Symptomatic Middle Cerebral Artery Stenosis Research Articles

Mechanism of Acute Ischemic Stroke in Patients with Severe Middle Cerebral Artery Atherosclerotic Disease

Intracranial atherosclerotic disease (ICAD) is one of the most common causes of ischemic stroke worldwide. Although the pathogenesis of cerebral infarct in ICAD has been reported from autopsy series, the mechanism of stroke is not well known. This study used baseline perfusion imaging and diffusion-weighted imaging (DWI) or computerized tomography (CT) imaging to help identify the mechanism of stroke in ICAD involving the middle cerebral artery (MCA). We retrospectively reviewed baseline CT or magnetic resonance (MR) perfusion studies and diffusion-weighted MR imaging or CT scans in patients with severe symptomatic MCA stenosis. Perfusion scans were classified according to stage of perfusion deficit, and the acute stroke patterns were categorized as borderzone, cortical, or perforating artery infarcts according to DWI or noncontrast CT. Fifteen patients were included in this analysis. All 15 patients had some type of borderzone infarct. Six had borderzone infarct only, 4 had borderzone and cortical infarcts, and 5 had borderzone, cortical, and perforating artery infarcts. Thirteen of the 15 patients had baseline perfusion deficits. In patients with severe MCA ICAD, the mechanism of stroke is multifactorial, but hemodynamic insufficiency plays a significant role. This finding is important in selecting a subgroup of patients who may benefit from revascularization.

Primary angioplasty for symptomatic atherosclerotic middle cerebral artery stenosis.

ObjectiveThe objective of this study is to evaluate the clinical and angiographic outcomes after primary balloon angioplasty in patients with symptomatic middle cerebral artery (MCA, M1 segment) stenosis refractory to medical therapy.Materials and MethodsEleven patients with intracranial stenosis were treated with primary balloon angioplasty. All patients had MCA stenosis with recurrent transient ischemic attack (TIA). The indication for balloon angioplasty was patients with significant MCA stenosis: 1) age older than 18 years with recurrent or progressive TIA or infarction despite optimal medical therapy, including anti-coagulation, dual anti-platelet, and anti-lipid medication; 2) previous ischemic events or asymptomatic severe stenosis (more than 50%) with poor collateral cerebral circulation, or diminished cerebral perfusion on single photon emission computed tomography before and after administration of the intravenous dosage of acetazolamide.ResultsThe median age of patients was 53 years (range 44-79). The technical success rate was 100%. Mean pretreatment stenosis degree was 83.63 ± 9.53% and 29.1 ± 15.4% before and after angioplasty, respectively. Procedural-related complications occurred in four of 11 patients (36%), but none of the patients had permanent neurological deficit. All patients were available for an average follow-up period of 19.4 ± 5.1 months. One patient had a stroke in the territory of angioplasty at two months after angioplasty. The stroke free survival rate at 30 days and 12 months was 100% and 91%, respectively. Restenosis over 50% was observed in three of 11 patients (27%); all were asymptomatic.ConclusionIntracranial angioplasty for symptomatic MCA stenosis refractory to medical therapy can be a treatment option to reduce the risk of further TIA or stroke.

Evaluation of cerebrovascular reserve using xenon-enhanced CT scanning in patients with symptomatic middle cerebral artery stenosis

Cerebrovascular reserve (CVR) is an important prognostic factor in patients with major cerebral arterial steno-occlusive disease. However, few studies have examined CVR in symptomatic intracranial stenosis without ipsilateral extracranial internal carotid artery stenosis. This study sought to evaluate CVR in patients with symptomatic middle cerebral artery (MCA) stenosis using xenon-enhanced computed tomography (Xe/CT) with acetazolamide (ACZ) challenge. Twelve patients with symptomatic MCA stenosis were recruited. All patients were examined by Xe/CT to quantitatively measure resting cerebral blood flow (CBF) and received ACZ challenge to evaluate CVR. For resting CBF, no significant differences were found between the sides in four regions of interest. After the ACZ challenge test, the CVR was significantly different between hemispheres (ipsilateral versus contralateral CVR: 12.9±24.3% versus 28.0±16.8%, respectively; p=0.005) and in the MCA territory (ipsilateral versus contralateral CVR: 8.7±24.7% versus 29.3±24%, respectively; p=0.003). However, no significant differences in CVR were detected between cortical comparisons and white matter comparisons from the two sides. Thus, ACZ-challenge Xe/CT is useful for the measurement of CBF and CVR in these patients. Impaired CVR is an important characteristic of patients with symptomatic MCA stenosis.

