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Lin MS, Huang CW, Tsuei YS. Clinical experience in intracranial stenting of Wingspan stent system under local anesthesia. Front Neurol 2024; 15:1348779. [PMID: 38585355 PMCID: PMC10995349 DOI: 10.3389/fneur.2024.1348779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
Objective The use of endovascular treatments for symptomatic intracranial atherosclerosis disease (ICAD) remains contentious due to high periprocedural complications. Many centers resort to general anesthesia for airway protection and optimal periprocedural conditions; however, this approach lacks real-time monitoring of patients' neurological status during procedures. In this study, we employed intracranial stenting with the Wingspan system under local anesthesia to address this challenge. Methods We conducted a retrospective study of 45 consecutive ICAD patients who underwent intracranial stenting with the Wingspan system at our hospital from August 2013 to May 2021. These stenting procedures were performed under local anesthesia in a hybrid operation room. Neurological assessments were conducted during the procedure. The patients with periprocedural complications were analyzed for the risk factors. Results The study included 45 ICAD patients (median age 62 years; 35 male and 10 female individuals). Among them, 30 patients had anterior circulation ICAD, and 15 had posterior circulation ICAD. The periprocedural complication rate was 8.9% (4/45), with an overall mortality rate of 2.2% (1/45). Notably, no procedure-related perforation complications were found, and all ischemic complications occurred in the perforating bearing artery, specifically in patients with stents placed in the middle cerebral artery or basilar artery, while no complications were observed in the non-perforating bearing artery of the internal carotid artery and vertebral artery (p = 0.04). Conclusion Our study demonstrates the safety and efficacy of the Wingspan stent system when performed on selected patients under local anesthesia. This approach seems to reduce procedural-related morbidity and be a safe intervention. In addition, it is crucial for surgeons to be aware that patients with perforator-bearing artery stenosis may be at a higher risk of complications.
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Affiliation(s)
- Mao-Shih Lin
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chih-Wei Huang
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Yuang-Seng Tsuei
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Neurosurgery, Tri-service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Wang T, Xing Z, Gong H, Derdeyn CP, Zaidat OO, Almallouhi E, Luo J, Gao P, Wang H, Jiao L. Stenting versus medical therapy alone for symptomatic intracranial arterial stenosis: protocol for a systematic review and individual patient data meta-analysis. BMJ Open 2023; 13:e071668. [PMID: 37339837 DOI: 10.1136/bmjopen-2023-071668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
INTRODUCTION Intracranial atherosclerotic stenosis (ICAS) is a common cause of stroke worldwide. However, whether the treatment options for symptomatic ICAS is stent placement or medical therapy alone is still controversial. At present, three multicentre randomised controlled trials (RCTs) have been published, but their research designs are also slightly different and the conclusions are not completely consistent. Therefore, we plan to conduct a systematic review and individual patient data (IPD) meta-analysis of randomised clinical trials to ascertain safety and efficacy of stenting versus medical therapy alone for symptomatic patients with intracranial arterial stenosis. METHODS AND ANALYSES We will identify RCTs comparing stenting vs medical therapy alone in patients with symptomatic ICAS stenosis (70%-99%) through a systematic search, mainly including PubMed, MEDLINE, EMBASE, the Cochrane Library and ClinicalTrials.gov. Individual-level patient data for a prespecified list of variables will be sought from authors of all eligible studies. The primary outcome was a composite of stroke or death within 30 days, or stroke in territory of qualifying artery beyond 30 days after randomisation. IPD meta-analysis will be conducted with a one-stage approach. ETHICS AND DISSEMINATION Ethical approval and individual patient consent will not be required in most cases since this IPD meta-analysis will use pseudoanonymised data from RCTs. Results will be disseminated through peer-reviewed journals and international conferences. PROSPERO REGISTRATION NUMBER CRD42022369922.
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Affiliation(s)
- Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Zixuan Xing
- Health Science Center, Xi'an Jiaotong University, Xi'an, China
| | - Haozhi Gong
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Colin P Derdeyn
- Departments of Radiology and Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Osama O Zaidat
- Neuroscience and Stroke Program, Bon Secours Mercy Health St Vincent Hospital, Toledo, Ohio, USA
| | - Eyad Almallouhi
- Departments of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jichang Luo
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Peng Gao
- Department of Neurosurgery and Interventional Neuroradiology, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
| | - Haibo Wang
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery and Interventional Neuroradiology, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, National Center for Neurological Disorders, Beijing, China
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Luo J, Bai X, Huang K, Wang T, Yang R, Li L, Tian Q, Xu R, Li T, Wang Y, Chen Y, Gao P, Chen J, Yang B, Ma Y, Jiao L. Clinical Relevance of Plaque Distribution for Basilar Artery Stenosis. AJNR Am J Neuroradiol 2023; 44:530-535. [PMID: 37024307 PMCID: PMC10171387 DOI: 10.3174/ajnr.a7839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/01/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND AND PURPOSE There is no clear association between plaque distribution and postoperative complications in patients with basilar artery atherosclerotic stenosis. The aim of this study was to determine whether plaque distribution and postoperative complications after endovascular treatment for basilar artery stenosis are related. MATERIALS AND METHODS Our study enrolled patients with severe basilar artery stenosis who were scanned with high-resolution MR imaging and followed by DSA before the intervention. According to high-resolution MR imaging, plaques can be classified as ventral, lateral, dorsal, or involved in 2 quadrants. Plaques affecting the proximal, distal, or junctional segments of the basilar artery were classified according to DSA. An experienced independent team assessed ischemic events after the intervention using MR imaging. Further analysis was conducted to determine the relationship between plaque distribution and postoperative complications. RESULTS A total of 140 eligible patients were included in the study, with a postoperative complication rate of 11.4%. These patients were an average age of 61.9 (SD, 7.7) years. Dorsal wall plaques accounted for 34.3% of all plaques, and plaques distal to the anterior-inferior cerebellar artery accounted for 60.7%. Postoperative complications of endovascular treatment were associated with plaques located at the lateral wall (OR = 4.00; 95% CI, 1.21-13.23; P = .023), junctional segment (OR = 8.75; 95% CI, 1.16-66.22; P = .036), and plaque burden (OR = 1.03; 95% CI, 1.01-1.06; P = .042). CONCLUSIONS Plaques with a large burden located at the junctional segment and lateral wall of the basilar artery may increase the likelihood of postoperative complications following endovascular therapy. A larger sample size is needed for future studies.
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Affiliation(s)
- J Luo
- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China
- Department of Neurosurgery (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.)
| | - X Bai
- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China
- Department of Neurosurgery (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.)
| | - K Huang
- The Eighth Affiliated Hospital (K.H.), SUN YAT-SEN University, Shenzhen, Guangdong Province, China
| | - T Wang
- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China
- Department of Neurosurgery (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.)
| | - R Yang
- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China
- Department of Neurosurgery (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.)
| | - L Li
- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China
- Department of Neurosurgery (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.)
| | - Q Tian
- Xuanwu Hospital, Beijing Key Laboratory of Clinical Epidemiology (Q.T.), School of Public Health
| | - R Xu
- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China
- Department of Neurosurgery (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.)
| | - T Li
- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China
- Department of Neurosurgery (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.)
| | - Y Wang
- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China
- Department of Neurosurgery (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.)
| | - Y Chen
- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China
- Department of Neurosurgery (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.)
| | - P Gao
- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China
- Department of Neurosurgery (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.)
- Department of Interventional Radiology (P.G., L.J.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - J Chen
- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China
- Department of Neurosurgery (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.)
| | - B Yang
- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China
- Department of Neurosurgery (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.)
| | - Y Ma
- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China
- Department of Neurosurgery (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.)
| | - L Jiao
- From the China International Neuroscience Institute (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.), Beijing, China
- Department of Neurosurgery (J.L., X.B., T.W., R.Y., L.L., R.X., T.L., Y.W., Y.C., P.G., J.C., B.Y., Y.M., L.J.)
