Intracranial Angioplasty Research Articles

Acute Anterior Circulation Stroke: Recanalization Using Clot Angioplasty

Different strategies have been employed to recanalize acutely occluded middle cerebral and internal carotid arteries (ICA) in the setting of acute stroke including intravenous and intra-arterial tPA. However, pharmaceutical thrombolysis alone, may not be effective in patients with a large amount of clot volume (complete M1, terminal internal carotid artery). We report our initial experience with endovascular clot disruption using a soft silicone balloon in addition to intravenous or intra-arterial thrombolysis with tPA. This is a retrospective review of nine patients with symptoms of acute stroke from clot in the middle cerebral or internal carotid territories who were treated with intracranial balloon angioplasty. All patients presented with symptoms of acute anterior circulation stroke less than six hours from onset. Patients in whom computed tomography (CT) angiography confirmed the presence of large vessel clot (terminal ICA, M1 or proximal M2) were included in the study. A CT perfusion was performed providing maps of cerebral blood volume, flow and mean transit time. If the patient presented less than three hours from onset then intravenous tissue plasminogen activator (tPA) was also administered. Intra-arterial tPA was delivered into the clot. If the volume of clot was judged to be significant by the treating neurointerventionist, then a limited trial of tPA was administered intra-arterially followed by balloon angioplasty of persistant clot. The time from imaging to vessel recanalization was recorded. Clinical outcomes were assessed using the modified Rankin scale and Barthel Index. Diagnostic CT perfusion studies were performed in 7 (78%), all of which showed a significant amount of salvageable tissue as judged by the treating neurointerventionist and neurologist. Recanalization (TIMI 2 or 3) was possible in 8 (89%). There were no cases of symptomatic intracranial hemorrhage and 2 (22%) asymptomatic hemorrhages. The average time from performance of the initial emergency CT to vessel recanalization was 2.1 hours with mean time from symptom onset to vessel recanalization of 4.1 hours. Five (56%) patients had good outcomes, 1 (11%) had mild and 3 (33%) had moderate to severe disability. Clot angioplasty can potentially shorten recanalization times in well-selected patients and can be an effective complimentary procedure in patients with tPA resistant clot. Angioplasty can be performed with a very low complication rate using the technique described and may be associated with good outcomes.

Intracranial Angioplasty and Stenting in the Awake Patient

Endovascular treatment for intracranial atherosclerosis is evolving, but complications remain an issue. Most interventions are performed under general anesthesia, preventing intraprocedural clinical evaluations. We describe our approach to intracranial angioplasty and stenting, using local rather than general anesthesia, and intraprocedural neurological assessment. We prospectively collected procedural and outcome information on all patients undergoing intracranial angioplasty and stenting. Patients underwent interventions under local anesthesia with mild intravenous sedation or analgesia only if needed. Intraoperative neurological evaluations were performed, and symptomatology was used to guide the interventional technique. Forty-eight arteries in 40 patients with a mean age of 65.2 years were treated. Thirty-two anterior and 16 posterior circulation segments were treated. Technical success was achieved in 100% of patients with reduction of the mean pretreatment stenosis from 85 +/- 8.6% to 7 +/- 10.1%. Stents were deployed in 40 segments; five patients were treated with drug-eluting stents. The cobalt-chromium coronary stents were the easiest to deliver. Thirty-seven patients were treated under local anesthesia and, of those, 61.4% experienced intraprocedural symptoms that led to some alteration of the interventional technique. Headache was the most common symptom, and, when persistent, it heralded the occurrence of subarachnoid hemorrhage. There were seven total neurological complications, but only five (10.5%) led to permanent morbidity (4 strokes) or mortality (1 death). Intracranial angioplasty and stenting can be successfully performed using coronary techniques and equipment including drug-eluting stents. Local anesthesia permits neurological evaluations and often leads to the adjustment of the interventional technique, potentially making the procedure safer.

