Risk factors associated with major cerebrovascular complications after intracranial stenting

Peritherapeutic intra-arterial flow changes predict long-term stent patency in patients with severe intracranial artery stenosis receiving PTAS

BACKGROUND AND PURPOSE

The quantitative intra-arterial flow dynamics following percutaneous transluminal angioplasty and stenting (PTAS) for severe intracranial artery stenosis have never been investigated. We aimed to evaluate peritherapeutic intracranial artery flow dynamics following PTAS with quantitative magnetic resonance angiography (qMRA) to predict long-term stent patency.

DESIGN

This is a prospective, single-center study.

METHODS

We recruited participants with severe symptomatic stenosis from intracranial internal carotid artery (ICA) to M1 segment of middle cerebral artery (MCA) between 2018 and 2022. qMRA was performed before (preprocedural), within 24 h after (early postprocedural) and 12 months after (delayed postprocedural) PTAS, and parameters including bilateral M1 segments and basilar artery (BA) flow were recorded. The calibrated M1 ratio was calculated using contralateral M1 (cM1) and BA (cMB) flows as references. We assessed differences in qMRA parameters between subjects with and without significant 12-month in-stent restenosis (ISR).

RESULTS

Forty-four subjects (12 with + 32 without ISR ≥ 50 %) were included. The early postprocedural M1 flow was higher than preprocedural M1 flow in subjects with (p = 0.030) and without (p = 0.031) ISR. The early postprocedural healthy-side M1 flow was lower than preprocedural healthy-side M1 flow (p = 0.014) in subjects without ISR. Both the early (p < 0.001) and delayed (p = 0.014) cM1s were greater than the preprocedural cM1. The residual stenosis grade was positively correlated with delayed postprocedural cM1 in all subjects (r2 = 0.190; p = 0.003).

CONCLUSIONS

The cM1 and a distinct flow dynamic pattern on early qMRA (within 24 h after PTAS) may predict 12-month ISR.

Intracranial stenting compared to medical treatment alone for intracranial atherosclerosis patients: An updated meta-analysis

OBJECTIVE

Stroke is the second-leading cause of death globally. Intracranial atherosclerotic stenosis (ICAS) represents 10-15% of ischemic strokes in Western countries and up to 47% in Asian countries. Patients with ICAS have an especially high risk of stroke recurrence. The aim of this meta-analysis is to reassess recurrent stroke, transient ischemic attack (TIA), and other outcomes with stenting versus best medical management for symptomatic ICAS.

METHODS

The search protocol was developed a priori according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The OVID Medline, Embase, Web of Science, and Cochrane Library databases were searched from inception to August 14th, 2022.

RESULTS

This Meta-analysis Included Four Randomized Controlled Trials (Rcts), With A Total Number Of 991 Patients. The Mean Age Of Participants Was 57 Years. The Total Number Of Intracranial Stenting Patients Was 495, And The Number Of Medical Treatment Patients Was 496. The Included Studies Were Published Between 2011 And 2022. Two Studies Were Conducted In The Usa, And The Other Two In China. All Included Studies Compared Intracranial Stenting To Medical Treatment For Icas.

CONCLUSIONS

In patients with ischemic stroke due to symptomatic severe intracranial atherosclerosis, the rate of 30-day ischemic stroke, 30-day intracerebral hemorrhage, one-year stroke in territory or mortality favored the medical treatment alone without intracranial stenting. The risk of same-territory stroke at last follow-up, disabling stroke at last follow-up, and mortality did not significantly favor either group. Intracranial stenting for atherosclerosis did not result in significant benefit over medical treatment.

Intracranial atherosclerosis update for neurointerventionalists

The management of intracranial atherosclerotic disease (ICAD) has been evolving with advanced imaging, refinements of best medical treatment, and the development of endovascular options. There has been a significant increase in the use of endovascular therapy for symptomatic ICAD in the USA over the past 6 years. The rationale for this review is to update neurointerventionalists in these areas so that evidence-based decisions can be considered when counseling potential patients regarding their risks, benefits, and potential complications. The landmark SAMMPRIS trial demonstrated superiority of aggressive medical management (AMM) over intracranial stenting as an initial treatment. However, the risk of disabling or fatal stroke remains high in patients presenting with stroke treated with AMM. Recent studies showed a significantly lower rate of periprocedural complications from intracranial stenting. Patients who have failed medical treatment may therefore benefit from intracranial stenting, particularly in those with hemodynamic compromise and large vessel embolic stroke. Drug coated angioplasty balloons and drug eluting stents may potentially reduce the risk of in-stent re-stenosis. Large vessel occlusion (LVO) due to underlying ICAD is seen in a subset of thrombectomy-eligible patients. The use of stenting as a rescue therapy in LVO thrombectomy has also shown promising early results.

The 2023 Taiwan Stroke Society Guidelines for the management of patients with intracranial atherosclerotic disease

Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, especially in Asian populations, which has a high risk of recurrent stroke and cardiovascular comorbidities. The present guidelines aim to provide updated evidence-based recommendations for diagnosis and management of patients with ICAD. Taiwan Stroke Society guideline consensus group developed recommendations for management of patients with ICAD via consensus meetings based on updated evidences. Each proposed class of recommendation and level of evidence was approved by all members of the group. The guidelines cover six topics, including (1) epidemiology and diagnostic evaluation of ICAD, (2) nonpharmacological management of ICAD, (3) medical therapy for symptomatic ICAD, (4) endovascular thrombectomy and rescue therapy for acute ischemic stroke with underlying ICAD, (5) endovascular interventional therapy for postacute symptomatic intracranial arterial stenosis, and (6) surgical treatment of chronic symptomatic intracranial arterial stenosis. Intensive medical treatment including antiplatelet therapy, risk factor control, and life style modification are essential for patients with ICAD.

Percutaneous transluminal angioplasty and stenting vs aggressive medical management on stroke or intracranial atherosclerotic stenosis: a systematic review and meta-analysis

There are currently two main treatment strategies mainly for high-risk patients: percutaneous transluminal angioplasty and stenting (PTAS) and aggressive medical management (AMM). However, the choice between PTAS or AMM remains controversial for patients with stroke or intracranial atherosclerotic stenosis (ICAS). The investigators searched the PubMed, Web of Science, Embase, Scopus, and Cochrane library databases. Randomized controlled trial (RCT) comparing PTAS and AMM for patients with stroke or ICAS were selected. RevMan 5.3 was used to analyze the results and assess risk of bias. The primary endpoints are stroke and death within 30 days after enrollment, or ischemic stroke in the territory of the qualifying artery beyond 30 days, and entire follow-up endpoints. The secondary outcomes were the disabling or fatal stroke, and incidence of death within 3 years. Four studies, 989 patients were included in this article. The AMM group was superior in the entire follow-up endpoint (OR 0.56; 95% CI 0.40, 0.79). The AMM also better in primary endpoint within 30 days (OR 0.32; 95% CI 0.17, 0.61). There was no significant difference beyond 30 days (OR 1.08; 95% CI 0.63, 1.86). The remaining outcomes, such as stroke and death, were not significantly different (P > 0.05). This meta-analysis shows AMM is significantly more effective than PTAS in subjects with ICAS due to the high rate of periprocedural stroke (OR 0.32; 95% CI 0.17, 0.61) and stroke during the entire follow-up (OR 0.56; 95% CI 0.40, 0.79) associated with PTAS. Furthermore, PTAS offers no additional benefits over AMM beyond 30 days (OR 1.08; 95% CI 0.63, 1.86).

The effectiveness of enterprise stent use on the treatment of intracranial atherosclerosis disease

OBJECTIVE

To examine the clinical outcome of Enterprise stent in patients with severe and symptomatic intracranial atherosclerosis.

MATERIAL AND METHOD

Twenty-five patients who underwent Enterprise stenting between January 2012 and March 2019 were included in this study. Exclusion criteria were previous intracranial stenting and inadequate follow-up. Technical success rates of the procedures were recorded. Clinical outcome was evaluated with pre- and post-treatment modified Rankin Scale scores. The patients were monitored for 18 months clinically and for 14.3 months radiologically.

RESULTS

The mean age of the 15 males and 10 females was 61.6 ± 8.19. Of these 25 patients, 6 (24%) were in the anterior system and 19 (76%) were in posterior system. The mean degree of pre-treatment stenosis was 86.4% ± 7 with the mean lesion length of 12.5 ± 7.5 mm. The residual stenosis rate was 23.8% ± 8.81. Technical success rate was 100%. There were two major complications within the first 30 days (8%). Late major complications (after 30 days) occurred in one case (4%). Stent restenosis was detected in two patients (8%). No intracranial bleeding or mortality was observed.

