Steno-occlusive Lesions Research Articles

Acute ischemic stroke with cervical internal carotid artery steno-occlusive lesion: multicenter analysis of endovascular approaches

BackgroundOcclusion of the internal carotid artery (ICA), whether isolated or in the setting of a tandem lesion (TL) have a poor response to treatment with intravenous thrombolysis. Previous studies ​​have demonstrated the superiority of mechanical thrombectomy in the treatment of acute ischemic stroke (AIS) following large vessel occlusion, compared to standard intravenous fibrinolysis. The aim of our study was to describe endovascular treatment (EVT) in AIS due to isolated ICA occlusion or TL.MethodsWe assessed the association between 90-day outcome and clinical, demographic, imaging, and procedure data in 51 consecutive patients with acute isolated ICA occlusion or TL who underwent EVT. We evaluated baseline NIHSS and mRS, ASPECTS, type of occlusion, stent placement, use of stent retrievers and/or thromboaspiration, duration of the procedure, mTICI, postprocedural therapy and complications.ResultsA favorable 90-day outcome (mRS 0–2) was achieved in 34 patients (67 %) and was significantly associated with the use of dual antiplatelet therapy after the procedure (p = 0.008), shorter procedure duration (p = 0.031), TICI 2b-3 (p < 0.001) and lack of post-procedural hemorrhagic transformation (p = 0.001). Four patients did not survive, resulting in a mortality rate of 8 %.ConclusionsOur study has shown that EVT in the treatment of AIS due to ICA occlusion is safe, and effective in determining a good functional outcome. ICA stenting led to good angiographic results and therapy with a glycoprotein IIb / IIIa inhibitor immediately after stent release did not result in a greater risk of hemorrhage. The use of post-procedural dual antiplatelet therapy was associated with favorable outcome, without a significant increase in hemorrhagic transformation.

Cerebral angiographic features of central retinal artery occlusion patients treated with intra-arterial thrombolysis

BackgroundCentral retinal artery occlusion (CRAO) is an ischemic stroke of the eye. The atherosclerotic lesions in the intracranial segment of the carotid artery (CA) and the ophthalmic artery (OphA) are...

Mechanical thrombectomy in acute ischemic stroke with tandem occlusions: impact of extracranial carotid lesion etiology on endovascular management and outcome.

Different etiologies of extracranial internal carotid artery steno-occlusive lesions (ECLs) in patients with acute ischemic stroke (AIS) and tandem occlusion (TO) have been pooled together in randomized trials. However, carotid atherosclerosis (CA) and carotid dissection (CD), the two most common ECL etiologies, are distinct nosological entities. The authors aimed to determine if ECL etiology has impacts on the endovascular management and outcome of patients with TO. A multicenter, retrospective study of prospectively collected data was conducted. AIS patients were included who had TO due to internal CA or CD and ipsilateral M1 middle cerebral artery occlusion and underwent endovascular treatment (EVT). Comparative analyses including demographic data, safety, successful recanalization rates, and clinical outcome were performed according to EVT and ECL etiology. In total, 214 AIS patients with TOs were included (77.6% CA related, 22.4% CD related). Patients treated with a retrograde approach were more often functionally independent at 3 months than patients treated with an antegrade approach (OR 0.6, 95% CI 0.4-0.9). Patients with CD-related TOs achieved 90-day clinical independence more often than patients with CA-related TOs (OR 1.4, 95% CI 1.1-2.0). Emergency stenting use was associated with good 3-month clinical outcome only in patients with CA-related TOs (OR 1.4, 95% CI 1.1-2.1). Symptomatic intracranial hemorrhage (sICH) occurred in 10.7% of patients, without differences associated with ECL etiology. ECL etiology impacts both EVT approach and clinical outcome in patients with TOs. Patients with CD-related TO achieved higher 3-month functional independence rates than patients with CA-related TOs. A retrograde approach can be desirable for both CA- and CD-related TOs, and emergency stenting is likely better justified in CA-related TOs.