Perforator stroke following intracranial stenting

Intracranial atherosclerosis accounts for 5–15% of ischemic strokes, depending on the population studied. Patients with recently symptomatic intracranial stenosis have high rates of stroke with medical therapy. In the Warfarin Aspirin Symptomatic Intracranial Disease (WASID) study, the rate of stroke was approximately 10% per year.1 The limitations of medical therapy coupled with technological advances have prompted consideration of intracranial stenting as treatment for intracranial stenoses in selected patients. A major concern of intracranial angioplasty with or without stent placement has been occlusion of the perforating vessels such as the lenticulostriate arteries during middle cerebral artery angioplasty. In this issue of Neurology , Jiang et al.2 report a large, single-center experience of intracranial stenting for symptomatic atherosclerotic disease. In this series, 181 lesions were treated with balloon-expandable stents. Perforator strokes occurred in only 3.0% of patients. Patients with preprocedural infarction of territories fed by perforators had postprocedural infarction (or transient worsening) at a rate significantly higher than patients without pretreatment perforator-region infarctions (8.2% vs 0.8%). These figures may …

Prospective study of symptomatic atherothrombotic intracranial stenoses

Symptomatic intracranial atherothrombotic stenoses (ICAS) are associated with high rates of cerebrovascular ischemic events. To conduct a prospective multicenter study to evaluate the natural history of ICAS and, in those patients refractory to medical treatment, the outcomes associated with intracranial angioplasty. Patients aged 18 to 80 were enrolled with symptoms attributed to a single ICAS of > or =50%. Optimal medical therapy of vascular risk factors and preventive antithrombotic therapy were at the discretion of the local investigator. Patients were eligible for intracranial angioplasty after experiencing recurrent stroke despite medical therapy. Neurologic and ultrasonographic examinations were performed at study inclusion, 3 months after enrollment, and every 6 months of follow-up thereafter, for 36 months. One hundred two patients were included, with a mean age of 63.3 +/- 10.4 years. Intracranial artery stenoses involved the vertebral artery in 22.5%, the basilar artery in 25.5%, the middle cerebral artery in 26.5%, and the internal carotid artery in 25.5%. In 27.4% of the patients, the stenoses had clinical hemodynamic characteristics. During a mean follow-up of 23.4 months, 38.2% of the patients had a cerebrovascular event: ischemic stroke in 13.7% and TIA in 24.5%. Among patients with a hemodynamically significant stenosis, 60.7% had a recurrent stroke or TIA in the territory of the stenotic artery; this association was significant in univariate analysis. Twenty-eight patients underwent an endovascular procedure with a neurologic periprocedural complication rate of 14.2%. The overall vascular death rate was 8.8%. Despite medical treatment, the 2-year recurrence rate of ischemic events in the territory of the stenotic artery was 38.2%. Cardiovascular events occurred in 18.6% of patients. Clinically significant hemodynamic stenoses were associated with stroke recurrence and may help identify a high risk subset of patients.

Intracranial angioplasty and stenting for cerebral atherosclerosis: new treatments for stroke are needed!

Intracranial atherosclerosis is a common cause of stroke. Recent technological developments offer improved methods for endovascular revascularization of symptomatic and asymptomatic cerebral artery stenosis. Identification of appropriate patients remains a diagnostic challenge, and our knowledge about the natural history of the disease remains limited. At this time, patients with significant intracranial stenosis should receive counseling on the benefits and risks of revascularization therapy. Ultimately, determination of which patients should undergo revascularization procedures will require carefully planned, randomized clinical trials.

