Atherosclerotic Intracranial Arterial Stenosis Research Articles

Case report of intracranial large vessel occlusion in glioblastoma multiforme patient after radiation therapy.

Vasculopathy of the large arteries is a prominent complication of radiotherapy. Radiation-induced cerebral vasculopathy can cause arterial stenosis/occlusion, cerebral hemorrhage, and aneurysm formation. We report a cases of glioblastoma multiforme (GBM) with occlusive radiation vasculopathy (ORV). This 28-year-old patient who suffered from GBM had surgery for cytoreduction and received postoperative CCRT. We adopted the radiotherapy and oncology group radiation guideline. This patient had cerebrovascular accident episodes without any known risk. Therefore, ORV was highly suspected and vascular stenosis was confirmed using magnetic resonance angiography (MRA) or digital subtraction angiography. Extracranial-intracranial bypass was performed and patency was confirmed. The patient had not suffered from recurrent symptoms of transient ischemic attack or ischemic stroke for 1.5 years. This is the first article to report bypass surgery for GBM patients. Although the median survival rate of GBM is approximately 15 months, the short survival time may be sufficient for occlusive vasculopathy to occur. Regular follow-up magnetic resonance imaging assessments are recommended, as is MRA as a screening tool for the early diagnosis of ORV.The Stenting versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial focused on atherosclerotic intracranial arterial stenosis, revealing that aggressive medical management was superior to stenting for secondary stroke prevention; however, it did not mention radiation-induced vasculopathy. Bypass surgery has yielded some positive outcomes. In the absence of contraindications, antiplatelet or anticoagulation agents could be added, and bypass surgery could be performed because there was no stent in the distal intracranial arteries. MRA is a potential screening tool for ORV in GBM patients and bypass surgery could be performed to improve brain perfusion. Bypass surgery could help patient with occlusive radiation vasculopathy.

Early Diagnosis of Intracranial Internal Carotid Artery Stenosis Using Extracranial Hemodynamic Indices from Carotid Doppler Ultrasound.

Atherosclerotic intracranial internal carotid artery stenosis (IICAS) is a leading cause of strokes. Due to the limitations of major cerebral imaging techniques, the early diagnosis of IICAS remains challenging. Clinical studies have revealed that arterial stenosis may have complicated effects on the blood flow’s velocity from a distance. Therefore, based on a patient-specific one-dimensional hemodynamic model, we quantitatively investigated the effects of IICAS on extracranial internal carotid artery (ICA) flow velocity waveforms to identify sensitive hemodynamic indices for IICAS diagnoses. Classical hemodynamic indices, including the peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index (RI), were calculated on the basis of simulations with and without IICAS. In addition, the first harmonic ratio (FHR), which is defined as the ratio between the first harmonic amplitude and the sum of the amplitudes of the 1st–20th order harmonics, was proposed to evaluate flow waveform patterns. To investigate the diagnostic performance of the indices, we included 52 patients with mild-to-moderate IICAS (<70%) in a case–control study and considered 24 patients without stenosis as controls. The simulation analyses revealed that the existence of IICAS dramatically increased the FHR and decreased the PSV and EDV in the same patient. Statistical analyses showed that the average PSV, EDV, and RI were lower in the stenosis group than in the control group; however, there were no significant differences (p > 0.05) between the two groups, except for the PSV of the right ICA (p = 0.011). The FHR was significantly higher in the stenosis group than in the control group (p < 0.001), with superior diagnostic performance. Taken together, the FHR is a promising index for the early diagnosis of IICAS using carotid Doppler ultrasound methods.

