Intracranial Balloon Angioplasty Research Articles

Strain-induced collagen denaturation is rate dependent in failure of cerebral arteries.

While soft tissues are commonly damaged by mechanical loading, the manifestation of this damage at the microstructural level is not fully understood. Specifically, while rate-induced stiffening has been previously observed in cerebral arteries, associated changes in microstructural damage patterns following high-rate loading are largely undefined. In this study, we stretched porcine middle cerebral arteries to failure at 0.01 and >150 s-1, both axially and circumferentially, followed by probing for denatured tropocollagen using collagen hybridizing peptide (CHP). We found that collagen fibrils aligned with the loading direction experienced less denaturation following failure tests at high than low rates. Others have demonstrated similar rate dependence in tropocollagen denaturation during soft tissue failure, but this is the first study to quantify this behavior using CHP and to report it for cerebral arteries. These findings may have significant implications for traumatic brain injury and intracranial balloon angioplasty. We additionally observed possible tropocollagen denaturation in vessel layers primarily composed of fibrils transversely aligned to the loading axis. To our knowledge, this is the first observation of collagen denaturation due to transverse loading, but further research is needed to confirm this finding. STATEMENT OF SIGNIFICANCE: Previous work shows that collagen hybridizing peptide (CHP) can be used to identify collagen molecule unfolding and denaturation in mechanically overloaded soft tissues, including the cerebral arteries. But experiments have not explored collagen damage at rates relevant to traumatic brain injury. In this work, we quantified collagen damage in cerebral arteries stretched to failure at both high and low rates. We found that the collagen molecule is less damaged at high than at low rates, suggesting that damage mechanisms of either the collagen molecule or other elements of the collagen superstructure are rate dependent. This work implies that arteries failed at high rates, such as in traumatic brain injury, will have different molecular-level damage patterns than arteries failed at low rates. Consequently, improved understanding of damage characteristics may be expanded in the future to better inform clinically relevant cases of collagen damage such as angioplasty and injury healing.

Rescue Intracranial Balloon Angioplasty with or without Stent Placement in Acute Strokes with Intracranial Atherosclerotic Disease

Optimal management of acute ischemic stroke (AIS) secondary to intracranial atherosclerotic disease (ICAD) refractory to conventional mechanical thrombectomy remains unclear. We aimed to investigate the clinical outcome of patients undergoing rescue intracranial balloon angioplasty with or without stent placement in the setting of AIS in our institution. This is a retrospective single-arm observational study to evaluate the efficacy and safety of rescue balloon angioplasty with or without stent placement in emergent large vessel occlusion (EVLO) strokes with underlying ICAD. We included all patients undergoing such rescue intervention within 24hours of AIS presentation with EVLO between 2017 and 2021. We further evaluated stent or vessel reocclusion. Of 20 patients undergoing rescue intervention, 3 cases achieved adequate recanalization of artery using balloon angioplasty alone. Seventeen patients required stent placement. Fourteen (70%) procedures resulted in National Institutes of Health Stroke Scale improvement in postprocedure and upon discharge. Among 6 (30%) procedures with worsening neurological measures, 3 had reoccluded stent 24-48hours after procedure, 2 had symptomatic hemorrhagic conversion, and 1 had perforator occlusion. Nine patients (45%) had favorable functional outcome (modified Rankin Scale ≤2) at discharge, unchanged or improved at 3-month follow-up. The median modified Rankin Scale score was 4 (Interquartile range: 1.75-4) at discharge, improving to 3 (Interquartile range: 0-4) at 3-month follow-up. Two patients (10%) died during hospital stay. Rescue angioplasty with or without stenting can lead to significant clinical improvement in patients with ICAD presenting with ELVO and refractory to thrombectomy; however, this procedure is associated with a high rate of morbidity in acute setting.

