Intracranial Atheromatous Disease Research Articles

Stent Implantation in One Case of Atherosclerotic Vertebrobasilar Artery Stenosis and Literature

Intracranial Atheromatous Disease (ICAD) accumulates intracranial large vessels, which is one of the most common causes of ischemic stroke. The risk factors for ICAD include advanced age, smoking, hypertension, hypercholesterolemia and insulin-dependent diabetes mellitus [1-3].

Predictors of response to endovascular treatment of posterior circulation stroke

BackgroundEndovascular treatment is considered a reasonable approach for patients with acute posterior circulation stroke, but it remains uncertain which patients will benefit the most from it. ObjectiveTo find independent clinical and angiographic predictors of outcome after endovascular treatment for posterior circulation stroke. MethodsWe evaluated consecutive patients with acute posterior circulation stroke who underwent endovascular treatment in our comprehensive stroke center from January 2015 to December 2017. Good outcome was defined as a modified Rankin score of 0–3 at 90 days. Intracranial atheromatous disease was established on focal stenosis recorded during endovascular treatment. Associations were sought between a good outcome and clinical and angiographic factors. Adjusted logistic regression models were used to define independent outcome predictors. ResultsForty-seven consecutive patients were included: mean age 70.9 ± 12.1 years, median admission NIHSS score, 16 (IQR: 8–30). On univariate analysis, age (p = 0.01), smoking (p = 0.04), hypertension (p = 0.03), successful reperfusion (p = 0.04), presence of extracranial atherosclerosis (p = 0.02), and absence of atherosclerosis (p = 0.03) were significantly associated with a good outcome. On multivariate analysis, age <70 years (odds ratio = 6.20, 95%CI 1.52–25.47, p = 0.01) and absence of intracranial atherosclerosis (odds ratio = 6.45, 95% CI 1.09–38.24, p = 0.04) were independently associated with a good outcome. ConclusionsPretreatment determination of the presence or absence of intracranial atherosclerosis can aid management of posterior circulation stroke patients. The absence of intracranial atherosclerosis may have value as a positive selection criterion for endovascular treatment in future trials. The presence of intracranial atherosclerosis could be used as a selection tool in future studies investigating new treatment protocols for this population.

Intracranial Atheromatosis Disease (ICAD) and Stent Supported Angioplasty

Objectives: The symptomatic intracranial atheromatous disease has unfavorable prognosis. The endovascular treatment with percutaneous transluminal angioplasty (PTA) assisted with stent must be held in accordance with the efficacy, safety, complications and the risk of restenosis in the long term. Materials and methods: A study conducted between 1996 and 2008 includes 28 patients with stenosis located in the internal carotid artery (11), basilar artery (14) and vertebral artery (5). All cases were symptomatic even under anticoagulation treatment and stenosis&gt; 60% (average 83.5%). Results: There was a significant reduction in the degree of stenosis (less than50%) with average residual stenosis of 36.8%. There were two complications, with reperfusion hematoma (6.6%). In the longterm follow-up, a single case of reestenosis was found and no patient had a transient or permanent ischemic stroke. Conclusion: The treatment of intracranial stenosis with stentassisted angioplasty is effective, with low complication and stenosis rate in this series.

Intracranial Atheromatosis Disease (ICAD) and Stent Supported Angioplasty

Objectives: Symptomatic intracranial atheromatous disease has an unfavorable prognosis. The endovascular treatment with percutaneous transluminal angioplasty (PTA) stent assisted must be held in accordance with the efficacy, safety, complications and the risk of restenosis in the long term. Materials and methods: A study conducted between 1996 and 2008, includes 28 patients with 30 cases of stenosis located in the internal carotid artery (11), basilar artery (14) and vertebral artery (5). All cases were symptomatic even under anticoagulation treatment and the stenosis grade &gt; 60% (average 83.5%). Results: There was a significant reduction in the degree of stenosis (less than 50%), with an average residual stenosis of 36.8%. There were two complications, with reperfusion bruising (6.6%). In the long term monitoring, we found a single case of restenosis and no patient had a transient or permanent ischemic stroke. Conclusion: The treatment of intracranial stenosis with stentassisted angioplasty is effective, with a low complication rate and restenosis in this series.