Abstract 159: Symptomatic MCA Plaque Enhancement on High Resolution MRI

Objective High-resolution MRI (HR-MRI) is the useful modality to evaluate the characteristics of intracranial arterial atherosclerotic plaque. The purpose of this study was to evaluate the relationship between the enhancement of middle cerebral artery (MCA) plaque on post-contrast HR-MRI and ischemic stroke. Materials and methods Thirty four patients (19 females, 15 males, mean age: 69.0 years ± 12.1) with isolated MCA stenosis of 50% or more were enrolled in this study. Post-contrast axial 3 dimensional T1-weighted VISTA sequence (TR, 350 ms; TE, 19.51 ms; matrix, 360x299; field of view, 113x180; section thickness, 1 mm; total scan time, 3 min 4 sec) was acquired for assessment of the plaque enhancement. The subjects were divided into two groups (symptomatic or asymptomatic), based on the presence of recent ischemic stroke in the same ipsilateral MCA territory as the MCA stenosis. The signal intensity of plague in the stenotic segment and the CSF were measured by ROI on T1-VISTA. It is subdivided the MCA stenosis into moderate stenosis and severe stenosis by the stenotic degree of 80%. The plaque-to-CSF contrast ratio, the stenotic degree, and the clinical parameters (age, sex, atherosclerotic risk factors, ESR) between two groups were compared. Multivariate logistic regression analysis was used to test for the association of contrast ratio, stenotic degree, and the clinical parameters with ischemic stroke. Results Twenty patients had symptomatic MCA stenosis, and 14 patients had asymptomatic lesion. The plaque-to-CSF contrast ratio was a statistically significant difference between the symptomatic group (mean 5.29 ± 1.78) and asymptomatic group (3.67 ± 1.38). In the multivariate logistic regression analysis, the plaque-to-CSF contrast ratio was the only independent factor for ischemic stroke (OR=7.5, P<0.05). Conclusion The results of our study showed that the enhancement of plaques were significantly higher in symptomatic groups than in asymptomatic groups. It is assumed that the enhancement of symptomatic plaques could be related with the vulnerability.

A single-center study of Wingspan stents for symptomatic atherosclerotic stenosis of the middle cerebral artery

The middle cerebral artery (MCA) is one of the most common sites of symptomatic intracranial atherosclerosis. We assessed the safety and efficacy of the Wingspan stent (Boston Scientific, Natick, MA, USA) for the treatment of symptomatic atherosclerotic MCA stenosis. Sixty-one patients with symptomatic MCA stenosis with narrowing of at least 70% among 61 patients were treated using Wingspan stents from March 2007 to December 2010. Clinical outcomes and imaging features were recorded and analyzed. The technical success rate was 98.4%. The rate of procedure-related complications during the periprocedural period (30days) was 5.0% (three of 61 patients), which included one ischemic complication and two hemorrhagic complications with no permanent neurological sequelae. The mean degree of stenosis decreased from 76.8±6.0% to 12.0±11.5% following treatment. Forty-five patients (74%) were available for follow-up imaging with digital subtraction arteriography. In-stent restenosis (ISR) was documented in seven of these patients. A total of 61 patients were available for a clinical follow up. Four ischemic events (6.6%) occurred during the follow-up period, which were all transient ischemic attacks including two symptomatic ISR. The cumulative probability of an adverse event was 11.7% at 1year. Of the 61 patients, 51 (83.6%) had their follow-up visit more than 12months after the procedure, and no adverse events were found beyond 12months after the procedure. Percutaneous transluminal angioplasty and stenting of the MCA was safe and associated with a low periprocedural complication rate. It may result in a good long-term benefit. Prospective randomized controlled trials and further long-term follow up are needed to provide more adequate statistical evidence to support our findings.