Endovascular management of tandem occlusions in stroke: Treatment strategies in a real-world scenario

“The association between intracranial large vessel occlusion (LVO) and concurrent steno-occlusive lesion of an ipsilateral extracranial internal carotid artery (ICA) is considered a tandem occlusion (TO) [1].

Limb-shaking TIA in Moyamoya angiopathy

BackgroundLimb shaking TIA(LS-TIA) is an rare manifestation seen in high grade steno-occlusive carotid disease. LS-TIA is rarely recognized as a presenting manifestation of MMA and has never been previously studied prospectively in MMA cohort. MethodsOf 104 cases of MMA collected in our Indian center in last 4 years, 5 new patients had LS-TIA. MMA was diagnosed by MR angiography and LS-TIA was confirmed by three different neurologist by detailed scrutiny of history, neurological examination and EEG-recording (to rule out seizure). Seven previously reported cases of LS-TIA in MMA were retrieved by literature search in PubMed using keywords “Moyamoya” AND “Limb shaking TIA”, “Moyamoya” AND “Limb shaking”. Subsequently all data were analyzed and compared using descriptive statistics. ResultsAnalysis of our 5 cases and those 7 found in the literature showed mean age at the time of diagnosis of MMA was 12.2 ± 8.9(Mean ± S.D.) years in our cases and 32.7 ± 13.6 years in previous cases. The commonest precipitating factors included prolonged crying and hyperventilation(3 of 5 our cases each) and exercise (3 of 7 previous cases). CT-perfusion demonstrated frontal white matter hypoperfusion in 2 of our 5 cases, corroborative with fronto-parietal hypoperfusion in previous cases. Medical management showed decreased symptoms in 4 of our 5 cases in a follow-up of 15.8 ± 11.6 months, while all previous patients had underwent revascularization surgery with resolution of symptoms. ConclusionLS-TIA in MMA may not be so uncommon, especially in children. Early recognition is imperative to avoid future catastrophe. Steno-occlusive posterior circulation lesions might be an independent predictor of development of LS-TIA in MMA. In a resource-limited setting, careful avoidance of triggers and anti-platelet therapy can lead to decreased symptomatology of LS-TIA in MMA.

Comparison of different techniques for the management of venous steno-occlusive lesions during placement of peripherally inserted central catheter

The purpose of this study is to investigate strategies for peripherally inserted central catheter (PICC) placement in patients with venous steno-occlusive lesion (VSOL). We performed a retrospective cohort study in adults with central or peripheral VSOL who underwent PICC placement procedures from January 2015 to December 2018. Four different strategies [selecting alternative pathway/over the wire (SAP/OTW), percutaneous transluminal angioplasty (PTA), re-puncture in ipsilateral arm (RIA), and catheter placement in the contralateral arm (CICA)] were analyzed and we compared the clinical outcomes by strategy and compared the strategy between central and peripheral VSOLs. During 4 years, 258 PICC procedures performed in patients with VSOLs, 100 PICC were included in the analysis. The overall technical success rate of initial attempt with SAP/OTW was 32.2%. As a second-line technique, PTA was most frequently used in both central (100%) and peripheral (68.2%) VSOL groups. The clinical success rates within 2 months of SAP/OTW, PTA, RIA, CICA were 55.2%, 43.2%, 14.3%, and 33.3%, respectively (P = 0.24). In conclusion, when the SAP/OTW failed, the PTA can be preferred as a second-line technique for both central and peripheral VSOLs. When guidewire passage fails, the operator could adopt the RIA or CICA technique as an alternative method.

Intractable Coronary Spasm Requiring Percutaneous Coronary Intervention after Coronary Artery Bypass Grafting in a Patient with Moyamoya Disease

Moyamoya disease (MMD) is characterized by progressive steno-occlusive lesions of the distal or proximal branch of the internal carotid arteries, and cerebrovascular symptoms are its major complications. Extracranial vascular involvement including the coronary artery has been reported, and some case reports have described variant angina or myocardial infarction. However, no report has yet described a case of myocardial infarction after coronary artery bypass grafting (CABG). Here, we present a patient with MMD who suffered cardiac arrest caused by myocardial infarction due to a coronary spasm after off-pump CABG and who was discharged successfully after treatment with a veno-arterial extracorporeal membrane oxygenator and percutaneous coronary intervention.