CONCLUSION

In this single-center study, we achieved high technical success and tolerable complication rates. Enterprise stent may be a good treatment alternative for severe intracranial stenosis especially in patients resistant to medical treatment when correct patient selection is made. However, further randomized controlled studies, including more cases should be carried out.

Effect of Stenting Plus Medical Therapy vs Medical Therapy Alone on Risk of Stroke and Death in Patients With Symptomatic Intracranial Stenosis: The CASSISS Randomized Clinical Trial

Importance

Prior randomized trials have generally shown harm or no benefit of stenting added to medical therapy for patients with symptomatic severe intracranial atherosclerotic stenosis, but it remains uncertain as to whether refined patient selection and more experienced surgeons might result in improved outcomes.

Objective

To compare stenting plus medical therapy vs medical therapy alone in patients with symptomatic severe intracranial atherosclerotic stenosis.

Design, Setting, and Participants

Multicenter, open-label, randomized, outcome assessor-blinded trial conducted at 8 centers in China. A total of 380 patients with transient ischemic attack or nondisabling, nonperforator (defined as nonbrainstem or non-basal ganglia end artery) territory ischemic stroke attributed to severe intracranial stenosis (70%-99%) and beyond a duration of 3 weeks from the latest ischemic symptom onset were recruited between March 5, 2014, and November 10, 2016, and followed up for 3 years (final follow-up: November 10, 2019).

Interventions

Medical therapy plus stenting (n = 176) or medical therapy alone (n = 182). Medical therapy included dual-antiplatelet therapy for 90 days (single antiplatelet therapy thereafter) and stroke risk factor control.

Main Outcomes and Measures

The primary outcome was a composite of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year. There were 5 secondary outcomes, including stroke in the qualifying artery territory at 2 years and 3 years as well as mortality at 3 years.

Results

Among 380 patients who were randomized, 358 were confirmed eligible (mean age, 56.3 years; 263 male [73.5%]) and 343 (95.8%) completed the trial. For the stenting plus medical therapy group vs medical therapy alone, no significant difference was found for the primary outcome of risk of stroke or death (8.0% [14/176] vs 7.2% [13/181]; difference, 0.4% [95% CI, -5.0% to 5.9%]; hazard ratio, 1.10 [95% CI, 0.52-2.35]; P = .82). Of the 5 prespecified secondary end points, none showed a significant difference including stroke in the qualifying artery territory at 2 years (9.9% [17/171] vs 9.0% [16/178]; difference, 0.7% [95% CI, -5.4% to 6.7%]; hazard ratio, 1.10 [95% CI, 0.56-2.16]; P = .80) and 3 years (11.3% [19/168] vs 11.2% [19/170]; difference, -0.2% [95% CI, -7.0% to 6.5%]; hazard ratio, 1.00 [95% CI, 0.53-1.90]; P > .99). Mortality at 3 years was 4.4% (7/160) in the stenting plus medical therapy group vs 1.3% (2/159) in the medical therapy alone group (difference, 3.2% [95% CI, -0.5% to 6.9%]; hazard ratio, 3.75 [95% CI, 0.77-18.13]; P = .08).

Conclusions and Relevance

Among patients with transient ischemic attack or ischemic stroke due to symptomatic severe intracranial atherosclerotic stenosis, the addition of percutaneous transluminal angioplasty and stenting to medical therapy, compared with medical therapy alone, resulted in no significant difference in the risk of stroke or death within 30 days or stroke in the qualifying artery territory beyond 30 days through 1 year. The findings do not support the addition of percutaneous transluminal angioplasty and stenting to medical therapy for the treatment of patients with symptomatic severe intracranial atherosclerotic stenosis.

Trial Registration

ClinicalTrials.gov Identifier: NCT01763320.

Current status and outlook of biodegradable metals in neuroscience and their potential applications as cerebral vascular stent materials

Over the past two decades, biodegradable metals (BMs) have emerged as promising materials to fabricate temporary biomedical devices, with the purpose of avoiding potential side effects of permanent implants. In this review, we first surveyed the current status of BMs in neuroscience, and briefly summarized the representative stents for treating vascular stenosis. Then, inspired by the convincing clinical evidence on the in vivo safety of Mg alloys as cardiovascular stents, we analyzed the possibility of producing biodegradable cerebrovascular Mg alloy stents for treating ischemic stroke. For these novel applications, some key factors should also be considered in designing BM brain stents, including the anatomic features of the cerebral vasculature, hemodynamic influences, neuro-cytocompatibility and selection of alloying elements. This work may provide insights into the future design and fabrication of BM neurological devices, especially for brain stents.

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The current status of the application of biodegradable metals (BM) in neuroscience was presented.

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We analyzed the possibility of producing biodegradable cerebrovascular Mg alloy stents for ischemic stroke treatment.

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Key factors in designing BM brain stents were discussed.

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This work may provide insights into the future design and fabrication of BM neurological devices, especially for brain stents.

Treatment of basilar artery stenosis with an Apollo balloon-expandable stent: a single-centre experience with 61 consecutive cases

Stent placement for basilar artery (BA) stenosis remains a technical and clinical challenge. This retrospective study introduces the experience with the Apollo balloon-expandable stent (BES) for patients with symptomatic BA stenosis in a single centre in China. Sixty one patients who had undergone intervention for severe symptomatic BA stenosis between May 2012 and September 2018 were enrolled in this study. All patients underwent angioplasty and stenting with an Apollo BES and were followed-up continuously. The technical success rate was 100%. During the procedure, there was no vessel rupture or dissection. Two patients died due to perforator occlusion. One patient developed vasospasm with no symptoms. The rate of complications during the procedure was 4.91% (3/61). BA stent-related stroke or death rates were 4.9% at 30 days (3/61), 6.6% at 3 months (4/61), and 6.6% (4/61) at 6 months. One patient had stent occlusion at 6 months with no symptoms. Restenosis was found in five patients with degrees of restenosis greater than ≥ 50% without any symptoms. In this study, the Apollo BES appeared to be feasible for BA stenosis. Our experience may be valuable for reducing the number of complications. However, further study is needed.

Acute intracranial stenting with mechanical thrombectomy is safe and efficacious in patients diagnosed with underlying intracranial atherosclerotic disease

OBJECTIVE

To investigate whether significant differences exist in recanalization rates and primary outcomes between patients who undergo mechanical thrombectomy alone versus those who undergo mechanical thrombectomy with acute intracranial stenting.

METHODS

Through the utilization of a prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2020, variables such as demographics, co-morbid conditions, symptomatic intracerebral hemorrhage, mortality rate at discharge, and good/poor outcomes in regard to modified thrombolysis in cerebral infarction score and modified Rankin Scale were examined. The outcomes between patients receiving acute intracranial stenting + mechanical thrombectomy and patients that underwent mechanical thrombectomy alone were compared.

RESULTS

There were a total of 420 acute ischemic stroke patients who met criteria for the study (average age 70.6 ± 13.01 years; 46.9% were women). Analysis of 46 patients from the acute stenting + mechanical thrombectomy group (average age 70.34 ± 13.75 years; 37.0% were women), and 374 patients from the mechanical thrombectomy alone group (average age 70.64 ± 12.92 years; 48.1% were women). Four patients (8.7%) in the acute stenting + mechanical thrombectomy group experienced intracerebral hemorrhage versus 45 patients (12.0%) in the mechanical thrombectomy alone group (p = 0.506); no significant increases were noted in the median length of stay (7 vs 8 days; p = 0.208), rates of modified thrombolysis in cerebral infarction 2B-3 recanalization (p = 0.758), or good modified Rankin Scale scores (p = 0.806).

CONCLUSION

Acute intracranial stenting in addition to mechanical thrombectomy was not associated with an increase in overall length of stay, intracerebral hemorrhage rates, or any change in discharge modified Rankin Scale. Further research is required to determine whether mechanical thrombectomy and acute intracranial stenting in acute ischemic stroke patients is unsafe.