Randomized Controlled Trial of Symptomatic Middle Cerebral Artery Stenosis

To investigate the efficacy and safety of percutaneous transluminal angioplasty and stenting (PTAS) for symptomatic middle cerebral artery stenosis compared with standard medical treatment in a low-risk Chinese population. A prospective, randomized, controlled, single-center clinical trial was conducted comparing PTAS with medical treatment for symptomatic middle cerebral artery stenosis (≥70%). Patients were enrolled according to 1:1 enroll ratio (PTAS: medical). The PTAS group received stenting or balloon angioplasty, whereas the medical treatment group received standard medical treatment (aspirin 100mg plus clopidogrel 75 mg/d), and all the patients were under strict control of the risk factors. The end point events were any kind of ipsilateral stroke or transient ischemic attack, or death from any origin during 1-year follow-up. The enrollment was stopped after 70 patients were enrolled from August 2007 to December 2010, with a 30-day rate of end point events of 8.3% versus 5.9% (P=0.69) for PTAS and medical group, respectively, and 1-year rate of end point events of 19.4% versus 17.6% (P=0.85), respectively. There was no significant difference in baseline characteristics between the 2 groups. The mean follow-up time, which was ongoing, was 9.9±3.9 and 9.7±4.4 months, respectively. Among the risk factors, hypertension was the independent related to the outcome (P=0.015). This study showed that endovascular treatment is as safe but not better than medical treatment for symptomatic middle cerebral artery stenosis in a low-risk Chinese population. History of hypertension increases the risk of recurrent ischemic events.

Clinical use of magnetic resonance plaque imaging for intracranial arteries.

To summarize the value and limitations of magnetic resonance (MR) plaque imaging for intracranial arteries. The data of MR plaque imaging of intracranial arteries in 422 patients performed in Peking Union Medical College Hospital from December 2006 to September 2010 were analyzed retrospectively. The success rate for MR plaque imaging of intracranial arteries was 97%. MR plaque imaging clearly displayed the wall structure of the arteries trunk (M1 segment of middle cerebral arteries, M2-3 segment of anterior cerebral arteries, and basilar arteries). Good inter-observer (k=0.91, 95% CI=0.80-1.03) and intra-observer reproducibility (k=0.96,95% CI=0.88-1.03) was observed in the evaluation of middle cerebral arteries' atherosclerosis. The wall features had significant difference between symptomatic and asymptomatic intracranial arteries'stenosis; compared with asymptomatic middle cerebral artery stenosis(35 cases), symptomatic middle cerebral artery stenosis(26 cases) had a significantly larger wall area (P=0.000), greater remodeling ratio (P=0.000), higher prevalence of expansive remodeling (outward expansion of the vessel wall) (P=0.003), and lower prevalence of constrictive remodeling (P=0.008). Arteritis of middle cerebral artery (3 cases) showed circular wall-thickening with apparent gadolinium-diethylene triamine pentaacetic acid-biotin enhancement. The MR plaque imaging is helpful in the evaluation of intracranial arteries stenosis, although it still has the limitations such as short scan range and low resolution.

High resolution MR imaging in patients with symptomatic middle cerebral artery stenosis