Preventive Effect of Bypass Surgery on Rebleeding in Patients with Hemorrhagic Twiglike Middle Cerebral Artery

Aplastic or twiglike middle cerebral artery (Ap/T-MCA) is a rare cerebrovascular anomaly correlated to stroke. The most common characteristic of the disease is intracerebral hemorrhage. However, treatment measures that can prevent rebleeding have not yet been established. We sought to validate whether extracranial-intracranial (EC-IC) bypass is effective in preventing recurrent intracerebral hemorrhage in patients with Ap/T-MCA. Ap/T-MCA was defined on the basis of the following criteria: 1) M1 occlusion with plexiform vessels, 2) unilateral MCA involvement without progression to the contralateral side, 3) no significant stenosis in the M2 segment, and 4) no stenoocclusive lesions in other intracranial major arteries. The clinical features, surgical procedures, radiologic changes, and treatment outcomes of patients with Ap/T-MCA who presented with ipsilateral intracerebral hemorrhage at our institution from April 2004 to December 2019 were retrospectively reviewed. Seven patients fulfilled the criteria for hemorrhagic Ap/T-MCA. Female preponderance was observed, and the mean age at the time of onset was 38 (range: 28-47) years. Three patients presented with pure intraventricular hemorrhage and 4 with intraparenchymal hemorrhage. Of the 4 patients, 2 had intraventricular extension. All patients underwent EC-IC bypass and did not present with stroke during the follow-up period (median: 36 [range: 5-140] months). Follow-up magnetic resonance imaging revealed regression of the twiglike vessels or periventricular choroidal anastomosis within 1 year after surgery in all patients. EC-IC bypass may be a treatment option that can prevent rebleeding in patients with hemorrhagic Ap/T-MCA.

ADVISABILITY OF USING CILOSTAZOL IN PATIENTS WITH CHRONIC LIMB-THREATENING ISCHEMIA

The article presents the results of surgical and conservative treatment of patients with chronic limb-threatening ischemia (CLTI) of the lower extremities due to steno-occlusive atherosclerotic arterial lesions. The definite role of cilostazol in creating favorable conditions for the healing of trophic wounds is shown.&#x0D; Aim: to improve the results of surgical treatment of patients with CLTI, with use of surgical and conservative methods of treatment, in particular the use of the Cilostazol (Plestazol).&#x0D; Materials and methods. The research included 60 people aged 53 to 82 years with CLTI. All patients had trophic skin changes on the lower extremities (IV grade according to Fontaine classification; 5, 6 category according to Rutherford classification). The operations were performed by the open method (aorto-bifemoral bypass grafting / prosthetics, femoral-popliteal / distal bypass grafting) and X-ray endovascular method (percutaneous balloon angioplasty of the arteries of the lower extremities and stenting of the arteries). The examined patients were divided into 2 groups statistically and clinically comparable (in the main group, open operations were performed in 12 patients, endovascular interventions in 18 patients). In the comparison group - 17 patients were operated openly, endovascular – 13 patients).&#x0D; The research evaluated the microflora sown from wounds on the foot, the size of the skin defect, the rate of healing of which was assessed in the dynamics (reduction of wound area), the rate of body and changes in white blood, antibacterial drugs were prescribed according to sensitivity. During microbiological examination and culture of wounds of the lower extremities, it was found that the most common flora were gram-positive staphylococci (S. aureus, S. epidermidis). E. coli, Pr. mirabilis, Ps were also sown as accompanying flora. The area of necrosis was determined using a transparent film with a grid of squares of 1 mm². Wounds were treated topically with antiseptic and antimicrobial drugs according to the stages of the wound process without the use of hardware treatments.&#x0D; The drug was prescribed as an additional antiplatelet therapy and as a vasodilator to assess the effectiveness of cilostazol in the main group. In the comparison group, patients received antiplatelet therapy.&#x0D; Research results. A homogeneous category of patients with chronic limb-threatening ischemia, who underwent revascularization, demonstrate different rates of healing of the initial trophic ulcers and the appearance of fresh granulation tissue. The fresh granulation tissue after treatment of wounds on the foot, including after performed necrectomy in patients in the main group appeared in 6-11 days (9.7 ± 2.83, confidence interval 8.69-10.71), while the time of appearance of the newly formed granulation tissue in the comparison group was 9-16 days. The total time of wound healing in the main group averaged 70 (73.1 ± 2.05) days, in the comparison group this figure was 90 (89 ± 2.63) days.&#x0D; All patients who received the drug Cilostazol had a faster rate of healing of necrosis, which is explained, among other things, by the pro-angioproliferative properties of the drug.&#x0D; Conclusions. The use of surgical and conservative methods of treatment in particular use of cilostazol (plestazol) in patients with chronic limb-threatening ischemia, can shorten the healing time of wounds.