Angioplasty for Symptomatic Intracranial Stenosis

Medical treatment of symptomatic intracranial stenosis carries a high risk of stroke. This study was done to evaluate the clinical and angiographic outcomes after intracranial angioplasty for this disease. A total of 120 patients with 124 intracranial stenoses were treated by primary angioplasty. All patients had neurologic symptoms (stroke or transient ischemic attack) attributable to intracranial stenoses > or =50%. Angiograms were evaluated before and after angioplasty for the degree of stenosis. Pretreatment stenoses varied from 50% to 95% (mean 82.2+/-10.2). Post-treatment stenoses varied from 0% to 90% (mean 36.0+/-20.1). There were 3 strokes and 4 deaths (all neurological) within 30 days of the procedure, giving a combined periprocedural stroke and death rate of 5.8%. A total of 116 patients (96.7%) were available for a mean follow-up time of 42.3 months. There were 6 patients who had a stroke in the territory of treatment and 5 additional patients with stroke in other territories. Ten deaths occurred during the follow-up period, none of which were neurological. Including the periprocedural stroke and deaths, this yielded an annual stroke rate of 3.2% in the territory of treatment and a 4.4% annual rate for all strokes. Intracranial angioplasty can be performed with a high degree of technical success and a low risk of complications. Long-term clinical follow-up of intracranial angioplasty patients demonstrates a risk of future strokes that compares favorably to patients receiving medical therapy.

Pathological Result of Basilar Artery Stenosis Rapidly Progressed and Ruptured with Stent-Assisted Angioplasty

Intracranial artery angioplasty utilizing coronary stent is now widely tried as an effective alternative for treating intracranial artery stenosis, and several successful result of stent-assisted angioplasty for intracranial artery were reported. Authors experienced a case of the basilar artery stenosis, in which re-stenosis progressed rapidly after simple balloon angioplasty and resulted in vessel rupture during stent-assisted angioplasty. Pathological result achieved by autopsy showed vessel wall disruption at the stent and multiple interruptions and defect of elastic laminar.

An evaluation of immediate sheath removal and use of the Angio-Seal vascular closure device in neuroradiological interventions

We set out to assess the effect of using an arteriotomy closure device in patients at high risk of access site complications. One-hundred nineteen patients with femoral artery access were prospectively included in five centers in France (56 males, 63 females, age range 20-84 years). The neurointerventional procedures were embolization of intracranial aneurysm (71.4%), carotid angioplasty (11.8%), cerebral angioplasty (1.7%), thrombolysis (0.8%), and other procedures (14.3%). Sheaths were removed and the closure device deployed immediately postprocedure. One patient developed a false aneurysm, and one developed a small hematoma. Neither required treatment. Postdevice deployment bleeding was experienced in three patients (2.5%), requiring minimal management. There were no major complications. Three patients died of causes unrelated to the vessel closure. Patient comfort was 2.2 on a scale of 1 (none) to 10 (severe). The results showed that immediate sheath removal followed by use of the closure device is safe in patients undergoing neurointerventional procedures and offers a low level of patient discomfort. In selected patients, early hospital discharge was possible.

Intracranial Angioplasty & Stenting For Cerebral Atherosclerosis: A Position Statement of the American Society of Interventional and Therapeutic Neuroradiology, Society of Interventional Radiology, and the American Society of Neuroradiology

STROKE is the third leading cause of death and the leading cause of adult disability in North America, Europe, and Asia ( 1 Taylor TN Davis PH Torner JC et al. Lifetime cost of stroke in the United States. Stroke. 1996; 27: 1459-1466 Crossref PubMed Scopus (677) Google Scholar , 2 Heart Disease and Stroke Statistics—2004 Update. American Heart Association, Dallas2004 Google Scholar ). Intracranial cerebral atherosclerosis accounts for approximately 8 to 10% of all ischemic strokes with a higher reported incidence in the Asian, African, and Hispanic descent populations ( 3 Caplan LR Gorelick PB Hier DB Race, sex and occlusive cerebrovascular disease: A review. Stroke. 1986; 17: 648-655 Crossref PubMed Scopus (480) Google Scholar , 4 Craig DR Meguro K Watridge C et al. Intracranial internal carotid artery stenosis. Stroke. 1982; 13: 825-828 Crossref PubMed Scopus (167) Google Scholar , 5 Wityk RJ Lehman D Klag M et al. Race and sex differences in the distribution of cerebral atherosclerosis. Stroke. 1996; 27: 1974-1980 Crossref PubMed Scopus (444) Google Scholar ). Risk factors include insulin-dependent diabetes mellitus, hypercholesterolemia, hypertension, and cigarette smoking ( 6 Ingall TJ Homer D Baker Jr, HL et al. Predictors of intracranial carotid artery atherosclerosis. Duration of cigarette smoking and hypertension are more powerful than serum lipid levels. Arch Neurol. 1991; 48: 687-691 Crossref PubMed Scopus (84) Google Scholar , 7 Inzitari D Hachinski VC Taylor DW Barnett HJ Racial differences in the anterior circulation in cerebrovascular disease. How much can be explained by risk factors? Arch Neurol. 1990; 47: 1080-1084 Google Scholar , 8 Fisher CM Cerebral arterial occlusion–remarks on pathology, pathophysiology, and diagnosis. Clin Neurosurg. 1963; 9: 88-105 PubMed Google Scholar ). In the United States, it is estimated that 40,000 to 60,000 new strokes per year are due to intracranial cerebral atherosclerosis.