Correlation between microalbuminuria and atherosclerotic intracranial and extracranial arterial stenosis in patients with cerebral infarction

Background and aimsMicroalbuminuria (MAU) reflects the generalized vascular endothelial dysfunction. Whether MAU has correlation with atherosclerotic intracranial and extracranial arterial stenosis in cerebral infarction patients is not known and is explored in the present investigation. MethodsWe enrolled 255 cerebral infarction patients hospitalized at the department of neurology. All patients underwent digital subtraction angiography (DSA) to evaluate the severity and distribution of intracranial and extracranial arterial stenosis. MAU was expressed as the urine albumin-to-creatinine ratio (UACR). We collected basic information, medical history reviews and laboratory results of each participant. The multivariate logistic regression analysis was utilized to analyze the risk factors for severity and distribution of cerebral arterial stenosis. ResultsThe prevalence of MAU in patients with cerebral infarction was 39.2%, patients with MAU had older age, lower blood uric acid, higher systolic blood pressure (SBP), higher prevalence of hypertension and diabetes (p < 0.05) and higher incidence of atherosclerotic intracranial and extracranial arterial stenosis (χ2 = 5.900, p = 0.015). In multiple logistic regression analysis for intracranial and extracranial arterial stenosis more than 50% or occlusion groups, UACR (OR 1.088 95%CI 1.012–1.170p = 0.022), male (OR 2.196 95%CI 1.085–4.442p = 0.029) as well as SBP (OR 5.870 95%CI 1.026–1.048p = 0.015) showed statistical significance. But UACR had no correlation with the distribution of intracranial and extracranial artery stenosis after adjusting for all potential confounders. ConclusionsMicroalbuminuria was an independent risk factor for intracranial and extracranial arterial stenosis more than 50% or occlusion.

Differences in cerebral blood flow measurement using arterial spin labeling MRI between patients with moyamoya disease and patients with arteriosclerotic cerebrovascular disease.

It is unclear whether the accuracy of arterial spin labeling (ASL) magnetic resonance imaging (MRI) is the same between moyamoya disease (MMD), which is known to have markedly elevated cerebral blood volume (CBV), and atherosclerotic intracranial arterial stenosis (AS), which has relatively less elevated CBV. To investigate how the differences in hemodynamics affect measurement of ASL-cerebral blood flow (CBF) using ASL for patients with MMD and AS. Fourteen MMD and ten AS patients were evaluated with ASL-MRI, magnetic resonance angiography (MRA), and 15O-gas positron emission computed tomography (PET). The regional CBF values of ASL using two post-labeling delays (PLDs; 1525 ms and 2525 ms) were compared with the PET-derived CBF, CBV, and mean transit time (MTT). Corresponding anterior circulation results were evaluated by flow territory map-based analysis. The correlation between the ASL-CBF values (2525 ms) and PET-CBF declined in the MMD group (r = 0.28; P < 0.01), while the AS group showed good correlation (r = 0.77; P < 0.01). In the MMD group, the ASL-CBF values (2525 ms) overestimated the PET-CBF values as the regional CBV values increased (r = 0.35; P < 0.01). When the regions of interest were divided into two subgroups according to the degree of arterial stenosis by MRA, the correlation coefficient between the ASL-CBF (2525 ms) and PET-CBF values improved (mild stenosis: r = 0.36; P = 0.06; severe stenosis: r = 0.51; P < 0.01). The accuracy of CBF measurements using ASL-MRI differed between patients with MMD and AS. The prominent increase of CBV and the degree of arterial stenosis may have affected the accuracy of ASL-CBF in patients with MMD.

Application of Multimodal MRI in Cerebral Infarction

Symptomatic atherosclerotic intracranial artery stenosis often causes ischemic cerebral infarction or transient ischemic attack in the stenosis area. Early detection of cerebral infarction and evaluation of ischemic penumbra and hemodynamics in the infarct area Information plays an extremely important role in clinical treatment and prognosis. This article briefly introduces the application of multimodal MRI in cerebral infarction.