- Department of Interventional Radiology (P.G., L.J.), Xuanwu Hospital, Capital Medical University, Beijing, China
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Luo J, Wang T, Yang K, Wang X, Xu R, Gong H, Zhang X, Wang J, Yang R, Gao P, Ma Y, Jiao L. Endovascular therapy versus medical treatment for symptomatic intracranial artery stenosis. Cochrane Database Syst Rev 2023; 2:CD013267. [PMID: 36738471 PMCID: PMC9897029 DOI: 10.1002/14651858.cd013267.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Intracranial artery stenosis (ICAS) is an arterial narrowing in the brain that can cause stroke. Endovascular therapy (ET) and conventional medical treatment (CMT) may prevent recurrent ischaemic stroke caused by ICAS. However, there is no consensus on the best treatment for people with ICAS. OBJECTIVES To evaluate the safety and efficacy of endovascular therapy plus conventional medical treatment compared with conventional medical treatment alone for the management of symptomatic intracranial artery stenosis. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, four other databases, and three trials registries on 16 August 2022. We contacted study authors and researchers when we required additional information. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing ET plus CMT with CMT alone for the treatment of symptomatic ICAS. ET modalities included angioplasty alone, balloon-mounted stent, and angioplasty followed by placement of a self-expanding stent. CMT included antiplatelet therapy in addition to control of risk factors such as hypertension, hyperlipidaemia, and diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently screened the records to select eligible RCTs, then extracted data from them. We resolved any disagreements through discussion, reaching consensus decisions among the full team. We assessed risk of bias and applied the GRADE approach to assess the certainty of the evidence. The primary outcome was death by any cause or non-fatal stroke of any type within three months of randomisation. Secondary outcomes included all-cause death or non-fatal stroke of any type occurring more than three months after randomisation, ipsilateral stroke, transient ischaemic attack, ischaemic stroke, haemorrhagic stroke, death, restenosis, dependency, and health-related quality of life. MAIN RESULTS We included four RCTs with 989 participants who had symptomatic ICAS, with an age range of 18 to 85 years. We identified two ongoing RTCs. All trials had high risk of performance bias, as it was impossible to blind participants and personnel to the intervention. Three trials were terminated early. One trial was at high risk of attrition bias because of substantial loss to follow-up after one year and a high proportion of participants transferring from ET to CMT. The certainty of evidence ranged from low to moderate; we downgraded for imprecision. Compared to CMT alone, ET plus CMT probably increases the risk of short-term death or stroke (risk ratio (RR) 2.93, 95% confidence interval (CI) 1.81 to 4.75; 4 RCTs, 989 participants; moderate certainty), short-term ipsilateral stroke (RR 3.26, 95% CI 1.94 to 5.48; 4 RCTs, 989 participants; moderate certainty), short-term ischaemic stroke (RR 2.24, 95% CI 1.30 to 3.87; 4 RCTs, 989 participants; moderate certainty), and long-term death or stroke (RR 1.49, 95% CI 1.12 to 1.99; 4 RCTs, 970 participants; moderate certainty). Compared to CMT alone, ET plus CMT may increase the risk of short-term haemorrhagic stroke (RR 13.49, 95% CI 2.59 to 70.15; 4 RCTs, 989 participants; low certainty), short-term death (RR 5.43, 95% CI 1.21 to 24.40; 4 RCTs, 989 participants; low certainty), and long-term haemorrhagic stroke (RR 7.81, 95% CI 1.43 to 42.59; 3 RCTs, 879 participants; low certainty). It is unclear if ET plus CMT compared with CMT alone has an effect on the risk of short-term transient ischaemic attack (RR 0.79, 95% CI 0.30 to 2.07; 3 RCTs, 344 participants; moderate certainty), long-term transient ischaemic attack (RR 1.05, 95% CI 0.50 to 2.19; 3 RCTs, 335 participants; moderate certainty), long-term ipsilateral stroke (RR 1.78, 95% CI 1.00 to 3.17; 4 RCTs, 970 participants; moderate certainty), long-term ischaemic stroke (RR 1.56, 95% CI 0.77 to 3.16; 4 RCTs, 970 participants; moderate certainty), long-term death (RR 1.61, 95% CI 0.77 to 3.38; 4 RCTs, 951 participants; moderate certainty), and long-term dependency (RR 1.51, 95% CI 0.93 to 2.45; 4 RCTs, 947 participants; moderate certainty). No subgroup analyses significantly modified the effect of ET plus CMT versus CMT alone. The trials included no data on restenosis or health-related quality of life. AUTHORS' CONCLUSIONS This review provides moderate-certainty evidence that ET plus CMT compared with CMT alone increases the risk of short-term stroke and death in people with recent symptomatic severe ICAS. This effect was still apparent at long-term follow-up but appeared to be due to the early risks of ET; therefore, there may be no clear difference between the interventions in terms of their effects on long-term stroke and death. The impact of delayed ET intervention (more than three weeks after a qualifying event) warrants further study.
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Affiliation(s)
- Jichang Luo
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Kun Yang
- Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xue Wang
- Medical Library of Xuanwu Hospital, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ran Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Haozhi Gong
- China International Neuroscience Institute (China-INI), Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Jie Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Renjie Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Peng Gao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
- Department of Interventional Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Wu X, Li J, Wang S, Zou Y, Tang L, Chen Z, Zhang W, Wang Z. Comparative effect of stenting plus medical therapy vs medical therapy alone on the risk of stroke and death in patients with symptomatic intracranial stenosis: a systematic review and meta-analysis. J Neurol 2023; 270:662-672. [PMID: 36301352 PMCID: PMC9886616 DOI: 10.1007/s00415-022-11429-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Recently, several randomized controlled trials (RCTs) of stenting plus medical therapy versus medical therapy alone have been successfully conducted for the treatment of patients with symptomatic intracranial stenosis. This study aimed to evaluate differences between these two therapies in the risk of stroke and death. METHODS MEDLINE, EMBASE, the Cochrane Library, and ClinicalTrials.gov were systematically searched to identify relevant studies published before August 24, 2022. Review Manager 5.3 software was used to assess the data. The risk ratio (RR) was analysed and calculated with a random effect model or a fixed effects model. RESULTS We pooled 921 participants from three RCTs. Compared to the medical therapy alone group, the stenting plus medical therapy group had a higher risk of 30-day death or stroke (RR = 2.69 [1.64-4.41], P < 0.0001, I2 = 0%). When the follow-up period exceeded 1 year (≥ 1 year), there was no significant difference in the risk of stroke or death between these two groups. The subgroup analysis showed that if the time from stroke onset to implantation was extended, additional stenting would have no effect on the risk of stroke or death, whether within 30 days or within 1 year (P = 0.16 and 0.78). CONCLUSION Medical therapy alone has a lower risk of stroke and death in the short term than stenting plus medical therapy, while no difference exists in the long term. More studies are still needed to further explore the precision strategy of stent implantation for symptomatic intracranial stenosis patients.
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Affiliation(s)
- Xin Wu
- Department of Neurosurgery, Suzhou Ninth People's Hospital, Suzhou, 215200, Jiangsu Province, China.,Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Jiaxuan Li
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Shixin Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Yu Zou
- Department of Neurosurgery, Suzhou Ninth People's Hospital, Suzhou, 215200, Jiangsu Province, China
| | - Liyan Tang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China
| | - Wei Zhang
- Department of Neurosurgery, Suzhou Ninth People's Hospital, Suzhou, 215200, Jiangsu Province, China.
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu Province, China.
