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Dmytriw AA, Ku J, Azzam AY, Elamin O, Cancelliere N, Kapadia A, Rabinov JD, Stapleton CJ, Regenhardt RW, Pereira VM, Patel AB, Yang VXD. Intracranial stenting compared to medical treatment alone for intracranial atherosclerosis patients: An updated meta-analysis. J Cerebrovasc Endovasc Neurosurg 2023:jcen.2023.E2023.03.002. [PMID: 38018077 DOI: 10.7461/jcen.2023.e2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 09/08/2023] [Indexed: 11/30/2023] Open
Abstract
Objective Stroke is the second-leading cause of death globally. Intracranial atherosclerotic stenosis (ICAS) represents 10-15% of ischemic strokes in Western countries and up to 47% in Asian countries. Patients with ICAS have an especially high risk of stroke recurrence. The aim of this meta-analysis is to reassess recurrent stroke, transient ischemic attack (TIA), and other outcomes with stenting versus best medical management for symptomatic ICAS. Methods The search protocol was developed a priori according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The OVID Medline, Embase, Web of Science, and Cochrane Library databases were searched from inception to August 14th, 2022. Results This Meta-analysis Included Four Randomized Controlled Trials (Rcts), With A Total Number Of 991 Patients. The Mean Age Of Participants Was 57 Years. The Total Number Of Intracranial Stenting Patients Was 495, And The Number Of Medical Treatment Patients Was 496. The Included Studies Were Published Between 2011 And 2022. Two Studies Were Conducted In The Usa, And The Other Two In China. All Included Studies Compared Intracranial Stenting To Medical Treatment For Icas. Conclusions In patients with ischemic stroke due to symptomatic severe intracranial atherosclerosis, the rate of 30-day ischemic stroke, 30-day intracerebral hemorrhage, one-year stroke in territory or mortality favored the medical treatment alone without intracranial stenting. The risk of same-territory stroke at last follow-up, disabling stroke at last follow-up, and mortality did not significantly favor either group. Intracranial stenting for atherosclerosis did not result in significant benefit over medical treatment.
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Affiliation(s)
- Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA
- Neurovascular Centre, Departments of Medical Imaging & Surgery, Sunnybrook Health Sciences Centre and St. Michael's Hospital, University of Toronto, Toronto ON, Canada
| | - Jerry Ku
- Neurovascular Centre, Departments of Medical Imaging & Surgery, Sunnybrook Health Sciences Centre and St. Michael's Hospital, University of Toronto, Toronto ON, Canada
| | - Ahmed Y Azzam
- Nested Knowledge, Department of Neuroradiology, Mayo Clinic, Rochester MN, USA
| | - Osman Elamin
- Nested Knowledge, Department of Neuroradiology, Mayo Clinic, Rochester MN, USA
| | - Nicole Cancelliere
- Neurovascular Centre, Departments of Medical Imaging & Surgery, Sunnybrook Health Sciences Centre and St. Michael's Hospital, University of Toronto, Toronto ON, Canada
| | - Anish Kapadia
- Neurovascular Centre, Departments of Medical Imaging & Surgery, Sunnybrook Health Sciences Centre and St. Michael's Hospital, University of Toronto, Toronto ON, Canada
| | - James D Rabinov
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA
| | - Christopher J Stapleton
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA
| | - Vitor Mendes Pereira
- Neurovascular Centre, Departments of Medical Imaging & Surgery, Sunnybrook Health Sciences Centre and St. Michael's Hospital, University of Toronto, Toronto ON, Canada
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA
| | - Victor X D Yang
- Neurovascular Centre, Departments of Medical Imaging & Surgery, Sunnybrook Health Sciences Centre and St. Michael's Hospital, University of Toronto, Toronto ON, Canada
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, London ON, Canada
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Muszynski P, Anadani M, Richard S, Gory B. Treatment of Sub-Acute Intracranial Stent Occlusion with Rescue Stenting After Failed Aspiration and Stent Retriever Thrombectomy. Cardiovasc Revasc Med 2023; 53S:S250-S252. [PMID: 36754772 DOI: 10.1016/j.carrev.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/02/2023] [Indexed: 02/05/2023]
Abstract
We report a case of middle age man presented a subacute balloon-mounted stent occlusion placed for M1 segment occlusion stroke due to intracranial atherosclerotic stenosis after thrombectomy failure and treated with a second balloon-mounted stent within the first one. Successful recanalization and complete clinical recovery were achieved. The coronary balloon-mounted stent is s a useful tool as a rescue treatment in case of intracranial stent occlusion.
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Affiliation(s)
- Patricio Muszynski
- Université de Lorraine, CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, F-54000 Nancy, France
| | - Mohammad Anadani
- Department of Neurology, Washington University School of Medicine, St Louis, United States of America
| | - Sébastien Richard
- Université de Lorraine, CHRU-Nancy, Department of Neurology, Stroke Unit, F-54000 Nancy, France
| | - Benjamin Gory
- Université de Lorraine, CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, F-54000 Nancy, France.
