Symptomatic Intracranial Stenosis Research Articles

Percutaneous transluminal angioplasty and stenting (PTAS) in patients with symptomatic intracranial vertebrobasilar artery stenosis (IVBS)

BackgroundApproximately 20% of all transient ischaemic attacks (TIAs) and ischaemic strokes occur within the posterior circulation, with vertebrobasilar stenosis identified as the cause in roughly 25% of the cases. Studies...

Stenting versus medical treatment alone for symptomatic intracranial artery stenosis: a preplanned pooled individual patient data analysis

BackgroundWhether the safety and efficacy of percutaneous transluminal angioplasty and stenting (PTAS) is significantly different from that of medical treatment alone for symptomatic intracranial arterial stenosis (ICAS) is debatable. A...

R1/ Assessment of Risk Factors in Patients Presented With symptomatic Intracranial Arterial Stenosis In Minia University Hospital

R1/ Assessment of Risk Factors in Patients Presented With symptomatic Intracranial Arterial Stenosis In Minia University Hospital

Residual inflammatory risk predicts long-term outcomes following stenting for symptomatic intracranial atherosclerotic stenosis

Background and purposeResidual inflammatory risk (RIR) can predict the unfavourable outcomes in patients with minor ischaemic stroke. However, the impact of preprocedural RIR on long-term outcomes in patients with symptomatic...

Self-expanding intracranial drug-eluting stent system in patients with symptomatic intracranial atherosclerotic stenosis: initial experience and midterm angiographic follow-up.

Symptomatic intracranial atherosclerotic stenosis (ICAS) is a major cause of ischemic stroke worldwide. In patients undergoing endovascular treatment for ICAS, in-stent restenosis (ISR) is associated with ischemic stroke recurrence. Intracranial drug-eluting self-expanding stent systems (COMETIU; Sinomed Neurovita Technology Inc., CHN) are new devices for treating ICAS. This study evaluated the perioperative experience and medium-term outcomes of COMETIU in 16 patients. We prospectively analyzed 16 patients with ICAS (≥ 70% stenosis) who underwent intravascular therapy between September 4, 2022, and February 1, 2023. The primary outcome was the incidence of ISR at 6 months postoperatively. The secondary efficacy outcomes were device and technical success rates. The secondary safety outcomes included stroke or death within 30 days after the procedure and the cumulative annual rate of recurrent ischemic stroke in the target-vessel territory from 31 days to 6 months and 1 year. A total of 16 patients with 16 intracranial atherosclerotic lesions were treated with 16 COMETIUs. All procedures were performed under general anesthesia with 100% device and technical success rates, with no cases of periprocedural stroke or death. The mean radiographic follow-up duration was at least 6 months postoperatively, and all patients presented for radiographic and clinical follow-up. There were no reported ischemic or hemorrhagic strokes. Angiographic follow-up for all patients revealed no cases of ISR. COMETIU is safe and effective for treating ICAS, with minimal risk during the procedure and a low rate of ISR during medium-term follow-up.

Impact of qualifying artery on the efficacy of stenting plus medical therapy versus medical therapy alone in patients with symptomatic intracranial stenosis: a post-hoc analysis of the CASSISS trial

BackgroundA recent trial failed to show any benefit of stenting plus medical therapy over medical therapy alone in patients with symptomatic intracranial stenosis. We aimed to examine whether the symptomatic...

Hemodynamic Impairment of Blood Pressure and Stroke Mechanisms in Symptomatic Intracranial Atherosclerotic Stenosis.

