Treatment Of Intracranial Stenosis Research Articles

The Enterprise stent…still useful after all these years.

The Enterprise stent (Codman Neuro, Massachusetts, USA) received Food and Drug Administration (FDA) approval in 2007 for stent-assisted coiling (SAC). Since its introduction, newer stents and devices for aneurysm treatment have been developed resulting in a shift in the utilization of this stent from SAC to other off-label indications. To describe our experience with the Enterprise stent being used for SAC and other off-label indications. This is a multi-center retrospective review of the use of the Enterprise stent between 2018 and 2023. All patients in which the Enterprise stent was successfully deployed were included in the study. Our study cohort comprised of 194 patients, mostly females (n = 112, 57.7%), with a mean age of 63.2 years ± 14.3. The Enterprise stent was used for SAC in only 24 (12.4%) patients and was used for rescue stenting in stroke in 101 patients (52.1%), treatment of intracranial stenosis in 53 patients (27.3%), treatment of in-stent stenosis in 1 patient (0.5%), and for treatment of dissections in 15 patients (7.7%). From 2018 to 2023, the use of Enterprise stents for SAC significantly decreased (p < 0.0001) while the use of Enterprise stents for non-SAC purposes was insignificantly variable (p = 0.05). Our study shows that the Enterprise stent remains a reliable tool in neuroendovascular procedures, even if its original intended use has been supplanted by other devices.

Recovery of intracranial stenoses in varicella zoster virus vasculitis after long-term treatment with valacyclovir and prednisolone

Background and purposeOptimal treatment of intracranial stenoses in varicella zoster virus (VZV)-associated vasculitis is unknown. This study aims to evaluate the merits and potential pitfalls of a specific therapeutic strategy, initially proposed by Don Gilden in 2015.MethodsWe describe three patients with intracranial stenoses caused by VZV vasculitis successfully treated by a long-term combination of valacyclovir and prednisolone.ResultsAll three patients were young men suffering from stroke. Only one reported a first contact to VZV in adulthood. All three presented stenoses in the intracranial part of the internal carotid artery or the proximal segments of the middle cerebral artery as well as an elevated cell count and positive VZV antibody index in cerebrospinal fluid. They received a combination therapy regimen with prednisone and valacyclovir about a minimum of one year. Intracranial stenoses improved markedly in one and almost resolved completely in the other two patients. Side effects of corticosteroid treatment occurred in two patients.ConclusionsLong-term combination treatment with prednisone and valacyclovir proved to be effective in three young men suffering from intracranial stenosis due to VZV vasculitis.

Intracranial Atheromatosis Disease (ICAD) and Stent Supported Angioplasty

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

Intracranial Atheromatosis Disease (ICAD) and Stent Supported Angioplasty

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

Diagnosis and Treatment of Intracranial Stenoses.

Stroke is one of the most frequent and most significant vascular diseases. According to estimates, 16.9 million people suffered a stroke in 2010, and over one-third of the incidents were lethal. The risk of suffering a stroke due to intracranial stenosis is between 7 and 24%. As opposed to extracranial stenoses of the internal carotid artery, there is no standardized treatment concept for intracranial stenoses. At present, treatment with a low daily dose of 100 mg aspirin is recommended by the guidelines for intracranial stenoses to additionally prevent dose-dependent gastrointestinal side effects and bleeding complications. The WINGSPAN study showed stroke rates and mortality rates amounting to 4.5% after 30 days and 7.0% after 6 months. The Stenting versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis study is a randomized, multicenter study that compared endovascular stent treatment in patients with symptomatic arteriosclerotic intracranial stenoses with intensified drug therapy. After the inclusion of 451 of 764 study patients planned initially, study recruitment was terminated prematurely because the stroke rate or mortality rate within 30 days was 14.7% in the endovascular treatment group compared with 5.8% in the drug therapy group and 20% within 12 months compared with 12.2%. Quite recently the results of a second randomized study of intracranial stents were published in the Vitesse Intracranial Stent Study for Ischemic Stroke Therapy study. In an analysis published by Liebeskind et al. concerning the impact of collateral vessels on the stroke risk based on data from the Warfarin-Aspirin Symptomatic Intracranial Disease study, it was demonstrated that a sufficiently formed collateral network in patients with high-degree vascular constrictions (≥ 70%) plays a crucial role in the avoidance of strokes. If there is no system of collateral vessels or if it is insufficient, the stroke risk in the dependent vascular territory is six times higher. So far it has not yet been possible to conclusively answer the question of optimal treatment for intracranial stenoses. There is particularly need for action regarding the treatment of high-degree recurrent symptomatic stenoses, not only in light of the unfavorable prognosis but also within the scope of demographic change.

Is the Wingspan Stent More Dangerous Than Natural History in Intracranial Stenosis?

In the August issue of the American Journal of Neuroradiology , Al-Ali et al[1][1] compared the results of percutaneous angioplasty (PTA), balloon-mounted stent (BMS), and the Wingspan system (Boston Scientific, Natick, Massachusetts) in the treatment of intracranial stenoses.[1][1] Both short- and

10 Questions About Intracranial Atherosclerotic Stenosis

Intracranial atherosclerotic disease is one of the most common causes of stroke worldwide, yet treatment for this disease is still uncertain. This article discusses challenges in the diagnosis and treatment of intracranial stenosis by posing 10 commonly asked questions about this disease.