PurposeHigh resolution magnetic resonance imaging (HRMRI) has been used as an imaging modality to depict the intracranial artery wall. The aim of this study was to compare images of the vessel wall between symptomatic and asymptomatic atherosclerotic plaques of the middle cerebral artery (MCA) using HRMRI. Materials and methodsFrom September 2009 to August 2010 we prospectively screened consecutive patients for MCA stenosis using time-of-flight (TOF) MR angiography. We studied 14 patients with symptomatic MCA stenosis and 16 patients with asymptomatic MCA stenosis. The HRMRI protocol included three different scans: T1-, T2-, and proton density (PD)-weighted black blood MRI. The cross-sectional images of the MCA wall on HRMRI were compared between the two groups based on the degree of stenosis, remodeling ratio, outward or inward remodeling, plaque signal intensity, plaque surface irregularity, and presence of an intact inner wall. ResultsThe degree of MCA stenosis and the ratio of plaque thickening to patent lumen in the symptomatic group were significantly higher than in the asymptomatic group. Outward remodeling of the stenotic area in symptomatic group was significantly higher than that seen in the asymptomatic group, and the reverse was true for inward remodeling of the stenotic area (it was significantly higher in the asymptomatic group compared to the symptomatic group). T2- and PD-weighted high signal foci, eccentric wall thickening, and plaque volume in the stenotic area were all similar between the two groups. ConclusionsHRMRI has the potential to distinguish between atherosclerotic plaques in symptomatic and asymptomatic MCA stenoses.

Value of imaging lenticulostriate arteries before middle cerebral artery stenting for the prevention of perforator stroke

In this study, we investigated whether pre-procedural imaging of LSAs would potentially be helpful for preventing LSAs from being covered. We retrospectively evaluated the LSAs of 15 consecutive patients who underwent revascularization for symptomatic middle cerebral artery (MCA) stenosis. All patients underwent two- (2D) and three-dimensional (3D) digital subtraction angiography. We found that 46.7 (7/15), 40 (6/15), and 13.3 % (2/15) of patients had stenotic lesions in the proximal, middle, and distal third of the M1 segment, respectively. There was a total of 32 LSAs that originated from the lesioned MCAs. Seven (21.9 %), 10 (31.3 %), 11 (34.4 %), and 4 (12.5 %) LSAs originated from the proximal third of the M1 segment, middle third of the M1 segment, distal third of the M1 segment, and starting segment of the superior M2 segment, respectively. Sixteen (76.2 %) of 22 LSAs in 13 patients were covered by stents. It would have been possible to avoid covering 43.8 % (7/16) of these LSAs with stents if they had been evaluated before stenting, and the stents had been accurately deployed. Among 16 LSAs which were covered by stent, only one (6.25 %) was occluded after coverage. Our data suggest that evaluation of LSAs during MCA stenting would be potentially helpful for preventing LSAs from being covered and subsequently occluded by stents.

FLAIR Vascular Hyperintensities in Acute ICA and MCA Infarction: A Marker for Mismatch and Stroke Severity?

Background: Vascular hyperintensities of brain-supplying arteries on stroke FLAIR MRI are common and represent slow flow or stasis. FLAIR vascular hyperintensities (FVH) are discussed as an independent marker for cerebral hypoperfusion, but the impact on infarct size and clinical outcome in acute stroke patients is controversial. This study evaluates the association of FVH with infarct morphology, clinical stroke severity and infarct growth in patients with symptomatic internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion. Methods: MR images of 84 patients [median age 73 years (IQR 65–80), 56.0% male, median NIHSS 7 (IQR 3–13)] with acute stroke due to symptomatic ICA or MCA occlusion or stenosis were reviewed. Vessel occlusions were identified by MRA time of flight and graded with the TIMI score. Diffusion and perfusion deficit volumes on admission and FLAIR lesion volumes on discharge were assessed. The presence and number of FVH were evaluated according to MCA-ASPECT areas, and associations with MR volumes, morphology of infarction, recanalization status, presence of white matter disease and hemorrhagical transformation as well as with stroke severity (NIHSS), stroke etiology and thrombolysis rate were analyzed. Results: FVH were detectable in 75 (89.3%) patients. The median number of FVH was 4 (IQR 2–7). Patients with FVH >4 presented with more severe strokes due to NIHSS (p = 0.021), had larger initial DWI lesions (p = 0.008), perfusion deficits (p = 0.001) and mismatch volumes/ratios (p = 0.005). The final infarct volume was larger (p = 0.005), and hemorrhagic transformation was more frequent (p = 0.029) in these patients. Conclusions: The presence of FVH indicates larger ischemic areas in brain parenchyma predominantly caused by proximal anterior circulation vessel occlusion. A high count of FVH might be a further surrogate marker for initial ischemic mismatch and stroke severity.