Stroke prevention

Patients who have had a stroke are at high risk for recurrent stroke, myocardial infarction, and vascular death. Prevention of these events should be initiated promptly after stroke, because many recurrent events occur early, and should be tailored to the precise cause of stroke, which may require specific treatment. Lifestyle advice including abstinence from smoking, regular exercise, Mediterranean-style diet, and reduction of salt intake and alcohol consumption are recommended for all patients with stroke. For most patients with ischemic stroke or TIA, control of risk factors, including lowering blood pressure under 140/90mmHg and LDL cholesterol under 1g/L, together with antiplatelet or oral anticoagulant therapy, depending on the cause of stroke, have been shown to decrease the risk of recurrent stroke and cardiovascular events. Aspirin, clopidogrel, or the combination of aspirin and dipyridamole, are all acceptable options for secondary prevention in patients with ischemic stroke or TIA of arterial origin. Dual therapy with aspirin and clopidogrel might be considered for 3weeks after a minor ischemic stroke or TIA and for 3months in patients with stroke due to severe intracranial stenosis. Oral anticoagulants are very effective to prevent cardioembolic stroke. Non-VKA oral anticoagulants have a favorable risk-benefit profile compared with VKAs, with significant reductions in stroke, intracranial hemorrhage, mortality, with similar major bleeding, but increased gastrointestinal bleeding. Carotid endarterectomy reduces the risk of ipsilateral stroke in patients with recent (<6months) non disabling ischemic stroke or TIA in the territory and severe carotid artery stenosis. Carotid stenting is a potential alternative to surgery in patients younger than ≈70years or patients with greater risk of surgery due to anatomic or medical conditions or specific circumstances such as radiation-induced stenosis or restenosis after surgery. For patients with hemorrhagic stroke due to hypertension-associated small vessel disease or cerebral amyloid angiopathy, strict control of blood pressure is essential. Restarting oral anticoagulants in patients after intracranial hemorrhage is a difficult decision that should weigh the risks of recurrent ischemic and hemorrhage stroke with and without oral anticoagulants. Several areas of uncertainty persist including the optimal target of blood pressure in patients with cerebrovascular disease, the benefit of PFO closure in patients with PFO-associated stroke, of stenting procedures in patients with atherosclerotic intracranial artery or extracranial vertebral artery stenosis, and of interventional procedures in patients with brain arteriovenous or cavernous malformations.

Aspirin against Atherosclerotic Intracranial Arterial Stenosis

There is no doubt that atherosclerosis is a chronic inflammatory disease in the inner wall of the arteries caused by the laws of hydrodynamics and environmental chemicals present into the bloodstream. Atheromatous plaques located at the mouths of the perforating and collateral arteries originated from the supraclinoid carotids, distal end of the basilar artery and the V4 segments of the vertebral arteries, usually cause neurological events of insidious onset, undulating course and progressive. In other cases it can manifest as transient ischemic attacks. For this reason, reducing the size of atheroma in the arteries with mild or moderate stenosis through medical treatment is the goal to follow to cause vascular recanalization and thus, increase the blood flow in the ischemic areas. Therefore, an antiinflammatory therapy is indicated against atheroma formation. Previous clinical results suggest that high doses of aspirin are required to prevent or reduce the formation of atheromatous plaques, due to their anti-inflammatory, anti-platelet and anti-thrombotic effects. While in patients with severe stenosis and/or thrombosis in the perforating and small arteries, omental transplantation is indicated, because this tissue causes revascularization in the underlying and adjacent areas to the omentum. In conclusion, without vascular recanalization or revascularization in the ischemic zone, no neuronal regeneration or neurogenesis occurs.

Endovascular treatment and the outcomes of atherosclerotic intracranial stenosis in patients with hyperacute stroke.