Intracranial atherosclerotic disease

Symptomatic intracranial arterial stenosis carries one of the highest rates of recurrent stroke (10%-20% per year) despite antithrombotic therapy. Stroke prevention strategies for intracranial atherosclerotic disease follow the guidelines for secondary stroke prevention that target atherogenic risk factors. These include following standard stroke prevention guidelines of weight loss for overweight patients, moderate physical exercise (at least 30 minutes most days), cessation of cigarette smoking, and a low-fat, low-cholesterol diet. Pharmacologic treatments include antiplatelet agents, statins, blood sugar control for diabetics, and antihypertensive medications. Goals may include low-density lipoprotein cholesterol less than 100 mg/dL (< 70 mg/dL in high-risk patients). The absolute blood pressure reduction target is uncertain, but average long-term reductions of 10/5 mm Hg are recommended. Angioplasty with stent placement for the treatment of symptomatic severe intracranial stenosis (>/= 70%) is currently being evaluated in a phase 3 randomized controlled trial. It is unclear whether angioplasty with stent placement is superior to angioplasty alone for the treatment of intracranial stenosis, so both endovascular methods are currently acceptable. Complication and success rates for intracranial angioplasty and stent placement are highly variable, so the widespread application of this procedure is generally not recommended outside of clinical trials and experienced centers.

Treatment of intracranial arterial stenosis

Intracranial stenosis accounts for 8–10% of ischemic strokes in the USA. Treatment of intracranial stenosis with extracranial-to-intracranial bypass surgery was investigated as a therapy in the 1980s, but was shown to be no better than aspirin alone. The Warfarin vs Aspirin for Symptomatic Intracranial Disease study found a 12% per year risk of recurrent stroke for symptomatic lesions of 50% or higher, with the majority of strokes occurring in the first year. Warfarin was no better than aspirin in the prevention of recurrent stroke and had a higher risk of serious bleeding and death. Subgroup analysis showed that patients with the highest risk of recurrent stroke included those with 70% or more stenosis and/or recent symptoms and women. Angioplasty and stenting of intracranial stenosis have been undergoing rapid evolution in technology and are emerging as a promising therapy. Current treatment recommendations include antiplatelet agents, with consideration for angioplasty alone or angioplasty and stenting in cases refractory to medical therapy.

Treatment of intracranial stenoses using the Neuroform stent system: initial experience in five cases

We assessed the technical feasibility of balloon-assisted angioplasty with consecutive stenting using a flexible, self-expanding neurovascular stent for the treatment of intracranial arteriosclerotic vascular stenoses. Five consecutive patients with symptomatic drug-resistant stenoses of the intracranial internal carotid artery (ICA) or the main stem of the middle cerebral artery (MCA) were treated by balloon-assisted angioplasty with consecutive stenting using the Neuroform stent system. Balloon dilatation of the stenoses and consecutive stent placement with complete coverage of the stenoses was feasible in all patients. One patient suffered acute thrombosis distally to the stented vessel segment which was successfully treated by fibrinolysis, and one patient suffered acute subarachnoid and parenchymal hemorrhage probably due to vessel perforation. In the other three patients, no complications occurred during or immediately after angioplasty. All patients were free of further ischemic events up to the 6-month follow-up. Our findings demonstrate that the Neuroform stent system can used successfully for the treatment of intracranial stenoses of the ICA and the main stem of the MCA. Although immediate angiographic results are promising, long-term angiographic and clinical follow-up is essential to demonstrate long-term outcome.

Safety and short-term results of stent-assisted angioplasty for the treatment of intracranial arterial stenosis

To evaluate the safety and short-term outcome of endovascular stent-assisted angioplasty for the treatment of intracranial arterial stenosis. Angioplasty and stent placement were administered to treat 46 patients with lesions of atherosclerotic intracranial stenosis, including 16 lesions of basilar artery, 12 of vertebral artery, 13 of internal carotid artery and 9 of middle cerebral artery. Technical success was achieved in 49 of 50 vessels (98%), with no procedure-related death or cerebral ischemic attack. Extracranial internal carotid artery dissection occurred in 1 patient and was successfully treated with a self-expand stent. One patient had subarachnoid hemorrhage because of perforation by microwire with no permanent neurologic deficit, and another 2 patients had groin hematoma. Angiographic examination immediately after stenting revealed that the stenosis rate was significantly reduced (72.4% +/- 12.3% vs 10.6% +/- 7.8%). There was no cerebral ischemic attack in the 37 patients who were clinically followed up (6 - 18 months, mean of 8.5 months). Angioplasty and stenting for the treatment of intracranial stenosis is safe and feasible, and it may be favorable for decreasing the incidence of ischemic attack.

Tratamiento médico de la estenosis arterial intracraneal. ¿Es el mismo en prevención primaria que secundaria?

In this study we review the risk factors associated with the formation and progression of an atheroma plaque, the mechanism involved in cerebral ischemia secondary to intracranial atheromatosis and possible medical treatment in primary and secondary prevention.Medical treatment of intracranial stenoses (ICS) is aimed at stopping the progression of the atheroma plaque and at preventing recurrences in the case of symptomatic stenoses. It is based on the control of vascular risk factors, the use of statins and antithrombotic therapy (antiplatelet or anticoagulation drugs). Although antiplatelet agents have not proved to be beneficial in the primary prevention of stroke, they are recommended in patients with ICS in order to lower the risk of heart attack associated with this pathology. The use of antiplatelet drugs in the secondary prevention of ischemic stroke secondary to an ICS is based on clinical trials which have shown that antiaggregation prevents non-cardioembolic strokes. Nevertheless, several retrospective studies have observed that oral anticoagulation is better than antiaggregation with aspirin. Two prospective clinical trials are currently being conducted which will, in the next few years, help to determine what the first choice medical treatment is for this group of patients.Medical treatment of ICS patients must include the control of vascular risk factors and the use of statins. New studies are needed to be able to establish the first choice antithrombotic drug in secondary prevention.