Hemodynamic impairment of blood pressure may play a crucial role in determining the mechanisms of stroke in symptomatic intracranial atherosclerotic stenosis). We aimed to elucidate this issue and assess the impacts of modifications to blood pressure on hemodynamic impairment. From the Third China National Stroke Registry III, computed fluid dynamics modeling was performed using the Newton-Krylov-Schwarz method in 339 patients with symptomatic intracranial atherosclerotic stenosis during 2015 to 2018. The major exposures were translesional systolic blood pressure (SBP) drop and poststenotic mean arterial pressure (MAP), and the major study outcomes were cortex-involved infarcts and borderzone-involved infarcts, respectively. Multivariate logistic regression models and the bootstrap resampling method were utilized, adjusting for demographics and medical histories. In all, 184 (54.3%) cortex-involved infarcts and 70 (20.6%) borderzone-involved infarcts were identified. In multivariate logistic model, the upper quartile of SBP drop correlated with increased cortex-involved infarcts (odds ratio, 1.92 [95% CI, 1.03-3.57]; bootstrap analysis odds ratio, 2.07 [95% CI, 1.09-3.93]), and the lower quartile of poststenotic MAP may correlate with increased borderzone-involved infarcts (odds ratio, 2.07 [95% CI, 0.95-4.51]; bootstrap analysis odds ratio, 2.38 [95% CI, 1.04-5.45]). Restricted cubic spline analysis revealed a consistent upward trajectory of the relationship between translesional SBP drop and cortex-involved infarcts, while a downward trajectory between poststenotic MAP and borderzone-involved infarcts. SBP drop correlated with poststenotic MAP negatively (rs=-0.765; P<0.001). In generating hemodynamic impairment, simulating blood pressure modifications suggested that ensuring adequate blood pressure to maintain sufficient poststenotic MAP appears preferable to the reverse approach, due to the prolonged plateau period in the association between the translesional SBP drop and cortex-involved infarcts and the relatively short plateau period characterizing the correlation between poststenotic MAP and borderzone-involved infarcts. This research elucidates the role of hemodynamic impairment of blood pressure in symptomatic intracranial atherosclerotic stenosis-related stroke mechanisms, underscoring the necessity to conduct hemodynamic assessments when managing blood pressure in symptomatic intracranial atherosclerotic stenosis.

Clinical implications of haemodynamics in symptomatic intracranial atherosclerotic stenosis by computational fluid dynamics modelling: a systematic review

BackgroundRecently, computational fluid dynamics (CFD) has been used to simulate blood flow of symptomatic intracranial atherosclerotic stenosis (sICAS) and investigate the clinical implications of its haemodynamic features, which were systematically...

Effect of Drug-Coated Balloon Versus Stent Angioplasty in Patients With Symptomatic Intracranial Atherosclerotic Stenosis.

Drug-coated balloons (DCBs) have exhibited promising results in coronary and peripheral artery diseases, but conclusive evidence is lacking in intracranial vasculature. We assessed the safety and efficacy of DCBs vs stent angioplasty for symptomatic intracranial atherosclerotic stenosis (sICAS) and initially identified patients who might have benefited most from DCB treatment. A single-center, retrospective cohort study was conducted from June 2021 to May 2022 with 154 patients with sICAS divided into 2 treatment groups: a DCB group (with or without remedial stenting, n = 47) and a stent group (n = 107). The treatment outcomes were compared using 1:2 propensity score matching. The primary safety end point was perioperative stroke or mortality, and the primary efficacy end point was the rate of target vessel restenosis at 12 months. The degree of luminal change was analyzed as a subgroup, defined as the difference between the degree of stenosis at follow-up and immediately after intervention. One hundred eighteen patients were enrolled using propensity score matching, with 43 patients in the DCB group and 75 in the stent group. The incidence of perioperative adverse events was 2.3% in the DCB group and 8.0% in the stent group (P = .420). At a median follow-up of 12 months, the incidence of restenosis (11.9% [5/43] vs 28.0% [21/75], P = .045) and the median degree of stenosis (30% [20%, 44%] vs 30% [30%, 70%], P = .009, CI [0-0.01, 0.2]) were significantly lower in the DCB group than in the stent group. DCB angioplasty effectively prevented adverse events in the target vessel area and significantly reduced the degree of luminal change in the M1 segment of the middle cerebral artery (0 [0, 15%] vs 10% [0, 50%], P = .016). DCB angioplasty might be a safe and effective alternative to stent angioplasty to treat sICAS, particularly among patients with M1 segment of the middle cerebral artery stenosis.

Commentary: Effect of Drug-Coated Balloon Versus Stent Angioplasty in Patients With Symptomatic Intracranial Atherosclerotic Stenosis.