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Imamura H, Sakai N, Sakai C, Hasegawa Y, Hyodo A, Iihara K, Minematsu K, Ogasawara K. Japanese Postmarket Surveillance of Percutaneous Transluminal Angioplasty and Wingspan Stenting for Intracranial Atherosclerotic Disease. World Neurosurg 2023; 173:e48-e54. [PMID: 36716851 DOI: 10.1016/j.wneu.2023.01.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/22/2023] [Accepted: 01/23/2023] [Indexed: 01/30/2023]
Abstract
BACKGROUND The Wingspan stent system was approved as a rescue device for angioplasty of intracranial atherosclerotic disease (ICAD) in 2012. We conducted the government-recommended Japanese Postmarket Surveillance of Percutaneous Transluminal Angioplasty and Wingspan Stenting for Intracranial Atherosclerotic Disease to monitor Wingspan safety and performance. METHODS In this open-label, single-arm study at 76 centers in Japan, ICAD subjects were treated with the Wingspan stent between 2014 and 2016. Efficacy end points were successful stent deployment and technical success, defined as stenosis improvement to <50%. Safety end points were ischemic stroke, modified Rankin Scale and National Institutes of Health Stroke Scale scores, adverse events, and mortality. Subjects were considered treated outside of current recommendations if not already receiving antithrombotics or if percutaneous transluminal angioplasty and stenting occurred within 7 days of onset. RESULTS The safety cohort included 305 subjects (mean age: 68.7 + 9.6; 83.3% male). Four subjects were removed due to being out of contract. Therefore, 301 subjects were included (mean age: 68.7 ± 9.7; 84.1% male). Successful stent placement was 96.7%. Technical success was observed in 86.8% of lesions. At 1 year, the rate of restenosis was 15.7%, ischemic stroke was 3.9%, and any stroke was 7.9%. Functionally independent outcome (modified Rankin Scale: 0-2) was 88.9% and mortality 3.0%. Significantly more serious adverse events occurred in subjects treated outside of current recommendations (17.9%) versus subjects treated per current recommendations (8.8%) (P = 0.045). CONCLUSIONS Endovascular treatment using the Wingspan stent for ICAD is safe and effective in the Japanese population.
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Affiliation(s)
- Hirotoshi Imamura
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Chiaki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Akio Hyodo
- Department of Neurosurgery, Dokkyo Medical University Saitama Hospital, Koshigaya, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Iwate, Japan
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Surgical Management of Intracranial Atherosclerotic Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023. [DOI: 10.1007/s11936-022-00974-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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8
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Zhong C, Chen S, Zhang J, Luo S, Ye Z, Liu Y, Pang L, Dong Z, Qin C. Intracranial angioplasty with a self-expandable stent for intracranial atherosclerotic stenosis: Systematic review and meta-analysis. Front Neurol 2023; 13:1074228. [PMID: 36698897 PMCID: PMC9870250 DOI: 10.3389/fneur.2022.1074228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Background Intracranial angioplasty with a self-expandable stent (SES) is an important endovascular therapy for symptomatic intracranial arterial stenosis. We sought to update the evaluation of the perioperative safety and long-term outcomes of self-expandable stent for the treatment of symptomatic intracranial arterial stenosis. Methods We comprehensively searched the published literature from each database through Sept 16, 2022, for the PubMed, EMBASE, Web of Science, Cochrane, and Clinical Trials databases. The characteristics of the studies and patients, perioperative complications, and long-term outcomes were extracted. The pooled outcomes and 95% confidence intervals (CIs) were estimated by Stata Statistical Software 14.0. Results A total of 4,632 patients from 58 studies were included. The pooled rate of perioperative stroke or death was 6.32% (95% CI 5.04-7.72%); ischemic stroke beyond 30 days through 1 year was 2.72% (95% CI 1.41-4.38%). Perioperative complications differed between the 2014-2022 and 2005-2013 subgroups, as did long-term outcomes between the off-label SES and Wingspan subgroups. Conclusion The perioperative complications of intracranial angioplasty with SES have been reduced, but the risk of perioperative stroke or death is still higher than that of aggressive medical therapy, and additional studies are needed to determine whether it has better long-term outcomes than aggressive medical therapy. Perioperative complications varied between the 2014-2022 and 2005-2013 subgroups, as did long-term outcomes between the off-label SES and Wingspan subgroups. Given the high level of heterogeneity observed between the included studies, these results should be interpreted with caution and additional studies are needed. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42022316066.
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Mao LL, Ma AJ, Liu ZQ, Zhang J, Xu YF, Chen WY, Cao YJ. A retrospective study of individualized endovascular treatment for symptomatic intracranial atherosclerotic stenosis in patients with ischemic stroke/transient ischemic attack. Front Neurol 2022; 13:1057935. [DOI: 10.3389/fneur.2022.1057935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022] Open
Abstract
BackgroundEndovascular treatment (EVT) is one of the effective treatment procedure for the symptomatic intracranial atherosclerotic stenosis (sICAS).Aim and methodsWe evaluated the efficacy and safety of individualized endovascular treatment for sICAS patients. Clinical and imaging follow-ups were carried out to collect the data of 29 sICAS patients after 6 months of individualized endovascular treatment. Different treatment strategies are selected based on arterial access and lesion morphology of patients. If standard surgical path, narrow artery straight, stenosis length ≤10 mm, then the appropriate specifications of balloon-mounted stent (BMS) treatment. the surgical path is tortuous, the narrow artery is curved, the angle is apparent, the diameter of the near and far ends is significantly different, or the length of the stenosis is >10 mm, self-expanding stent (SES) with appropriate specifications is selected for treatment. If the narrowed artery is hyper flexed and the surgeon deems stenting inappropriate, balloon dilation angioplasty (BDA) treatment is chosen.Results and conclusion31 lesions of 29 sICAS patients received endovascular treatment. The median age was 61 years (IQR 54–69 years). The median preoperative stenosis was 90% (IQR 80–95%), and the mean stenosis length was (8.10 ± 3.27) mm. The most commonly used surgical procedure was Balloon-Mounted Stent (BMS) in 19 cases (65.52%), Self-expanding Stent (SES) in seven cases (24.14%), Balloon Dilation Angioplasty (BDA) in three cases (10.34%). (11.86 + 1.46 mm) was greater than that in the BMS group (6.14 + 1.59 mm) (P < 0.001). The median stenosis was 90% (IQR 80–92.5%) in the BMS group, lower than 99% (IQR 95–100%) in the SES group (P < 0.001). The median post-operative residual stenosis was 20% (IQR 15–25%), significantly improved compared with preoperative (P < 0.001). The success rate of the surgical technique was 93.10% (27/29). One patient (3.45%) had IS recurrence within 48 h after surgery, and the restenosis rate within 6 months after surgery was 6.90% (2/29). No patient died or had recurrent IS. Our data demonstrated that individualized endovascular treatment method could be potentially significant and safe for sICAS patients. This study will provide an important reference for the endovascular treatment of sICAD.
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10
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Diagnostic Predictive Value of Tryptase, Serum Amyloid A and Lipoprotein-Associated Phospholipase A2 Biomarker Groups for Large Atherosclerotic Cerebral Infarction. Emerg Med Int 2022; 2022:5784909. [PMID: 36225714 PMCID: PMC9550468 DOI: 10.1155/2022/5784909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/14/2022] [Accepted: 09/19/2022] [Indexed: 12/01/2022] Open
Abstract
Background There has been a gradual trend towards younger ageing of acute cerebral infarction in recent years. Atherosclerotic plaque rupture followed by dislodgement of emboli and resulting arterial embolism is an important mechanism for the development of acute cerebral infarction. Traditional independent risk factors for cerebral infarction have received attention from clinicians, but the risk factors for large artery atherosclerotic cerebral infarction are still unclear. Various blood biomarkers have an important role in the early diagnosis of large artery atherosclerotic cerebral infarction. Objective To assess the diagnostic predictive value of a group of biomarkers for large artery atherosclerotic cerebral infarction. Methods Lipoprotein-associated phospholipase A2 (LP-PLA2), trypsin-like protein (TPS), serum amyloid A (SAA), and supersensitive C-reactive protein (hs-CRP) levels were measured in the case group (30 cases) and control group (54 cases), respectively. Results The differences in the general data between the two groups were not statistically significant (P > 0.05). Logistic regression and ROC curve analysis showed that Lp-PLA2, TPS, and SAA were positively associated with the diagnosis of large atherosclerotic cerebral infarction (P < 0.05). The area under the ROC curve of the multivariate model for the biomarker group reached 0.995. Conclusion Biomarkers are closely associated with the occurrence of large atherosclerotic cerebral infarction and can be used as clinical adjuncts for diagnosis and assessment of prognosis.