Recent advances in endoluminal revascularization for intracranial atherosclerotic disease

More than 750,000 strokes occur annually in the United States. Of these, 8–10% are due to intracranial atherosclerosis. Less than 50% of patients with strokes from intracranial atherosclerosis will have a transient ischemic attack. For those patients with symptomatic intracranial atherosclerosis, the prognosis is poor; and the recent Warfarin-Aspirin Symptomatic Intracranial Stenosis (WASID) trial results have demonstrated the high risk of warfarin without clear benefit. Intracranial angioplasty and stenting is emerging as a viable and effective treatment alternative for patients with symptomatic intracranial stenosis. Advances in stent design, endovascular wires, and catheters and balloons are allowing endovascular surgeons to safely treat intracranial atherosclerosis. Wider clinical experience has led to refinement of patient selection and endoluminal techniques. Drug eluting-stents have the promise of decreasing the risk of restenosis. In this review, the most recent clinical, laboratory, and technical details for the treatment of intracranial angioplasty and stenting are discussed.

Symptomatic Middle Cerebral Artery Stenosis Treated with Intracranial Angioplasty: Experience in 32 Patients

To retrospectively review the outcome after angioplasty in patients with symptomatic, high-grade middle cerebral artery (MCA) stenosis refractory to medical therapy. Institutional review board approval to perform angioplasty procedures for MCA stenosis was obtained, and written informed consent was obtained from each patient or the patient's family. Institutional review board approval was also obtained for the retrospective review of patients' data. The institutional review board waived the need for informed consent for this retrospective analysis.Thirty-two consecutive patients (18 men, 14 women; median age, 55 years) with symptomatic MCA stenosis greater than 70% underwent angioplasty between June 1994 and July 2003. The indication for angioplasty was recurrent transient ischemic attack (TIA) refractory to antithrombotic therapy in 24 patients and acute ischemic stroke in eight. Patient records were retrospectively reviewed for angiographic findings, periprocedural complications, and follow-up data. Angioplasty reduced the degree of stenosis to less than 50% in 29 of 32 patients (91%). There were two major complications during angioplasty: acute occlusion of the treated MCA and vascular rupture that resulted in death. Thus, the risk of disabling stroke or death was 6% (two of 32 patients), and the mortality rate was 3% (one of 32 patients). The rate of periprocedural TIA was 19% (six of 32 patients). Five patients had asymptomatic intimal dissection. During the follow-up period, which ranged from 5 to 92 months (median, 20 months), TIA occurred in one patient in whom the results of angioplasty were suboptimal. The remaining 29 patients did not experience further ischemic events attributable to the treated MCA stenosis during the follow-up period. Asymptomatic restenosis occurred in one of five patients in whom data from follow-up angiography were available. MCA angioplasty resulted in a low recurrence rate of ischemic symptoms during long-term follow-up.