Risk factors associated with recurrence of ischemic stroke after intracranial stenting in china: a case-control study

Objectives: To investigate the factors affecting the risk of recurrent stroke after intracranial artery stenting.Methods: This is a subgroup analysis of a prospective single-arm registry study with 20 participating sites. Patients aged 18-85 years old with symptomatic intracranial atherosclerotic stenosis caused by 70-99% stenosis combined with poor collaterals were included in this study. The median follow-up in this study was 26.4 months.Results: A total of 260 patients were recruited in this study. Ischemic stroke related to target vessel occurred in 11 patients (4.2%) from 30 days to the last follow-up. The multivariate analysis revealed age ≥60 years old (OR: 11.991, 95% CI: 1.400-102.716; p = 0.023), no smoking (OR: 0.087, 95% CI: 0.010-0.787; p = 0.030), and Mori C type (OR: 5.129, 95% CI: 1.242-21.178; p = 0.024) retained significance in the model. There was no significant difference in the ischemic stroke based on medical history of hypertension, diabetes, dyslipidemia, baseline percent stenosis, length of stenosis, residual stenosis, and different stent types.Conclusions: Recurrence of ischemic stroke after intracranial stenting may be associated with elderly age, non-smoking, and Mori C type lesion. These factors will need to be monitored in future trials of intracranial stenting.Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01968122.

Timing and Outcomes of Intracranial Stenting in the Post-SAMMPRIS Era: A Systematic Review

Objective: To investigate the impact of timing on the safety and efficacy of stenting for ICAS, we reviewed high-volume randomized controlled trials or prospective cohort studies of stenting for intracranial atherosclerotic artery stenosis (ICAS) after the SAMMPRIS trial.

Methods: We included randomized controlled trials or prospective cohort studies since 2011 (the publication of the SAMMPRIS trial), evaluating the outcomes of intracranial stenting for ICAS patients. The primary outcomes were perioperative and 1-year stroke or death rate. The interaction of timing and outcomes were shown on trend plots. Overall meta-analysis and subgroup analysis by timing of intracranial stenting were conducted.

Results: Fourteen studies with a total of 1,950 patients were included. The perioperative and post-operative stroke or death rates decreased with the time of stenting to the qualifying events. The perioperative stroke rate was significantly higher in patients treated within 21 days after the qualifying events, compared to those beyond 21 days (IRR = 1.60, 95%CI: 1.10–2.33; p = 0.014), similar relationships were obtained for both post-procedural (IRR = 1.61, 95%CI: 1.02–2.55; p = 0.042) and 1-year (IRR = 1.51, 95%CI: 1.10–2.08; p = 0.012) stroke or death rate.

Conclusions: The timing of intracranial stenting may influence the safety and efficacy outcomes of stenting. Intracranial stenting within 21 days from the qualifying events may confer a higher risk of stroke or death. More studies are needed to confirm the impact of timing and the proper cut-off value.

The WOVEN trial: Wingspan One-year Vascular Events and Neurologic Outcomes

BACKGROUND

Prior studies evaluating the Wingspan stent for treatment of symptomatic intracranial atherosclerotic disease have included patients with a spectrum of both on-label and off-label indications for the stent. The WEAVE trial assessed 152 patients stented with the Wingspan stent strictly by its current on-label indication and found a 2.6% periprocedural stroke and death rate.

OBJECTIVE

This WOVEN study assesses the 1-year follow-up from this cohort.

METHODS

Twelve of the original 24 sites enrolling patients in the WEAVE trial performed follow-up chart review and imaging analysis up to 1 year after stenting. Assessment of delayed stroke and death was made in 129 patients, as well as vascular imaging follow-up to assess for in-stent re-stenosis.

RESULTS

In the 1-year follow-up period, seven patients had a stroke (six minor, one major). Subsequent to the periprocedural period, no deaths were recorded in the cohort. Including the four patients who had periprocedural events in the WEAVE study, there were 11 strokes or deaths of the 129 patients (8.5%) at the 1-year follow-up.

CONCLUSIONS

The WOVEN study provides the 1-year follow-up on a cohort of 129 patients who were stented according to the current on-label use. It provides a more homogeneous patient group for analysis than prior studies, and demonstrates a relatively low 8.5% 1-year stroke and death rate in stented patients.

Comparison of safety and mid-term effects between direct stenting and angioplasty before stenting in the basilar artery

OBJECTIVES

Symptomatic atherosclerotic disease of the basilar artery (BA) portends a poor prognosis, and BA seemed to be the most dangerous site for stenting. The authors review their interventional results and mid-term results with or without predilation in BA stenting to find a safer interventional approach.

PATIENTS AND METHOD

A database review identified 94 patients with severe symptomatic BA stenosis were treated with stenting. According to with balloon predilation or not, they were divided into two groups: direct stenting group and angioplasty before stenting group. Baseline data, lesion characteristics, complications and follow-up data from the two groups were compared and analyzed.

RESULTS

The length of lesion in angioplasty before stenting group was longer than that in the direct stenting group (8.12 ± 2.76 mm versus 6.83 ± 2.27 mm, p = 0.015). The proportions of Mori C type lesion was higher in angioplasty before stenting group (31.3 % versus 8.7 %, p = 0.006). The residual stenosis was higher in angioplasty before stenting group (12.66 ± 9.24 % versus 7.67 ± 8.01 %, p = 0.006). There were no significant differences in TIA, stroke, and death between the two groups in the perioperative and postoperative > 1 year follow-up (p > 0.05).

CONCLUSION

BA stenting is relatively safe and has a good results for experienced operators. Angioplasty before stenting is a good way for BA stenting, it makes the operations on difficult lesions as safe as normal one. More optimized stents and safer interventional approach need to be further explored and verified.

Stenting with Acclino (flex) for symptomatic intracranial stenosis as secondary stroke prevention

BACKGROUND AND PURPOSE

Stroke recurrence is high in patients with symptomatic intracranial stenosis despite best medical treatment. Based on evidence from past studies using previous stent generations, elective intracranial stenting (eICS) is considered in a minority of patients. This study aims to report on experience performing eICS with a novel device combination.

METHODS

We retrospectively reviewed data from three high volume stroke centers and analyzed patients that were treated with eICS for symptomatic intracranial stenosis using the Acclino (flex) stent and the NeuroSpeed balloon catheter (Acandis GmbH, Pforzheim, Germany). Study endpoints were periprocedural rates of stroke regardless of territory or death at discharge and at the time of follow-up after eICS. Safety evaluation included asymptomatic and symptomatic intracranial hemorrhage, serious adverse events related to the intervention, and evaluation of stent patency at the time of follow-up.

RESULTS

The median age of patients that met the inclusion criteria (n=76) was 69 years. Target vessels were located in the anterior circulation in 55.3% (42/76) of patients. The periprocedural stroke rate was 6.5% (fatal stroke 2.6%; non-fatal stroke 3.9%) at discharge after eICS. Asymptomatic intracranial hemorrhage was observed in 5.2% (4/76) of patients. Follow-up DSA revealed in-stent restenosis of 25% (15/60), and percutaneous transluminal angioplasty was performed again in 11.6% (7/60) of patients.

CONCLUSION

Stenting for symptomatic intracranial stenosis with the Acclino (flex)/NeuroSpeed balloon catheter seemed to be safe and reinforces eICS as an endovascular therapy option for secondary stroke prevention. Future studies are warranted to confirm these findings and investigate antithrombotic strategies and in-stent restenosis to minimize periprocedural complications and guarantee long term stent patency.

WEAVE Trial: Final Results in 152 On-Label Patients

Background and Purpose- The WEAVE trial (Wingspan Stent System Post Market Surveillance) is a postmarket surveillance trial mandated by the Food and Drug Administration to assess the periprocedural safety of the Wingspan Stent system in the treatment of symptomatic intracranial atherosclerotic disease. Methods- A total of 152 consecutive patients who met the Food and Drug Administration on-label usage criteria were enrolled at 24 hospitals and underwent angioplasty and stenting with the Wingspan stent. On-label criteria included age 22 to 80 years, symptomatic intracranial atherosclerotic stenosis of 70% to 99%, baseline modified Rankin Scale score ≤3, ≥2 strokes in the vascular territory of the stenotic lesion with at least 1 stroke while on medical therapy, and stenting of the lesion ≥8 days after the last stroke. The primary analysis assessed the periprocedural stroke, bleed, and death rate within 72 hours of the procedure with adjudication by a core study Stroke Neurologist. Results- The trial was stopped early after interim analysis of 152 consecutive patients demonstrated a lower than expected 2.6% (4/152 patients) periprocedural stroke, bleed, and death rate. This was lower than the 4% periprocedural primary event safety benchmark set for the interim analysis in the study. A total of 97.4% (148/152) patients were event-free at 72 hours, 1.3% (2/152) had nonfatal strokes, and 1.3% (2/152) of patients died. Conclusions- With experienced interventionalists, and proper patient selection following the on-label usage guidelines, the use of the Wingspan stent for intracranial atherosclerotic disease demonstrated a low periprocedural complication rate and excellent safety profile. This is the largest on-label, multicenter, prospective trial of the Wingspan stent system to date with the lowest reported complication rate. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02034058.