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3
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Funatsu T, Imamura H, Tani S, Adachi H, Adachi H, Sakai N. Cerebral hyperperfusion syndrome after stenting for revascularization of intracranial internal carotid artery dissection. Clin Neurol Neurosurg 2023; 227:107667. [PMID: 36934635 DOI: 10.1016/j.clineuro.2023.107667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/09/2023] [Accepted: 03/03/2023] [Indexed: 03/11/2023]
Abstract
Cerebral hyperperfusion syndrome (CHS) is one of the complications of cerebral revascularization. The main pathophysiology of CHS was considered to be cerebral autoregulation impairment due to long-standing cerebral hypoperfusion. Herein, we describe the case of a 40-year-old man with symptomatic intracranial arterial dissection (IAD) related to internal carotid artery stenosis. The patient underwent intracranial stenting 11 days after onset due to severe cerebral hypoperfusion presenting with neurological symptoms, and CHS presenting with intracerebral hemorrhage, post-operatively. The present case indicated not only the potential risk of CHS after intracranial stenting in IAD-related stenosis but also that cerebral hypoperfusion-even in a short period-might lead to CHS.
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Affiliation(s)
- Takayuki Funatsu
- Department of Neurosurgery, Kobe City Medical Center General Hospital, 2-1-1, Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, 2-1-1, Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan.
| | - Shoichi Tani
- Department of Neurosurgery, Kobe City Medical Center General Hospital, 2-1-1, Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Hidemitsu Adachi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, 2-1-1, Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Hiromasa Adachi
- Department of Neurosurgery, Kobe City Medical Center General Hospital, 2-1-1, Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, 2-1-1, Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan
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4
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Jung WS, Kim SS, Lee KY, Suh SH. Usefulness of Self-Expandable Stent for Recanalization of Intracranial Atherosclerotic Disease: Preliminary Experience with Enterprise Stent. Neurointervention 2022; 17:37-44. [PMID: 35184435 PMCID: PMC8891589 DOI: 10.5469/neuroint.2022.00017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/10/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose The purpose of this preliminary study is to evaluate the efficacy and safety of the Enterprise stent for intracranial atherosclerotic disease (ICAD) in patients who presented with acute stroke due to vessel steno-occlusion and in patients with symptomatic disease despite optimum medical management. Materials and Methods A retrospective data analysis was performed on 15 consecutive patients who were treated with Enterprise stenting for recanalization of symptomatic intracranial steno-occlusive arteries due to underlying ICAD. Their clinical and radiological data were reviewed to evaluate procedural results, periprocedural and postprocedural complications, and clinical outcome. Results Enterprise stents were deployed as a rescue method in 15 patients for recanalization of steno-occlusion. All patients achieved final modified thrombolysis in cerebral infarction (mTICI) score improvement (53.3% with a mTICI score from 0 to 2b or 3, 46.7% with a mTICI score from 1 to 3). Two postprocedural complications (1 symptomatic intracranial hemorrhage and 1 severe brain edema, 13.3%) occurred among 15 patients. Among 12 patients with acute ischemic stroke (AIS), 6 patients (50%) had improvement in their National Institute of Health Stroke Scale of more than 4 at discharge. Seven patients (58.3%) had a good functional outcome with 3-month modified Rankin Score (mRS)≤2, and mortality occurred (mRS=6) in 2 patients (16.7%). None of the 10 AIS and 3 transient ischemic attack patients experienced further ischemic events attributable to the treated steno-occlusion during the follow-up period (ranged from 4 to 36 months, median 12 months). Conclusion This retrospective study suggests that Enterprise stenting can effectively and safely achieve recanalization in symptomatic steno-occlusive intracranial arteries.
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Affiliation(s)
- Woo Sang Jung
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Sam-Soo Kim
- Department of Radiology, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Jee TK, Yeon JY, Kim KH, Kim JS, Hong SC, Jeon P. Early clinical experience of using the Surpass Evolve flow diverter in the treatment of intracranial aneurysms. Neuroradiology 2021. [PMID: 34453182 DOI: 10.1007/s00234-021-02793-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Here, we presented our early experience with flow diversion procedures using the Surpass Evolve flow diverter (SE, Stryker) and reported the feasibility and safety profile compared to those of a control group treated with other types of flow diverters. METHODS We included 31 and 53 consecutive flow diversion procedures performed using the SE and other commercial flow diverters, respectively, to treat intracranial aneurysms at our institution. We used two commercial flow diversion systems in the comparison group: the pipeline embolization device and Surpass Streamline. RESULTS In the SE group, technical failures occurred in three (9.7%) cases, due to either incomplete wall apposition (n = 1, 3.2%) or stent migration (n = 2, 6.5%). Major complications occurred in four (12.9%) cases: delayed rupture of the target aneurysm (n = 1, 3.2%), major ischemic stroke (n = 1, 3.2%), sudden death from an unidentified cause (n = 1, 3.2%), and parent artery occlusion with stent thrombosis (n = 1, 3.2%). Balloon angioplasty was performed in eight (25.8%) cases. On post-procedure MRI, a DWI-positive lesion was detected in three (9.7%) cases. After multivariate adjustment, the SE group was independently associated with less procedural time of ≥ 90 min (adjusted OR, 0.09; 95% CI, 0.03-0.29; p < 0.001), balloon angioplasty (adjusted OR, 0.22; 95% CI, 0.07-0.75; p = 0.015), and DWI-positive lesions (adjusted OR, 0.04; 95% CI, 0.01-0.19; p < 0.001). CONCLUSION The SE is safe and easy to deploy.
