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Sharma VK, Gopinathan A, Tan BYQ, Loh PH, Hung J, Tang D, Chua C, Chan ACY, Ong JJY, Chin A, Jing M, Goh Y, Sunny S, Keat CH, Ka Z, Pandya S, Wong LYH, Chen JT, Yeo LLL, Chan BPL, Teoh HL, Sinha AK. Enhanced external counter pulsation therapy in patients with symptomatic and severe intracranial steno-occlusive disease: a randomized clinical trial protocol. Front Neurol 2023; 14:1177500. [PMID: 37325226 PMCID: PMC10262049 DOI: 10.3389/fneur.2023.1177500] [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] [Grants] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/02/2023] [Indexed: 06/17/2023] Open
Abstract
Intracranial stenosis is prevalent among Asians and constitutes a common cause of cerebral ischemia. While the best medical therapy carries stroke recurrence rates in excess of 10% per year, trials with intracranial stenting have been associated with unacceptable peri-procedural ischemic events. Cerebral ischemic events are strongly related to the severity of intracranial stenosis, which is high in patients with severe intracranial stenosis with poor vasodilatory reserve. Enhanced External Counter Pulsation (EECP) therapy is known to improve myocardial perfusion by facilitating the development of collateral blood vessels in the heart. In this randomized clinical trial, we evaluate whether EECP therapy may be useful in patients with severe stenosis of intracranial internal carotid (ICA) or middle cerebral artery (MCA). The review of literature, methods of evaluation, status of currently used therapeutic approaches, and trial protocol have been presented. Clinical trial registration ClinicalTrials.gov, Identifier: NCT03921827.
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Affiliation(s)
- Vijay K. Sharma
- Divisin of Neurology, National University Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Anil Gopinathan
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Benjamin Y. Q. Tan
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Poay Huan Loh
- Department of Cardiology, National University Hospital, Singapore, Singapore
| | - Jennifer Hung
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - David Tang
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Christopher Chua
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Amanda C. Y. Chan
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Jonathan J. Y. Ong
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Amanda Chin
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Mingxue Jing
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Yihui Goh
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Sibi Sunny
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Chin Howe Keat
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Zhang Ka
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Shivani Pandya
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Lily Y. H. Wong
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Jin Tao Chen
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Leonard L. L. Yeo
- Divisin of Neurology, National University Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bernard P. L. Chan
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Hock Luen Teoh
- Divisin of Neurology, National University Hospital, Singapore, Singapore
| | - Arvind K. Sinha
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
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Low SW, Teo K, Lwin S, Yeo LLL, Paliwal PR, Ahmad A, Sinha AK, Teoh HL, Wong LYH, Chong VF, Seet RCS, Chan BPL, Yeo TT, Chou N, Sharma VK. Improvement in cerebral hemodynamic parameters and outcomes after superficial temporal artery-middle cerebral artery bypass in patients with severe stenoocclusive disease of the intracranial internal carotid or middle cerebral arteries. J Neurosurg 2015; 123:662-9. [PMID: 26023999 DOI: 10.3171/2014.11.jns141553] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [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: 11/06/2022]
Abstract
OBJECT Both the older and the recent extracranial-intracranial (EC-IC) bypass trials for symptomatic carotid occlusion failed to demonstrate a reduction in stroke recurrence. However, the role of superficial temporal artery (STA)-middle cerebral artery (MCA) bypass in patients with symptomatic intracranial stenoocclusive disease has been rarely evaluated. The authors evaluated serial changes in various cerebral hemodynamic parameters in patients with severe stenoocclusive disease of the intracranial internal carotid artery (ICA) or middle cerebral artery (MCA) and impaired cerebral vasodilatory reserve (CVR), treated by STA-MCA bypass surgery or medical treatment. METHODS Patients with severe stenoocclusive disease of the intracranial ICA or MCA underwent transcranial Doppler (TCD) ultrasonography and CVR assessment using the breath-holding index (BHI). Patients with impaired BHI (< 0.69) were further evaluated with acetazolamide-challenge technitium-99m hexamethylpropyleneamine oxime ((99m)Tc HMPAO) SPECT. STA-MCA bypass surgery was offered to patients with impaired CVR on SPECT. All patients underwent TCD and SPECT at 4 ± 1 months and were followed up for cerebral ischemic events. RESULTS A total of 112 patients were included. This total included 73 men, and the mean age of the entire study population was 56 years (range 23-78 years). (99m)Tc HMPAO SPECT demonstrated impaired CVR in 77 patients (69%). Of these 77 patients, 46 underwent STA-MCA bypass while 31 received best medical treatment. TCD and acetazolamide-challenge (99m)Tc HMPAO SPECT repeated at 4 ± 1 months showed significant improvement in the STA-MCA bypass group. During a mean follow-up of 34 months (range 18-39 months), only 6 (13%) of 46 patients in the bypass group developed cerebral ischemic events, as compared with 14 (45%) of 31 patients receiving medical therapy (absolute risk reduction 32%, p = 0.008). CONCLUSIONS STA-MCA bypass surgery in carefully selected patients with symptomatic severe intracranial stenoocclusive disease of the intracranial ICA or MCA results in significant improvement in hemodynamic parameters and reduction in stroke recurrence.
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Affiliation(s)
| | | | | | | | | | | | - Arvind K Sinha
- Department of Diagnostic Imaging, National University Hospital System, Singapore; and
| | | | | | - Vincent F Chong
- Department of Diagnostic Imaging, National University Hospital System, Singapore; and
| | | | | | | | | | - Vijay K Sharma
- Division of Neurology, and.,YLL School of Medicine, National University of Singapore, Singapore
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