Commentary: Effect of Drug-Coated Balloon Versus Stent Angioplasty in Patients With Symptomatic Intracranial Atherosclerotic Stenosis.

Enterprise stents for the treatment of symptomatic non-acute intracranial artery stenosis disease: safety and efficiency evaluation

ABSTRACT Background Enterprise stent was approved for the treatment of wide-necked intracranial aneurysms. However, it has been widely used in the endovascular treatment of intracranial artery stenosis, which is still controversial. The purpose of this study was to evaluate the safety and efficiency of the Enterprise stent in the endovascular treatment of intracranial artery stenosis disease. Methods We conducted a retrospective case series of 107 patients with intracranial artery stenosis who received Enterprise stent implantation at Nanjing Drum Tower Hospital from January 2020 to December 2022. The rates of recanalization, perioperative complications, in-stent restenosis at 3–12 months and stroke recurrence were assessed for endovascular treatment. Results A total of 107 individuals were included in this study, 88 were followed up, and 19 (17.8%) patients were lost to follow-up. The operation success rate was 100%, During the procedure,4（3.7%）patients had vasospasm, and 2(1.9%) patients showed symptomatic bleeding. The overall perioperative complication rate was 5.6%, including 2.8% distal artery embolism, 0.9% in-stent thrombosis, and 1.9% symptomatic bleeding. 88 (82.2%) patients were followed up from 3 to 12 months, of whom 12 (13.6%) had in-stent restenosis, 4 (4.7%) recurrent strokes and 2 died of pulmonary infection caused by COVID-19. Patients were divided into 3 groups according to the cerebral artery, including the middle cerebral artery group, internal carotid artery group, and vertebrobasilar artery group. Conclusions In this study, the placement of the Enterprise stent in patients with symptomatic non-acute intracranial stenosis was successful. However, the occurrence of periprocedural and long-term complications after stenting remains of high concern.

156 Stenting of Intracranial Stenosis With a Fibrin-heparin Coated Stent Multicentre Experience

INTRODUCTION: Mechanical thrombectomy (MT) has become the standard treatment for acute ischemic stroke due to large vessel occlusions (LVO). However, in up to 30% MT may not result in successful recanalization due to an underlying stenosis or clot recalcitrant to retrieval. Bail-out stenting has been reported to be a treatment option to achieve permanent recanalization. METHODS: We retrospectively analysed data from 16 stroke centres. Patients treated with the CREDO heal Stent were divided into two groups: symptomatic high-grade intracranial stenosis (sICAD group) and persisting LVO due to underlying stenosis after at least one mechanical thrombectomy attempt (Rescue Stenting group). Primary endpoints were the improvement of stenosis grade and the rate of successful recanalization after stenting defined as mTICI = 2b for the sICAD and the Rescue Stenting group respectively. Favourable neurological outcome was defined by modified Rankin Score (mRS) at 90 days. RESULTS: 121 patients were treated from 2021-2023 with the CREDO heal Stent. Rescue stenting and sICAD treatment was performed in 82 and 39 cases respectively. Overall, a final TICI = 2b score was achieved in 94.5%. In 14% periprocedural complications occurred were in-stent thrombosis accounted for 6.3% (rescue stenting group). The mean stenosis grade in the sICAD group was 90% before and 15% after PTA and stenting. On follow-up (n = 27) restenosis was observed in 2.8%. CONCLUSIONS: The CREDO® heal stent offers a new treatment option for patients with sICAD or with persistent occlusion during thrombectomy procedures. The final mTICI sore is in accordance with uncoated devices. The rate of restenosis is low compared to previous trials. Its effectiveness with regard to long-term ischemic complications has to be evaluated in the prospective ReCHRUT trial.

Hemodynamic Impairments of Evaluating Symptomatic Intracranial Atherosclerotic Stenosis using Quantitative Flow Ratio on Digital Subtraction Angiography : AComparison with Computed Tomography Perfusion, MRI and Fractional Flow Reserve.