Extending Reperfusion Therapy for Acute Ischemic Stroke

Reperfusion is the most beneficial of all therapeutic strategies for acute ischemic stroke. However, the standard cerebral reperfusion treatment of the first decade of the reperfusion era, noncontrast computed tomography (CT)-guided, < or =3 hours, intravenous tissue plasminogen activator, has many limitations. This review surveys emerging strategies that have the potential to extend cerebral reperfusion therapy to larger numbers of patients. Innovative intravenous pharmacological reperfusion strategies include novel fibrinolytic agents (tenecteplase, reteplase, desmetolplase, plasmin, and microplasmin), glycoprotein (GP) IIb/IIIa antagonists with platelet disaggregating effects (abciximab and tirofiban), combination therapies to improve efficacy of clot lysis (fibrinolytics and GP IIb/IIIa agents, and fibrinolytics and direct thrombin inhibitors), increase the time window for clot lysis (fibrinolytics and neuroprotectants), and reduce the frequency of hemorrhagic complications (fibrinolytics and vasoprotectants), and externally applied ultrasound to enhance enzymatic fibrinolysis. Promising intra-arterial pharmacological reperfusion approaches include novel fibrinolytic agents, combined intravenous and intra-arterial fibrinolysis, and combined fibrinolytics and GP IIb/IIIa agents. Emerging endovascular mechanical reperfusion strategies include intra-arterial thrombectomy (clot retrieval devices and suction thrombectomy devices), mechanical disruption (micro-guidewire passage, laser photoacoustic emulsification, and primary intracranial angioplasty), and augmented fibrinolysis by endovascular ultrasound. Multimodal imaging, with magnetic resonance (MR) or CT, can rapidly assess infarct core, penumbra, site of vessel occlusion, and tissue hemorrhagic propensity, enabling improved selection of patients for reperfusion therapy beyond any arbitrary fixed time window. Therapeutic reperfusion is emerging as a treatment strategy of remarkable power and scope for rescuing patients experiencing acute brain ischemia, applicable within and beyond the 3-hour time window.

Assessment of changes in cerebral circulation time due to vasospasm in a specific arterial territory: effect of angioplasty

This study demonstrates that in experienced hands, intracranial angioplasty is a feasible and safe option in a selected group of patients with severe (>50% stenosis) symptomatic vasospasm following subarachnoid hemorrhage. Cerebral circulation time is a surrogate parameter closely linked to cerebral perfusion. The study presented shows that not only stenosis but also changes in circulation time are obtained by angioplasty. Twenty angioplasties of one or two vessel segments were performed over 2 years in 18 consecutive patients with posthemorrhagic vasospasm fulfilling criteria for invasive treatment. In all patients, degree of stenosis and circulation time could be reduced by angioplasty. Clinical results were ranked according to Glasgow Outcome Scale. Imaging after 15/20 angioplasties showed no additional infarction. In 4/20 cases, CT showed demarcation of infarction after angioplasty. In 1/20 cases of posterior circulation angioplasty, CT is not sensitive enough to exclude smaller infarctions. Imaging and clinical outcome reveal a definite benefit.

Training, competency, and credentialing standards for diagnostic cervicocerebral angiography, carotid stenting, and cerebrovascular intervention

Appropriate and adequate cognitive and technical training, proficiency and experience are essential for the safe performance of procedures that confer significant risk to patient well-being. This principle is the foundation of all medical education and is especially important when considering the cerebral vasculature, for which stroke is a defined risk for every endovascular procedure. Despite recent advances in noninvasive diagnostic neuroimaging, diagnostic cervicocerebral angiography remains the cornerstone and “gold standard” for the evaluation and treatment of patients with cerebrovascular disease.1 In addition to a high level of technical expertise, performance and interpretation of diagnostic cervicocerebral angiography requires in-depth cognitive knowledge of related neurological pathophysiology, neurovascular anatomy and pathology, and an understanding of the full range of neurodiagnostic possibilities. Expert diagnostic cervicocerebral angiography is the foundation for safe and successful cervicocerebral endovascular intervention, including carotid artery angioplasty and stenting for atherosclerosis, interventional stroke therapy, intracranial angioplasty and stenting, and embolization of cerebral aneurysms, epistaxis and vascular malformations. All of these procedures are increasing in volume and complexity with recent technological advances that further mandate the need for adequate cognitive acumen and technical skills. To ensure proper outcomes, formal neuroscience training, adequate procedural training and sufficient experience are all essential for competency in diagnostic cervicocerebral angiography and interventional procedures, including carotid stenting. These concepts have been delineated in training requirements by the Accreditation Council for Graduate Medical Education (ACGME) and by previously published official society statements. The purpose of this document is to define the minimum training and experience necessary to provide adequate quality of patient care for extracranial cerebrovascular interventions, particularly carotid artery stenting. Hospital credentialing is the mechanism by which competence is ensured. ### Risks of diagnostic cervicocerebral angiography. Stroke is recognized as the most disabling and costly of all medical conditions.2 Stroke is also the most feared of all iatrogenic medical and procedural …