Abstract TP156: Balloon Angioplasty For Symptomatic Intracranial Artery Stenosis

Background: Intracranial atherosclerotic disease is the most common cause of ischemical cerebrovascular events. The risk of stroke recurrence or death of ICAD patients remains very high. Previous nonrandomized studies have showed that stroke and death rate of angioplasty for ICAD patients with severe stenosis of intracranial artery is lower than that of aggressive medication. Methods: The trial is a multicenter, prospective, randomized, parallel controlled study, with the primary idea to determine whether intracranial balloon angioplasty combined with aggressive medical therapy is superior to aggressive medical treatment alone in patients with cerebral ischemic stroke due to neurovascular stenosis (≥70%) for preventing the primary endpoint: 1.Stroke (including hemorrhagic and ischemic stroke) and all-cause mortality within 30 days after enrollment. 2. Ischemic stroke attributed to the offending vessel from 31 days to 12 months after enrollment. Aggressive medical treatment is identical in both arms, which consists of aspirin 100 mg per day during the entire follow-up and clopidogrel 75mg per day for the first 90 days after enrollment. Management of primary risk factors (blood pressure 130-140 / 90-100 mmHg and LDL < 70 mg/dl) and secondary risk factors is also required in both arms. Result: We postulate that balloon angioplasty with submaximal balloon is safe enough and effective enough, not increasing ischemic/hemorrhagic stroke rate within 30 days. Moreover, we expect primary angioplasty combined with optimal medical management can reduce a relatively 50% risk of recurrent ischemic stroke due to attributed artery with estimated rate of 15% at 1 year in the control group and 7% in the treatment group in 1-year follow-up. Conclusion: BASIS is the first randomized trial comparing primary angioplasty combined with optimal medical regime with optimal medical regime alone. With enough evidence, we believe the risk of major hemorrhage can also be maximal minimized by using submaximal balloon during the procedure and probably shorter-term dual antiplatelet treatment after procedure. With the result of BASIS, we hope primary angioplasty can serve as an independent or alternative treatment in patients with severe intracranial atherosclerotic stenosis

Technique for Treatment of a Symptomatic Intracranial Stenosis With Balloon Angioplasty and Wingspan Stent Placement: 3-Dimensional Operative Video.

Intracranial angioplasty and stenting is an increasingly common modality to treat intracranial atherosclerosis, which accounts for 80 000 strokes annually. Early trials showed there to be a high complication rate1,2 associated with stenting but with improved technique this complication rate has dramatically decreased.3 The following video details the procedure of intracranial balloon angioplasty and stenting for a high-grade stenosis of the right internal carotid artery. The risks and benefits of the procedure were discussed with the patient and they consented to the procedure.

Augmented reality enhanced tele-proctoring platform to intraoperatively support a neuro-endovascular surgery fellow.

Remote tele-proctoring has been conducted in neuro-endovascular surgery, however, evidence to support its use in the fellowship training is limited. We demonstrate a novel augmented reality tele-proctoring platform to enable a remote attending to guide a fellow. A consecutive series of neuro-endovascular cases were performed by a neuro-endovascular fellow with remote guidance from an attending surgeon. The fellow and attending were connected using a commercially available cloud-based platform designed to capture and stream up to four live video feeds from a clinical environment to a remote user. In this setting, two video streams were obtained directly from the anteroposterior and lateral cameras on the biplane. Additional video of the operator from a telescopic camera was streamed live to the remote attending surgeon. The attending could provide immediate vocal feedback and also deploy the platform's augmented reality tools to communicate with the fellow in the angiography suite. A total of 10 cases were performed on eight patients utilizing the cloud-based tele-proctoring platform to facilitate instruction. The series included diagnostic angiograms and interventions such as intracranial balloon angioplasty, carotid stenting, and intracranial stenting. All cases were a technical success. No complications or deaths occurred. When compared to similar cohort of 10 cases prior to these which utilized a traditional instruction paradigm; we saw no differences in contrast use (p = 0.38), fluoroscopy time (p = 0.85), or technical success. This study demonstrates successful use of an augmented reality tele-proctoring platform to guide a neuro-endovascular fellow through complex neuro-interventional procedures from a remote setting.