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Dossani RH, Waqas M, Cappuzzo JM, Sonig A, Siddiqui AH, Levy EI, Davies JM. Intracranial Stenting: Angioplasty Basic Technique, Indications, and Sizing: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E115-E116. [PMID: 33956956 DOI: 10.1093/ons/opab124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/22/2021] [Indexed: 11/13/2022] Open
Abstract
Intracranial atherosclerotic disease (ICAD) is a common cause of stroke. Antiplatelet therapy is the mainstay for symptomatic ICAD treatment. Endovascular management with submaximal angioplasty and/or intracranial stenting is reserved for patients with repeated ischemic events despite optimal medical therapy. We demonstrate intracranial angioplasty and stenting technique, technique indications, and sizing of stent and target vessel diameter. Stenting and angioplasty have been described in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis and Wingspan Stent System Post Market Surveillance trials.1,2 Submaximal angioplasty has also been described.3 This patient, who had been on dual antiplatelet therapy for several months, initially presented with occlusion of the left middle cerebral artery M2 inferior division and underwent mechanical thrombectomy with successful reperfusion. Postoperatively, the patient's symptoms did not improve. Medical management was optimized with heparin infusion. However, repeat stroke study demonstrated M2 inferior division reocclusion. A decision was made to proceed with intracranial angioplasty and stenting. P2Y12 levels were therapeutic. Under moderate conscious sedation, submaximal angioplasty of up to 80% of the normal M2 caliber was attempted. However, we observed persistent high-grade stenosis of the M2 inferior division. The major risk of crossing the lesion for angioplasty is vessel perforation. To safely perform this maneuver, we used a J-configured Synchro-2 microwire (Stryker). Because of the patient's recent thrombectomy, we also had prior tactile feedback about how much resistance was encountered while crossing the occlusion. We then deployed a balloon-mounted intracranial stent for optimal radial force across the stenotic area to restore perfusion. Postoperative computed tomography perfusion showed resolution of the previously noticed perfusion deficit. The patient gave informed consent for the procedures and video recording. Institutional review board approval was deemed unnecessary. Video. ©University at Buffalo Neurosurgery, September 2020. With permission.
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Affiliation(s)
- Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Ashish Sonig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA.,Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
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Hadley C, Burkhardt JK, Johnson JN, Kan P. Crossing the Carotid Siphon: Techniques to Facilitate Distal Access in Tortuous Anatomy: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E41-E42. [PMID: 33822191 DOI: 10.1093/ons/opab084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/25/2021] [Indexed: 11/14/2022] Open
Abstract
As capabilities for endovascular treatment of intracranial vascular pathologies continue to expand, the need for access to the distal internal carotid artery with rigid support catheter systems continues to increase. One of the dominant factors limiting this access is patient anatomy, specifically vessel tortuosity. Increased tortuosity of the carotid siphon is a frequently encountered anatomic variant and may complicate endovascular procedures in adults and children.1,2 Failed attempts to navigate the carotid siphon with a distal access catheter carry a risk of vessel injury and treatment failure. For this reason, techniques that aid in supporting safe advancement of a distal access catheter across a tortuous carotid siphon are essential.3,4 In this video, we demonstrate 2 ways in which this may be accomplished. The first technique uses a larger diameter microcatheter, such as the AXS Offset catheter (Stryker, Kalamazoo, Michigan), to increase support for the distal access catheter, while the second uses a buddy wire technique to accomplish this increased support. Both of these techniques can help increase the safety of navigating a tortuous carotid siphon and increase the likelihood of successful treatment. The procedures shown were performed with the informed consent of the patients.