Outcome of Endovascular Treatment in Symptomatic Intracranial Vascular Stenosis

ObjectiveThe outcome evaluation for the revascularization of intracranial vascular stenoses has not been fully described due to the highly technical nature of the procedure. We report here on the early and late clinical outcomes of angioplasty and/or stenting of symptomatic severe intracranial vascular stenoses at a single institute.Materials and MethodsSince 1995, we have treated 35 patients with symptomatic intracranial vascular stenosis (more than 70% stenosis, mean stenosis: 78.6% ± 6.2%). Angioplasty (n = 19) was performed for the horizontal segment of the middle cerebral artery (M1) (n = 16) and the basilar artery (BA) (n = 1), the intradural vertebral artery (VA) (n = 1), and the cavernous internal carotid artery (ICA) (n = 1). Stenting (n = 16) was performed for the cavernous or petrous ICAs (n = 9), the intradural VA (n = 3), BA (n = 2), and M1 (n = 2) artery. We assessed the angiographic success (defined as residual stenosis < 50%) rate, the periprocedural complications during the 30-day periprocedural period, the symptomatic recurrence and restenosis during a mean 22-month follow-up (FU) period. The Kaplan-Meier estimate of the cumulative event-free rate of the major cerebrovascular events, i.e. death, stroke or restenosis, was also done.ResultsAngiographic success was achieved in 97% of our patients (34/35). There were four procedure-related complications (11%) including a death and a minor stroke. During the mean 22-month FU, the asymptomatic restenosis rate was 9% and the symptomatic restenosis rate was 6% in the target lesion and 9% in all the vascular territories. The Kaplan-Meier estimate was 70.6% (95% confidence interval = 46.5-94.7) after 33 months of FU.ConclusionIn addition to a high angiographic success rate and an acceptable periprocedural complication rate, intracranial angioplasty and/or stenting revealed a relatively low symptomatic recurrence rate. Hemorrhage is a rare, but the physician must aware that potentially fatal periprocedural complications can occur.

1290 Intracranial angioplasty for treatment of middle cerebral artery stenosis

1290 Intracranial angioplasty for treatment of middle cerebral artery stenosis

Postpartum cerebral angiopathy: atypical features and treatment with intracranial balloon angioplasty

Postpartum cerebral angiopathy (PCA) is an uncommon cause of ischemic and hemorrhagic stroke in young women. It is usually clinically benign and not relapsing. We describe a patient with nonhemorrhagic PCA who had an atypical progressive neurological deficit from bilateral hemisphere watershed ischemia despite treatment with aggressive medical therapy and intracranial balloon angioplasty.

Intracranial Revascularization Therapy: Angioplasty and Stenting.

Depending on the population studied, intracranial atherosclerosis accounts for 10% to 29% of ischemic brain events. A significant number of patients with intracranial atherosclerosis continue to suffer from repeated strokes or transient ischemic attacks despite optimal medical management. In selected patients, intracranial angioplasty with or without stenting is a promising treatment option. Patient selection, careful periprocedural medical management, and a highly skilled neuroendovascular interventionalist are required in order to perform the procedure with an acceptable risk.