Intracranial Stenting: Is It Still an Option for Treatment of Patients With Intracranial Atherosclerosis?

Intracranial atherosclerotic disease (ICAD) is considered a major cause of recurrent cerebrovascular events. ICAD continues to be a disease without an effective method of reducing the risk of recurrent stroke and death, even with aggressive, highly monitored medical treatment. We reviewed data from three randomized controlled studies that published data comparing intracranial stenting vs. medical treatment for symptomatic severe-ICAD. Ethnic, demographic, clinical, and procedural differences were observed among the data from these trials that might influence their results. Future research should aim at establishing refined selection criteria that can identify high-risk ICAD patients who may benefit from intracranial stenting.

Update in the treatment of intracranial atherosclerotic disease

This review highlights the recent evolution of the imaging, medical management, surgical options and endovascular therapies for symptomatic intracranial atherosclerotic disease (ICAD). Recent imaging developments including optical coherence tomography and other modalities to assess the intracranial arteries for symptomatic ICAD are reviewed, not only to diagnose ICAD but to determine if ICAD plaques have any high-risk features for treatment. Potential future developments in the treatment of ICAD are discussed, including the development of trackable drug-coated balloons for the cerebral circulation to treat primary or restenotic arteries, new iterations of self-expanding intracranial stents with easier delivery systems, and the re-examination of indirect surgical bypass techniques for revascularisation. In addition to these important technological developments, however, is the evolving evidence regarding the best treatment window for these techniques and additional factors in medical management which can improve patient outcomes in this devastating pathology.

Neuroform EZ Stenting for Symptomatic Intracranial Artery Stenosis: 30 Days Outcomes in a High-Volume Stroke Center

Objective: To test whether Neuroform EZ stent placement combined with the modified techniques in symptomatic severe intracranial stenosis (ICAS) would result in lower rates of peri-procedural complications of intracranial stenting. Methods: We retrospectively reviewed the clinical data from 71 consecutive patients who underwent Neuroform EZ stent placement combined with the modified techniques for symptomatic severe ICAS at our institute between January 2016 and October 2017. The primary outcomes were ipsi-lateral ischemic stroke, intra-cerebral hemorrhage, or death within 30 days after stenting. The secondary outcome was technical success. Results: The technical success rate was 100%. The mean pre and post-stent stenoses were 84.2% ± 9.1% (median 85%, IQR75% to 90%) and 16.9% ± 10.2 % (median 15%, IQR 10% to 25%). The frequency of ipsi-lateral stroke, intra-cerebral hemorrhage, or death within 30 days was 0%. Conclusions: The combined use of Neuroform EZ stent placement and the modified techniques for symptomatic severe ICAS is technically feasible and safe, with very low peri-procedural complications. Further studies are required to assess the long-term results of this approach.

Morphologic characteristics of severe basilar artery atherosclerotic stenosis on 3D high-resolution MRI

Background

Two-dimensional high-resolution MRI (2D HRMRI) faces many technical challenges for fully assessing morphologic characteristics of inherent tortuous basilar arteries. Our aim was to investigate remodeling mechanisms and plaque distribution in symptomatic patients with basilar artery stenosis on three-dimensional (3D) HRMRI.

Methods

Forty-six consecutive patients with symptomatic basilar artery atherosclerotic stenosis on MRA (70–99%) were enrolled. The remodeling index (RI) was the ratio of vessel area at the maximal-lumen-narrowing (MLN) site to reference vessel area. RI ≥ 1.05 was defined as positive remodeling (PR), RI ≤ 0.95 as negative remodeling (NR), and 0.95 < RI < 1.05 as intermediate remodeling (IR). The remodeling patterns were divided into two groups (PR and non-PR [NR and IR]). The cross-sectional and longitudinal distribution of BA plaques were evaluated.

Results

Two patients were excluded because of poor-quality images. Images of 44 patients were available for measurements. PR was found in 23 (52.3%) patients, and non-PR in 21 (47.7%) patients. At the MLN sites, vessel area, wall area, plaque size and percentage of plaque burden of PR group were significantly greater than non-PR group (p < .001). Most plaques (90.9%) of the 44 patients were located at the dorsal, left and right walls. For the longitudinal distribution of plaque, 8 (18.2%) and 36 (81.8%) plaques were located in BA proximal and distal to AICA, respectively. Most plaques (68.2%) were eccentrically distributed.

Conclusions

3D HRMRI with postprocessing multiple planar reconstruction is able to evaluate the remodeling pattern and plaque distribution of basilar artery atherosclerotic stenosis, which might be used to guide intracranial intervention.

Different learning curves between stent retrieval and a direct aspiration first-pass technique for acute ischemic stroke

OBJECTIVEThe clinical outcomes of a direct aspiration first-pass technique (ADAPT) and stent retriever (SR) have been reported to be similar in several observational studies. In this study, procedural and clinical outcomes with ADAPT and SR for the treatment of acute ischemic stroke with large artery occlusion were compared in different time periods.METHODSIn each specific time period, SR and ADAPT were used as the first-line treatment approach for acute ischemic stroke patients with large artery occlusion at the authors' institution. Baseline characteristics, procedural variables, and functional outcome at 90 days were compared between patients treated with SR and those treated with ADAPT. These 2 groups were divided into 3 sequential subgroups to assess the learning curve effects of the endovascular team and individual operators on the procedural variables of each treatment strategy.RESULTSOverall, 89 patients were treated. In the SR group, the recanalization rate was higher (84% vs 65%; p = 0.01) and the procedure time was shorter than in the ADAPT group (median 42 minutes vs 76 minutes, p = 0.04). On the subgroup analysis of the learning curve, the SR group showed more rapid improvement in procedure time than the ADAPT group (p = 0.01 for the team; p < 0.01 for individual operators).CONCLUSIONSIn this initial experience, a higher recanalization rate and shorter procedure time were achieved with SR than with ADAPT. A high recanalization rate with SR was possible with relatively less clinical experience, whereas procedure time dramatically decreased with experience. These observed effects on the learning curve might be useful when choosing the method for initial endovascular treatment of acute ischemic stroke at relatively small stroke centers.

Endovascular Treatment of Intracranial Atherosclerotic Stenosis: Current Debates and Future Prospects

Intracranial atherosclerotic stenosis (ICAS) is a common cause of transient ischemic attack (TIA) and ischemic stroke. Endovascular treatment, including balloon angioplasty alone, balloon-mounted stents, and self-expandable stent placement with or without prior angioplasty, is an alternative to medical treatment for the prevention of recurrent TIA or ischemic stroke in patients with ICAS. Although the SAMMPRIS and VISSIT trials supported medical management alone against endovascular treatments, both randomized controlled trials (RCT) were criticized due to flaws relating to patient-, intervention-, and operator-related factors. In this review, we discuss the current debate regarding these aspects and suggest approaches to solve current controversies in the future. In our opinion, endovascular treatment in carefully selected patients, individualized choice of endovascular treatment subtypes, and an experienced multidisciplinary team managing the patient in the pre-, peri- and post-procedural period have the potential to provide safe and efficious treatment of patients with symptomatic ICAS.

Technical factors affecting outcomes following endovascular treatment of posterior circulation atherosclerotic lesions

Background

Atherosclerotic disease of the vertebrobasilar system causes significant morbidity and mortality. All lesions require aggressive medical management, but the role of endovascular interventions remains unsettled. This study examines such endovascular interventions for vertebrobasilar atherosclerosis.

Methods

Retrospective review was performed of prospectively maintained procedure logs at three hospitals with comprehensive neurointerventional services. Patients with angiographically-proven stenosis undergoing elective stent placement were selected for analysis of demographic factors, lesion characteristics, and treatment details. Multivariate analysis was performed to evaluate for associations with ischemic stroke, death, and functional status as measured by modified Rankin scale at multiple intervals.