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Affiliation(s)
- Caroline Hadley
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jeremiah N Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
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Diana F, Di Gregorio M, Frauenfelder G, Saponiero R, Romano DG. Watershed subarachnoid hemorrhage after middle cerebral artery rescue stenting in patients with acute ischemic stroke. Neuroradiology 2021; 63:1383-8. [PMID: 33760956 DOI: 10.1007/s00234-021-02692-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/15/2021] [Indexed: 11/24/2022]
Abstract
Cortical subarachnoid hemorrhage is an infrequent subtype of non-aneurysmal subarachnoid hemorrhage, rarely reported in watershed territories (wSAH) after carotid stenting. It has never been reported after treatment of middle cerebral artery stenosis (MCAS) that is increasingly used in selected patients, as rescue treatment of failed mechanical thrombectomy, due to recent advancements in endovascular interventions. We present a series of patients with MCAS that developed a wSAH after stenting.
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Jafari M, Nguyen TN, Ortega-Gutierrez S, Hussain MS, Hassan AE, Ikram A, Eliyas JK, Rodriguez GJ, Divani AA. Current Advances in Endovascular Treatment of Intracranial Atherosclerotic Disease and Future Prospective. J Stroke Cerebrovasc Dis 2021; 30:105556. [PMID: 33360252 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105556] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/12/2020] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES/BACKGROUND Medical therapy is the first line of treatment for intracranial atherosclerotic disease (ICAD). Percutaneous transluminal angioplasty and stenting (PTAS) are mainly considered for those patients with severe stenosis and recurrent events despite aggressive medical therapy. In this review, we discuss the application of PTAS as a treatment option for ICAD and its future prospect. MATERIALS AND METHODS We did the literature review of the key articles and guidelines to elaborate on the role of PTAS in the management of ICAD based on the current data and expert opinion. We searched PubMed, Google Scholar, and Scopus up to August 2020, and included articles published only in the English language. RESULTS Since the publication of the results from SAMMPRIS and VISSIT trials, stenting is no longer recommended for secondary stroke prevention in patients with symptomatic ICAD. However, recent clinical studies on intracranial stenting for a subgroup of ICAD patients have shown promising results, likely due to better patient selection and continued advancement of endovascular techniques. CONCLUSION There exists a lack of consensus regarding the best endovascular treatment approach (e.g., angioplasty alone or balloon mounted stent vs. self-expanding stent with or without prior angioplasty) or management of in-stent restenosis. Another area of clinical controversy relates to the ideal use and duration of antiplatelet therapy.
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Goyal M, Orlov K, Jensen ME, Taylor A, Majoie C, Jayaraman M, Liu J, Milot G, Brouwer P, Yoshimura S, Albuquerque F, Arthur A, Kallmes D, Sakai N, Fraser JF, Nogueira R, Yang P, Dorn F, Thibault L, Fiehler J, Chapot R, Ospel JM. A DELPHI consensus statement on antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of mechanical thrombectomy. Neuroradiology 2021; 63:627-32. [PMID: 32974691 DOI: 10.1007/s00234-020-02556-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/10/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE There is little data and lack of consensus regarding antiplatelet management for intracranial stenting due to underlying intracranial atherosclerosis in the setting of endovascular treatment (EVT). In this DELPHI study, we aimed to assess whether consensus on antiplatelet management in this situation among experienced experts can be achieved, and what this consensus would be. METHODS We used a modified DELPHI approach to address unanswered questions in antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of EVT. An expert-panel (19 neurointerventionalists from 8 countries) answered structured, anonymized on-line questionnaires with iterative feedback-loops. Panel-consensus was defined as agreement ≥ 70% for binary closed-ended questions/≥ 50% for closed-ended questions with > 2 response options. RESULTS Panel members answered a total of 5 survey rounds. They acknowledged that there is insufficient data for evidence-based recommendations in many aspects of antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of EVT. They believed that antiplatelet management should follow a standardized regimen, irrespective of imaging findings and reperfusion quality. There was no consensus on the timing of antiplatelet-therapy initiation. Aspirin was the preferred antiplatelet agent for the peri-procedural period, and oral Aspirin in combination with a P2Y12 inhibitor was the favored postprocedural regimen. CONCLUSION Data on antiplatelet management for intracranial stenting due to underlying atherosclerosis in the setting of EVT are limited. Panel-members in this study achieved consensus on postprocedural antiplatelet management but did not agree upon a preprocedural and intraprocedural antiplatelet regimen. Further prospective studies to optimize antiplatelet regimens are needed.