Intracranial Arterial Stenosis Among Filipino Ischemic Stroke Patients: A Single Center Study

Introduction: Intracranial arterial stenosis (ICAS) is common among certain race. It is prevalent in Asians, Hispanics, and African Americans, who constitutes about 2/3 of the world population making it the most common cause of stroke worldwide. Objectives: The objectives are to describe the demographic data and risk factors of patients with ICAS and 1-year outcome. Methods: Patients who had ischemic stroke by cranial computed tomography scan or magnetic resonance imaging, magnetic resonance angiography, computed tomographic angiography, or transcranial Doppler with periodic follow-up for 1 year were consecutively collected. Patients without intracranial stenosis were also collected and served as control. The demographic data, risk factors, modified Rankin Scale, stroke recurrence and mortality between ICAS and large artery atherosclerosis (LAA) patients were compared. The distribution and the degree of steno-occlusive lesions were estimated. Results: A total of 258 cases were consecutively collected. ICAS was demonstrated in 109 patients and 149 were LAA patients. There were 62 (56.88%) males. The age range distribution was as follows: 18 to 45 year olds, 15 (13.76%); 46 to 60 year olds, 28 (25.69%); and 61 year olds and above 66 (60.55%). Risk factors were hypertension 82 (75.23%), diabetes mellitus 46 (42.20%), hyperlipidemia 27 (24.77%), atrial fibrillation 16 (14.68%), history of previous stroke 23 (21.10%), alcohol drinker 28 (25.69%), obesity 8 (7.34%), and family history of cerebrovascular disease 33 (30.28%). ICAS was seen in the middle cerebral artery 46 (46.9%), ICA 21 (21.4%), BA 11 (11.2%), VA 8 (8.16%), PCA 7 (7.14%), and ACA 5 (5.1%). Majority of the patients showed moderate to severe stenosis. Modified Rankin Scale ranged from 0 to 2 in the majority of the patients and showed not much difference compared to LAA patients. The recurrence of stroke and death rate showed no significant difference between the 2 groups. Conclusion: In this study, no difference was seen between ICAS and LAA patients.

High-resolution magnetic resonance imaging for the follow-up of intracranial arterial dissections.

High-resolution magnetic resonance imaging (HRMRI) with a 3-T system can be utilized to identify intracranial arterial dissections (ICADs) as it reveals more than three key features with better clarity than other conventional imaging modalities. This study aimed to assess the changes in the key features of ICADs on HRMRI over time. We screened patients who had undergone HRMRI within 7days of symptom onset for the evaluation of characteristics associated with intracranial steno-occlusive lesions. Among them, patients who (1) were diagnosed with ICAD based on HRMRI findings and (2) underwent follow-up HRMRI 3-12months after the initial HRMRI were included in the final study. Baseline HRMRI revealed an intramural hematoma, a flap, and a double lumen in 17 (100%), 15 (88%), and 10 (59%) individuals, respectively. At the 3-months follow-up, an intramural hematoma was still observed in two patients; however, there were various changes in the double lumen and intimal flap. At the 6-months follow-up, an intramural hematoma was not observed in most patients, whereas the double lumen and intimal flap persisted in most patients. The 9-months follow-up displayed distinct differences from the initial status, whereas the 12-months follow-up exhibited no intramural hematomas, intimal flaps, or double lumens in most patients. In those with ICAD, radiological changes were observed between the initial HRMRI and subsequent HRMRI. Moreover, typical ICAD features were hardly retained at the 1-year follow-up. These changes might reflect dynamic processes, including the healing state of the patients.