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11
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Ari O, Nas OF, Inecikli MF, Hakyemez B. The effectiveness of enterprise stent use on the treatment of intracranial atherosclerosis disease. Neuroradiol J 2022; 35:612-618. [PMID: 35392732 PMCID: PMC9513921 DOI: 10.1177/19714009221083143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Oguz Ari
- Department of Radiology, Bursa City Hospital, Turkey
| | - Omer F Nas
- Department of Radiology, School of
Medicine, Bursa Uludag University, Turkey
| | - Mehmet F Inecikli
- Department of Radiology, School of
Medicine, Bursa Uludag University, Turkey
| | - Bahattin Hakyemez
- Department of Radiology, School of
Medicine, Bursa Uludag University, Turkey
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12
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Putera RM, Sani AF. A rare case of recurrent headache during exercise due to severe intracranial atherosclerotic stenosis. J Neurosci Rural Pract 2022; 13:775-777. [PMID: 36743748 PMCID: PMC9894330 DOI: 10.25259/jnrp-2022-5-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 02/07/2023] Open
Abstract
Intracranial atherosclerotic stenosis (ICAS) can cause ischemic stroke, up to 30-50% stroke in Asian population. However, recurrent exercise-induced headache due to ICAS has not been reported. We present a case of a patient 60-year-old male suffering from recurrent headache during exercise due to severe ICAS. The headache occurred after 5 minutes of running, appeared shortly after every running, and resolved at rest. Head magnetic resonance angiography showed moderate bilateral stenosis at middle cerebral artery (MCA), and cerebral catheter angiography confirmed 70% stenosis of the left MCA and 20% stenosis of the right MCA, with robust antegrade flow and good collaterals which explained why there was no neurological deficit. After treated with best medical therapy, including dual antiplatelet, statin therapy, and risk factor modification, for 90 days, he was capable of running for 20 min without headache.
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Affiliation(s)
- Rudolph Muliawan Putera
- Department of Neurology, Airlangga Faculty of Medicine, Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Achmad Firdaus Sani
- Department of Neurology, Airlangga Faculty of Medicine, Dr. Soetomo General Hospital, Surabaya, Indonesia
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13
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Tosello R, Riera R, Tosello G, Clezar CN, Amorim JE, Vasconcelos V, Joao BB, Flumignan RL. Type of anaesthesia for acute ischaemic stroke endovascular treatment. Cochrane Database Syst Rev 2022; 7:CD013690. [PMID: 35857365 PMCID: PMC9298671 DOI: 10.1002/14651858.cd013690.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The use of mechanical thrombectomy to restore intracranial blood flow after proximal large artery occlusion by a thrombus has increased over time and led to better outcomes than intravenous thrombolytic therapy alone. Currently, the type of anaesthetic technique during mechanical thrombectomy is under debate as having a relevant impact on neurological outcomes. OBJECTIVES To assess the effects of different types of anaesthesia for endovascular interventions in people with acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Specialised Register of Trials on 5 July 2022, and CENTRAL, MEDLINE, and seven other databases on 21 March 2022. We performed searches of reference lists of included trials, grey literature sources, and other systematic reviews. SELECTION CRITERIA: We included all randomised controlled trials with a parallel design that compared general anaesthesia versus local anaesthesia, conscious sedation anaesthesia, or monitored care anaesthesia for mechanical thrombectomy in acute ischaemic stroke. We also included studies reported as full-text, those published as abstract only, and unpublished data. We excluded quasi-randomised trials, studies without a comparator group, and studies with a retrospective design. DATA COLLECTION AND ANALYSIS Two review authors independently applied the inclusion criteria, extracted data, and assessed the risk of bias and the certainty of the evidence using the GRADE approach. The outcomes were assessed at different time periods, ranging from the onset of the stroke symptoms to 90 days after the start of the intervention. The main outcomes were functional outcome, neurological impairment, stroke-related mortality, all intracranial haemorrhage, target artery revascularisation status, time to revascularisation, adverse events, and quality of life. All included studies reported data for early (up to 30 days) and long-term (above 30 days) time points. MAIN RESULTS We included seven trials with 982 participants, which investigated the type of anaesthesia for endovascular treatment in large vessel occlusion in the intracranial circulation. The outcomes were assessed at different time periods, ranging from the onset of stroke symptoms to 90 days after the procedure. Therefore, all included studies reported data for early (up to 30 days) and long-term (above 30 up to 90 days) time points. General anaesthesia versus non-general anaesthesia(early) We are uncertain about the effect of general anaesthesia on functional outcomes compared to non-general anaesthesia (mean difference (MD) 0, 95% confidence interval (CI) -0.31 to 0.31; P = 1.0; 1 study, 90 participants; very low-certainty evidence) and in time to revascularisation from groin puncture until the arterial reperfusion (MD 2.91 minutes, 95% CI -5.11 to 10.92; P = 0.48; I² = 48%; 5 studies, 498 participants; very low-certainty evidence). General anaesthesia may lead to no difference in neurological impairment up to 48 hours after the procedure (MD -0.29, 95% CI -1.18 to 0.59; P = 0.52; I² = 0%; 7 studies, 982 participants; low-certainty evidence), and in stroke-related mortality (risk ratio (RR) 0.98, 95% CI 0.52 to 1.84; P = 0.94; I² = 0%; 3 studies, 330 participants; low-certainty evidence), all intracranial haemorrhages (RR 0.92, 95% CI 0.65 to 1.29; P = 0.63; I² = 0%; 5 studies, 693 participants; low-certainty evidence) compared to non-general anaesthesia. General anaesthesia may improve adverse events (haemodynamic instability) compared to non-general anaesthesia (RR 0.21, 95% CI 0.05 to 0.79; P = 0.02; I² = 71%; 2 studies, 229 participants; low-certainty evidence). General anaesthesia improves target artery revascularisation compared to non-general anaesthesia (RR 1.10, 95% CI 1.02 to 1.18; P = 0.02; I² = 29%; 7 studies, 982 participants; moderate-certainty evidence). There were no available data for quality of life. General anaesthesia versus non-general anaesthesia (long-term) There is no difference in general anaesthesia compared to non-general anaesthesia for dichotomous and continuous functional outcomes (dichotomous: RR 1.21, 95% CI 0.93 to 1.58; P = 0.16; I² = 29%; 4 studies, 625 participants; low-certainty evidence; continuous: MD -0.14, 95% CI -0.34 to 0.06; P = 0.17; I² = 0%; 7 studies, 978 participants; low-certainty evidence). General anaesthesia showed no changes in stroke-related mortality compared to non-general anaesthesia (RR 0.88, 95% CI 0.64 to 1.22; P = 0.44; I² = 12%; 6 studies, 843 participants; low-certainty evidence). There were no available data for neurological impairment, all intracranial haemorrhages, target artery revascularisation status, time to revascularisation from groin puncture until the arterial reperfusion, adverse events (haemodynamic instability), or quality of life. Ongoing studies We identified eight ongoing studies. Five studies compared general anaesthesia versus conscious sedation anaesthesia, one study compared general anaesthesia versus conscious sedation anaesthesia plus local anaesthesia, and two studies compared general anaesthesia versus local anaesthesia. Of these studies, seven plan to report data on functional outcomes using the modified Rankin Scale, five studies on neurological impairment, six studies on stroke-related mortality, two studies on all intracranial haemorrhage, five studies on target artery revascularisation status, four studies on time to revascularisation, and four studies on adverse events. One ongoing study plans to report data on quality of life. One study did not plan to report any outcome of interest for this review. AUTHORS' CONCLUSIONS In early outcomes, general anaesthesia improves target artery revascularisation compared to non-general anaesthesia with moderate-certainty evidence. General anaesthesia may improve adverse events (haemodynamic instability) compared to non-general anaesthesia with low-certainty evidence. We found no evidence of a difference in neurological impairment, stroke-related mortality, all intracranial haemorrhage and haemodynamic instability adverse events between groups with low-certainty evidence. We are uncertain whether general anaesthesia improves functional outcomes and time to revascularisation because the certainty of the evidence is very low. However, regarding long-term outcomes, general anaesthesia makes no difference to functional outcomes compared to non-general anaesthesia with low-certainty evidence. General anaesthesia did not change stroke-related mortality when compared to non-general anaesthesia with low-certainty evidence. There were no reported data for other outcomes. In view of the limited evidence of effect, more randomised controlled trials with a large number of participants and good protocol design with a low risk of bias should be performed to reduce our uncertainty and to aid decision-making in the choice of anaesthesia.