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Weyland CS, Neuberger U, Potreck A, Pfaff JAR, Nagel S, Schönenberger S, Bendszus M, Möhlenbruch MA. Reasons for Failed Mechanical Thrombectomy in Posterior Circulation Ischemic Stroke Patients. Clin Neuroradiol 2020; 31:745-752. [PMID: 32894352 PMCID: PMC8463404 DOI: 10.1007/s00062-020-00950-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/06/2020] [Indexed: 01/18/2023]
Abstract
Background and Purpose To determine reasons for failed recanalization in mechanical thrombectomy (MT) of the posterior circulation. Methods Retrospective single center analysis of reasons for MT failure in the posterior circulation. Failed MTs were categorized according to the reason for procedure failure in failed vascular access, failed passage of the target vessel occlusion and MT failure after passing the occluded target vessel. Patient characteristics were compared between failed and successful MT. Results Patients with failed MT (30/218 patients, 13.8%) were categorized into futile vascular access (13/30, 43.3%), abortive passage of the target vessel occlusion (6/30, 20.0%) and MT failure after passing the vessel occlusion (11/30, 36.7%). In 188/218 (86.2%) successful MTs alternative vascular access, local intra-arterial (i.a.) thrombolysis and emergency stent-assisted PTA prevented 65 MT failures. Patients with failed MT showed a higher NIHSS at discharge, a higher pc-ASPECTS in follow-up imaging, a higher mRS 90 days after stroke onset and a high mortality rate of 77.0% (mRS at 90 days, median (IQR): 6 (6–6) vs. 4 (2–6) for successful MT, p-value < 0.001). Co-morbidities and stroke etiology were not different compared to sufficient recanalization with atherosclerotic disease as the leading stroke etiology in both groups. Conclusion Failure of MT in posterior circulation ischemic stroke patients is associated with a high mortality rate. Reasons for MT failure are diverse with futile vascular access and MT failure after passing the vessel occlusion as the leading causes. Alternative vascular access, local i.a. thrombolysis and stent-assisted PTA can prevent MT failure.
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Affiliation(s)
- Charlotte S Weyland
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Ulf Neuberger
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Arne Potreck
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Johannes A R Pfaff
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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Potts MB, da Matta L, Abdalla RN, Shaibani A, Ansari SA, Jahromi BS, Hurley MC. Stenting of Mobile Calcified Emboli After Failed Thrombectomy in Acute Ischemic Stroke: Case Report and Literature Review. World Neurosurg 2019; 135:245-251. [PMID: 31881346 DOI: 10.1016/j.wneu.2019.12.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 12/14/2019] [Accepted: 12/16/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Mobile calcified emboli are a rare cause of large vessel occlusion and acute ischemic stroke and pose unique challenges to standard mechanical thrombectomy techniques. Intracranial stenting has been reported as a rescue maneuver in cases of failed mechanical thrombectomy owing to dissection or calcified atherosclerotic plaques, but its use for calcified emboli is not well described. CASE DESCRIPTION We present 2 cases of acute ischemic stroke caused by mobile calcified emboli. Standard mechanical thrombectomy techniques using aspiration catheters and stent-retrievers failed to remove these emboli, so intracranial stenting was successfully performed in each case, albeit after overcoming unique challenges associated with the stenting of calcified emboli. We also review the literature on intracranial stenting as a salvage therapy for failed mechanical thrombectomy. CONCLUSIONS Mobile calcified emboli are rare causes of acute ischemic stroke. Intracranial stenting can be used to successfully treat calcified emboli when mechanical thrombectomy has failed.
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Affiliation(s)
- Matthew B Potts
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Lucas da Matta
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ramez N Abdalla
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ali Shaibani
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sameer A Ansari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael C Hurley
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Bender MT, Vo CD, Jiang B, Campos JK, Zarrin DA, Xu R, Westbroek EM, Caplan JM, Huang J, Tamargo RJ, Lin LM, Colby GP, Coon AL. Pipeline Embolization for Salvage Treatment of Previously Stented Residual and Recurrent Cerebral Aneurysms. Interv Neurol 2018; 7:359-369. [PMID: 30410513 DOI: 10.1159/000489018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/06/2018] [Indexed: 11/19/2022]
Abstract
Introduction This study assessed the safety and effectiveness of the Pipeline embolization device (PED) for persistent and recurrent aneurysms previously treated with either a vascular reconstruction device (VRD) or a flow diverter (FD). Methods A prospective, IRB-approved database was analyzed for patients treated with PED for aneurysms previously treated with a stent. Results Twenty procedures were performed on 18 patients, 11 with prior FD, 7 with VRD, and 2 previously treated with both. Overall, 15 aneurysms were saccular (75%), and size was 13.5 ± 7.6 mm. Location was internal carotid artery (ICA) in 14 cases (70%) and posterior circulation in 6 cases (30%). Average prior treatments were 1.7. Previously FD cases were re-treated at an average of 18.1 months from most recent treatment. Each case used 1 device, 82% with distal coverage and 82% with proximal coverage of prior stent. Balloon remodeling was performed in 3 cases (27%) and no in-stent thrombosis was observed. Previously VRD stent-coiled cases were re-treated at an average of 87.5 months. These cases used on average 1.9 devices, 89% with distal and 100% proximal coverage. Adjunctive coiling was performed in 1 case (11%), balloon remodeling in 5 cases (56%), and 2 cases (28%) developed thrombosis that resolved with abciximab. Re-VRD cases were longer (59.1 vs. 33.7 min, p = 0.02) than re-FD. Angiographic follow-up was available for 16 cases (80%). In re-FD, occlusion was complete in 56% and partial progressive in 33% at 17.1 months digital subtraction angiography. In re-VRD, occlusion was complete in 57% and partial progressive in 27% at 8.1 months. Two complications occurred (10%), including one asymptomatic cervical ICA occlusion and one stent occlusion with associated mortality (5%). Clinical follow-up was 17.8 months on average (range 0.5-51.9). Conclusions Salvage flow diversion for previously stented aneurysms is technically challenging but offers good prospects of aneurysm obliteration with acceptable complication rates.