Symptomatic Middle Cerebral Artery Stenosis Treated by Percutaneous Transluminal Angioplasty: Improvement of Cerebrovascular Reserves

This study evaluated the recoveries of cerebrovascular reserves (CVR) after applying percutaneous transluminal angioplasty (PTA) to patients with symptomatic middle cerebral artery (MCA) stenosis of varying severity. The patients were submitted to single photon emission computed tomography (SPECT) to obtain their regional cerebral blood flows at resting stage (rCBF(rest)) and acetazolamide-challenged CBF in five regions of interest (ROIs), including the MCA, on the ipsilateral and contralateral sides of the hemisphere. rCVR values were then calculated from these CBF data to evaluate the CVR recoveries after PTA treatment. When the PTA effects were statistically analyzed of the patients dichotomized into more severe (n=9) and less severe (n=5) groups, distinctly significant ROI-specific PTA effectiveness was observed for CVR rather than CBF values in the patients of the severer group.

Winspan stent for symptomatic atheroscloretic stenosis in middle cerebral arteries

Objective To assess the safety and efficacy of the treatment for symptomatic atherosclerotic middle cerebral artery stenosis with Wingspan stent.Methods One hundred and twenty -seven symptomatic middle cerebral artery stenoses with narrow more than 50％ in 127 patients were treated using Wingspan stents.Clinical manifestations and imaging features were recorded and analyzed whether they were associated with in - stent restenosis.Results The technical success rate was 98.4％.The rate of procedure - related complieations was 3.1％ (4/127).Ninety - nine patients (78.0％) were available for follow - up imaging with digital subtraction arteriography or computerized tomography angiography.In - stent restenosis was documented in 20 of these patients,including 1 symptomatic in - stent restenosis.Hyperlipidemia,reference artery diameter,and residual stenosis have a statistically significant trend to an increased risk of in - stent restenosis.Conclusions Percutaneous transluminal angioplasty and stenting of middle cerebral artery was safe and was with low periprocedural complications.The in - stent restenosis had a high incidence; and was usually asymptomatic. Key words: Middle cerebral vessel; Stent; Atherosclerosis

Frequent Ischemic Events Related to Varying Middle Cerebral Artery Stenosis

We herein present the cases of two patients with multiple ischemic events, presumably due to varying degrees of middle cerebral artery (MCA) stenosis. The first patient was treated medically, and the symptoms and degree of MCA stenosis varied over several months. The second patient received emergent bypass surgery and experienced no further events, although the MCA stenosis progressed over four months. Emergent intracranial bypass surgery is an option for preventing further ischemic events in patients with symptomatic MCA stenosis.

Intracranial Angioplasty and Stenting Through Direct Carotid Puncture

To describe a case of successful intracranial angioplasty and stenting of a symptomatic middle cerebral artery (MCA) stenosis using a transcervical approach. A 73-year-old woman presented with several ischemic strokes in the left MCA distribution. A diagnostic cerebral angiogram demonstrated more than 80% stenosis of her left MCA. Because the patient failed maximal medical therapy, it was decided to perform angioplasty and stenting. Given the patient's tortuous arch and rigid vessels, access was obtained through a transcutaneous puncture with direct visualization of the surgically exposed common carotid artery (CCA). The patient tolerated well the procedure and after successful stenting her symptoms resolved. Access of the intracranial circulation through direct CCA puncture may be a feasible alternative when the transfemoral access is not possible. The transcervical approach may be safe even with the use of antiplatelet medications and anticoagulation.