Risk of mechanical thrombectomy recanalization failure: Intraoperative nuances and the role of intracranial atherosclerotic disease

ObjectiveTo present intraoperative observations that when recognized may facilitate the identification of patients at high risk of MT recanalization failure. We illustrate 4 cases of successful recanalization via rescue treatment with balloon angioplasty and/or stenting when such observations were noted. We also discuss the role of intracranial atherosclerotic disease in recanalization failure. Patients and methodsWe conducted a retrospective review of a prospectively maintained database for 450 stroke patients and identified 122 patients who underwent MT that failed to achieve recanalization. Operative notes were reviewed, and intraoperative nuances were discussed amongst neurointerventionalists. ResultsIntraoperative observations that may suggest a high risk of MT recanalization failure include resistance to microwire advancement, significant resistance to microcatheter advancement, temporary antegrade flow upon stent retriever (SR) deployment, temporary retrograde flow upon SR deployment with simultaneous aspiration, restricted SR expansion (“pinched device”), moderate resistance to total impedance of SR removal causing vessel/SR stretch on angiographic roadmap, and minimal recanalization after ≥3 device passes. ConclusionIntraoperative observations may facilitate early recognition of patients at high risk of MT recanalization failure. We suggest considering rescue treatment when such observations are noted to avoid prolonged procedure times, futile reperfusion, and reocclusion post-MT. Intracranial balloon angioplasty and/or stenting may be a safe and effective treatment in this patient subgroup. Stent placement may be considered depending on the patient’s antiplatelet status, angioplasty success, and concern for intracranial hemorrhage. Further studies amongst larger patient cohorts are needed.

Preliminary Experience With Proximal Flow Reversal During Intracranial Balloon Angioplasty and Stenting for Symptomatic, Severe Intracranial Stenosis

Abstract INTRODUCTION The frequency of balloon-angioplasty and stenting for symptomatic intracranial stenosis was drastically reduced after publication of the negative SAMMPRIS trial. In part, this was due to a higher than expected periprocedural complication rate (14.7% 30-d stroke or death) compared to maximal medical therapy (5.8%). Although the cause of periprocedural stroke was not defined, intraprocedural artery-to-artery embolism is a likely contributor. The Silk Road ENROUTE Transcarotid Neuroprotection System (TCNS) was designed as an alternative revascularization strategy for carotid bifurcation disease. It provides direct transcarotid access and proximal protection through flow reversal. We adapted this system as a proximal protection strategy for balloon angioplasty and stenting of severe, symptomatic intracranial stenosis. METHODS From May-2017 to May-2019, 7 patients underwent intracranial balloon angioplasty and stenting for symptomatic intracranial stenosis using the TCNS. Baseline demographics, comorbidities, procedure-related parameters, and outcomes were assessed. RESULTS A total of 7 patients (mean age 63, SEM 4.7 yr, 57% female) with severe (84% +/− 5%) supraclinoid internal carotid artery (ICA) and/or M1 stenosis presented with recurrent strokes (86% left sided) despite dual antiplatelet therapy (DAPT). Angiographically, cessation or reversal of flow was seen in the supraclinoid ICA in all patients, with confirmation by transcranial doppler in selected cases, after the institution of flow reversal by the TCNS. A noncompliant balloon was used to perform submaximal angioplasty, followed by stenting with intracranial stents. All procedures were technically successful with no evidence of periprocedural thromboembolic complications. Follow-up ranged from 6 to 12 mo. One patient suffered a fatal reperfusion hemorrhage on POD 3. One patient suffered from a minor recurrent stroke at 7 mo (after the cessation of DAPT) and was restarted on DAPT. CONCLUSION Traditional methods of intracranial balloon angioplasty and stenting suffer from high periprocedural ischemic stroke rates. TCNS can be adapted to provide a means of proximal protection during the treatment of these high-risk lesions. This procedural innovation warrants further investigation.