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Affiliation(s)
- Matthew T Bender
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chau D Vo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bowen Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica K Campos
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David A Zarrin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Li-Mei Lin
- Department of Neurosurgery, University of California Irvine, Orange, California, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Schillinger G, Hagenmeyer EG, Pritzkau A, Friedrich J. DO STUDY RESULTS TRANSLATE INTO PRACTICE? INTRACRANIAL STENTING IN GERMANY. Int J Technol Assess Health Care 2017; 33:222-6. [PMID: 28849759 DOI: 10.1017/S0266462317000411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Enrolment into the SAMMPRIS trial published in September 2011 had to be stopped due to a 2.5 higher 30-day stroke and death rate in patients with percutaneous transluminal angioplasty and stenting (PTAS) compared with the control group with only medical therapy. After these results were published, one would have expected a change toward a clearer definition of indications for intracranial stent implantation in patients with intracranial artery stenosis, using this treatment only in patients suffering from recurrent strokes despite aggressive medical management. METHODS The frequency of intracranial stenting and indication parameters in patients with intracranial artery stenosis were assessed from 2010 to 2013 using claims data for all inpatient episodes from Germany's largest provider of statutory health insurance. RESULTS The number of intracranial stenting procedures decreased slowly from 580 in 2010 to 375 in 2013. With a rate of 29 percent there was no change between 2010 and 2013 of patients who were admitted to hospital for stent implantation, without documentation of an acute stroke or transient ischemic attack (TIA). Before PTAS, one-third of patients were admitted twice because of a stroke or TIA over a period of 5 years, 17 percent of patients had been prescribed platelet aggregation inhibitors and at least two admissions to hospital were for an ischemic cerebrovascular event before PTAS. CONCLUSIONS Our analysis of German claims data provides little evidence of changed indications for stenting in cases of intracranial atherosclerotic disease which one might expect to be caused by the emergence of high-level evidence.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Adrianto Y, Yang KH, Koo HW, Park W, Park JC, Lee DH. Easy Advancement of a Large-Profile Microcatheter (Excelsior XT27™) by Parallel Use of Two Microguidewires For Stent Delivery. Neurointervention 2016; 11:24-9. [PMID: 26958409 PMCID: PMC4781913 DOI: 10.5469/neuroint.2016.11.1.24] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 02/12/2016] [Indexed: 11/24/2022] Open
Abstract
Purpose In the endovascular treatment of cerebral aneurysms, navigating a large-bore microcatheter for delivery of an open-cell stent can be challenging, especially in wide-necked bifurcation aneurysms. We were able to overcome this difficulty by parallel use of two microguidewires through the stent-delivery microcatheter. Materials and Methods From December 2014 to April 2015, we treated 15 patients with wide-necked bifurcation aneurysms. For stent delivery, we used a 300-cm 0.014-in microguidewire (Transend), which was placed into the target branch using an exchange technique. A 0.027-in microcatheter (Excelsior XT-27), which was designed for the stent, was advanced over the exchange microguidewire. If we had trouble in advancing the microcatheter over the exchange microguidewire, we inserted a regular microguidewire (Traxcess), into the microcatheter lumen in a parallel fashion. We also analyzed the mechanism underlying microcatheter positioning failure and the success rate of the 'parallel-wire technique'. Results Among the 15 cases, we faced with navigation difficulty in five patients. In those five cases, we could advance the microcatheter successfully by applying the parallel-wire technique. There were no procedure-related complications. Conclusion Simply by using another microguidewire together with pre-existing microguidewire in a parallel fashion, the stent-delivery microcatheter can be easily navigated into the target location in case of any advancement difficulty.