Results

One hundred and twenty-three lesions were treated in 110 patients. A total of 43 (58.1%) lesions caused stroke, while 66 (89.2%) caused transient ischemic attacks (TIAs). Forty lesions (32.5%) were at the vertebral origin; 97 (60.2%) were intracranial. A total of 112 (91.1%) were treated successfully. 4 (3.3%) of 10 (8.1%) procedural complications were symptomatic. Intracranial lesions were associated with death at 1 and 2 years (OR 24.91, P < 0.001) and mRS >2 at last contact (OR 12.83, P < 0.001). Stenting treatment with conjunctive angioplasty had lower rates of death (OR 0.303, P = 0.046) and mRS >2 at last contact (OR 0.234, P = 0.018) when angioplasty was performed with a device other than that packaged with the stent.

Conclusion

Endovascular treatment of vertebrobasilar atherosclerosis can be performed safely, particularly for vertebral origin lesions. Higher rates of technical failure and complication may be acceptable for certain intracranial lesions due to their refractory nature and the morbidity caused by such lesions. Treatment should be tailored to features of each individual lesion.

Angioplasty, Stenting and Other Potential Treatments of Atherosclerotic Stenosis of the Intracranial Arteries: Past, Present and Future

Although there is an intuitive appeal to treat symptomatic stenotic intracranial arteries with endovascular therapies such as angioplasty and stenting, current data from randomized trials show intensive medical therapy is far superior for preventing stroke. This is in large part due to the high risk of peri-procedural stroke from angioplasty and stenting. If angioplasty and stenting is to emerge as a proven treatment for intracranial stenosis, endovascular techniques will need to become much safer, identification of patients with intracranial stenosis who are at particularly high risk of stroke despite intensive medical therapy will need to be targeted, and well-designed randomized trials will be necessary to show endovascular therapy is superior to medical therapy in these high-risk patients.

Prophylactic Dual Catheter Technique to Prevent Side Branch Snowplowing Complications during Angioplasty and Stenting

Objective

Angioplasty and Stenting of intracranial atherosclerotic lesions have a higher complication rate and a large proportion of this is attributable to side branch arterial occlusion from forceful displacement of the atheroma into the ostia or snowplowing effect. This can result in severe disabilities when it result in small infarcts involving eloquent areas in the posterior circulation or the motor tracts.

Materials and Methods

We present a series of 6 cases utilizing a new dual catheter technique for maintaining the patency of at-risk vessels during angioplasty and stenting. There are several methods previously described to help reduce the incidence of stroke but because they do not have a physical presence in the ostia to protect it, they are unable to guarantee the patency of the vessel.

Results

All 6 patients underwent angioplasty and stenting with the technique. The patients were assessed for complications with post-procedure magnetic resonance imaging and no complications were found.

Conclusion

In this preliminary series, the dual catheter technique appears to safe and effective in preventing occlusion of the adjacent branch arteries. This technique may facilitate the use of the Wingspan stent in the treatment of intracranial atherosclerotic stenotic segments by reducing the risk of peri-procedural stroke.

Effect of Hemodynamics on Stroke Risk in Symptomatic Atherosclerotic Vertebrobasilar Occlusive Disease

IMPORTANCE

Atherosclerotic vertebrobasilar (VB) occlusive disease is a significant etiology of posterior circulation stroke, with regional hypoperfusion as an important potential contributor to stroke risk.

OBJECTIVE

To test the hypothesis that, among patients with symptomatic VB stenosis or occlusion, those with distal blood flow compromise as measured by large-vessel quantitative magnetic resonance angiography (QMRA) are at higher risk of subsequent posterior circulation stroke.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, blinded, longitudinal cohort study was conducted at 5 academic hospital-based centers in the United States and Canada; 82 patients from inpatient and outpatient settings were enrolled. Participants with recent VB transient ischemic attack or stroke and 50% or more atherosclerotic stenosis or occlusion in vertebral and/or basilar arteries underwent large-vessel flow measurement in the VB territory using QMRA. Physicians performing follow-up assessments were blinded to QMRA flow status. Follow-up included monthly telephone calls for 12 months and biannual clinical visits (for a minimum of 12 months, and up to 24 months or the final visit). Enrollment took place from July 1, 2008, to July 31, 2013, with study completion on June 30, 2014; data analysis was performed from October 1, 2014, to April 10, 2015.

EXPOSURE

Standard medical management of stroke risk factors.

MAIN OUTCOMES AND MEASURES

The primary outcome was VB-territory stroke.

RESULTS

Of the 82 enrolled patients, 72 remained eligible after central review of their angiograms. Sixty-nine of 72 patients completed the minimum 12-month follow-up; median follow-up was 23 (interquartile range, 14-25) months. Distal flow status was low in 18 of the 72 participants (25%) included in the analysis and was significantly associated with risk for a subsequent VB stroke (P = .04), with 12- and 24-month event-free survival rates of 78% and 70%, respectively, in the low-flow group vs 96% and 87%, respectively, in the normal-flow group. The hazard ratio, adjusted for age and stroke risk factors, in the low distal flow status group was 11.55 (95% CI, 1.88-71.00; P = .008). Medical risk factor management at 6-month intervals was similar between patients with low and normal distal flow. Distal flow status remained significantly associated with risk even when controlling for the degree of stenosis and location.

CONCLUSIONS AND RELEVANCE

Distal flow status determined using a noninvasive and practical imaging tool is robustly associated with risk for subsequent stroke in patients with symptomatic atherosclerotic VB occlusive disease. Identification of high-risk patients has important implications for future investigation of more aggressive interventional or medical therapies.

Risk factors associated with in-hospital serious adverse events after stenting of severe symptomatic intracranial stenosis

OBJECTIVES

Severe symptomatic intracranial stenosis is an important cause of stroke. Intracranial stenting is alternatively applied to treat intracranial atherosclerotic disease. However, Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis trial (SAMMPRIS) and Vitesse Stent Ischemic Therapy trial (VISSIT) both demonstrated intracranial stenting were inferior to aggressive medical treatment. But careful patient selection probably can improve the outcome of stenting in intracranial artery stenosis. Therefore, the validation of risk factors associated with serious adverse events (SAEs) after intracranial stenting may contribute to identify patients who are at high risk of stenting therapy and benefit patient selection for stenting.

PATIENTS AND METHODS

Patients who underwent intracranial stenting with symptom attributable to severe (>70%) intracranial stenosis were included in our institution. In-hospital SAEs after procedure were reviewed. Risk factors associated with SAEs were analyzed using multivariable logistic regression analysis.

RESULT

Thirty serious adverse events (5.1%) occurred among a total of 583 patients, with a mean age of 58.1±9.7, including 13 ischemic strokes, 12 brain hemorrhages and 5 deaths. Bivariate analysis and multivariable logistic regression analysis showed age (OR=0.94, 95% CI:0.900-0.983), history of DM (OR=2.439, 95% CI:1.107-5.371), preprocedural mRS score (OR=3.076, 95% CI:1.290-7.336) and lesion site in BA (OR=9.056, 95% CI:1.147-71.524) were risk factors associated with SAEs.

CONCLUSION

History of DM and lesion site in BA were risk factors associated with postprocedural in-hospital SAEs after stenting of severe symptomatic intracranial stenosis. But considering of the limitation of this retrospective study, further studies are necessary to confirm our results.

Multicenter Prospective Trial of Stent Placement in Patients with Symptomatic High-Grade Intracranial Stenosis

BACKGROUND AND PURPOSE

On the basis of the high 1-month stroke and/or death (14.7%) rates associated with stent placement in the Stenting versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis trial, modifications in patient selection and procedural aspects for intracranial stent placement have been recommended. We performed a multicenter prospective single-arm trial to determine whether such modifications would result in lower rates of periprocedural stroke and/or death.

MATERIALS AND METHODS

The study enrolled patients with recent transient ischemic attack or ischemic stroke (excluding perforator ischemic events) related to high-grade (70%-99% in severity) stenosis of a major intracranial artery. Patients were treated by using angioplasty and self-expanding stents 3 weeks after the index ischemic event at 1 of the 10 high-volume centers in China. An independent neurologist ascertained the occurrence of any stroke and/or death within 1 month after the procedure.

RESULTS

A total of 100 consecutive patients were recruited. The target lesions were located in the middle cerebral artery (M1) (n = 38, 38%), intracranial internal carotid artery (n = 17, 17%), intradural vertebral artery (n = 18, 18%), and basilar artery (n = 27, 27%). The technical success rate of stent deployment with residual stenosis of <50% was 100%. The overall 1-month stroke and/or death rate was 2% (95% confidence interval, 0.2%-7.0%). Two ischemic strokes occurred in the pontine region (perforator distribution) in patients following angioplasty and stent placement for basilar artery stenosis.