Acetazolamide-challenged perfusion magnetic resonance imaging for assessment of cerebrovascular reserve capacity in patients with symptomatic middle cerebral artery stenosis: comparison with technetium-99m-hexamethylpropyleneamine oxime single-photon emission computed tomography

Objectives Acetazolamide-challenged perfusion magnetic resonance imaging (MRI) has been shown as a method for assessment of cerebrovascular reserve (CVR) capacity in patients with atherosclerotic steno-occlusive disease of internal carotid artery. We have assessed the feasibility of the acetazolamide-challenged perfusion MRI for evaluating CVR in symptomatic patients with severe middle cerebral artery (MCA) stenosis (≥70%) by comparison with the acetazolamide-challenged technetium-99m-hexamethylpropyleneamine oxime (HMPAO) single-photon emission computed tomography (SPECT). Methods Seventeen prospectively enrolled patients with symptomatic unilateral MCA stenosis underwent technetium-99m-hexamethylpropyleneamine oxime SPECT and perfusion MRI without and with acetazolamide challenge, respectively. Acetazolamide-challenged SPECT and perfusion MRI were compared quantitatively by Region of interest (ROI) analysis. Results At all ROIs, there were no significant differences in percent change between SPECT and perfusion MRI. Patients with impaired CVR showed significant decreases in the percent changes of respective cerebral blood flow ( P=.016) and respective cerebral blood volume ( P=.029). Conclusion Acetazolamide-challenged perfusion MRI is feasible for evaluating CVR in symptomatic patients with severe MCA stenosis quantitatively.

Plaque Distribution of Stenotic Middle Cerebral Artery and Its Clinical Relevance

Microanatomy studies reveal that most penetrating branches of middle cerebral artery (MCA) arise from the dorsal-superior surface of the trunk. Using high-resolution MRI, we sought to explore the plaque distribution of MCA atherosclerosis and its clinical relevance in relation to the orifices of penetrating arteries. We retrospectively analyzed the imaging and clinical data of 86 patients with atherosclerotic MCA stenosis. On high-resolution MRI, plaques were categorized based on the involvement of the superior, inferior, ventral, or dorsal MCA wall. The relationship of plaque distribution and clinical presentation was analyzed. A total of 92 stenotic MCAs (40 symptomatic and 52 asymptomatic) on 828 image slices were studied. Overall, of the 251 slices with identified plaques, plaques were more frequently located at the ventral (44.8%) and inferior (31.7%) wall as compared with the superior (14.3%) and dorsal wall (9.0%; P<0.001). Symptomatic MCA stenosis had more superior (P=0.016) and less inferior (P=0.023) wall plaques than asymptomatic stenosis. Within the group of symptomatic MCA stenosis, vessels with penetrating artery infarctions had more superior (P=0.001) but less ventral (P=0.038) and inferior (P=0.024) plaques than without penetrating artery infarctions. MCA plaques tend to locate opposite to the orifices of penetrating arterial branches. Further studies are required to investigate whether MCA plaque distribution is an independent determinant of stroke occurrence and its subtypes.

Wingspan stenting with modified predilation for symptomatic middle cerebral artery stenosis

Our purpose was to assess the feasibility, safety, and effectiveness of a modified predilation for middle cerebral artery (MCA) stenosis. Wingspan stenting of MCA remains a technical challenge, and rates of residual stenosis and restenosis must be lowered. A series of 48 patients with symptomatic MCA stenosis greater than 50% and refractory to medical therapy underwent Wingspan stenting with different balloon/artery ratios before (group 1, Boston guidelines predilation) or after (group 2, modified predilation) July of 2008. Technical success, periprocedural complications, recurrent symptoms, and restenosis were assessed retrospectively, and risk factors for restenosis were analyzed using logistic regression. Successful stenting occurred in 48 of 49 (98%) lesions. Primary endpoints within 30 days included one (2.12%) minor stroke and two (4.26%) transient ischemic attacks. Stenoses were reduced from 77.11% ± 10.09% to 27.50% ± 6.91% in group 1 versus from 72.56% ± 10.46% to 8.20% ± 5.41% in group 2. A total of 43 patients were followed up for 12.92 ± 5.08 months, and recurrent stroke or transient ischemic attack occurred in two (4.65%) patients. Vessels were followed with transcranial Doppler (43 vessels), angiography (23 vessels), or computed tomographic angiography (one vessel). The restenosis rate was 8 of 18 (44%) in group 1 and 3 of 25 (12%) in group 2. Restenosis was associated with residual stenosis and diabetes. Wingspan stenting for symptomatic MCA stenosis can be performed with high success and low complication rates, and modified predilation with the Gateway balloon can reduce the rates of residual stenosis and restenosis.