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Affiliation(s)
- Yudhi Adrianto
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.; Department of Neurology, Soetomo General Hospital/Airlangga University Hospital, Airlangga University Medical Faculty, Surabaya, Indonesia
| | - Ku Hyun Yang
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hae-Won Koo
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok Hee Lee
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Lee JW, Woo JM, Lim OK, Jo YE, Kim JK, Kim ES, Lee DH. Enlarged Parent Artery Lumen at Aneurysmal-Neck Segment in Wide-Necked Distal Internal Carotid Artery Aneurysms. Neurointervention 2015; 10:82-8. [PMID: 26389011 PMCID: PMC4571558 DOI: 10.5469/neuroint.2015.10.2.82] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 07/06/2015] [Indexed: 12/04/2022] Open
Abstract
Purpose Hypothesizing that the parent artery (PA) diameter of the aneurysm-neck segment is larger than those of normal segments, especially in wide-necked aneurysm cases, we conducted 3D angiographic analyses in wide-necked aneurysm cases focusing on the luminal morphologic change of the PA. Materials and Methods Under the approval of local IRB, we enrolled 26 patients with distal internal carotid artery (ICA) aneurysms, which were treated with stent assisted coiling. The PA diameters along the centerline were measured at 6 points with built-in software by two observers. Those 6 points were P1 and P2 proximally, P3 and P4 at the aneurysm ostium margins, and P5 and P6 distally. We performed an ANOVA test and a Bonferroni method for post hoc analyses. Linear regression analysis was performed to find any morphologic influencing factors. Results There were 20 distal ICA aneurysms out of 26 consecutive cases after exclusion. The differences in diameter at each point were statistically significant (p<0.0001). On post hoc analyses, the difference between P4 and P5 was significant both in maximum and mean PA diameters (p<0.0001 and p<0.001, respectively). Multivariate analyses failed to reveal any morphological influencing factor. Conclusion PAs harboring a wide-necked aneurysm requiring stent assistance for coiling showed significant enlargement of the lumen, especially at the distal transition segment of the aneurysm ostium and the PA.
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Affiliation(s)
- Jong Won Lee
- Department of Medicine, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jung Min Woo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea
| | - Ok Kyun Lim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea
| | - Ye-Eun Jo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea
| | - Jae Kyun Kim
- Department of Radiology, Chung-Ang University College of Medicine, Seoul, Korea
| | | | - Deok Hee Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea. ; Department of Medicine, University of Ulsan College of Medicine, Ulsan, Korea
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Abou-Chebl A. Percutaneous Treatment of Severe Intracranial Carotid and Middle Cerebral Artery Stenosis. Interv Cardiol Clin 2014; 3:135-143. [PMID: 28582150 DOI: 10.1016/j.iccl.2013.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Due to the lack of efficacy and durability data from prospective, randomized, multicenter trials, intracranial stenting remains investigational and should be used only in carefully selected patients after thorough evaluation of their clinical and anatomic factors. Stenting should not be performed in chronic total occlusions and asymptomatic lesions and generally should be avoided in very old patients, especially those with underlying dementia and severe calcification of their vessels. Symptomatic patients with angiographically documented greater than 70% stenosis and who have failed medical therapy are appropriate candidates for intracranial angioplasty and stenting and should be enrolled in clinical trials when possible.
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Affiliation(s)
- Alex Abou-Chebl
- Department of Neurology, University of Louisville School of Medicine, Room 114, 500 South Preston Street, Louisville, KY 40202, USA.
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Tanweer O, Wilson TA, El Helou A, Becske T, Riina HA. National trends in utilization and outcomes of angioplasty and stenting for revascularization in intracranial stenosis. Clin Neurol Neurosurg 2014; 116:54-60. [PMID: 24314879 DOI: 10.1016/j.clineuro.2013.10.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 10/31/2013] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Angioplasty and intracranial stenting (ICS) are both endovascular revascularization procedures that have emerged as treatment options for intracranial atherosclerotic disease (ICAD). Some believe angioplasty alone is better, while others believe stenting is better. This study examines recent trends in utilization and outcomes of angioplasty alone and ICS in the United States using a population-based cohort. METHODS The National Inpatient Sample (NIS) database was queried for patients with ICAD who underwent angioplasty or ICS from 2005 to 2010. RESULTS There were 1115 patients (angioplasty: n=495, ICS: n=620) with ICAD who underwent endovascular revascularization. Over time, the number of endovascular revascularization procedures increased. The percentage of symptomatic patients (p=0.015) as well as in the number of comorbidities of patients treated (p<0.001) also increased. Combined post-procedure stroke and death rates were 16% and 28.9% for angioplasty and ICS, respectively (p<0.001). A larger percentage of angioplasty patients presented symptomatically compared to those who underwent ICS (p<0.001). CONCLUSION Angioplasty appears to be associated with higher rates of peri-procedural complications; however, that may represent patient selection bias. Further studies are needed to identify patients who would benefit from revascularization and to clarify the roles of angioplasty and ICS.