Novel triple coaxial system to navigate 9French balloon guiding catheter into common carotid artery.

It is often hard to navigate a 9 French (F) balloon guiding catheter in patients with type III or bovine aortic arch. Also, a common carotid artery stenosis is challenging, because a guidewire cannot be advanced distally. We developed the combination of a 4F Simmons-type catheter and a 6F distal access catheter as a coaxial inner catheter to navigate a 9F balloon guiding catheter to overcome these difficulties. Medical record at our institution was retrospectively reviewed and carotid artery stenting cases in which the 4F Simmons-6F distal access catheter system was employed as a coaxial catheter to navigate a 9F balloon guiding catheter were identified. To construct this system, a 4F 145cm SY3 (Hanako Medical, Saitama, Japan) and a 6F 118cm Cerulean DD6 (Medikit Co. Ltd., Tokyo, Japan) were usually employed. A rotating hemostatic valve should be as short as possible and was attached to only a 9F balloon guiding catheter. The length of a 0.035-in. guidewire needed to be 180cm or longer. During the study period, 106 carotid artery stenting cases were identified. Of these, this system was employed in 29 cases that included 5 cases with a steno-occlusive lesion at common carotid artery/external carotid artery, 10 with type III or bovine arch, and 11 harboring both. In all the cases, a 9F balloon guiding catheter was successfully navigated. The 4F Simmons-6F distal access catheter system was useful in navigating a 9F balloon guiding catheter in patients with a common carotid artery stenosis, an external carotid artery occlusion, and an in-stent restenosis, especially when they also harbored type III or bovine aortic arch.

The role of MRA in pediatric sickle cell disease with normal transcranial Doppler imaging velocities

PurposeThe purpose of this study was to determine the additional information provided by Magnetic Resonance Angiography (MRA) in pediatric sickle cell disease (SCD) patients with normal Transcranial Doppler imaging (TCDI) examinations. MethodsThis cohort study included all pediatric SCD patients over an 18-year period who had no history of stroke and had normal TCDI examinations and subsequently underwent MRA. Routine TCDI inclusive of time-averaged mean of maximum velocities (TAMMV) were assesses and compared with tortuosity on MRA and silent infarct on MRI. Results86 children (52.3% female; mean age 8.7 ± 3.5years) were included. There were 77 patients (89.5%) with Hb-SS disease and 9(10.4%) with HB-S beta-thalassemia. All patients had normal TAMMV (<170 cm/s) on TCDI. 76/86 (88.3%) patients also had one or more velocity readings <70 cm/s, albeit none in the middle cerebral arteries. Posterior cerebral arteries had the lowest velocities, <70 cm/s in 51.7% (right) and 60.9% (left). Silent MRI infarcts were seen in 27/86 (31.4%) patients. No new lesions were identified on follow-up MRI. Although mild vascular tortuosity was appreciated in 31/86 (36.0%) of the patients, there were no steno-occlusive lesions in the circle of Willis. ConclusionsTCDI and MRA are routinely performed for non-invasively evaluating intracranial vascular abnormalities in children with SCD. In SCD children with no history of TIA or stroke, MRA following a normal TCDI examination is unlikely to show vascular abnormality. However, almost a third of these patients show silent infarcts on MRI, unassociated with MRA changes.