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Affiliation(s)
- Renato Tosello
- Department of Neurointerventional Radiology, Hospital Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil
| | - Rachel Riera
- Centre of Health Technology Assessment, Universidade Federal de São Paulo, São Paulo, Brazil
- Núcleo de Ensino e Pesquisa em Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde (NEP-Sbeats), Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Caroline Nb Clezar
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jorge E Amorim
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Benedito B Joao
- Division of Anesthesia, Pain, and Intensive Medicine, Department of Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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Nso N, Nassar M, Trimingham M, Mbome Y, Lyonga Ngonge A, Badejoko SO, Akbar S, Azhar A, Lakhdar S, Ghallab M, Guzman Perez LM, Rizzo V, Munira MS. Invasive Management of Vertebrobasilar Artery Stenosis and Occlusion: A Meta-Analysis on Efficacy and Safety Endpoints. Cureus 2022; 14:e24751. [PMID: 35686282 PMCID: PMC9170364 DOI: 10.7759/cureus.24751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/05/2022] Open
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15
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Wu X, Ya J, Zhou D, Ding Y, Ji X, Meng R. Pathogeneses and Imaging Features of Cerebral White Matter Lesions of Vascular Origins. Aging Dis 2021; 12:2031-2051. [PMID: 34881084 PMCID: PMC8612616 DOI: 10.14336/ad.2021.0414] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/14/2021] [Indexed: 01/10/2023] Open
Abstract
White matter lesion (WML), also known as white matter hyperintensities or leukoaraiosis, was first termed in 1986 to describe the hyperintense signals on T2-weighted imaging (T2WI) and fluid-attenuated inversion recovery (FLAIR) maps. Over the past decades, a growing body of pathophysiological findings regarding WMLs have been discovered and discussed. Currently, the generally accepted WML pathogeneses mainly include hypoxia-ischemia, endothelial dysfunction, blood-brain barrier disruption, and infiltration of inflammatory mediators or cytokines. However, none of them can explain the whole dynamics of WML formation. Herein, we primarily focus on the pathogeneses and neuroimaging features of vascular WMLs. To achieve this goal, we searched papers with any type published in PubMed from 1950 to 2020 and cross-referenced the keywords including “leukoencephalopathy”, “leukoaraiosis”, “white matter hyperintensity”, “white matter lesion”, “pathogenesis”, “pathology”, “pathophysiology”, and “neuroimaging”. Moreover, references of the selected articles were browsed and searched for additional pertinent articles. We believe this work will supply the robust references for clinicians to further understand the different WML patterns of varying vascular etiologies and thus make customized treatment.
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Affiliation(s)
- Xiaoqin Wu
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jingyuan Ya
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,4Division of Clinical Neuroscience, Queen's Medical Center School of Medicine, the University of Nottingham, Nottingham NG7 2UH, UK
| | - Da Zhou
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- 3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,5Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
| | - Xunming Ji
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ran Meng
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
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16
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Nguyen L, Maingard J, Jhamb A, Brooks M, Barras C, Kok HK, Asadi H. Intracranial atherosclerotic disease and acute ischaemic stroke: A review of diagnosis and management. J Med Imaging Radiat Oncol 2021; 66:391-403. [PMID: 34894071 DOI: 10.1111/1754-9485.13366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 11/23/2021] [Indexed: 11/29/2022]
Abstract
Intracranial atherosclerotic disease is highly prevalent and a common cause of ischaemic stroke globally. With the increasing use of endovascular treatment for acute stroke management, computed tomography and magnetic resonance imaging have become an essential part of patient selection. In this review, we present the typical imaging findings of intracranial atherosclerosis and an overview of management as relevant to diagnostic and interventional radiologists.
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Affiliation(s)
- Lauren Nguyen
- NeuroInterventional Radiology Unit, Monash Health, Melbourne, Victoria, Australia
| | - Julian Maingard
- NeuroInterventional Radiology Unit, Monash Health, Melbourne, Victoria, Australia.,Department of Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Ashu Jhamb
- Interventional Neuroradiology Service, Austin Health, Melbourne, Victoria, Australia
| | - Mark Brooks
- School of Medicine, Deakin University, Geelong, Victoria, Australia.,Interventional Neuroradiology Service, Austin Health, Melbourne, Victoria, Australia
| | - Christen Barras
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,The University of Adelaide, Adelaide, South Australia, Australia
| | - Hong Kuan Kok
- Department of Radiology, Northern Health, Melbourne, Victoria, Australia
| | - Hamed Asadi
- NeuroInterventional Radiology Unit, Monash Health, Melbourne, Victoria, Australia.,Department of Imaging, Monash Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia.,Interventional Neuroradiology Service, Austin Health, Melbourne, Victoria, Australia
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17
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Zhang H, Yan QF, Shen H, Jin W, Zhang Z, Miao Z, Zhang Y, Sun X. Recurrent in-stent thrombosis following V4 segment of vertebral artery stenting: A case report. Int J Surg Case Rep 2021; 85:106288. [PMID: 34393097 PMCID: PMC8361038 DOI: 10.1016/j.ijscr.2021.106288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/30/2021] [Accepted: 08/01/2021] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE We report a rare case of subacute recurrent in-stent thrombosis after vertebral artery stenting of the left intracranial segment. CASE PRESENTATION A 56-year-old man presented with V4 segment severe stenosis of the left vertebral artery. Stent (Apollo, 2.5 mm × 8 mm) implantation was performed for severe stenosis of the left vertebral artery. Approximately 48 h after operation, the patient developed dizziness and drowsiness. DSA showed stent thrombosis, which was treated by PTAS (Apollo, 2.5 mm × 13 mm), and the preoperative symptoms resolved. Two days later, symptoms of posterior circulation ischemia reappeared, DSA showed recurrence of stent thrombosis and CYP2C19 genotypic analysis showed intermediate metabolizers. Revision PTAS (Enterprise, 4.5 mm × 28 mm) was performed followed by administration of Ticagrelor instead of tirofiban. The patient showed good neurological outcomes. CTA performed both one week and four months after the operation showed that the blood flow of the left vertebral artery was unobstructed. CLINICAL DISCUSSION Endovascular therapy is an alternative treatment for severe intracranial vascular stenosis, and reocclusion is one of the serious complications. CONCLUSION our case report highlights that recurrent in-stent thrombosis maybe be caused by inadequate preoperative assessment and unsuitable therapeutic drug selection for the stents.
