Abstract
Objective: Recurrent cerebral ischemic events are estimated to appear in between 12-15% of symptomatic intracranial atherosclerotic disease (ICAD), regardless of the use of leading pharmacological therapies. Balloon expandable stent (balloon mounted coronary stent) could represent a feasible alternative in this disease’s treatment. This study pretends to report the balloon-expandable placement experience in our center. Materials and Methods: A unicentric retrospective study dated between September 2009 and March 2018 was conducted. Patients previously diagnosed with ICAD and symptomatic stenosis treated with balloon-expandable stent were included. Clinical features, morbidity, mortality, short and long-term evolution, and pre-and post-treatment angiographic features were analyzed, as well as a mean 8 years-period follow-up. Data are presented as means, frequencies, and percentages for categorical variables, and ranks for continuous variables. Statistical analysis was carried by IBM SPSS Statistics Base V22.0 (IBM Corporation, Mexico). A Wilcoxon Signed-rank test statistical analysis was performed. Statistical significance was considered when a p-value lesser than 0.05 was measured for every result. Results: A total of 6 patients with 7 affected vessels were treated, with an average age of 62.7 years. Affected and treated vessels were located in the Internal Carotid Artery (ICA) segment in 42.9%, Vertebral Artery (VA) V4 segment in 14.3%, Middle Cerebral Artery (MCA) M1 segment in 28.5%, and Posterior Cerebral Artery (PCA) P1 segment in 14.3%. The incidence of peri-operatory thrombotic events was 0%. Intracranial hemorrhage presented in 0% of cases. Recurrent ischemic or thrombotic events were not reported in a 97-months mean follow-up. 71.4% of patients scored ≤2 in the modified Rankin Score (mRS) pre-treatment, in a 90 day and 12-month follow-up. 100% presented a favorable evolution with mRS ≤2. Restenosis cases were not reported in radiologic control and retreatment was not needed in a 97-month mean follow-up. Conclusions: This study suggests that balloon-expandable stent therapy with some technical endovascular variants for its navigation and placement could be a safe and effective alternative in the treatment of ICAD as a means of cerebral ischemic event early secondary prevention. We propose to consider not to limit endovascular treatment exclusively to those symptomatic ICAD patients refractory to medical-exclusive treatment, as a means to reduce the risk of presenting a new neurological deficit. Further expanded clinical trials are needed to confirm these findings and the advantage of this kind of stents against other kinds reported in the literature.
Highlights
Intracranial atherosclerotic disease (ICAD) is a frequent cause of cerebral ischemic events in adults, it represents 10% of ischemic cerebral disease in the United States of America, 14.7% in Mexico, and 26% in the Asiatic and Afro-American population. [1,2,3,4] In addition to genetic and ethnic components, diabetes mellitus, systemic arterial hypertension, dyslipidemia, and smoking have been associated with a higher incidence of ICAD. [5]ICAD representative clinical feature is transient ischemic attack, characterized by specific neurologic deficit such as hemiparesis, hemihypoesthesia, dysarthria, or amaurosis fugax
[7] Variability in clinical evolution in ICAD has been described for medical-exclusive treatment against endovascular therapy. [8,9] WASID (Warfarin versus Aspirin for Symptomatic Intracranial Disease) study states that the risk of recurrence of ischemic cerebrovascular disease depends on the stenosis grade, with 19% recurrence risk in 70-99% stenosis, and 10% risk in stenosis lesser than 70%. (10) SAMPRIS (Stenting versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis) describes a higher risk of recurrence posterior to endovascular stenosis treatment with non-coronary stent vs. medical-exclusive treatment in one-year follow-up (23.4% vs 12.0%). [11] VISSIT (Vitesse Intracranial Stent Study for Ischemic Stroke Therapy) study reports similar findings to those of SAMPRIS, with 36.2% recurrence for endovascular treatment with a noncoronary stent versus 15.15% for medical- exclusive treatment. [11,12]
Posterior to SAMPRIS, other studies have described a lessening in morbidity (2-4.4%) in symptomatic ICAD with treatment based on stents in selected patients. [15,16] our study aims to test the safety and efficiency of using balloon expandable stent with some technical deployment variants in early secondary prevention of patients with previous ischemic cerebrovascular disease
Summary
Intracranial atherosclerotic disease (ICAD) is a frequent cause of cerebral ischemic events in adults, it represents 10% of ischemic cerebral disease in the United States of America, 14.7% in Mexico, and 26% in the Asiatic and Afro-American population. [1,2,3,4] In addition to genetic and ethnic components, diabetes mellitus, systemic arterial hypertension, dyslipidemia, and smoking have been associated with a higher incidence of ICAD. [5]ICAD representative clinical feature is transient ischemic attack, characterized by specific neurologic deficit such as hemiparesis, hemihypoesthesia, dysarthria, or amaurosis fugax. [7] Clinical treatment is based on lifestyle changes and risk-factor control such as diabetes mellitus, systemic arterial hypertension, hypercholesterolemia, and smoking, as well as pharmacological therapy with platelet antiaggregant, and statins. (10) SAMPRIS (Stenting versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis) describes a higher risk of recurrence posterior to endovascular stenosis treatment with non-coronary stent vs medical-exclusive treatment in one-year follow-up (23.4% vs 12.0%). [11] VISSIT (Vitesse Intracranial Stent Study for Ischemic Stroke Therapy) study reports similar findings to those of SAMPRIS, with 36.2% recurrence for endovascular treatment with a noncoronary stent versus 15.15% for medical- exclusive treatment. Durst et al described lesser morbidity than that previously reported (7.1%), when using balloon expandable stent in the secondary prevention of ischemic cerebrovascular disease in symptomatic patients with ICAD, despite medical treatment based on double platelet antiaggregant and statins. Posterior to SAMPRIS, other studies have described a lessening in morbidity (2-4.4%) in symptomatic ICAD with treatment based on stents in selected patients. [15,16] our study aims to test the safety and efficiency of using balloon expandable stent with some technical deployment variants in early secondary prevention of patients with previous ischemic cerebrovascular disease
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