Hybrid surgery in treatment of patients with obliterating atherosclerosis of lower extremities (review)

The literature review presents the possibilities and current trends in the use of hybrid surgery in patients with multilevel multifocal lesions of the arterial bed of the lower extremities with obliterating lesions. Methods of open bypass surgery for chronic atherosclerosis of the arteries have long been developed, put into practice and can be considered individually for each patient. However, given the frequent complicated atherosclerotic history in patients with multifocal lesions of various arterial pools, most patients can be recommended more gentle endovascular methods of blood flow correction — balloon angioplasty or stenting. But given certain technical and general parameters (prolonged occlusion, severe calcification, kidney disease, an allergic reaction to a contrast drug, etc.), it is not yet possible to use intravascular correction in absolutely all patients, as a result of which the method of simultaneous or phased hybrid surgery seems to be very relevant and can be used even in patients at extremely high risk. The review describes the possible uses of hybrid technology depending on the level of steno-occlusive lesion and the general prolongation of narrowing of the arterial bed. Also considered are some features of the use of simultaneous or multi-stage hybrid operations. On the basis of modern literature data, the advantage of using a combination of open surgeries and endovascular interventions in comparison with any one revascularization method is shown.

Abstract WP270: Etiopathologies of Symptomatic and Asymptomatic Intracranial Large Arterial Disease: The Results of HR-MRI and Genetic Studies

Introduction: Intracranial large arterial disease (ILAD) is common, especially in Asians. We compared clinical, genetic, and imaging features between symptomatic and asymptomatic ILAD. Methods: We conducted a prospective study of patients with acute symptomatic ILAD and subjects with asymptomatic ILAD diagnosed during medical checkups. Patients who had steno-occlusive lesions on the middle cerebral artery and/or distal internal carotid artery underwent high-resolution MRI (HR-MRI) and RNF213 (p.Arg4810Lys variant) gene studies. We excluded patients who had proximal embolic sources in ipsilateral carotid and heart. A presumptive etiology of ILAD was made based on HR-MRI and RNF213 gene studies. Patients were classified into intracranial atherosclerosis (ICAS) when relevant plaques existed on HR-MRI; moyamoya disease (MMD) when patients had RNF213 variant and HR-MRI showed no plaque but characteristic features of MMD (negative remodeling and basal collaterals); and intracranial arterial dissection (ICAD) when pathognomic features (intimal flap/double lumen or mural hematoma) exist on HR-MRI. Results: Among 224 patients analyzed, 124 were symptomatic and 100 were asymptomatic. ICAS-type was more common in symptomatic ILAD than in asymptomatic ILAD (61.4% vs. 45.0%, p=0.009). The RNF213 variant was observed in one third of ICAS-type ILAD (37.0% in asymptomatic and 38.6% in symptomatic). Similarly, the proportion of MMD-type was similar between asymptomatic (33, 21.3%) and symptomatic (32, 19.0%) ILAD. Multivariate testing showed that symptomatic ILAD was associated with the presence of intracranial plaque on HR-MRI, regardless of the presence of the RNF213 variant, site of ILAD, and number of tandem stenosis. Conclusions: While various etiopathologies can cause ILAD, ICAS is an important pathology of symptomatic ILAD and should be target for medical management.

Endovascular treatment of atherosclerotic lesions in the superficial femoral artery and proximal popliteal artery using the sinus-SuperFlex-635 stent: twelve-month results from the HERO Registry.

The aim of this study was to evaluate the safety and performance of the sinus-SuperFlex-635 self-expandable nitinol stent (Optimed GmbH) for the treatment of steno-occlusive lesions in the superficial femoral artery (SFA) and proximal popliteal artery (PPA). The prospective, multicenter, observational HERO study recruited 117 eligible patients (83 men; mean age 69.4±9.7y) from 7 centers in Belgium. A total of 129 stents were successfully deployed in 121 lesions in 117 patients (100%). The patients presented with symptomatic ≥50% stenosis or chronic total occlusion (CTO) (30.6%). Mean lesion length was 71.4±56.3 mm. Moderate to severe calcification was present in 82.6% of the lesions. Acute lesion success (<30% residual stenosis) was achieved in 96.0%. There were no in-hospital serious adverse events. Duplex ultrasound-driven primary patency at 12 months was recorded in 84 of 107 (78.5%) lesions. The overall target lesion revascularization (TLR) rate was 8.4% at 12 months; the target extremity revascularization (TER) rate was 4.7%. Clinical assessment at 12 months demonstrated improvement by at least 1 Rutherford class, without the need for TLR (i.e. primary sustained clinical improvement) in 83.9% of patients and with the need for TLR in 90.6% of patients (i.e. secondary sustained clinical improvement). Based on the high primary patency, low stent fracture rate and significant clinical improvement, combined with refined stent design and long stent availability, the sinus-SuperFlex-635 self-expandable nitinol stent proves its value in the treatment of complex femoropopliteal lesions.