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Affiliation(s)
- Huijun Zhang
- Department of Neurology, Tong Ren Hospital Shanghai Jiaotong University School of Medicin
| | - Qian Feng Yan
- Department of Neurology, Tong Ren Hospital Shanghai Jiaotong University School of Medicin
| | - Hua Shen
- Department of Neurology, Tong Ren Hospital Shanghai Jiaotong University School of Medicin
| | - Wei Jin
- Department of Neurology, Tong Ren Hospital Shanghai Jiaotong University School of Medicin
| | - Zhichen Zhang
- Department of Neurology, Tong Ren Hospital Shanghai Jiaotong University School of Medicin
| | - Zhongrong Miao
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University
| | - Yun Zhang
- Department of Neurology, Tong Ren Hospital Shanghai Jiaotong University School of Medicin,Corresponding authors at: Department of Neurology, Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, 119 South Fourth Ring West Road, Fengtai District, Beijing, China.
| | - Xuan Sun
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University,Corresponding authors at: Department of Neurology, Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, 119 South Fourth Ring West Road, Fengtai District, Beijing, China.
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18
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Tang H, Lu Z, Zeng Z, Zuo Q, Li Q, Xu F, Huang Q, Liu J. Endovascular treatment of symptomatic intracranial atherosclerotic stenosis with low profile visualized intraluminal support stent. J Clin Neurosci 2021; 90:256-261. [PMID: 34275559 DOI: 10.1016/j.jocn.2021.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/08/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Severe intracranial atherosclerotic stenosis has become one of the main causes resulting transient ischemic attack and stroke. This study aimed to evaluate the efficacy and safety of low profile visualized intraluminal support (LVIS) stent in treating symptomatic intracranial atherosclerotic stenosis. METHODS Data of 31 patients with at least 70% stenosis treated with LVIS stent in our center were retrospectively collected between July 2017 and November 2020. Further evaluation of lesion characteristics, technical success rate, preoperative complication, clinical and angiographic follow-up outcome, delayed in-stent stenosis were conducted. RESULTS Stent delivery and deployment were successfully achieved in all 31 patients (100%). 22 cases (71%) were located in anterior circulation and 9 cases (29%) were located in posterior circulation. The mean degree of stenosis lesion before stent deployment was 85.6 ± 9.4%, while after stenting was 11.2 ± 11.8%. One patient suffered from ischemic complication in stenting procedure, and timely delivery of rt-PA successfully recanalized the artery. Clinical follow-up was available in all 31patients (100%) with mean follow-up time 15.0 ± 12.1(3-45) months. No patients experienced the recurrence of stroke or TIA or death after discharge. Angiographic follow-up was available in 21patients (67.7%) with mean follow-up time 11.43 ± 6.8 (6-36) months. 19 patients (90.5%) were stable while 2 patients (9.5%) developed ISR in their last angiographic follow-up. The 2 patients received balloon angioplasty and reached satisfactory results after retreatment. CONCLUSION This preliminary study suggests that LVIS stent deployment was a feasible approach in treating intracranial atherosclerotic stenosis with satisfactory procedure success rate, low complication rate and favorable long-term outcome.
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Affiliation(s)
- Haishuang Tang
- Department of Neurosurgery, Changhai Hospital, Navy Military Medical University, Shanghai 200433, People's Republic of China; Naval Medical Center of PLA, Navy Military Medical University, Shanghai 200050, People's Republic of China
| | - Zhiwen Lu
- Department of Neurosurgery, Changhai Hospital, Navy Military Medical University, Shanghai 200433, People's Republic of China
| | - Zhangwei Zeng
- Department of Neurosurgery, Changhai Hospital, Navy Military Medical University, Shanghai 200433, People's Republic of China
| | - Qiao Zuo
- Department of Neurosurgery, Changhai Hospital, Navy Military Medical University, Shanghai 200433, People's Republic of China
| | - Qiang Li
- Department of Neurosurgery, Changhai Hospital, Navy Military Medical University, Shanghai 200433, People's Republic of China
| | - Fengfeng Xu
- Naval Medical Center of PLA, Navy Military Medical University, Shanghai 200050, People's Republic of China.
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital, Navy Military Medical University, Shanghai 200433, People's Republic of China.
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Navy Military Medical University, Shanghai 200433, People's Republic of China
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19
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Luo J, Li L, Wang T, Yang K, Feng Y, Yang R, Ma Y, Gao P, Yang B, Jiao L. Risk Factors of New Cerebral Infarctions After Endovascular Treatment for Basilar Artery Stenosis Based on High-Resolution Magnetic Resonance Imaging. Front Neurol 2021; 11:620031. [PMID: 33551976 PMCID: PMC7855455 DOI: 10.3389/fneur.2020.620031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/18/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: The current study aims to analyze the risk factors of new cerebral infarctions in the distribution of basilar artery (BA) detected by diffusion-weighted imaging (DWI) after endovascular treatment in patients with severe BA stenosis. Methods: Data was collected from the electronic medical records of patients with severely atherosclerotic basilar artery stenosis (≥70%) who underwent endovascular treatment. The plaque characteristics, including the plaque distribution, plaque burden, plaque enhancement index, remodeling ratio, and stenosis degree, were evaluated qualitatively and quantitatively using high-resolution magnetic resonance imaging (HR-MRI) and digital subtraction angiography (DSA). The characteristics of the procedure, such as the type of treatment, balloon diameter, balloon length, stent diameter, and stent length, were analyzed. Results: A total of 107 patients with severe basilar artery stenosis (≥70%) who underwent endovascular treatment were enrolled. The study participants included 77 men and 30 women, with an average age of 61.6 ± 8.1 years. The rate of postoperative new cerebral infarctions was 55.1% (59/107), of which 74.6% (44/59) were caused by artery-to-artery embolism, 6.8% (4/59) due to perforator occlusion, and 18.6% (11/59) were caused by a mixed mechanism. Twelve of 59 patients had ischemic events, with nine cases of stroke and three cases of transient ischemic attacks (TIA). The plaque burden in the DWI-positive group was significantly larger than that in the DWI-negative group (3.7% vs. -8.5%, p = 0.016). Positive remodeling was more common in the DWI-positive group than in the DWI-negative group (35.6% vs. 16.7%, p = 0.028). Smoking was inversely correlated with the rate of new cerebral infarctions (odds ratio, 0.394; 95% confidence interval, 0.167-0.926; p = 0.033). Conclusion: The plaque characteristics are not associated with new cerebral infarctions in the distribution of BA, although a large plaque burden and positive remodeling are more likely to appear in patients with new cerebral infarctions after BA stenting, which warrants further studies with a larger sample size. As for smoking, the inverse correlation with new cerebral infarctions in the BA territory needs large-scale prospective randomized controlled trials to verify.
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Affiliation(s)
- Jichang Luo
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Long Li
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Wang
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yao Feng
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Renjie Yang
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Ma
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Peng Gao
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bin Yang
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liqun Jiao
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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20
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Piano M, Milonia L, Cervo A, Modello B, Macera A, Pero G, Quilici L, Boccardi E, Valvassori L. Endovascular Treatment of Symptomatic Intracranial Vertebrobasilar Stenosis: A 10-Year Single Centre Experience Using Balloon-Expandable Coronary Artery Stents. J Stroke Cerebrovasc Dis 2020; 30:105431. [PMID: 33161353 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/14/2020] [Accepted: 10/25/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Symptomatic intracranial vertebro-basilar stenoses (SIVBS) are associated with high risk of recurrent ischemic stroke, even in patients receiving the best medical treatment. Although medical treatment is still the standard of care, non-responding patients may require endovascular treatment; balloon-mounted coronary stents (BMCS) could be successfully employed. This study aims to retrospectively analyze our high volume Interventional Neurovascular center ten-year experience in the off-label use of BMCS for the treatment of SIVBS, in order to assess its feasibility and safety. METHODS We retrospectively analyzed all consecutive patients with SIVBS treated with BMCS in the last ten years in our center. Data collected included patient demographics, stenosis location and characteristics, early (<30 days) and late (>30 days) stroke and death rates, pre-symptomatic and post-treatment modified Rankin Scale (mRS) scores. RESULTS 42 patients (35 males, average age 65,7 ± 10,7, range 37-85) with SIVBS were treated with BMCS. Thirty-four (80,9%) patients were symptomatic despite ongoing best medical therapy; eight (19,1%) patients were treated in emergency for large vessel occlusion, due to an underlying stenosis. BMCSs were successfully deployed in all cases. The incidence of stroke and death at one month was 7,1% (3/42). The incidence of TIA, stroke and death at long-term follow-up (average time of 3 years) was 14,3% (4,7 per 100 person-years). At long-term follow-up, mRS improved in 82% of patients who underwent elective treatment. CONCLUSIONS In our experience, the off-label use of BMCS in the endovascular treatment of SIVBS resistant to medical treatment is feasible and safe.