The importance of underlying atherosclerotic intracranial artery stenosis (ICAS) in hyperacute stroke patients who receive endovascular therapy remains unknown. To report and compare the outcomes of multimodal endovascular therapy in patients with hyperacute stroke with and without underlying ICAS. A total of 172 consecutive patients with acute stroke were treated with multimodal endovascular therapy that was heavily weighted toward stent-based thrombectomy. Patients with ICAS underwent emergent intracranial angioplasty or stenting. Data were compared between patients with and without ICAS. Revascularization was defined as Thrombolysis in Cerebral Infarction grade ≥2b. A favorable outcome was defined as a modified Rankin Scale score ≤2 or equal to the premorbid modified Rankin Scale score at 3 months. ICAS was responsible for acute ischemic symptoms in 40 patients (22.9%). Revascularization and favorable outcome occurred more frequently in the ICAS group than in the control group (95% vs 81.8%, P = .04; 65% vs 40.2%, P = .01, respectively). The median baseline National Institutes of Health Stroke Scale score was significantly lower in the ICAS group compared with the control group (10 vs 12; P = .002). There were no significant differences between the 2 groups in the rates of symptomatic hemorrhage and mortality. Emergent intracranial angioplasty with or without stenting is safe and feasible and yields a high rate of revascularization and favorable outcome in patients with hyperacute stroke and underlying ICAS. Patients with underlying ICAS have less severe infarctions at presentation and higher successful revascularization after multimodal endovascular therapy in the setting of hyperacute stroke compared with those with other stroke subtypes.

Abstract 135: Angiogenic Factors and Response to Intensive Medical Management in Atherosclerotic Intracranial Arterial Stenosis

Introduction: Intracranial atherosclerotic steno-occlusive disease (ICASD) is the most common cause of stroke worldwide accounting for 33-67% of stroke in countries with predominantly Asian, Hispanic, and Black populations and at least 10% of all strokes in the US. In this study we test the hypothesis that circulating angiogenic factor profiles are associated with response to medical management. Methods: This is a prospective cohort of participants in the Angiogenic Factors in Intracranial Arterial Stenosis (ANFIS) Study, age 30-80, with a diagnosis of 70-99% ICASD of a major intracranial artery. All patients had optimization of medical management. Failure of medical treatment was defined as presence of TIA or strokes within 30 days of enrollment. Angiogenic factors were isolated in peripheral blood: HBEGF, VEGF, VEGF-D, TGFB1, TGFB2, PDGFAA, PDGFBB, Endostatin, Angiostatin, and VEGFR2. A correlation matrix was used to group highly correlated factors. Multivariable logistic-regression models were prepared to estimate risk of medical management failure. Results: Thirty patients (53% female) age 28-86 (mean 62.5) were enrolled. There were 10 (33.3%) failures of medical management. Age, gender, ethnicity and race were not significantly different between responders and failures of medical treatment. The multivariate analysis showed that higher VEGFD levels were associated with reduced failure (OR=0.26 95%CI 0.06-0.63, p=0.02) and higher HBEGF was associated with increased failure (OR=2.52 95%CI 1.28-7.34, p=0.03). The multivariate logistic model including VEGFD, HBEGF, female sex and black race had 90% sensitivity and 75% specificity (AUC 0.87) in predicting failure of management. Conclusion: In patients with severe (&gt;70%) ICASD, elevated circulating HBEGF levels were associated with failure of medical treatment, while elevated circulating VEGFD levels were associated with protection from TIA/stroke. Further evaluation of the role of these factors in stroke prevention and potential collateral formation could elucidate new pathways for the treatment of intracranial atherosclerotic disease.

Application of the Enterprise Stent in Atherosclerotic Intracranial Arterial Stenosis: A Series of 60 Cases.

We assessed the safety and effectiveness of the Enterprise stent in treating atherosclerotic intracranial arterial stenosis (AIAS). This was a retrospective study conducted with 60 consecutive patients with 62 AIAS lesions who received the Enterprise stent at the Department of Neurosurgery, Second Hospital of Shandong University between June 2012 and January 2014. All patients were assessed using the modified Rankin scoring system at discharge. Clinical follow-ups and digital subtraction angiography (DSA) were performed at 1, 3, 6 and 12 months postoperatively. There were 42 men and 18 women with a mean age of 56.8 ± 8.0 years. Fourteen lesions (22.6%) were at the anterior and 48 (77.4 %) were at the posterior circulation. The mean stenosis rate was 76.3 ± 12.7%. The mean stenotic vessel length was 7.7 ± 2.0 mm. The technical success rate was 100%. The mean post-stent residual stenosis rate was 22.8 ± 4.8%. Five patients (8.3%) had perioperative complications, but no disability or mortality occurred within 30 days. The mean follow-up duration was 6.2 months. DSA was used to evaluate 45 lesions (72.6%) six months postoperatively: 6 (13.3%) had postoperative restenoses, 2 at the anterior circulation, and 4 at the posterior circulation. Of these 6, 4 (66.7%) were immediate residual stenoses after stenting. The residual stenosis rate was identified as a risk factor for restenosis. Five (8.3%) ischemic events, consistent with the vascular lesions, occurred. Application of the Enterprise stent was safe and efficacious. The technical success rate was high while the perioperative complication rate was low.