Small vessel stents for intracranial angioplasty: in vitro evaluation of in-stent stenoses using CT angiography

Our aim was to determine whether CT angiography is suitable for the evaluation of in-stent restenoses in small vessel stents for intracranial angioplasty. Therefore, we simulated stenoses with degrees of 25, 50, 75 and 90% in a total of 12 stents with different designs (MEDTRONIC AVE; ABBOT BioDivYsio, GUIDANT Neurolink, TERUMO Tsunami, COOK V-Flex Plus) and sizes (3.0 mm, 4.0 mm). For each stenosis, the apparent stenotic degree (ASD) was measured by CT angiography. Subjective (viewing at the CT images) and objective (acquisition of a density profile) evaluations were made after the stents were filled with a solution of 0.9% NaCl and with a diluted contrast medium. It was not possible to visualize the patent lumen in any of the stenotic stent segments by viewing at the CT images. After objective evaluation, the degree of the stenoses was generally overestimated. In the group with the 3.0-mm stents, ASD ranged from 73.6 to 100% in 25% degree stenoses. With the exception of one stent, stenoses with a degree of more than 25% appeared as vessel obstruction (ASD = 100%) in the 3.0-mm group. In the 4.0-mm group, the mean ASD was 60% for 25% degree stenoses, 76% for 50% degree stenoses, 91% for 75% degree stenoses and 96% for 95% degree stenoses. The minimum diameter of stents for differentiation between in-stent restenosis and vessel occlusion using CT angiography is 4.0 mm. In CT angiography, the degrees of in-stent stenoses are generally overestimated. The evaluation of in-stent restenoses only seems to be possible when CT angiographic images before and after contrast application are evaluated objectively by density profiles.

頭蓋内血行再建術（Ｓｔｅｎｔ．ＰＴＡ）経皮的脳血管形成術の現状と可能性

Percutaneous cerebral balloon angioplasty (PTCBA) has been developed. Procedural success and risks or long-term benefits must be anticipated before PTCBA for intracranial atherosclerotic lesions. To estimate them, you have to know angiographic lesions' characteristics appropriate to PTCBA.1) Intracranial balloon angioplasty Forty-two clinically symptomatic patients with 42 hemodynamical1y significant intracranial lesions (% diameter stenosis>70) underwent initial and elective PTCBA between January 1992 and May 1996. Before the angioplasty treatment, the patients were classified into three groups according to the angiographic lesions' characteristics summarized as follows : type A, a short and concentric stenosis ; type B, a tubular lesion, or an extreme eccentric lesion ; and type C, a diffuse lesion. They were followed after PTCBA from one month to six years to compare between the three groups. Primary end points were death, stroke, or bypass surgery. The clinical success rates in type A, B and C groups were 92%, 86% and 33% (p = 0.0032), respectively. Cumulative risks of fatal or nonfatal ischemic stroke/ipsilateral bypass surgery in type A, B and C groups were 8%, 26% and 87% (p<0.0001), respectively. The cumulative risk of 8% in type A group patients appeared to be smaller than in historical studies. PTCBA for intracranial simple (type A) lesions produces a favorable clinical outcome for symptomatic patients.2) Cerebral artery stentingBetween March 1998 and November 1998, 12 intracranial atherosclerotic lesions (type B or C) of the vertebrobasilar artery and the distal internal carotid artery in 10 patients were treated with stenting treatment using flexible balloon-expandable coronary stents. Ten lesions in 8 patients were sufficiently dilated with stents. No complications occurred during or after the procedure and no neurological ischemic events or restenosis have occurred during follow-up since successful CAS. Cerebral angioplasty and stenting may be a safe and effective means to resolve an intracranial atherosclerotic type B or C lesions and yield a favorable arteriographic and clinical outcome. Cerebral artery stenting can increase success rate and reduce risks for lesions inappropriate to balloon angioplasty.3) PTCBA for chronic total occlusionChronic total occlusions younger than 3 months, shorter than 10 mm, are classified into type B lesions. They can be opened.4) PTCBA and stenting for acute stroke patientsClinical outcome of acute stroke patients presenting serious neurological symptoms due to total occlusions of the vertebro-basilar artery (VBA) is poor and direct percutaneous transluminal cerebral balloon angioplasty (PTCBA) and/or cerebral artery stenting (CAS) for recanalization of the VBA is promising.In conclusion, PTCBA and stenting for ntracranial arteries is feasible and safe, and good clinical outcome following PTCBA and/or CAS for ntracranial arteries is expected.