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Affiliation(s)
- Mariangela Piano
- Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Amedeo Cervo
- Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | | | - Guglielmo Pero
- Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Luca Quilici
- Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Edoardo Boccardi
- Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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21
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Park JS, Kwak HS, Kim JW. Bench-Top Comparison of Three Different Types of Stents Used for Treatment of Intracranial Atherosclerotic Stenosis. Neurointervention 2020; 15:117-125. [PMID: 33075860 PMCID: PMC7608503 DOI: 10.5469/neuroint.2020.00248] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/30/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose Four key bench-top tests, including trackability, conformability, wall-apposition, and bending stiffness, were performed to understand the mechanical characteristics in 3 different types of stents applicable for treatment of intracranial atherosclerotic stenosis: Balloon-expandable D+Storm, Pro-Kinetic Energy, and self-expandable Wingspan stents. Materials and Methods Trackability was assessed by measuring the tracking forces of each stent with its delivery systems. Conformability and wall apposition were quantified and analyzed using curved vessel models. A 3-point bending test was employed to evaluate bending stiffness. Results D+Storm showed the lowest tracking forces while the conformability of the Wingspan stent was superior to that of the tested stents. Pro-Kinetic Energy and D+Storm had better wall apposition in curved vessels than the Wingspan stent. Bending stiffness of the Wingspan stent was notably lower, whereas no significant differences were found between D+Storm and Energy. Pro-Kinetic Energy and D+Storm not only indicated lower gap ratios between the struts and the vessel wall but also maintained good wall apposition even in the curved model. Conclusion These bench-top measurements may provide clinicians with useful information in regard to selecting suitable stents for treatment of intracranial atherosclerotic stenosis.
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Affiliation(s)
- Jung-Soo Park
- Department of Neurysurgery, Jeonbuk National University Hospital, Jeonju, Korea
| | - Hyo Sung Kwak
- Department of Radiology, Jeonbuk National University Hospital, Jeonju, Korea
| | - Jin-Woo Kim
- Department of Bionanosystem Engineering, Graduate School, Jeonbuk National University, Jeonju, Korea
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22
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Higashida T, Uchida T, Osakabe M, Takahashi Y, Kanazawa R. Improvement of Cerebrovascular Reserve by Percutaneous Transluminal Angioplasty for Symptomatic Middle Cerebral Artery Stenosis. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 15:24-31. [PMID: 37503451 PMCID: PMC10370609 DOI: 10.5797/jnet.oa.2020-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/25/2020] [Indexed: 07/29/2023]
Abstract
Objective The purpose of this study was to investigate the efficacy of percutaneous transluminal angioplasty (PTA) for symptomatic middle cerebral artery stenosis by analyzing cerebral blood flow (CBF). Methods Between January 2016 and December 2018, six patients with symptomatic middle cerebral artery stenosis underwent CBF analysis by single-photon emission computed tomography (SPECT) with acetazolamide challenge before and after PTA for stenosis. They were retrospectively reviewed, and the blood flow in the area of the affected middle cerebral artery before and after angioplasty was compared. Results The mean stenosis rate and length of lesion before angioplasty were 76.4 ± 5.4% and 6.5 ± 2.1 mm, respectively. Balloon angioplasty without stenting was performed on all patients. The mean residual stenosis rate just after angioplasty was 45.4 ± 9.3%. No periprocedual complications developed, and there were no notable cerebral ischemic events during the postprocedural follow-up period. One patient underwent repeat angioplasty for restenosis. Although there was only a mild decrease in blood flow at rest, the cerebrovascular reserve (CVR) in the area of the affected middle cerebral artery was markedly decreased before angioplasty (mean, 3.6 ± 4.3%). After angioplasty, the CVR was significantly improved (mean, 18.0 ± 4.7%, p <0.01). Conclusions PTA for symptomatic middle cerebral artery stenosis can be safely performed using appropriate interventional techniques for select patients. Reduced CVR due to stenosis can be improved after angioplasty, which may reduce the risk of cerebral ischemic events.
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Affiliation(s)
- Tetsuhiro Higashida
- Department of Neurosurgery, Nagareyama Central Hospital, Nagareyama, Chiba, Japan
| | - Takanori Uchida
- Department of Neurosurgery, Nagareyama Central Hospital, Nagareyama, Chiba, Japan
| | - Manabu Osakabe
- Department of Neurosurgery, Nagareyama Central Hospital, Nagareyama, Chiba, Japan
| | - Yuichi Takahashi
- Department of Neurosurgery, Nagareyama Central Hospital, Nagareyama, Chiba, Japan
| | - Ryuzaburo Kanazawa
- Department of Neurosurgery, Nagareyama Central Hospital, Nagareyama, Chiba, Japan
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23
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Wang T, Luo J, Wang X, Yang K, Jadhav V, Gao P, Ma Y, Zhao N, Jiao L. Endovascular therapy versus medical treatment for symptomatic intracranial artery stenosis. Cochrane Database Syst Rev 2020; 8:CD013267. [PMID: 32789891 PMCID: PMC7437396 DOI: 10.1002/14651858.cd013267.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Intracranial atherosclerotic stenosis (ICAS) is an arterial narrowing in the brain that can cause stroke. Endovascular therapy and medical management may be used to prevent recurrent ischaemic stroke caused by ICAS. However, there is no consensus on the best treatment for people with ICAS. OBJECTIVES To compare the safety and efficacy of endovascular therapy (ET) plus conventional medical treatment (CMT) with CMT alone for the management of symptomatic ICAS. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (30 August 2019), Cochrane Central Register of Controlled Trials (CENTRAL: to 30 August 2019), MEDLINE Ovid (1946 to 30 August 2019), Embase Ovid (1974 to 30 August 2019), Scopus (1960 to 30 August 2019), Science Citation Index Web of Science (1900 to 30 July 2019), Academic Source Complete EBSCO (ASC: 1982 to 30 July 2019), and China Biological Medicine Database (CBM: 1978 to 30 July 2019). We also searched the following trial registers: ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and Stroke Trials Registry. We also contacted trialists and researchers where additional information was required. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing ET plus CMT with CMT alone for the treatment of symptomatic ICAS. ET modalities included angioplasty alone, balloon-mounted stent, and angioplasty followed by placement of a self-expanding stent. CMT included antiplatelet therapy in addition to control of risk factors such as hypertension, hyperlipidaemia, and diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently screened trials to select potentially eligible RCTs and extracted data. Any disagreements were resolved by discussing and reaching consensus decisions with the full team. We assessed risk of bias and applied the GRADE approach to assess the quality of the evidence. The primary outcome was death of any cause or non-fatal stroke of any type within three months of randomisation. Secondary outcomes included any-cause death or non-fatal stroke of any type more than three months of randomisation, ipsilateral stroke, type of recurrent event, death, restenosis, dependency, and health-related quality of life. MAIN RESULTS We included three RCTs with 632 participants who had symptomatic ICAS with an age range of 18 to 85 years. The included trials had high risks of performance bias and other potential sources of bias due to the impossibility of blinding of the endovascular intervention and early termination of the trials. Moreover, one trial had a high risk of attrition bias because of the high rate of loss of one-year follow-up and the high proportion of participants transferred from endovascular therapy