Abstract T P87: Does an Increased Pulsatility of the Intracranial Blood Flow Spectral Waveform on Transcranial Doppler (TCD) Point to Peripheral Arterial Disease in Stroke Patients?

Background: Peripheral arterial disease (PAD) is common in patients with acute cerebral ischemia, yet little testing, if any, is done during in-hospital stay. The pulsatility index (PI) from the systolic and diastolic velocity measurements on TCD is routinely used in stroke patients to assess resistance to flow and thereby intracranial atheromatous disease. We sought to explore whether the PI can indirectly predict the presence of PAD in these patients. Methods: We prospectively evaluated consecutive patients with acute cerebral ischemia by TCD and ankle-brachial-index (ABI) measurements. Clinical variables were collected at baseline. On TCD, peak systolic, end-diastolic and mean flow velocities in both middle cerebral and basilar arteries were manually measured. According to a complete four-cardiac cycle sweep without arrhythmias, PI was automatically calculated for each of the 3 arteries and the average was used for analysis. Bilateral brachial, tibial and pedal systolic blood pressures were measured using a 4-MHz continuous-wave Doppler (average over two measurements). ABI 0.91 to 0.99 was considered as borderline, ABI &lt;=0.9 as abnormal and predictive of PAD. All examinations were done in supine position. Results: We enrolled a total of 53 patients: 68% ischemic stroke, 32% TIA, 60% Caucasians, 42% male, mean age 64±10 yrs, median NIHSS 4 (range 0-20). ABI was borderline or abnormal in 26/53 (49%) including 12/53 (23%) patients with ABIs consistent with PAD. Baseline characteristics were similar between patients with and without PAD. The mean PI did not differ among patients with and without PAD (0.92±0.08 vs. 1.01±0.04, p=0.24). The PI was not found to be an independent predictor of PAD (OR=0.21, 95% CI 0.01-3.64, p=0.285). Similarly, the PI did not predict ABI (p=0.96). PI strongly predicted history of arterial hypertension (OR=530.04, 95%CI 5.18-54215.57, p=0.008). Conclusions: Our findings do not suggest that the presence of PAD can be inferred from intracranial flow parameters predictive of atheromatous disease and risk factors such as hypertension among patients with acute cerebral ischemia. However, the high frequency of PAD in these patients warrants further investigation to facilitate routine and early detection of this disease.

Intracranial atheromatous disease treatment with the Wingspan stent system: Evaluation of clinical, procedural outcome and restenosis rate in a single-center series of 21 consecutive patients with acute and mid-term results

BackgroundIntracranial atherosclerosis may be the underlying pathology in up to 15% of ischemic strokes, but may account for about 40% of strokes in some populations. After an ischemic event determined by intracranial atherosclerosis, patients have a 12% annual risk of stroke recurrence, mostly during the first year. ObjectiveTo evaluate procedural safety, clinical outcome and restenosis rate of Wingspan stent placement. MethodsTwenty-one caucasoid patients were enrolled. Target patients were affected by high-grade, symptomatic, intracranial atherosclerotic lesions, were on antithrombotic therapy and at high stroke risk. All patients were treated with the Wingspan stent system. ResultsTechnical success resulted 100%, with all target lesions being reduced to <50%. No stroke or death were observed at 30.The mean percent of stenosis was reduced from a middle value of 84% to a middle value of 17% after stent placement. Medium follow-up was 19.5months (range 6–36months). No stroke or death occurred in any patient. None of the patients presented a <50% stent patency rate at follow-up. ConclusionsThe short-term results and follow up analysis provide evidence demonstrating the safety of the Wingspan system when used in high-risk patient population. Due to concerns regarding long-term stent patency and ischemic events occurrence emerged from clinical trials such as the SAMMPRIS, intracranial angioplasty and stent with the Wingspan system should be considered only for high risk patients in which it may be considered the only viable therapeutic option.