Full steam ahead with remote ischemic conditioning for stroke.

Full steam ahead with remote ischemic conditioning for stroke.

Efficacy and safety of intensive statin therapy in Chinese patients with atherosclerotic intracranial arterial stenosis: A single-center, randomized, single-blind, parallel-group study with one-year follow-up

ObjectivesThe purpose of this study is to validate the efficacy of intensive statin therapy for patients with atherosclerotic intracranial arterial stenosis (AICAS). MethodsIn this study, we performed a single-center, randomized, single-blind, parallel-group clinical trial. A total of 120 Chinese patients with AICAS were enrolled and randomly divided into three groups [low-dose atorvastatin therapy (LAT, 10mg/day), standard-dose atorvastatin therapy (SAT, 20mg/day), and intensive-dose atorvastatin therapy (IAT, 40mg/day) groups] in a 1:1:1 ratio. Evaluation variables, including changes in serum lipid profiles, degree of stenosis, and perfusion-related parameters derived from computed tomography perfusion (CTP) imaging from baseline to weeks 26 and 52, as well as the occurrence of cerebrovascular events during the study period, were used to compare the benefits of these three statin therapies. ResultsAfter 52 weeks of treatment, improvement of serum lipid profiles, degree of stenosis, and perfusion-related parameters were all significantly better in the IAT group. In addition, the cumulative probability of cerebrovascular events at 52 weeks was significantly lower in the IAT group than in the LAT group, although there was no statistical difference between the IAT group and the SAT group. The proportion of patients experiencing any adverse event was similar among the three treatment groups. Adverse events caused by IAT were generally mild; no serious adverse events occurred throughout the entire period of study. ConclusionIn conclusion, long-term use of IAT appears to be a safe and effective treatment at least for Chinese patients with AICAS.

A Markov model to compare the long-term effect of aspirin, clopidogrel and clopidogrel plus aspirin on prevention of recurrent ischemic stroke due to intracranial artery stenosis

Given the importance of intracranial stenosis as a cause of recurrent ischemic stroke and the lack of evidence supporting a clear choice for prevention of recurrent ischemic events, a computer simulation model for prognostic prediction could be used to improve decision making. The aim of the following study is to compare the long-term effect of aspirin, clopidogrel and clopidogrel plus aspirin for prevention of recurrent stroke due to atherosclerotic intracranial artery stenosis. The cohort consisted of 206 patients from 2006 to 2011. A two-state Markov model was used to predict the prognosis of patients with stroke or transient ischemic attack (TIA) caused by angiographically verified 50-99% stenosis of a major intracranial artery to receive aspirin, clopidogrel, or dual therapy. Two tests were used: Pearson Chi-square test or Fisher's exact test (for percentages) and Kruskal Wallis test (for rank order data). In the 10-year Markov cohort analysis, 36.24% of patients who were treated with clopidogrel plus aspirin developed to recurrent stroke while the probability for patients in the aspirin group and clopidogrel group was 42.60% and 48.39% respectively. Patients with clopidogrel plus aspirin had the highest quality-adjusted life years, followed by aspirin and clopidogrel. To prevent recurrent stroke in patients with intracranial artery stenosis, especially in those patients with a history of TIA or coronary artery disease, medical therapy with clopidogrel plus aspirin should be considered in preference to aspirin alone.

