomatic vertebrobasilar insufficiency for the occasional patient in whom occlusion or tortuosity precludes direct access to the VA.
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Affiliation(s)
- Paul T L Chiam
- Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
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Hopkins LN, Ecker RD. CEREBRAL ENDOVASCULAR NEUROSURGERY. Neurosurgery 2008; 62:SHC1483-SHC1502. [DOI: 10.1227/01.neu.0000315304.66122.f0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Accepted: 03/05/2008] [Indexed: 11/19/2022] Open
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Suh DC, Kim JK, Choi JW, Choi BS, Pyun HW, Choi YJ, Kim MH, Yang HR, Ha HI, Kim SJ, Lee DH, Choi CG, Hahm KD, Kim JS. Intracranial stenting of severe symptomatic intracranial stenosis: results of 100 consecutive patients. AJNR Am J Neuroradiol 2008; 29:781-5. [PMID: 18310234 DOI: 10.3174/ajnr.a0922] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE There are a few reports regarding the outcome evaluation of balloon-expandable intracranial stent placement (BEICS). The purpose of our study was to evaluate the outcome and factors related to the adverse events (AEs) of BEICS. MATERIALS AND METHODS We evaluated 100 consecutive patients who underwent BEICS. We assessed the procedural success (residual stenosis < 50%), AEs (minor strokes, major strokes, and death), clinical outcome, and restenosis (> 50%) at 6 months. We also analyzed 18 factors including symptom patterns related to AE rate. Symptom patterns revealed 1) stable patients (n = 73) with improving, stationary, or resolved symptoms; and 2) unstable patients (n = 27) with gradual worsening or fluctuating symptoms (National Institutes of Health Stroke Scale [NIHSS] > or = 4) within 2 days before stent placement. RESULTS The procedural success rate was 99%. Overall, there were 10 (10%) AEs within the 6 months: 4 (4%) minor strokes, 3 (3%) major strokes, and 3 (3%) deaths including a death from myocardial infarction. AE rate was 4.1% in stable and 25.9% in unstable patients. Restenosis at 6 months revealed 0% (0/59). Good outcome (modified Rankin Scale < or = 2) at 6 months was 97% (71/73) in stable and 67% (18/27) in unstable patients. Stepwise logistic regression model revealed that symptom pattern (unstable versus stable) was the only significant risk factor (OR, 8.167; 95% CI, 1.933-34.500; P = .004). CONCLUSION BEICS revealed a low AE and good outcome rate at 6 months, especially in the stable patients. Midterm outcome was also favorable in the unstable patient group.
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Affiliation(s)
- D C Suh
- Department of Radiology, Asan Medical Center, University of Ulsan, College of Medicine, 388-One Pungnap-2 Dong, Songpa-Gu, Seoul 138-736, Korea.
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Derdeyn CP, Chimowitz MI. Angioplasty and stenting for atherosclerotic intracranial stenosis: rationale for a randomized clinical trial. Neuroimaging Clin N Am 2007; 17:355-63, viii-ix. [PMID: 17826637 PMCID: PMC2040119 DOI: 10.1016/j.nic.2007.05.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Atherosclerotic disease of the major intracranial arteries is a frequent cause of stroke. In addition, many patients who have symptomatic intracranial stenosis are at very high risk for recurrent stroke. Preliminary studies suggest that angioplasty and stenting may reduce the risk of stroke in patients who have severe stenosis of intracranial arteries. Data for angioplasty and stenting, however, consist of case series; no randomized studies have been completed to date. This article reviews these data and discusses the rationale for a randomized trial of angioplasty and stenting versus best medical management for patients who have symptomatic intracranial stenosis.
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Affiliation(s)
- Colin P Derdeyn
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Blvd, St. Louis, MO 63110, USA.