Abstract TP25: Features of Patients With Stroke Receiving Intracranial Balloon Angioplasty for Secondary Prevention in Comparison to Rescue Recanalization

Background: Susceptibility to intracranial atherosclerosis is a unique feature of stroke in Asian patients. Intracranial percutaneous transluminal balloon angioplasty/stenting (IC-PTAS) is an important therapy for secondary prevention and rescue in such patients. Objective: The purpose of this study is to clarify features of Japanese patients with stroke receiving IC-PTAS for secondary prevention or for rescue recanalization. Methods: Medical records of 116 consecutive stroke patients treated with IC-PTAS at our hospital from April 2006 to May 2018 were retrospectively reviewed. The patients were divided into secondary prevention (P) and rescue (R) groups based on the purpose of IC-PTAS. Backgrounds, procedures, andtechnical and clinical outcomes were compared between the groups. Results: In groups P (n=60, male=40) and R (n=56, male=35), the mean ages were 70 and 72 years, the median times from ischemic events to IC-PTAS were 21 and 0.5 days, the mean stenotic ratios were 84.6% and 97.9%, the number of cases with morphology suitable for IC-PTAS (modified Mori class A or B1) were 35 and 8, and the distributions of treated vessels (extradural ICA, intradural ICA, MCA, BA, VA, others) were 31, 6, 11, 5, 5, 2, and 4, 14, 24, 6, 5, 3, respectively. In groups P and R, stents were deployed in 26 (43%) and 23 (41%) cases, technical success was achieved in 60 (100%) and 48 (86%) cases, the mean residual stenotic ratios were 27.6% and 40.3%, and there were major complications in 4 (7%) and 6 (12%) cases, stroke within 30 days in 4 (7%) and 6 (12%) cases, and symptomatic intracranial hemorrhage in 0 and 1 cases, respectively. Conclusion: Stroke patients receiving IC-PTAS for secondary prevention in Japan have a longer interval between the ischemic event and the procedure and a higher number of safer lesions, such as those with a lower stenotic ratio, suitable morphology, and an intradural site, compared to patients who receive this treatment for rescuerecanalization. This might result in favorable technical and clinical outcomes for patients receiving IC-PTAS in Japan.

Experimental determination of rupture pressure and stress of adventitia of human middle cerebral arteries.

Background Intracranial arterial dissections might be attributed to the particular biomechanical properties of their specific layers. Also, knowledge of adventitia properties would be crucial in the context of intracranial balloon angioplasty. Aims The purpose of this work was to determine the rupture pressure of separated adventitia and compare it to intact cerebral arterial segments. Methods Brain specimens were harvested from 14 autopsy subjects (age range from 23 to 86 years). Pressure-inflation tests were conducted on proximal segments of middle cerebral arteries and separated adventitia layers from contralateral arteries to assess the rupture pressure values. Results The averaged rupture pressure of adventitia layers was 1.41 SD 0.25 atm (1072 SD 190 mmHg), whereas for intact arterial segments it was 2.32 SD 0.70 atm (1763 SD 532 mmHg) and diminished with age according to nonlinear regression trends. The difference beetween the aformentioned rupture pressures was positively correlated with rupture pressure of intact arterial segments ( R2 = 0.88; p < 0.001). Conclusions The obtained experimental results indicate a leading role of adventitia in building arterial strength under supraphysiological pressure conditions. The greater the rupture pressure of complete cerebral arteries, the smaller the contribution of adventitia in overall wall resistance.