Abstract TP231: Predictors of Early Neurological Deterioration in Acute Minor Ischemic Stroke

Introduction: Early neurological deterioration is one of the critical determinants of functional outcomes in patients with minor ischemic stroke. The purpose of this study was to identify predictors of early neurological deterioration in patients with acute minor ischemic stroke. Methods: A total of 739 patients with acute minor ischemic stroke who are admitted within 24 hours after onset of stroke symptom between January 2014 and December 2018 were enrolled in this study. We analyzed demographic characteristics, risk factors for vascular diseases, stroke severity, stroke subtypes, neuroimaging parameters, and relevant arterial steno-occlusive lesions. Early neurological deterioration was defined as any worsening of neurological deficits within 3 days after admission. Logistic regression was used to determine independent predictors of early neurological deterioration. Results: Seventy-eight of 739 (10.5%) patients had early neurological deterioration. Among 78 patients with early neurological deterioration, 61 (78.2%) had poor functional outcomes at 90 days after stroke onset. By contrast, 131 of 661 (19.8%) patients without early neurological deterioration had poor functional outcomes. Multivariate analysis identified hemorrhagic transformation (OR, 3.8; 95% CI, 1.4-10.5; P=0.010), higher score of NIHSS on admission (OR, 1.4; 95% CI, 1.1-1.7; P=0.003), relevant arterial stenosis (OR, 2.0; 95% CI, 1.2-3.5; p=0.014) and occlusion (OR, 2.6; 95% CI, 1.4-4.8; p=0.004) were the factors associated with early neurological deterioration. Conclusions: The results of this study suggest that hemorrhagic transformation, higher NIHSS score on admission, relevant arterial steno-occlusive lesions are independent predictors of early neurological deterioration in patients with acute minor ischemic stroke.

Emergent carotid artery stenting in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion: Comparison of tandem intracranial occlusion and isolated cervical internal carotid artery occlusion

Acute ischemic strokes caused by steno-occlusive lesion of the cervical internal carotid artery are associated with poor clinical outcome. We evaluated the clinical efficacy of emergent carotid artery stenting for the management of these lesions. We compared the clinical outcomes regarding the intracranial lesion, namely tandem occlusions versus isolated cervical internal carotid artery occlusion. We retrospectively reviewed patients with acute ischemic stroke who underwent carotid artery stenting for cervical internal carotid artery steno-occlusive lesion between 2011 and 2018. After dividing the patients into two groups according to the presence or absence of intracranial lesions (tandem group and isolated cervical group), we analyzed demographic data, angiographic findings, and clinical outcomes. A modified Rankin Scale score ≤2 was defined as a favorable clinical outcome. Of 75 patients, 46 patients (61.3%) had tandem lesions, and the remaining 29 had only cervical internal carotid artery steno-occlusive lesion. Successful stenting was performed in all patients with favorable clinical outcomes (64.0%). Successful reperfusion score (thrombolysis in cerebral infarction ≥2 b) was 84.0%; tandem group (76.1%) versus isolated cervical group (96.6%) of cases. Mean modified Rankin Scale score at 90-days was 2.09. The rate of favorable clinical outcome showed no statistically significant difference between the two groups (p = 0.454). Endovascular treatment in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion is a technically feasible and clinically effective intervention regardless of intracranial occlusion. Therefore, we recommend endovascular treatment regardless of the presence of concomitant intracranial artery occlusion for patients with acute ischemic stroke caused by cervical internal carotid artery steno-occlusive lesion.