CONCLUSIONS

The results of this prospective multicenter study demonstrated that modifications in patient selection and procedural aspects can substantially reduce the 1-month stroke and/or death rate following intracranial stent placement.

Wingspan stenting can effectively prevent long-term strokes for patients with severe symptomatic atherosclerotic basilar stenosis

OBJECTIVE

To investigate the safety and long-term effect of using the Wingspan stent for severe symptomatic atherosclerotic basilar artery stenosis (≥70%).

MATERIALS AND METHODS

Between July 2007 and April 2013, we had 91 consecutive patients (age range 41-82 years old) with symptomatic severe basilar stenosis (70-99%) who underwent Wingspan stenting at our center. All patients had stenosis-related temporary ischemic attack or strokes. We analyzed the demographic data, pre- and post-procedural cerebral angiography, technical success rate, peri-procedural complications, and clinical and imaging follow-ups.

RESULTS

The Wingspan stenting procedure was successful in all patients: The stenosis was reduced from 82.2% ± 5.8% pre-stenting to 15.9% ± 5.7% post-stenting. The 30-day peri-operative rate for stroke or death was 14.3%, which included ischemic stroke in 12 cases (12/91 = 13.2%) and subarachnoid hemorrhage in one case (1/91 = 1.1%), with a fatal or disabling stroke rate of 2.2%. Among the 77 patients with clinical follow-up assessment within 7-60 months (mean 31.3 ± 15.1 months) after stenting, four patients (5.2%) had posterior ischemia, including one patient with disabling ischemic stroke (1.3%) and three patients (3.9%) with temporary ischemic attack. The 2-year cumulative stroke rate was 16% (95% CI: 8.2-23.8%). Among 46 patients with imaging assessments at 3-45 months (mean, 9.5 ± 8.3) post-stenting, six (13.0%) patients had restenosis, including two (2/46 = 4.3%) with symptomatic restenosis.

CONCLUSIONS

The benefit of stenting for patients with severe basilar artery stenosis (> 70%) may lie in lowering the long-term fatal and disabling stroke rate; and as long as the peri-operative stroke rate can be kept at a relatively lower level, patients with severe basilar stenosis can benefit from basilar artery stenting.

Stenting in Intracranial Stenosis: Current Controversies and Future Directions

Angioplasty and stenting for intracranial atherosclerotic stenosis (ICAS) are a last resort for patients with high-grade intracranial stenosis with multiple ischemic events unresponsive to medical therapy. Medical management, consisting of aggressive risk factor control and dual antiplatelet therapy, is superior to angioplasty and stenting for the prevention of future stroke. Future studies of angioplasty and stenting in this population are important, as the stroke risk on medical therapy is 12 % at 1 year and post-procedure stroke rates are similar to rates with medical treatment. There are many issues that will need to be resolved for stenting to offer any benefit, however. Procedural risks of hemorrhagic and ischemic stroke are unacceptably high. High-risk subgroups, potentially based on hemodynamic factors, will need to be identified for future interventional trials. Nevertheless, it is still reasonable to consider angioplasty and stenting for selected patients with multiple recurrent events despite aggressive medical management, but benefits are unclear at this time.

China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis (CASSISS): A new, prospective, multicenter, randomized controlled trial in China

BACKGROUND

Patients with symptomatic stenosis of intradural arteries are at high risk for subsequent stroke. Since the SAMMPRIS trial, stenting is no longer recommended as primary treatment; however, the results of this trial, its inclusion criteria and its center selection received significant criticism and did not appear to reflect our experience regarding natural history nor treatment complications rate. As intracranial atherosclerosis (ICAS) is the most common cause for stroke in Asian countries, we are hereby proposing a refined prospective, randomized, multicenter study in an Asian population with strictly defined patient and participating center inclusion criteria.

METHODS

The China Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis (CASSISS) trial is an ongoing, government-funded, prospective, multicenter, randomized trial. It recruits patients with recent TIA or stroke caused by 70%-99% stenosis of a major intracranial artery. Patients with previous stroke related to perforator ischemia will not be included. Only high-volume centers with a proven track record will enroll patients as determined by a lead-in phase. Patients will be randomized (1:1) to best medical therapy alone or medical therapy plus stenting. Primary endpoints are any stroke or death within 30 days after enrollment or after any revascularization procedure of the qualifying lesion during follow-up, or stroke in the territory of the symptomatic intracranial artery beyond 30 days. The CASSISS trial will be conducted in eight sites in China with core imaging lab review at a North American site and aims to have a sample size of 380 participants (stenting, 190; medical therapy, 190). Recruitment is expected to be finished by December 2016. Patients will be followed for at least three years. The trial is scheduled to complete in 2019.

CONCLUSION

In the proposed trial, certain shortcomings of SAMMPRIS including patient and participating center selection will be addressed. The present manuscript outlines the rationale and design of the study. We estimate that this trial will allow for a critical reappraisal of the role of intracranial stenting for selected patients in high-volume centers.

Lesion location, stability, and pretreatment management: factors affecting outcomes of endovascular treatment for vertebrobasilar atherosclerosis

BACKGROUND AND PURPOSE

The proper role of endovascular treatment of cervicocerebral atherosclerosis is unclear. Posterior circulation disease has not been investigated as extensively as disease in the anterior circulation. In this study, we characterized the rates of technical success, transient ischemic attack, stroke, and death or disability, for both acute and elective endovascular treatment of atherosclerosis in the vertebrobasilar system.

METHODS

We identified patients with atherosclerosis of the vertebrobasilar circulation who underwent endovascular intervention at our hospital through retrospective medical record review, and evaluated the association between lesion and treatment features and subsequent stroke, death, or disability at 30 days and 1 year.

RESULTS

We identified 136 lesions in 122 patients, including 13 interventions for acute strokes. Technical success was achieved in 123 of 136 cases (90.4%). Elective procedures had higher rates of technical success (6.5% vs 15.4%, p=0.21) and better clinical outcomes. In multivariate analysis, intracranial lesions were associated with more disability (modified Rankin Scale score >2) at 30 days (OR 7.1, p=0.01) and 1 year (OR 10, p=0.03). Patients with non-hypoperfusion related symptoms had fewer strokes at follow-up at 1 year when treated after an asymptomatic interval of >10 days compared with those treated within 10 days of the presenting symptoms (OR 0.2, p=0.03). Statin treatment prior to intervention was associated with favorable outcomes across several examined endpoints. Preoperative antiplatelet treatment was associated with lower rates of disability at 30 days and 1 year (OR 0.1, p<0.01 and OR 0.07, p=0.01, respectively), and preoperative anticoagulation treatment was associated with higher rates of death at 30 days, particularly when prescribed for reasons other than atrial fibrillation (OR 6.4, p=0.01).

CONCLUSIONS

Endovascular treatment of symptomatic vertebrobasilar atherosclerosis can be performed safely and with good outcomes. Technical results were better for those with extracranial disease while clinical outcomes were more favorable in those patients with non-progressive symptoms in the subacute period and those receiving statin therapy.

Stroke recurrence rates among patients with symptomatic intracranial vertebrobasilar stenoses: systematic review and meta-analysis

BACKGROUND

A recent randomized trial of patients with primarily anterior circulation intracranial artery stenosis showed that intensive medical therapy was superior to intracranial stenting in preventing recurrent stroke. The rate of stroke recurrence or death in symptomatic intracranial vertebrobasilar stenosis with medical therapy alone may be especially high, and rates compared with endovascular therapy need further study.

METHODS

We conducted a systematic review and meta-analysis of studies reporting the rates of stroke recurrence or death (the primary outcome) in symptomatic intracranial vertebrobasilar stenosis with medical or endovascular treatment over a minimum follow-up period of 6 months. We included all studies in any language indexed in MEDLINE or EMBASE, supplemented by bibliography searches and by contacting the authors. The secondary endpoints were stroke recurrence, and basilar artery and vertebral artery stroke recurrence rates.

RESULTS

23 studies (592 medical treatment patients and 480 endovascular treatment patients) were included. The risk of combined stroke recurrence or death was 14.8 per 100 person-years (95% CI 9.5 to 20.1) in the medical group compared with 8.9 per 100 person-years (95% CI 6.9 to 11.0) in the endovascular group. The incidence rate ratio was 1.3 (95% CI 1.0 to 1.7). The stroke recurrence rate was 9.6 per 100 person-years (95% CI 5.1 to 14.1) in the medical group compared with 7.2 per 100 person-years (95% CI 5.5 to 9.0) in the endovascular group.