Postprocedural MR diffusion-weighted abnormalities after elective intracanial angioplasty and stenting with the Gateway balloon-Wingspan stent system

Purpose: To evalute postprocedural MR diffusion-weighted abnormalities after elective intracanial angioplasty and stenting with the Gateway balloon-Wingspan stent system (Boston Scientific), the first self-expanding stent system designed for the treatment of intracranial atheromatous disease.

WINGSPAN IN-STENT RESTENOSIS AND THROMBOSIS

Abstract OBJECTIVE Wingspan (Boston Scientific, Fremont, CA) is a self-expanding stent designed specifically for the treatment of symptomatic intracranial atheromatous disease. The current series reports the observed incidence of in-stent restenosis (ISR) and thrombosis on angiographic follow-up. METHODS A prospective, intent-to-treat registry of patients in whom the Wingspan stent system was used to treat symptomatic intracranial atheromatous disease was maintained at five participating institutions. Clinical and angiographic follow-up results were recorded. ISR was defined as stenosis greater than 50% within or immediately adjacent (within 5 mm) to the implanted stents and absolute luminal loss greater than 20%. RESULTS To date, follow-up imaging (average duration, 5.9 mo; range, 1.5–15.5 mo) is available for 84 lesions treated with the Wingspan stent (78 patients). Follow-up examinations consisted of 65 conventional angiograms, 17 computed tomographic angiograms, and two magnetic resonance angiograms. Of these lesions with follow-up, ISR was documented in 25 and complete thrombosis in four. Two of the 4 patients with stent thrombosis had lengthy lesions requiring more than one stent to bridge the diseased segment. ISR was more frequent (odds ratio, 4.7; 95% confidence intervals, 1.4–15.5) within the anterior circulation (42%) than the posterior circulation (13%). Of the 29 patients with ISR or thrombosis, eight were symptomatic (four with stroke, four with transient ischemic attack) and 15 were retreated. Of the retreatments, four were complicated by clinically silent in-stent dissections, two of which required the placement of a second stent. One was complicated by a postprocedural reperfusion hemorrhage. CONCLUSION The ISR rate with the Wingspan stent is higher in our series than previously reported, occurring in 29.7% of patients. ISR was more frequent within the anterior circulation than the posterior circulation. Although typically asymptomatic (76% of patients in our series), ISR can cause neurological symptoms and may require target vessel revascularization.

US Multicenter Experience With the Wingspan Stent System for the Treatment of Intracranial Atheromatous Disease: Periprocedural Results

To the Editor: We read with great interest the recent article published by Fiorella et al who report a multicenter experience with the use of the Wingspan stent system (Boston Scientific) for the treatment of intracranial atherosclerosis.1 This collaborative effort should be applauded, but we would advocate for closer scrutiny to future registry designs in order to enhance our understanding of treatment modalities being used. A total of 78 patients with 82 lesions were treated with a high technical success rate and a periprocedural complication rate (stroke or death) of 6.1%.1 We would like to bring attention to 3 issues that may help with further study in this area. The first is the patient selection …

A 7-YEAR EXPERIENCE WITH BALLOON-MOUNTED CORONARY STENTS FOR THE TREATMENT OF SYMPTOMATIC VERTEBROBASILAR INTRACRANIAL ATHEROMATOUS DISEASE