Cerebral hemodynamics are important for the management of intracranial atherosclerotic stenosis (ICAS). The quantitative flow ratio (QFR) is anovel angiography-derived index for assessing the functional relevance of ICAS without pressure wires and adenosine. Good diagnostic yield with the hyperemic fractional flow reserve (FFR) have been reported, while data on the comparison of QFR to FFR are scarce. In this prospective study 56patients with anterior circulation symptomatic ICAS who received endovascular treatment were included. The new method of computing QFR from asingle angiographic view, i.e., the Murray law-based QFR (μQFR), was applied to the examined vessels. An artificial intelligence algorithm was developed to realize the automatic delineation of vascular contour. Pressure gradients were measured before and after treatment within the lesion vessel using apressure guidewire and the FFR was calculated. There was agood correlation between μQFR and FFR. Preoperative FFR predicted DWI watershed infarction (FFR optimal cut-off level: 0.755). Preoperative μQFR predicted DWI watershed infarction (μQFR optimal cut-off level: 0.51). Preoperative FFR predicted CTP hypoperfusion (FFR best predictive value: 0.62). Preoperative μQFR predicted CTP hypoperfusion (μQFR best predictive value: 0.375). The μQFR based on DSA images can be used as an indicator to assess the functional status of the lesion in patients with ICAS.

Has collateral blood flow any effect on restenosis rate? Our experience.

Restenosis is one of the important factors affecting the effectiveness of percutaneous transluminal angioplasty and stenting in the treatment of intracranial atherosclerotic stenosis. We aimed to clarify whether recruitable collateral flow could cause restenosis in patients treated with percutaneous transluminal angioplasty and stenting. Our study retrospectively analyzed patients with symptomatic severe intracranial atherosclerotic stenosis (≥70%) who underwent percutaneous transluminal angioplasty and stenting. We enrolled 28 patients with restenosis and 71 patients without restenosis. We analyzed baseline data, perioperative events, and follow-up results of patients in the two groups. Binary logistic regression analysis was used to identify restenosis predictors. For preoperative stroke, the restenosis group had a greater likelihood of having a previous stroke (89.3%), which was less prevalent in the non-restenosis group (66.2%) (P = 0.020). The restenosis group had a higher rate of re-stroke (21.4 vs. 4.2%, P = 0.022). After binary logistic regression analysis, collateral circulation and residual stenosis were independent risk factors of restenosis, with overall risk (95% confidence intervals) of 5.034 (1.484-4.066, P < 0.001) and 1.064 (1.006-1.125, P = 0.030), respectively. Restenosis risk increased 1.456-fold for each collateral circulation grade increase. However, for each 1% increase in residual stenosis, restenosis risk increased by 5.9% (P = 0.03). The chance of restenosis is minimal when the residual stenosis rate after percutaneous transluminal angioplasty and stent implantation is 15.85%. Good collateral circulation was significantly associated with restenosis in patients undergoing intracranial angioplasty, the residual stenosis rate tends to be 15.85% to reduce restenosis risk. Compared to patients with restenosis, those without restenosis have a low stroke risk during follow-up.

Endovascular treatment of symptomatic severe intracranial atherosclerotic stenosis with a novel intracranial dedicated drug-eluting stent: a more effective treatment approach.

Endovascular treatment of severe intracranial atherosclerotic stenosis (ICAS) using coronary drug-eluting stents (DESs) significantly reduces the risk of in-stent restenosis (ISR) and stroke recurrence. However, there are few reports regarding the treatment of ICAS with intracranial dedicated DES. Herein, we present our experience with the feasibility, safety, and medium-term follow-up outcomes of a novel intracranial DES, named NOVA stent, in patients with symptomatic severe ICAS (≥70%). From December 2021 to May 2022, patients with symptomatic severe ICAS who underwent implantation of the NOVA stent in our institution were retrospectively analyzed for procedural results, perioperative complications, imaging and clinical follow-up outcomes. Twenty-four patients, 16 (66.7%) with anterior circulation lesions and 8 (33.3%) with posterior circulation lesions, were enrolled. All patients with intracranial ICA (n = 6), middle cerebral artery (n = 10), basilar artery (n = 3), intracranial vertebral artery (n = 3), and the vertebrobasilar junction (n = 2) stenosis were treated successfully using NOVA stents. The severity of stenosis ranged from 75 to 96% (mean 85.9%) before treatment and this was reduced to 0 to 20% (mean 8.6%) immediately after stent placement. Symptomatic distal embolism occurred in one case; however, there were no other perioperative complications. The mean follow-up duration was 12.2 ± 1.06 months. No symptomatic ischemic events occurred during follow-up. Follow-up cerebral angiography was performed in 22 of 24 patients (91.7%), and significant ISR occurred in one patient (4.2%). Our results demonstrate that implantation of the novel intracranial DES NOVA in severe ICAS is feasible, safe, and effective in selected cases, reducing the incidence of ISR, and showing excellent midterm clinical outcomes, providing a promising option for ICAS treatment.