CONCLUSIONS

Our results showed that the risk of stroke recurrence or death or the risk of stroke recurrence alone was comparable between the medical and endovascular therapy groups. A small preventive effect of endovascular therapy may exist, particularly if the 30 day postprocedural risk is reduced.

Lesion stability characteristics outperform degree of stenosis in predicting outcomes following stenting for symptomatic intracranial atherosclerosis

BACKGROUND

Intracranial atherosclerotic disease (ICAD) causes substantial morbidity and mortality. Treatment decisions have most commonly been driven by the degree of luminal stenosis. This study compares ICAD lesion stability features with percentage stenosis for associations with adverse outcomes following treatment with stents.

MATERIALS AND METHODS

Retrospective analysis was performed of prospectively maintained procedure logs. Lesions were classified by symptom type as hypoperfusion, non-hypoperfusion, or indeterminate, and pretreatment asymptomatic intervals were noted. Hypoperfusion lesions and indeterminate or non-hypoperfusion lesions with ≥14 days of asymptomatic interval were classified as stable. Percentage stenosis was calculated and compared against these other symptom features for value in predicting technical complication, ischemic stroke, disability, or death at 90 days and 2 years using univariate and multivariate analysis.

RESULTS

130 lesions were treated in 124 patients. The only statistically significant percent stenosis finding was lesions with 60-99% stenosis were less likely to have technical complications. In univariate analysis, stroke at 2 years was less common with hypoperfusion and stable lesions. In multivariate analysis, only hypoperfusion status was associated with lower stroke rates at 2 years.

CONCLUSIONS

Lesion stability features, particularly non-hypoperfusion symptomatology, outperform percentage stenosis in predicting outcomes following treatment of ICAD with stents. Further examination is needed to better classify the natural history of ICAD and more precisely classify lesion stability.

Diabetes mellitus does not increase the risk of adverse long-term outcomes after intracranial stent placement

The present study is to investigate whether diabetes mellitus (DM) increases risk of adverse long-term outcomes after intracranial stent placement. Patients receiving intracranial stenting were assigned to DM group and non-DM group according to diabetes status. The long-term follow-up endpoint was composite of any stroke and death within 30 days, any ischemic stroke beyond 30 days, and transient ischemic attack in the territory of the stented artery at any time. A total of 44 stenoses in 43 patients were retrospectively analyzed. The cumulative probability of the composite outcomes were 15.4% (95% CI 15.3-47.3%) at 1 year and 30.8% (95% CI 26.5-33.6%) at 2 years for DM group; 17.5% (95% CI 16.0-31.2%) at both 1 year and 2 years for non-DM group (log-rank test, P = 0.424). After adjusting for the confounders, the risk of DM versus non-DM for composite outcomes remained insignificant (hazard ratio: 2.84, 95% CI 0.46-17.66; P = 0.26). Our results showed that there is no significant difference between patients with DM and without DM in cumulative probability of the composite outcomes. It suggests that based on our data, there is no evidence that DM increases the risk of adverse long-term outcomes after intracranial stent placement.

Symptom differences and pretreatment asymptomatic interval affect outcomes of stenting for intracranial atherosclerotic disease

BACKGROUND AND PURPOSE

Different types of symptomatic intracranial stenosis may respond differently to interventional therapy. We investigated symptomatic and pathophysiologic factors that may influence clinical outcomes of patients with intracranial atherosclerotic disease who were treated with stents.

MATERIALS AND METHODS

A retrospective analysis was performed of patients treated with stents for intracranial atherosclerosis at 4 centers. Patient demographics and comorbidities, lesion features, treatment features, and preprocedural and postprocedural functional status were noted. χ(2) univariate and multivariate logistic regression analysis was performed to assess technical results and clinical outcomes.

RESULTS

One hundred forty-two lesions in 131 patients were analyzed. Lesions causing hypoperfusion ischemic symptoms were associated with fewer strokes by last contact [χ(2) (1, n = 63) = 5.41, P = .019]. Nonhypoperfusion lesions causing symptoms during the 14 days before treatment had more strokes by last contact [χ(2) (1, n = 136), 4.21, P = .047]. Patients treated with stents designed for intracranial deployment were more likely to have had a stroke by last contact (OR, 4.63; P = .032), and patients treated with percutaneous balloon angioplasty in addition to deployment of a self-expanding stent were less likely to be stroke free at point of last contact (OR, 0.60; P = .034).

CONCLUSIONS

More favorable outcomes may occur after stent placement for lesions causing hypoperfusion symptoms and when delaying stent placement 7-14 days after most recent symptoms for lesions suspected to cause embolic disease or perforator ischemia. Angioplasty performed in addition to self-expanding stent deployment may lead to worse outcomes, as may use of self-expanding stents rather than balloon-mounted stents.

Angioplasty and stenting of intracranial atherosclerosis with the Wingspan system: 1-year clinical and radiological outcome in a single Asian center

BACKGROUND

This study aimed to evaluate the 1-year clinical and angiographic outcome of angioplasty and stenting of intracranial atherosclerosis using Wingspan and Gateway system.

METHODS

In this prospective study, patients with symptomatic lesions were treated and followed clinically and angiographically by digital subtraction angiography (DSA) for 1 year. The two primary endpoints were recurrent ipsilateral ischemic stroke and in-stent restenosis (ISR) at 1 year. Secondary endpoints included periprocedural death or stroke and all strokes at 1 year. Potential factors correlated with ISR were studied using univariate and multivariate analysis.

RESULTS

Treatment was attempted in 65 patients and successfully completed in 61 (93.8%). Fifty-nine patients (44 men, 15 women) aged 62.86 ± 11.38 years with 66 stenoses (average degree of stenosis 71.78 ± 11.23%) underwent clinical and DSA follow-up at 1 year. There were 66 stenotic lesions. ISR occurred in 11 of the 66 lesions (16.7%). Luminal gain occurred in 32 of the lesions (48.5%), an unchanged lumen in 4 (6%) and luminal loss in 30 (45.4%). The periprocedural stroke or death rate was 6.1% (4/65), including three hemorrhagic and one ischemic stroke, all of which occurred at the corresponding site and resulted in death. There were no interval strokes between the periprocedural time and the 1-year follow-up. The occurrence of ISR was correlated with the degree of stenosis before treatment and was not correlated with patient age or sex, vessel diameter, location of stenosis or failure to control risk factors for atherosclerosis.

CONCLUSIONS

One-year clinical and angiographic outcomes of angioplasty and stenting are promising for symptomatic intracranial atherosclerosis.

The challenge of stroke prevention with intracranial arterial stenosis

Patients with symptomatic intracranial atherosclerotic disease have a high risk of recurrent stroke, and secondary prevention in these patients remains a challenge. Aggressive medical management of vascular risk factors is safe and effective for most high risk patients, but the role of endovascular and surgical therapies still remain uncertain. Future studies may identify novel therapeutic strategies for patients with intracranial atherosclerotic disease, but aggressive risk factor control remains the mainstay of evidenced-based treatment at this time.

Mechanisms of stroke after intracranial angioplasty and stenting in the SAMMPRIS trial

BACKGROUND

Enrollment in the stenting and aggressive medical management for the prevention of stroke in intracranial stenosis (SAMMPRIS) trial was halted owing to higher-than-expected 30-day stroke rates in the stenting arm. Improvement in periprocedural stroke rates from angioplasty and stenting for intracranial atherosclerotic disease (ICAD) requires an understanding of the mechanisms of these events.

OBJECTIVE

To identify the types and mechanisms of periprocedural stroke after angioplasty and stenting for ICAD.

METHODS

Patients who experienced a hemorrhagic or ischemic stroke or a cerebral infarct with temporary signs within 30 days of attempted angioplasty and stenting in SAMMPRIS were identified. Study records, including case report forms, procedure notes, and imaging were reviewed. Strokes were categorized as ischemic or hemorrhagic. Ischemic strokes were categorized as perforator territory, distal embolic, or delayed stent thrombosis. Hemorrhagic strokes were categorized as subarachnoid or intraparenchymal. Causes of hemorrhage (wire perforation, vessel rupture) were recorded.

RESULTS

Three patients had an ischemic stroke after diagnostic angiography. Two of these strokes were unrelated to the procedure. Twenty-one patients had an ischemic stroke (n = 19) or cerebral infarct with temporary signs (n = 2) within 30 days of angioplasty and stenting. Most (n = 15) were perforator territory and many of these occurred after angiographically successful angioplasty and stenting of the basilar artery (n = 8). Six patients experienced a subarachnoid hemorrhage (3 from wire perforation) and 7 had a delayed intraparenchymal hemorrhage.