Emergent Intracranial Balloon Angioplasty and Bailout Self-Expandable Stent Placement in Acute Large Vessel Occlusion of the Anterior Circulation: Experience of a Single Institution

Emergent Intracranial Balloon Angioplasty and Bailout Self-Expandable Stent Placement in Acute Large Vessel Occlusion of the Anterior Circulation: Experience of a Single Institution

E-041 Subacute endovascular recanalization of supraclinoid internal carotid artery occlusions

PurposeManaging subacute or chronic cervical/intracranial thromboembolic occlusions can be challenging. With respect to the COSS trial, when medical treatment fails and ischemic symptoms persists, surgical bypass procedures may be considered...

Neurointerventional Treatment of Amphetamine-Induced Acute Occlusion of the Middle Cerebral Artery by Intracranial Balloon Angioplasty

Neurointerventional Treatment of Amphetamine-Induced Acute Occlusion of the Middle Cerebral Artery by Intracranial Balloon Angioplasty

Acute Intraprocedural Thrombus Formation During Wingspan Intracranial Stent Placement for Intracranial Atherosclerotic Disease

Treatment of intracranial atherosclerotic disease with the Wingspan-Gateway intracranial stent and balloon angioplasty system has been reported in several multicenter registries. To date, the incidence of acute intraprocedural thrombus formation during Wingspan stent placement has not been reported. We reviewed the incidence of acute thrombus formation, treatment, and outcome for patients who underwent Wingspan stent placement by the senior author (B.L.H.) between June 2006 and April 2009. We routinely perform angiograms every 10 minutes for at least 30 minutes after placement of a Wingspan stent to check for acute thrombus formation. Acute thrombus was graded: (1) visible thrombus but not flow limiting, (2) visible and flow-limiting thrombosis, and (3) complete stent occlusion. Recanalization was graded according to Thrombosis In Myocardial Infarction score. Forty-one patients underwent Wingspan stent placement for intracranial stenosis. Acute intraprocedural thrombus formation developed in 6 (14.6%) within 20 minutes after stent placement: 3 grade 1, 1 grade 2, and 2 grade 3. All 6 were successfully recanalized with Thrombosis In Myocardial Infarction score 3 after intravenous abciximab with or without intra-arterial tissue plasminogen activator and/or balloon angioplasty. There was no morbidity, and all 6 patients were discharged home at their neurological baseline. We recommend serial angiography every 10 minutes for at least 30 minutes after placement of Wingspan stents. Once detected, acute thrombosis can be successfully treated with intravenous abciximab with or without intra-arterial tissue plasminogen activator and/or balloon angioplasty.

Angioplasty for Acute Stroke With Pediatric Moyamoya Syndrome

Moyamoya vasculopathy is a progressive, occlusive vasculopathy leading to ischemic and hemorrhagic strokes. No treatments are established to treat acute ischemic stroke with moyamoya vasculopathy. A 3-year-old girl with moyamoya syndrome developed acute left hemiplegia. Emergent angiography showed near-occlusion of the supraclinoid segment of the right internal carotid artery. Balloon angioplasty was performed within 6 hours of symptom onset, with significant improvement in the child's neurological symptoms. This is the youngest case of intracranial balloon angioplasty, and this article discusses the paucity of data regarding angioplasty and other forms of endovascular intervention in pediatric cerebrovascular disease and moyamoya vasculopathy. Further study is needed to determine the safety and efficacy of endovascular intervention in these diseases.

Limb-shaking Transient Ischemic Attack Masquerading as Lumbar Radiculopathy from Pericallosal Artery Stenosis Treated Successfully with Intracranial Angioplasty and Stenting

The pericallosal artery is rarely associated with intracranial atherosclerotic disease and, until recently, was usually not amenable to endovascular therapy with balloon angioplasty and stenting. We present an elderly patient with postural left leg-shaking episodes secondary to pericallosal artery stenosis, which was treated initially with primary intracranial balloon angioplasty, and subsequently, angioplasty and stenting as a result of recurrent stenosis. Both procedures were preformed without complications, and the patient remained free of symptoms on 6-month follow-up. This case demonstrates unique clinical and neuroendovascular aspects; the isolated postural leg-shaking transient ischemic attacks, initially mistaken for radiculopathy and local joint etiology, were found later to be cerebrovascular ischemic in origin. Moreover, the correlation between the findings of computed tomography perfusion and angiography localized the lesion into the medial frontal lobe and pericallosal artery territory. In addition, the technical aspect provides insight into the current state of neuroendovascular techniques, addressing the difficulty of access into very small and distal intracranial arteries affected by stenosis.