Higher numbers of circulating endothelial progenitor cells in stroke patients with intracranial arterial stenosis

BackgroundBone marrow-derived endothelial stem cells participate in vascular repairs. Numbers of circulating endothelial progenitor cells (cEPCs) are associated with atherosclerosis. Fibrinogen plays a key role in atherosclerosis. Objective was to assess if cEPC counts were associated with atherosclerotic intracranial artery stenosis (IAS).MethodsThree hundred subjects (108 patients with stroke and IAS (IAS), 120 control patients with stroke without IAS (CP), and 72 healthy controls (HC)) were retrospectively analyzed. cEPCs were identified and counted by flow cytometry using CD34, CD133 and KDR. Plasma fibrinogen was measured by immunoturbidimetry. cEPC counts were compared between the three groups.ResultscEPC numbers were significantly higher in IAS (0.059 ± 0.031%) than in CP (0.026 ± 0.012%) (P < 0.001) and HC (0.021 ± 0.011%) (P < 0.001), but without difference between CP and HC (P = 0.401). Multiple logistic regression analysis showed that cEPC levels (OR 3.31, 95%CI 1.26-8.87, P = 0.025; IAS vs. CP) were independent markers of IAS after adjustment for hypertension, diabetes and smoking. No significant correlation between cEPC counts and plasma fibrinogen levels was observed (P > 0.05).ConclusioncEPC numbers were associated with degrees of IAS. This measurement may be useful for non-invasive evaluation of atherosclerotic IAS.

Improved medical treatment in secondary prevention of stroke

Atherosclerotic intracranial arterial stenosis is a cause of transient ischaemic attack and ischaemic stroke, and is associated with a high risk of recurrence. Patients with recently symptomatic severe (70–99%) stenosis are at particularly high risk.1 In the SAMMPRIS trial,2 investigators compared two alternative treatment strategies in patients with a recent (<30 days) transient ischaemic attack or non-disabling stroke attributed to angiographically verified 70–99% intracranial stenosis: aggressive medical treatment (combination antiplatelet therapy and intensive management of risk factors) versus aggressive medical treatment and percutaneous transluminal angioplasty and stenting (PTAS), using the self-expanding Wingspan stent.

Abstract TMP104: Arm Ischemic Preconditioning Prevents Stroke Recurrence in Octogenarians with Intracranial Arterial Stenosis

Introduction: Symptomatic atherosclerotic intracranial arterial stenosis (SAIS) has a high incidence of stroke and recurrence, especially in octogenarians. Currently available therapies including stenting are unable to prevent strokes recurrence completely and may result in worse clinical outcomes. Emerging experimental investigations have suggested that remote ischemic preconditioning may be clinically effective in stroke intervention. Hypothesis: Brief repetitive bilateral arm ischemic preconditioning (BAIPC) may be safe and prevent stroke occurrence and recurrence in octogenarians with SAIS. Methods: A total of 58 consecutive octogenarians with SIAS (diagnosed by imaging) enrolled in this prospective, single blind and randomized study. All patients enrolled underwent standard medical care. In addition, patients in BAIPC group (n=30) underwent five cycles consisting of bilateral arms 5min ischemia followed by 5min reperfusion twice daily for the total of 180 consecutive days. Blood pressure, heart rate, local skins integrity and plasma myoglobin levels before and during the first 30-days of treatment were documented. Finally, Plasma levels of thrombosis and inflammation markers, clinical outcomes (modified Rankin Scale 0-1) and the incidence of stroke recurrence during the180-days of treatment in the two groups were compared. Clinical Trial Registration-URL: www.clinicaltrials.gov , unique identifier: NCT01570231 . Results: Compared to the controls (n=28), BAIPC had no adverse effects on blood pressure, heart rate, local skins integrity and plasma myoglobin, and BAIPC did not contribute to cerebral hemorrhage. BAIPC decreased plasma levels of hsCRP, IL-6, PAI-1, leukocyte count, platelet aggregation rate as well as increased TPA, improved the 180-days of modified Rankin Scale and decreased the incidences of ischemic stroke recurrence and TIA onset (6.7% and 23.3% in BAIPC group versus 28.6% and 39.3% in control group, P &lt; 0.01). Conclusions: Our study provides a proof-of-concept that BAIPC is a safe and feasible method to protect the ischemic brain in octogenarians with SIAS. Further investigation in an enlarged trial is ongoing.