Balloon-mounted coronary stents (BMCS) have been adapted for use in the intracranial circulation for the treatment of symptomatic intracranial atheromatous disease (ICAD). We performed a retrospective analysis of our 7-year experience with these devices in an attempt to quantify the periprocedural risks and long-term outcomes in patients with symptomatic ICAD of the vertebrobasilar (VB) system treated with BMCS. A retrospective review of a prospectively maintained database was performed to determine the neurological and non-neurological periprocedural risks of BMCS treatment of ICAD. Patients were followed with serial transcranial Doppler (TCD) and, in some cases, angiographic imaging. The clinical status was determined based on clinic visits and by telephone interviews when possible. Over the 6-year period from March 1999 to May 2005, 44 patients (35 men, 9 women; average age, 64.8 yr) with 47 symptomatic atheromatous lesions of the VB system were treated with BMCS. In two patients, the BMSC could not be delivered across the target lesion. Treatment of the remaining 45 lesions was technically successful (95.7%). The periprocedural neurological morbidity and mortality was 26.1% (10 clinically evident strokes, 2 deaths). One additional patient experienced a periprocedural transient ischemic attack (TIA). Two patients died of non-neurological causes within 6 months (4.3%, myocardial infarction and cholecystitis). The average stenosis measured 82.5%, declining to 10.0% stenosis after BMCS. TCD examinations showed a preprocedural velocity of 127.7 cm/second (n = 43; standard deviation, 63.7 cm/s), which declined to 54.0 cm/s immediately after the procedure (n = 42; standard deviation, 22.7 cm/s). In patients with serial TCD evaluations, velocities were typically constant over years of follow-up (six patients with >5 yr of follow-up; average velocity, 52.2 cm/s). Angiographic follow-up was available for 11 patients. Three patients had stent occlusion (all symptomatic with TIAs), one patient had greater than 50% in-stent restenosis (ISR) (symptomatic with TIA) and seven had no significant (<50%) stenosis. The overall ISR/occlusion rate was 12.5% (4 out of 32 lesions with angiographic and/or TCD follow-up > 6 mo). Of the 42 patients who successfully underwent BMCS, clinical follow-up was available for 33 (78.6%, average follow-up period, 43.5 mo), three patients died before any follow-up could be performed, and seven were lost to follow-up. Of the patients with follow-up, five had recurrent vertebrobasilar ischemic symptoms (15%; four TIA, one stroke). Four out of five patients with recurrent symptoms had ISR or occlusion verified on conventional angiography. At the time of the last follow-up examination, seven patients of 44 patients who underwent attempted treatment were dead (modified Rankin Scale [mRS] score, 6); four had an mRS score of 3 to 5, 16 had an mRS score of 1 or 2, and 10 had an mRS score of 0. Percutaneous transluminal angioplasty and stenting using BMCS for the treatment of symptomatic VB ICAD can be carried out with high rates of technical success and excellent immediate angiographic results. However, the procedure carries with it a very high rate of periprocedural morbidity and mortality. Greater than 50% ISR or stent occlusion occurred in 12.5% of the patients and was associated with recurrent TIAs. In the absence of ISR/occlusion, patients who tolerated the initial procedure did well neurologically and did not typically experience recurrent ischemic symptoms.

US Multicenter Experience With the Wingspan Stent System for the Treatment of Intracranial Atheromatous Disease

The current report details our initial periprocedural experience with Wingspan (Boston Scientific/Target), the first self-expanding stent system designed for the treatment of intracranial atheromatous disease. All patients undergoing angioplasty and stenting with the Gateway balloon-Wingspan stent system were prospectively tracked. During a 9-month period, treatment with the stent system was attempted in 78 patients (average age, 63.6 years; 33 women) with 82 intracranial atheromatous lesions, of which 54 were > or =70% stenotic. Eighty-one of 82 lesions were successfully stented (98.8%) during the first treatment session. In 1 case, the stent could not be delivered across the lesion; the patient was treated solely with angioplasty and stented at a later date. Lesions treated involved the internal carotid (n=32; 8 petrous, 10 cavernous, 11 supraclinoid segment, 3 terminus), vertebral (n=14; V4 segment), basilar (n=14), and middle cerebral (n=22) arteries. Mean+/-SD pretreatment stenosis was 74.6+/-13.9%, improving to 43.5+/-18.1% after balloon angioplasty and to 27.2+/-16.7% after stent placement. Of the 82 lesions treated, there were 5 (6.1%) major periprocedural neurological complications, 4 of which ultimately led to patient death within 30 days of the procedure. Angioplasty and stenting for symptomatic intracranial atheromatous disease can be performed with the Gateway balloon-Wingspan stent system with a high rate of technical success and acceptable periprocedural morbidity. Our initial experience indicates that this procedure represents a viable treatment option for this patient population.