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Freitas JMM, Zenteno M, Aburto-Murrieta Y, Koppe G, Abath C, Nunes JA, Raupp E, Hidalgo R, Pieruccetti MA, Lee A. Intracranial arterial stenting for symptomatic stenoses: a Latin American experience. ACTA ACUST UNITED AC 2007; 68:378-86. [PMID: 17905061 DOI: 10.1016/j.surneu.2006.11.062] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2006] [Accepted: 11/28/2006] [Indexed: 11/27/2022]
Abstract
BACKGROUND The proportionally higher incidence of intracranial atherosclerosis among Asian and black patients and a greater proclivity for intracranial artery stenosis in the Hispanic population merit drawing attention to a Latin American experience with intracranial arterial stenting. METHODS This is a retrospective analysis of an observational study of 33 intracranial lesions (each >50% stenosis) in 32 patients treated by intracranial angioplasty in 6 Latin American centers over a 3-year period. The investigation used a unique device, a balloon-expandable stent (Lekton Motion stent system, now Pharos, Biotronik, AG, Bülach, Switzerland). RESULTS The treated patients ranged in age from 30 to 81 years (mean, 59.3 years; SD, 12 years), including 24 male and 8 female patients (sex ratio, 4:1). Two were Asians, 4 were blacks, and the rest were white Hispanic. Our mean follow-up is of 10.2 months (SD, 7.84 months), with a mortality rate of 9.4% (3/32), a nonfatal complication rate of 6.2%, and a stroke rate (rate of recurrence) of 0%. The mean pretreatment stenosis of 68.75% (SD, 14%) was reduced to a residual of 5.16% (SD, 16%) (P = .000; 95% confidence interval, 56.8%-70.3%). A control angiogram was performed in 82% of patients, and in that case, the restenosis 50% or greater was of 8.7% during the follow-up period. CONCLUSION The treatment of intracranial stenosis with the Lekton Motion stent (Pharos) is feasible with a high technical success rate. Restenosis as well as the rate of new neurologic events during follow-up suggests some efficacy of stroke prevention by using the latest-generation, highly trackable, balloon-expandable stents.
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Affiliation(s)
- José Maria Modenesi Freitas
- Department of Neuroradiology and Neurological Endovascular Therapy, Hospital Santa Rita, São Paulo, Brazilia, CEP: 04013-004, Brazil
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Abstract
Recently completed prospective studies have shown that with an incidence of recurrent stroke of approximately 10% per year, significant mortality, and other vascular comorbidities, symptomatic intracranial stenosis is a marker of aggressive vascular disease. Although strict control of atherosclerotic risk factors and antithrombotic therapy preferably with antiplatelet agents should be the mainstay of treatment for every patient with this disease, some patients are likely to remain refractory to medical therapy. These high-risk patients appear to be individuals with recent symptoms and severe (> 70%) stenosis with clinical and imaging evidence of hemodynamic impairment distal to the stenotic artery. Advances in balloon and stent technology have made consideration of these high-risk patients for endovascular management with angioplasty and stenting possible, which should ideally take place as part of randomized clinical trials, because the benefit of these high-risk therapies compared with medical therapy is not yet established. This article reviews available medical treatment options for symptomatic intracranial disease and outlines the current state of endovascular therapy for this disease.
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Affiliation(s)
- Tudor G Jovin
- University of Pittsburgh Medical Center, Stroke Institute, 200 Lothrop Street, Suite C-400, Pittsburgh, PA 15213, USA.