Robotic-assisted operations for pathology of the aortoiliac segment: own experience

The present study was aimed at assessing the results of a total of 40 vascular operations carried out using the robotic-assisted da Vinci surgical system. Between January 2013 and September 2019, a total of 40 robotic-assisted vascular operations were performed at the Department of Vascular Pathology and Hybrid Technologies of the Centre of Vascular and Hybrid Surgery. Of these, 31 interventions were carried out for occlusion of the aortoiliac segment and 9 for removal of an aneurysm of the infrarenal portion of the abdominal aorta. The patients were arbitrarily divided into 2 groups: the first group included those subjected to aortofemoral bypass grafting procedures for atherosclerotic steno-occlusive lesions of the aorta and iliac arteries, whereas the second group comprised the patients who underwent aneurysmoectomies with linear prosthetic repair of the abdominal aorta. Altogether, elective robotic-assisted operations were successfully performed in 38 (95%) cases. Conversion to a laparotomic approach was required in 2 (5%) patients. The mean time of creating an anastomosis with the abdominal aorta amounted to 51 minutes (range 30-90), being 42±4.75 min for aortofemoral bypass grafting and 83±5.00 min for aneurysmoectomies with linear prosthetic repair of the abdominal artery. The average blood loss was 316 (range 50-1000) ml, amounting to 280±209 ml and 438±322 ml for group I and group II, respectively. With the exception of one case, all patients spent 24 hours in the intensive care unit to be then transferred to the specialized ward. The average length of hospital stay amounted to 9.8 days. One patient experienced haemorrhage from the central anastomosis in the early postoperative period and was emergently operated on from a laparotomic approach. Four (10%) patients developed nonlethal complications which were treated conservatively. During the 30-day follow-up period, no lethal outcomes, thromboses, nor infections of the prostheses were observed. From a practical point of view, the major advantages of using the robotic-assisted complex include minimal surgical trauma, reduced blood loss, a wide range of high-precision movements of the manipulators, 3-D visualization with a 5-fold magnification, thus making it possible to create a vascular anastomosis sufficiently fast in very tight spaces in the body. Our experience with laparoscopic robotic-assisted surgery demonstrated feasibility of using this technique for treatment of pathology of the aortoiliac segment.

Vessel Wall Thickening and Enhancement in High-Resolution Intracranial Vessel Wall Imaging: A Predictor of Future Ischemic Events in Moyamoya Disease.

Very few data are available with regard to high-resolution intracranial vessel wall imaging characteristics of Moyamoya disease and their relation to ischemic stroke risk. We investigated the high resolution imaging characteristics of MMD and its correlation with recent ischemic events. Patients with Moyamoya disease confirmed by DSA, including patients after revascularization, were enrolled. All the patients underwent high-resolution intracranial vessel wall imaging. Vessel wall thickening, enhancement, and the remodeling index of the bilateral distal ICA and proximal MCA were noted. The patients were followed up at 3 months and 6 months after high-resolution intracranial vessel wall imaging and the association of ischemic events with imaging characteristics was assessed. Twenty-nine patients with Moyamoya disease were enrolled. The median age at symptom onset was 12 years (range, 1-51 years). A total of 166 steno-occlusive lesions were detected by high-resolution intracranial vessel wall imaging. Eleven lesions with concentric wall thickening (6.6%) were noted in 9 patients. Ten concentric contrast-enhancing lesions were observed in 8 patients, of which 3 patients (4 lesions) showed grade II enhancement. The presence of contrast enhancement (P = .01) and wall thickening (P ≤ .001) showed a statistically significant association with ischemic events within 3 months before and after the vessel wall imaging. Grade II enhancement showed a statistically significant (P = .02) association with ischemic events within 4 weeks of high-resolution intracranial vessel wall imaging. The mean ± standard deviation outer diameter of the distal ICA (right, -3.3 ± 0.68 mm; left, 3.4 ± 0.60 mm) and the remodeling index (right, 0.71 ± 0.13; left, 0.69 ± 0.13) were lower in Moyamoya disease. High-resolution intracranial vessel wall imaging characteristics of concentric wall thickening and enhancement are relatively rare in our cohort of patients with Moyamoya disease. The presence of wall thickening and enhancement may predict future ischemic events in patients with Moyamoya disease.