First-in-human experience of sirolimus coated balloon for symptomatic intracranial artery stenosis

BackgroundThe drug coated balloon is a promising endovascular therapy for intracranial atherosclerosis (ICAS), potentially combining the advantages of primary angioplasty and antiproliferative drugs. Previous studies have focused on the paclitaxel...

A case report: new-onset nummular headache after stenting of the middle cerebral artery

BackgroundNummular headache (NH) is categorized as a primary headache in the International Classification of Headache Disorders, Third edition (ICHD-3) diagnostic criteria, but there are secondary etiologies as well. We present a case of secondary NH that associated with vascular lesion.Case presentationWe report on a 40-year-old man with a medical history of symptomatic intracranial arterial stenosis who developed a headache after percutaneous transluminal angioplasty and stenting because of Intracranial atherosclerotic stenosis(ICAS). This new-onset headache was a pinprick headache confined to the parietal part of the head and 5 cm in size. This headache most closely resembled the phenotype of a NH. And other causes of secondary headache were excluded. Thus, the diagnosis of NH was highly speculated. This patient represents a rare headache phenomenon after intracranial arterial stent placement.ConclusionThis is the first report of NH after stent placement treatment in a patient with ICAS.

Thromboelastographic and Gene Polymorphism Bimodality Detection for Dual Antiplatelet Aggregation Therapy in Individuals with Clopidogrel-resistant Symptomatic Intracranial Artery Stenosis.

Recent research indicates that clopidogrel resistance is connected with a patient's future ischemia risk, hence increasing the likelihood of recurrent ischemic cerebrovascular disease. Thromboelastographic and clopidogrel gene polymorphism testing can be used to see how a person responds to antiplatelet therapy and change the treatment plan accordingly. This may be a good way to make antiplatelet aggregation therapy more effective and safer. The objective of this study was to investigate the efficacy of dual antiplatelet aggregation therapy in patients with symptomatic intracranial large artery stenosis being resistant to clopidogrel tablets. The thromboelastographic and gene polymorphism bimodality detection techniques were used to analyze the clopidogrel resistance influencing factors. 89 patients with symptomatic intracranial large arterial stenosis who were admitted to our hospital from February 2021 to February 2022 were selected, classified as large artery atherosclerotic type by TOAST, and confirmed as having severe intracranial large arterial stenosis (70 % to 99 %) by magnetic resonance angiography (MRA), computed tomographic angiography (CTA), and digital subtraction angiography (DSA). All patients were treated with dual antiplatelet therapy with aspirin and clopidogrel, and thromboelastography and clopidogrel gene polymorphism were monitored 1 week later. 44 of 89 patients were clopidogrel-resistant. Among 44 patients, 20 were ticagrelorresistant and 24 were cilostazol-resistant. Clopidogrel had a resistance rate of 49.4%. The recurrence of ischemic cerebrovascular disease in the three groups was statistically significant (P<0.05) after 3 months of follow-up treatment, but bleeding (intracranial, gastrointestinal, respiratory, urinary, and mucocutaneous) and dyspnea were not. The clopidogrel-resistant group had a higher number of females, as well as higher levels of hypertension, diabetes, and platelet count than the sensitive group (P<0.05), but there was no significant difference in age, smoking, alcohol consumption, previous stroke, glycosylated haemoglobin, creatinine, or low-density cholesterol. Using thromboelastographic and gene polymorphism bimodality detection, we found switching to ticagrelor antiplatelet aggregation therapy as better than switching to cilostazol in patients with symptomatic intracranial large artery stenosis being resistant to clopidogrel tablets. The results may be biased due to the study being a single-centre study and having a limited sample size.