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Berkefeld J, Hamann GF, du Mesnil R, Kurre W, Steinmetz H, Zanella FE, Sitzer M. Endovaskuläre Behandlung intrakranieller Stenosen. DER NERVENARZT 2006; 77:1444-55. [PMID: 17119891 DOI: 10.1007/s00115-006-2182-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Intracranial stenoses cause 5-10% of all strokes and are increasingly detected by means of modern imaging methods. The stroke danger of high-grade symptomatic stenoses is relatively high, with an annual risk of approximately 10% under medical treatment. Coumadin increases the risk of hemorrhage, and after risk/benefit considerations, antiplatelets should be preferred for antithrombotic therapy. Despite optimized medical treatment, a small group of patients with recurrent symptoms or symptomatic stenoses without adequate collateral supply probably carry higher spontaneous stroke risk and may be considered for intracranial stenting, which itself is associated with procedural risks of up to 10%. Currently published case series show relatively high complication rates as a major drawback of endovascular treatment, mainly strokes after occlusion of perforating branches extending from the stenotic vessel segment or hemorrhagic complications. According to data from smaller feasibility studies, stroke rates in follow-up after successful stenting seem to be low. The average rate of high-grade restenosis with possible indication for reintervention is 10%. Improvements in endovascular treatment aim at reducing vessel wall trauma during balloon angioplasty by underdilatation or the use of self-expanding stents. Until complication rates are dependably reduced to values of 5-6%, indication for endovascular treatment should be restricted to patients without therapeutic alternatives. According to limited data with large variation between different studies, a prospective multicentric registry is proposed for systematic evaluation and further development of the method.
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Affiliation(s)
- J Berkefeld
- Institut für Neuroradiologie, Klinikum der Johann-Wolfgang-Goethe-Universität, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany.
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Ecker RD, Levy EI, Sauvageau E, Hanel RA, Hopkins LN. Current Concepts in the Management of Intracranial Atherosclerotic Disease. Neurosurgery 2006; 59:S210-8; discussion S3-13. [PMID: 17053605 DOI: 10.1227/01.neu.0000237326.06732.aa] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
MEDICALLY REFRACTORY, SYMPTOMATIC intracranial atherosclerotic disease has a poor prognosis. Based on the results of the Warfarin-Aspirin Symptomatic Intracranial Disease study, the risk of ipsilateral stroke at 1.8 years is between 13 and 14% in patients with symptomatic intracranial atherosclerosis. Synergistic advances in intracranial angioplasty and stenting, modern neuroimaging techniques, and periprocedural and postprocedural antithrombotic regimens are creating new models for the diagnosis and successful endovascular treatment of intracranial stenosis. In this article, the most recent clinical developments and concepts for the diagnosis and endovascular treatment of intracranial atherosclerotic disease are discussed.
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Affiliation(s)
- Robert D Ecker
- Department of Neurosurgery,School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 14209, USA
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50
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Parkinson RJ, Demers CP, Adel JG, Levy EI, Sauvageau E, Hanel RA, Shaibani A, Guterman LR, Hopkins LN, Batjer HH, Bendok BR. Use of heparin-coated stents in neurovascular interventional procedures: preliminary experience with 10 patients. Neurosurgery 2006; 59:812-21; discussion 821. [PMID: 17038945 DOI: 10.1227/01.neu.0000232836.66310.46] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Currently, there is minimal published data on the use of heparin-coated stents in the neurovasculature; however, these stents have a proven clinical record in the treatment of coronary disease. This article details our experience with the safety and technical aspects of stent deployment in the first 10 patients who had heparin-coated stents placed in the intracranial and cervical vasculature and the preliminary follow-up in most cases. METHODS We retrospectively reviewed the clinical history, intra- and periprocedural data, and imaging for the patients who received heparin-coated stents in the cervical and intracranial vasculature for cerebrovascular disease between October 2002 and October 2003. RESULTS Thirteen heparin-coated stents were placed in 10 patients. Seven out of the 10 patients had heparin-coated stents placed in the posterior circulation; the remaining three patients had stents placed in the anterior circulation. Four patients had stents placed intracranially. There was no acute or subacute in-stent thrombosis and no procedure-related complications. Follow-up was performed on most patients, with no clinical symptoms attributable to restenosis in any patient. CONCLUSION This small series suggests that heparin-coated stents are safe for use in the treatment of cervical and intracranial atherosclerotic disease. Longer-term follow-up is needed to study the heparin coating effect on in-stent restenosis rates and to assess the long-term durability and clinical efficacy of this stent. The use of drug-coated stents in the cerebrovascular circulation is an area that warrants further investigation.
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