Penumbra Stroke System as an “add-on” for the treatment of large vessel occlusive disease following thrombolysis: first results

The Penumbra Stroke System (PSS) was cleared for use in patients with ischemic stroke by the FDA in January 2008. We describe our experience of using this new system in acute large vessel occlusive disease following thrombolysis. Fifteen consecutive patients (mean age 60 years) suffering from acute ischemic stroke were treated with the PSS after intravenous or intra-arterial standard treatment with tissue plasminogen activator (n = 14) or ReoPro (n = 1). All patients presented with TIMI 3 before use of the PSS. Carotid stenting (n = 3) and intracranial balloon angioplasty or stenting (n = 2) were performed if indicated. Neurological evaluation was performed using the NIHSS score and the mRS score. Initial median NIHSS score in 12 patients with occlusions in the anterior circulation was 15; three patients with basilar artery occlusion presented with coma. Median symptom to procedure start time was 151 min. In the anterior circulation, 9 of the 12 target vessels were recanalised successfully (TIMI 2 and 3). The rate of patients with independent clinical outcome (mRS </= 2) was 42%. One patient died 5 days after unsuccessful treatment, one after 28 days and one after 85 days owing to heart attack. Basilar artery occlusions could be recanalised in all cases to TIMI 3. The clinical result after 90 days was mRS 4 in two cases and mRS 5 in one case. Symptomatic haemorrhage did not occur. The PSS can safely be used for recanalisation in patients with acute ischemic stroke due to large vessel occlusion, who have already received thrombolysis treatment. The recanalisation rate was 80%. Symptomatic haemorrhage did not occur. Randomized trials may demonstrate that endovascular mechanical thrombectomy improves patient outcome.

Intracranial angioplasty and stent placement for direct cerebral revascularization of nonacute intracranial occlusions and near occlusions

The authors reviewed their experience in 7 cases of nonacute intracranial occlusions and near occlusions in which the patients underwent intracranial angioplasty and stent implantation for direct cerebral revascularization. Between 2005 and 2008, 4 men and 3 women underwent direct cerebral revascularization of nonacute intracerebral occlusions or near occlusions. Five patients had chronic angiographically documented occlusion and 2 patients had chronic angiographically documented near occlusions. The locations of the treated vessels included 2 supraclinoid internal carotid arteries, 4 middle cerebral arteries, and 1 vertebral artery. Prior to intervention, all patients were symptomatic and experienced strokes ipsilateral to their occlusions. In addition, all patients had clinical or radiographic evidence of ongoing hemodynamic compromise. Five patients underwent successful intracranial angioplasty and stent placement and 2 patients underwent successful intracranial balloon angioplasty alone. The mean time from documented vessel occlusion to treatment was 35 days. All patients had successful revascularization determined using the Thrombolysis in Cerebral Infarction (TICI) scale: TICI Score 3, 2b, and 2a in 4, 2, and 1 patient, respectively, and the mean residual stenosis was 38%. After uneventful technical procedures, 1 patient suffered a perforator vessel stroke and 1 patient suffered a fatal hemorrhage. Mean modified Rankin Scale score of 2 (range 1-5) and mean Glasgow Outcome Scale score of 4 (range 1-6) were achieved during a mean clinical follow-up period of 399 days (range 1-840 days). Asymptomatic restenosis was documented in 4 patients, 1 underwent bypass retreatment, and 1 patient received repeated balloon angioplasty. Combined intracranial angioplasty and stent placement is a potential treatment option in selected patients for the direct revascularization of nonacute intracranial occlusions and near occlusions. Whether this represents a substantial risk reduction compared with the best medical therapy or a long-lasting treatment option is unknown.