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Brzezicki G, Machinis T, Reavey-Cantwell J. Occlusion of all aortic arch great vessels: acute revascularization to perform endovascular stroke therapy. World Neurosurg 2013; 82:535.e17-21. [PMID: 24055566 DOI: 10.1016/j.wneu.2013.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 08/26/2013] [Accepted: 09/10/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND We present a case of a patient with a left-sided stroke and occlusion of all aortic arch great vessels who was treated successfully with endovascular intervention followed by delayed cardiothoracic revascularization. CASE REPORT A 46-year-old man presented with acute onset of dense right hemiparesis, facial droop, and aphasia with an initial National Institute of Health Stroke Score of 15. The patient was taken for emergent angiography after failing intravenous tissue plasminogen activator thrombolysis. Dedicated angiography of the aortic arch revealed occlusion of all great vessels, including the right brachiocephalic, left common carotid, and left subclavian artery. Delayed arterial filling of the right brachiocephalic and left subclavian artery by aberrant collaterals was seen. More distally, flow into the bilateral subclavian arteries, right common carotid artery, and left vertebral artery was appreciated. Serial balloon angioplasty of the left common carotid artery origin reconstituted flow. Subsequent selective angiogram of the left internal carotid artery revealed a proximal middle cerebral artery occlusion. Intra-arterial injection of tissue plasminogen activator followed by mechanical thrombectomy and intracranial stenting restored flow in the middle cerebral artery. Two months later the patient underwent aortic arch reconstruction with bifurcated graft to the brachiocephalic artery and left common carotid artery. At 1-year follow-up, the patient's examination revealed almost complete resolution of right hemiparesis with minimal hand weakness and mild expressive aphasia. CONCLUSIONS We report a rare case of occlusion of all aortic arch great vessels. Combined endovascular intervention and surgical revascularization resulted in an excellent durable outcome.
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Affiliation(s)
- Grzegorz Brzezicki
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Theofilos Machinis
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - John Reavey-Cantwell
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA.
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Abstract
PURPOSE Wingspan is the only FDA approved self-expanding stent for intracranial artery and known to have better delivery compared to balloon expandable stent. However, some delivery failure has been reported but incidence and mechanism of the failure have not been completely elucidated. We present the cause and mechanism of Wingspan deployment failure experienced in our Institute. MATERIALS AND METHODS We experienced deployment failure in seven patients (8.8%) out of 80 patients who underwent Wingspan stenting since 2007. Mean age of the patients was 62 (range 47~78) and male to female ratio was 6:1. We evaluated the cause and mechanism why the deployment was not successful and how we could manage it subsequently. RESULTS WE CATEGORIZED FAILURES OCCURRED IN SEVEN PATIENTS INTO THREE CATEGORIES: delivery failure (n = 3), deployment failure of stent (n = 3), retrieval failure of dual tapered (olive) tip of the inner body through the deployed the stent (n = 1). The technical failure in using Wingspan stent (delivery, deployment and retrieval failures) are related to tortuousness of the proximal (n =4) as well as distal (n =1) cerebral vessels to the stenotic lesion and bulky profile of the olive tip (n =2). CONCLUSION The technical failure in using Wingspan stent (delivery, deployment and retrieval failures) are related to tortuousness of the proximal as well as distal cerebral vessels to the stenotic lesion and bulky profile of the olive tip. To avoid device-related complication, complete understanding of the stent design is mandatory before using the stent.
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Affiliation(s)
- Lin-Bo Zhao
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
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Park TS, Choi BJ, Lee TH, Song JS, Lee DY, Sung SM. Urgent recanalization with stenting for severe intracranial atherosclerosis after transient ischemic attack or minor stroke. J Korean Neurosurg Soc 2011; 50:322-6. [PMID: 22200014 DOI: 10.3340/jkns.2011.50.4.322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 08/19/2011] [Accepted: 10/17/2011] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Stenting of symptomatic intracranial stenosis has recently become an alternative treatment modality. However, urgent intracranial stenting in patients with intracranial stenosis following a transient ischemic attack (TIA) or minor stroke is open to dispute. We sought to assess the feasibility, safety, and effectiveness of urgent intracranial stenting for severe stenosis (>70%) in TIA or minor stroke patients. METHODS Between June 2009 and October 2010, stent-assisted angioplasty by using a balloon-expandable coronary stent for intracranial severe stenosis (>70%) was performed in 7 patients after TIA and 5 patients after minor stroke (14 stenotic lesions). Technical success rates, complications, angiographic findings, and clinical outcomes were retrospectively analyzed. RESULTS Stenting was successful in all 12 patients. The mean time from symptom onset to stenting was 2.1 days (1-8 days). Post-procedural angiography showed restoration to a normal luminal diameter in all patients. In-stent thrombosis occurred in one patient (n=1, 8.3%), and was lysed with abciximab. No device-related complications, such as perforations or dissections at the target arteries or intracranial hemorrhaging, occurred in any patient. The mortality rate was 0%. No patient had an ischemic event over the mean follow-up period of 12.5 months (range, 7-21 months), and follow-up angiography (n=7) revealed no significant in-stent restenosis (>50%). CONCLUSION Urgent recanalization with stenting is feasible, safe, and effective in patients with TIA or acute minor stroke with intracranial stenosis of ≥70%.
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Affiliation(s)
- Tae Sik Park
- Department of Neurosurgery, Wallace Memorial Baptist Hospital, Busan, Korea
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