Spotlight on the October 30 Issue

This study followed 1,768 women who used hormone therapy, with 176 developing incident Alzheimer disease. Hormone therapies are associated with a reduced risk of subsequent Alzheimer dementia if taken during a critical window near menopause, but may be associated with an increased risk if initiated later in life. See p. 1846; Editorial, p. 1840 The authors evaluated protective effects of brief repetitive bilateral arm ischemic preconditioning on stroke recurrence in 68 patients with symptomatic atherosclerotic intracranial arterial stenosis. This noninvasive strategy has promise …

Upper limb ischemic preconditioning prevents recurrent stroke in intracranial arterial stenosis

This study aims to evaluate protective effects of brief repetitive bilateral arm ischemic preconditioning (BAIPC) on stroke recurrence in patients with symptomatic atherosclerotic intracranial arterial stenosis (IAS). A total of 68 consecutive cases with symptomatic IAS, diagnosed by imaging, were enrolled in this prospective and randomized study. All patients received standard medical management. Patients in the BAIPC group (n = 38) underwent 5 brief cycles consisting of bilateral upper limb ischemia followed by reperfusion. The BAIPC procedure was performed twice daily over 300 consecutive days. Incidence of recurrent stroke and cerebral perfusion status in BAIPC-treated patients were compared with the untreated control group (n = 30). In the control group, incidence of recurrent stroke at 90 and 300 days were 23.3% and 26.7%, respectively. In the BAIPC group, incidence of recurrent stroke was reduced to 5% and 7.9% at 90 and 300 days (p < 0.01), respectively. The average time to recovery (modified Rankin Scale score 0-1) was also shortened by BAIPC. Cerebral perfusion status, measured by SPECT and transcranial Doppler sonography, improved remarkably in BAIPC-treated brain than in control (p < 0.01). This study provides a proof-of-concept that BAIPC may be an effective way to improve cerebral perfusion and reduce recurrent strokes in patients with IAS. Further investigation of this therapeutic approach is warranted as some patients were excluded after randomization.

Preconditioning reaches clinical practice in intracranial arterial stenosis

Symptomatic atherosclerotic intracranial arterial stenosis is a common etiologic mechanism of ischemic stroke. Patients with intracranial arterial stenosis carry a high risk of recurrent stroke that persists even with aggressive preventive measures.[1][1] The growing popularity of endovascular

A Single Center Experience of Stenting in Symptomatic Intracranial Atherosclerosis

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 been compared with medical management in a randomized trial (SAMMPRIS), where aggressive medical management was superior to PTAS with the use of the Wingspan stent system, however in our experience we have had good results and have experienced no complications with this therapy. In a retrospective, single-center study we enrolled seven consecutive patients with a symptomatic angiographically proven atherosclerotic intracranial arterial stenosis of the anterior and posterior circulation. All cases received adjuvant therapy (aspirin and clopidogrel or ticlopidine) before and after deployment of the device. The procedures were performed with the patient under general anesthesia. We use the Wingspan stent system. The occlusion site was middle cerebral artery (MCA) in three patients, proximal internal carotid artery (ICA) in one patient and vertebrobasilar artery in three patients. Primary interventional successful revascularization was achieved in all cases. Four patients had no residual stenosis, and the other three had 20%, 30% and 40% residual stenosis (Table 1). All patients showed a clinical improvement after stent deployment. No peri-interventional events or neurologic complications occurred directly related to the technique. Patency rate was 100% at the last examination in six cases, one case had a pre-occlusive stenosis, requiring angioplasty. No patients died during the follow-up period, and 100% of patients showed good functional outcome at three months (modified Rankin Scale score ≤ 2). Although the SAMMPRIS study showed that aggressive medical management was superior to PTAS, our results suggest that intracranial stenting is safe and effective, probably due to an extraordinary selection of candidates and to an exquisite technique.