Emerging Endovascular Therapies for Symptomatic Intracranial Atherosclerotic Disease

Marc Fisher MD Section Editor Over the past 2 decades there has been an exponential growth in the scope of disease processes amenable to neuroendovascular treatment. The number and sophistication of the available devices and correspondingly the number of patients undergoing treatment has expanded accordingly. The development and implementation of these new procedures has in some cases outpaced our ability to carefully assess their merits. In comparison to peripheral and coronary vascular disease, neurovascular lesions are less common and far more heterogeneous, ranging from acquired cerebrovascular ischemic disease to hemorrhagic congenital arteriovenous malformations. Each individual disease process (eg, cerebral aneurysm) is composed of a myriad of lesions with different anatomical and pathophysiological characteristics. The natural history of these lesions and their subtypes are likewise poorly defined. For these reasons, personal bias, institutional custom, and anecdotal experience rather than scientific evidence have played a dominant role in guiding therapy. We must move toward collaborative multi-center efforts, prospective data collection and well designed randomized controlled trials to mature as a field over the coming decades. In some ways, symptomatic intracranial atherosclerotic disease (SxICAD) represents an optimal disease process with which to establish this progress toward evidenced based treatment. SxICAD is considerably less heterogeneous than other cerebrovascular disease processes and is arguably best suited as a paradigm for study. In the current article we have attempted to review the available evidence describing the natural history of medically treated SxICAD to determine those patients best suited for invasive treatment strategies. We will also discuss the available treatment modalities which may represent viable options to medical therapy. These data form the basis for the design of future prospective multicenter studies to evaluate the relative merits of interventional treatment. Any invasive treatment strategy for symptomatic intracranial atherosclerosis must satisfy two criteria to establish viability as a …

頭蓋内狭窄病変に対する抗血栓療法と脳血管内治療

Atherosclerotic intracranial stenosis is a common etiology for ischemic stroke and TIA in Japan. The natural history of intracranial stenosis is poorer than that of patients with extracranial stenosis, with annual stroke rates that approximate 5% to 15%. There are no conclusive answers about the best medical treatment of intracranial stenosis. Retrospective data suggest that long-term anticoagulation with warfarin is more effective than antiplatelet therapy. However, recent data of a randomized prospective study suggest that aspirin rather than warfarin should be used to treat intracranial stenosis, because warfarin was associated with significantly higher rates of adverse events and provided no benefit over aspirin. Patients with symptomatic intracranial stenosis who fail antithrombotic therapy appear to have a high incldence of subsequent cerebral ischemic events. The optimal treatment strategy for patients with this disease remains undetermined. Intracranial balloon angioplasty and stenting has recently been proposed as a promising treatment for patients with ongoing cerebral ischemic events despite standard medical therapy. The success rates of angioplasty alone and stent-assisted angioplasty have been reported to be approximately 85% and 95%, respectively. The complication rates of these procedures have been reported to be approximately 15%. Despite the recent advances in technology and experience, there are potential technical problems with the procedure, including dissection, vessel rupture, acute closure, elastic recoil, perforator occlusion, distal embolism, in-stent thrombosis, and hemorrhage due to hyperperfusion. Currently the efficacy of endovascular therapy versus medical therapy for patients with symptomatic intracranial stenosis has not been compared in a randomized prospective trial. Therefore, for symptomatic patients with a severe intracranial stenosis who have failed medical therapy, balloon angioplasty with or without stenting should be considered. Patients who have an asymptomatic intracranial arterial stenosis should first be counseled regarding optimizing medical therapy. There is insufficient evidence to make definitive recommendations regarding endovascular therapy in asymptomatic patients with severe intracranial atherosclerosis.

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.