Wingspan stent for symptomatic M1 stenosis of middle cerebral artery

Stent placement for intracranial atherosclerotic stenosis has become an alternative treatment technique; however, stent placement for middle cerebral artery (MCA) stenosis remains a technical and clinical challenge. Our purpose was to assess the safety and feasibility of Wingspan stent for patients with symptomatic M1 stenosis, and its initial effect on prevention of ischemic events. Fifty-three cases with recurrent symptomatic MCA stenosis resistant to medical therapy treated by self-expanding stent were reviewed retrospectively (average 58±18.5 years old, 19 women). All patients underwent angioplasty and stenting with the Gateway balloon-Wingspan stent system, and advised follow-up with DSA or TCD at 6th month. Patients had an average stenosis ratio of 76.5±15.4% prior to the treatment. Of the 53 patients, the technical success rate was 98.1% as a whole (52/53). The mean degree of stenosis reduced from (76.5±15.4)% to (18.2±11.3)%. Complications associated with the procedure include subarachnoid hemorrhage (1.89%) and occlusion (3.78%) occurred. During a follow-up of 6 months, there was no recurrence of transient ischemic attack or stroke in 52 cases with successful stenting. Cerebral hemodynamics of MCA using transcranial Doppler monitoring were at normal level (<120 cm/s) in 41 follow-up patients. The follow up angiography at 6 month post-procedure was conducted in 32 patients and showed good patency in stented vessels. Wingspan stent for symptomatic stenosis of middle cerebral artery is a safe and feasible procedure. It improves clinical outcome in the intermediate follow up, but its long-term effect remains to be further evaluated.

Primary angioplasty for a subtype of symptomatic middle cerebral artery stenosis

The purpose of this study was to assess the long-term efficacy of middle cerebral artery revascularisation by primary balloon angioplasty for the prevention of stroke in a certain subtype of patients. A retrospective study was performed to evaluate 33 patients with symptomatic middle cerebral artery stenoses who underwent primary balloon angioplasty; the selection criteria were: greater than 70% stenosis measured by digital subtraction angiography, lesions equal to or shorter than 5mm, lesions near or across a bifurcation, and lesions with very tortuous proximal vessels that increase the risk of stenting. All patients were available for follow-up ranging from 6 to 60months. The technical success rate, periprocedural complications, and long-term outcome were retrospectively reviewed. The mean stenosis degree was reduced from 87.12 ± 7.40 to 23.03 ± 9.84 after angioplasty. The periprocedural complication rate was 18.18% (six dissections without an ischemic event). Two patients had strokes in the territory of the angioplasty at 6 and 32months after angioplasty, and the stroke-free survival at 5years was 90.04% (mean survival time, 56.42 ± 2.43months; 95% CI, 51.66-61.19months). These results suggest that this treatment is safe and could provide a durable clinical result at long-term follow-up in this subtype of patients, but the high rate of dissection remains a major technical drawback.

Techniques in angioplasty with stent for stenosis of middle cerebral artery with extremely tortuous access

Objective To explore the techniques with angioplasty and stenting for symptomatic stenosis of middle cerebral artery (MCA) with extremely tortuous access. Method Angioplasty and stenting was performed in 18 patients with symptomatic stenosis of MCA( >50% ). The guidingwire and stenting -system could not be dilivered to the stenotic lesions via standard technique of single wire in 5 patients for extremely tortuous cartoid siphon. So we chose the technique of double wires. Results Angioplasty and stenting was performed successfully in patients by double - wire technique when the standard single - wire techniques failed. Conclusions Double - wire technique used in intracranial stenosis with extremely tortuous access could obviously raise the rate of successful angioplasty and stenting. Key words: Middle cerebral artery; Stents; Extremely tortuous access; Single - wire technique; Double - wire technique