CONCLUSION

Efforts at reducing complications from angioplasty and stenting for ICAD must focus on reducing the risks of regional perforator infarction, delayed intraparenchymal hemorrhage, and wire perforation.

Learning curve of Wingspan stenting for intracranial atherosclerosis: single-center experience of 95 consecutive patients

Background

Symptomatic brain hemorrhage was a significant cause of periprocedural stroke or death following stenting in the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis trial, which called into question the safety of Wingspan stenting for intracranial atherosclerosis. This study analyzed the role of a learning curve in the safety and outcome of Wingspan stenting from the experience of 95 consecutive patients at a single center.

Methods

In this prospective study the endpoints were major stroke or death (modified Rankin Scale score >3) within 30 days, other neurological complications, technical procedural problems, technical success in completion of angioplasty and stenting and recurrent ischemic stroke in the corresponding vascular territory after 30 days. Data splitting into quarters was used for learning curve analysis.

Results

The periprocedural major stroke or death rate was 4.2% (4/95), minor stroke rate was 5.3% (5/95), total 9.5% (9/95). The technical procedural problem rate was 11.6% (11/95) and the technical success rate was 93.7% (89/95). The 89 patients were followed for 38.9±22.7 months (median 40.8, range 0.2–72, 3463 patient-months) after stenting. The risk of recurrent ischemic stroke in the corresponding vascular territory was 0.7% per patient per year (2/3463 patient-months). Guidewire- or angioplasty-related hemorrhage was the major cause of periprocedural major stroke or death (3/4, 75%) and did not occur in the last quarter. Periprocedural intracerebral hemorrhage was uncommon and perforator stroke did not occur.

Conclusions

There may be a learning curve for mastering the safety precautions of Wingspan stenting for intracranial atherosclerosis.

Detailed analysis of periprocedural strokes in patients undergoing intracranial stenting in Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS)

BACKGROUND AND PURPOSE

Enrollment in the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial was halted due to the high risk of stroke or death within 30 days of enrollment in the percutaneous transluminal angioplasty and stenting arm relative to the medical arm. This analysis focuses on the patient and procedural factors that may have been associated with periprocedural cerebrovascular events in the trial.

METHODS

Bivariate and multivariate analyses were performed to evaluate whether patient and procedural variables were associated with cerebral ischemic or hemorrhagic events occurring within 30 days of enrollment (termed periprocedural) in the percutaneous transluminal angioplasty and stenting arm.

RESULTS

Of 224 patients randomized to percutaneous transluminal angioplasty and stenting, 213 underwent angioplasty alone (n=5) or with stenting (n=208). Of these, 13 had hemorrhagic strokes (7 parenchymal, 6 subarachnoid), 19 had ischemic stroke, and 2 had cerebral infarcts with temporary signs within the periprocedural period. Ischemic events were categorized as perforator occlusions (13), embolic (4), mixed perforator and embolic (2), and delayed stent occlusion (2). Multivariate analyses showed that higher percent stenosis, lower modified Rankin score, and clopidogrel load associated with an activated clotting time above the target range were associated (P ≤ 0.05) with hemorrhagic stroke. Nonsmoking, basilar artery stenosis, diabetes, and older age were associated (P ≤ 0.05) with ischemic events.

CONCLUSIONS

Periprocedural strokes in SAMMPRIS had multiple causes with the most common being perforator occlusion. Although risk factors for periprocedural strokes could be identified, excluding patients with these features from undergoing percutaneous transluminal angioplasty and stenting to lower the procedural risk would limit percutaneous transluminal angioplasty and stenting to a small subset of patients. Moreover, given the small number of events, the present data should be used for hypothesis generation rather than to guide patient selection in clinical practice. Clinical Trial Registration Information- URL: http://clinicaltrials.gov. Unique Identifier: NCT00576693.

Acute intracranial in-stent thrombosis after angioplasty of middle cerebral artery symptomatic stenosis: a case report

INTRODUCTION

Intracranial atherosclerotic disease is one of the major risk factors of ischemic stroke. Percutaneous transluminal angioplasty with stent deployment may be effective for the treatment of symptomatic intracranial stenosis, however its value is yet to be determined. High possibility of serious periprocedural complications, such as acute in-stent thrombosis or stroke, narrows the current recommendations for this treatment to patients with high-grade stenosis (>70%), and to experienced neurointerventional centers.

CASE REPORT

We present a 44-year-old male with symptomatic high-grade stenosis of the M1 segment of left middle cerebral artery, treated with percutaneous transluminal angioplasty with stenting. The procedure was complicated with acute in-stent thrombosis treated with intra-arterial thrombolysis, which resulted in a nondisabling stroke.

CONCLUSIONS

The procedure-related stroke in this patient was probably caused by middle cerebral artery perforator ostium occlusion with balloon predilatation and transient in-stent thrombosis related to insufficient antiplatelet pretreatment. Exhausted cerebrovascular reserve due to long-lasting high-grade intracranial stenosis should also be considered as a factor contributing to ischemic complications.

Prevention of intracranial in-stent restenoses: predilatation with a drug eluting balloon, followed by the deployment of a self-expanding stent

Purpose

Stenting in intracranial atherosclerotic disease (ICAD) is increasingly debated, due to issues of procedural safety, technical efficacy, and in-stent recurrent stenoses (ISR). In the present study, feasibility, safety, and efficacy of angioplasty using a drug-eluting balloon (DEB) followed by the implantation of a self-expanding stent (Enterprise) were evaluated for the treatment of ICAD lesions.

Methods

Fifty-two patients (median age: 71 years; range: 54–86 years; male/female ratio 37:15) underwent stenting of high-grade ICAD lesions between February 2010 and November 2011 in a single center. Angioplasty using a paclitaxel coated SeQuent Please (B. Braun, Germany) or DIOR (Eurocor, Germany) coronary PTCA balloon, followed by the implantation of a self-expanding stent (Enterprise, Codman, USA) was performed in 54 lesions. Angiographic and clinical follow-up was performed at 6 and 12 weeks, 6 and 12 months, and yearly thereafter. Technical success rate, periprocedural complications, occurrence of recurrent ischemic symptoms, and the development of an ISR were analyzed.

Results

Angioplasty using a DEB followed by stent implantation was successfully performed in 44 (81 %) cases. DEB insertion failed in 19 % of the cases and angioplasty was finally performed using a conventional PTCA balloon. The combined procedure related permanent neurologic morbidity and mortality rate (stroke, ICH, and subarachnoid hemorrhage) at 30 days and beyond was 5 %. Angiographic and clinical follow-up were obtained in 33 (61 %) lesions in 32 patients. Recurrent stenosis was seen in one (3 %) lesion.

Conclusion

Angioplasty and stenting using a DEB is safe and yields encouragingly low ISR rates. Further technical developments to improve lesion accessibility are, nevertheless, mandatory.

Perioperative management of a neurosurgical patient requiring antiplatelet therapy

In patients who undergo neurovascular stent placement with postoperative dual antiplatelet therapy to prevent in-stent thrombosis, there is no protocol for balancing the risk of acute stent thrombosis and bleeding if urgent neurosurgical procedures are required. We detail perioperative management of dual antiplatelet therapy in a 66-year-old man with a dolichoectatic aneurysm of the basilar artery treated with a Pipeline stent. Postoperatively, the patient was placed on aspirin and clopidogrel to prevent in-stent thrombosis. One month after the procedure, his neurological status declined secondary to obstructive hydrocephalus. His condition necessitated urgent placement of a ventriculoperitoneal shunt, despite the dual antiplatelet therapy for the flow-diverting Pipeline stent. Aspirin and clopidogrel were discontinued seven days prior to the planned shunt placement. To minimize time off antiplatelet therapy, aspirin was immediately replaced with ibuprofen. Eptifibatide was then started three days prior to surgery. The ibuprofen/eptifibatide bridge was discontinued at midnight prior to surgery. Aspirin was restarted on the first postoperative day and clopidogrel was restarted on the second postoperative day. The patient tolerated shunt placement without excessive bleeding or hemorrhagic complications. During the remainder of his hospital course, no evidence of stent thrombosis or intracranial hemorrhage was noted. We conclude that management of antiplatelet prophylaxis for neurovascular stent thrombosis in patients requiring urgent neurosurgical procedures may be successfully achieved by bridging aspirin and clopidogrel with ibuprofen and eptifibatide in the preoperative period.