Abstract TP299: The Relationship Between Intracranial Arterial Stenosis Rate and Cerebral Perfusion

Background and and Objectives: The pressure ratio (PR) across lesions is a vital indicator for assessing residual blood flow after stenosis, yet the relationship between symptomatic intracranial atherosclerotic stenosis degrees and cross-lesion pressure ratios remains unclear. Methods: Data were derived from the Chinese National Stroke Registry III (CNSR III). Three-dimensional meshes were constructed based on TOF-MRA using the finite element method controlled by the Navier-Stokes equation to obtain pressure values. PR was calculated as the ratio of proximal to distal pressure at the stenosis site, indicating post-stenosis blood flow. PR &gt; 0.76 meant normal pressure ratio, while PR ≤ 0.76 indicated reduced ratio. Arterial stenosis severity was categorized using the WASID Method: 50%-69% for moderate and 70%-99% for severe. Statistical analysis explored the correlation between stenosis severity and low PR. Results: The study included 438 patients with symptomatic intracranial arterial stenosis (50-99%), median age 64, 33.79% female. PR ≤ 0.76 accounted for 30%. Among them, PR ≤ 0.76 was observed in 26% of moderate stenosis (50-69%) patients and 39% of severe stenosis (70-99%) patients (Figure A). The PR ≤ 0.76 frequency was significantly higher in severe compared to moderate stenosis (P=0.01). For anterior (Figure B) and posterior (Figure C) circulation stenosis, PR ≤ 0.76 accounted for 43% and 22% respectively, more prevalent in severe stenosis (P=0.01 and P=0.61, respectively). Conclusion: Most patients with symptomatic intracranial atherosclerotic stenosis exhibit normal PR levels, with a correlation between arterial stenosis and cross-lesion pressure ratio. Further research is needed to determine if PR is a more suitable criterion than arterial stenosis for selecting patients for stent treatment.

Abstract TP174: Balloon Expandable Stents versus Self-Expanding Stents for Treatment of Intracranial Arterial Stenosis: A Systematic Review and Meta-Analysis

Background: There is limited data regarding the comparison of balloon-expanding stents (BES) and self-expanding stents (SES) for the treatment of intracranial arterial stenosis. Methods: We conducted a systematic review to identify studies that compared SES and BES in patients with symptomatic intracranial arterial stenosis. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until May 2023. Statistical pooling with random-effects meta-analysis was undertaken to compare the rates/severity of post-procedure stenosis, technical success, stroke and/or mortality, long-term events, and restenosis rates between BES and SES. Results: A total of 20 studies were included. The standardized mean difference (SMD) for post-procedure stenosis (%) was significantly lower (SMD: -0.52, 95% confidence interval [CI]: -0.79 to -0.24, p &lt; 0.001, 10 studies involving 1515 patients) with BES. The odds for technical success were non-significantly lower (odds ratio [OR]: 0.99, 95% CI 0.43-2.26, p = 0.983, 9 studies involving 1001 patients) with BES. The odds for post-procedure 30-day stroke and/or death were significantly lower (OR 0.68, 95% CI: 0.50-0.94, p = 0.019, 15 studies involving 2431 patients), and stroke and/or death beyond 30 days were non-significantly lower (OR 0.64, 95% CI: 0.30-1.37, p = 0.250, 10 studies involving 947 patients) with BES. The odds for restenosis rate were significantly lower (OR 0.50, 95% CI: 0.31-0.80, p = 0.004, 13 studies involving 1115 patients) with BES. Conclusions: Compared with SES, BES was associated with lower rates of post-procedure 30-day stroke and/or death presumably due to less severe post-procedure stenosis in the treatment of symptomatic intracranial arterial stenosis.