to medical management. The quality of evidence ranged from low to moderate, downgraded for imprecision. Compared to CMT, ET probably results in a higher rate of 30-day death or stroke (risk ratio (RR) 3.07, 95% confidence interval (CI) 1.80 to 5.24; 3 RCTs, 632 participants, moderate-quality evidence), 30-day ipsilateral stroke (RR 3.54, 95% CI 1.98 to 6.33; 3 RCTs, 632 participants, moderate-quality evidence), 30-day ischaemic stroke (RR 2.52, 95% CI 1.37 to 4.62; 3 RCTs, 632 participants, moderate-quality evidence), and 30-day haemorrhagic stroke (RR 15.53, 95% CI 2.10 to 115.16; 3 RCTs, 632 participants, low-quality evidence). ET was also likely associated with a worse outcome in one-year death or stroke (RR 1.69, 95% CI 1.21 to 2.36; 3 RCTs, 632 participants, moderate-quality evidence), one-year ipsilateral stroke (RR 2.28, 95% CI 1.52 to 3.42; 3 RCTs, 632 participants, moderate-quality evidence), one-year ischaemic stroke (RR 2.07, 95% CI 1.37 to 3.13; 3 RCTs, 632 participants, moderate-quality evidence), and one-year haemorrhagic stroke (RR 10.13, 95% CI 1.31 to 78.51; 2 RCTs, 521 participants, low-quality evidence). There were no significant differences between ET and CMT in 30-day transient ischaemic attacks (TIA) (RR 0.52, 95% CI 0.11 to 2.35, P = 0.39; 2 RCTs, 181 participants, moderate-quality evidence), 30-day death (RR 5.53, 95% CI 0.98 to 31.17, P = 0.05; 3 RCTs, 632 participants, low-quality evidence), one-year TIA (RR 0.82, 95% CI 0.32 to 2.12; 2 RCTs, 181 participants, moderate-quality evidence), one-year death (RR 1.20, 95% CI 0.50 to 2.86, P = 0.68; 3 RCTs, 632 participants, moderate-quality evidence), and one-year dependency (RR 1.90, 95% CI 0.91 to 3.97, P = 0.09; 3 RCTs, 613 participants, moderate-quality evidence). No data on restenosis and health-related quality of life for meta-analysis were available from the included trials. Two RCTs are ongoing. AUTHORS' CONCLUSIONS This systematic review provides moderate-quality evidence showing that ET, compared with CMT, in people with recent symptomatic severe intracranial atherosclerotic stenosis probably does not prevent recurrent stroke and appears to carry an increased hazard. The impact of delayed ET intervention (more than three weeks after a qualifying event) is unclear and may warrant further study.
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Affiliation(s)
- Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jichang Luo
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xue Wang
- Medical Library of Xuanwu Hospital, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kun Yang
- Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Vikram Jadhav
- Neurosciences, Essentia Health, St Mary's Medical Center, Duluth, Minnesota, USA
- Neurosciences, Stroke and Cerebrovascular, CentraCare Health System, St Cloud, Minnesota, USA
| | - Peng Gao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Na Zhao
- Department of Anesthesiology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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24
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Tosello R, Riera R, Tosello G, Clezar CNB, Amorim JE, Vasconcelos V, Joao BB, Flumignan RLG. Type of anaesthesia for acute ischaemic stroke endovascular treatment. Hippokratia 2020. [DOI: 10.1002/14651858.cd013690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Renato Tosello
- Department of Neurointerventional Radiology; Hospital Beneficencia Portuguesa de Sao Paulo; Sao Paulo Brazil
| | - Rachel Riera
- Cochrane Brazil; Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde; São Paulo Brazil
| | | | - Caroline NB Clezar
- Department of Surgery, Division of Vascular and Endovascular Surgery; Universidade Federal de São Paulo; São Paulo Brazil
| | - Jorge E Amorim
- Department of Surgery, Division of Vascular and Endovascular Surgery; Universidade Federal de São Paulo; São Paulo Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery; Universidade Federal de São Paulo; São Paulo Brazil
| | - Benedito B Joao
- Division of Anesthesia, Pain, and Intensive Medicine, Department of Surgery; Universidade Federal de São Paulo; São Paulo Brazil
| | - Ronald LG Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery; Universidade Federal de São Paulo; São Paulo Brazil
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25
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Krasteva MP, Lau KK, Mordasini P, Tsang ACO, Heldner MR. Intracranial Atherosclerotic Stenoses: Pathophysiology, Epidemiology, Risk Factors and Current Therapy Options. Adv Ther 2020; 37:1829-1865. [PMID: 32270364 PMCID: PMC7467483 DOI: 10.1007/s12325-020-01291-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Indexed: 01/03/2023]
Abstract
Intracranial atherosclerotic stenoses (ICAS) are one of the most common causes of first and recurrent cerebrovascular ischaemic events worldwide, with highest prevalence in Asian, Hispanic and African populations. Clinical trials have improved the understanding of epidemiology, risk factors and imaging characteristics of patients with ICAS. Current therapeutic approaches concerning these patients include management of risk factors, best medical therapy, potentially endovascular and rarely surgical therapy. In our review, we elucidate the current epidemiology and evidence in evaluation of risk factors and therapeutic options for providing favourable outcome for patients with ICAS.
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Affiliation(s)
- Marina Petrova Krasteva
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Kui Kai Lau
- Division of Neurology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Anderson Chun On Tsang
- Division of Neurosurgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Mirjam Rachel Heldner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland.
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26
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Gruber P, Remonda L. Device profile of different paclitaxel-coated balloons: Neuro Elutax SV, Elutax '3' Neuro and SeQuent Please NEO for the treatment of symptomatic intracranial high-grade stenosis: overview of their feasibility and safety. Expert Rev Med Devices 2020; 17:87-92. [PMID: 31962054 DOI: 10.1080/17434440.2020.1719829] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Intracranial atherosclerotic disease (ICAD) is highly prevalent and probably the most common cause of stroke worldwide. Despite best medical treatment (BMT), the rate of recurrent stroke in symptomatic ICAD patients is elevated, especially in those with high-grade stenosis. Thus, alternative treatment options are needed. So far, endovascular ICAD treatment has been considered a second-line therapy. However, recent progress in the endovascular acute stroke treatment challenges this issue. Drug-coated balloon (DCB) - percutaneous transluminal angioplasty (PTA) represents a promising alternative to BMT alone.Areas covered: In this review, current clinical studies on paclitaxel-coated DCB-PTA in symptomatic high-grade ICAD patients will be presented and discussed. Furthermore, technical profile of the different paclitaxel-coated DCB, which has been used for intracranial use (Neuro Elutax SV, Elutax '3' Neuro, and SeQuent Please NEO) are being presented.Expert opinion: Despite limited data and its experimental (off-line) use, DCB-PTA has been demonstrated to be feasible and safe in selected ICAD patients with symptomatic high-grade stenosis. DCB-PTA offers several advantages compared to alternative endovascular therapy option as well as BMT alone. Consequently, DCP-PTA might be a promising candidate for the future armamentarium in ICAD treatment.
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Affiliation(s)
- Philipp Gruber
- Department of Neuroradiology, Cantonal Hospital of Aarau, Aarau, Switzerland
| | - Luca Remonda
- Department of Neuroradiology, Cantonal Hospital of Aarau, Aarau, Switzerland
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27
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Ghuman M, Tsang ACO, Klostranec JM, Krings T. Sentinel Angiographic Signs of Cerebral Hyperperfusion after Angioplasty and Stenting of Intracranial Atherosclerotic Stenosis: A Technical Note. AJNR Am J Neuroradiol 2019; 40:1523-1525. [PMID: 31345945 DOI: 10.3174/ajnr.a6149] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 06/25/2019] [Indexed: 11/07/2022]
Abstract
Cerebral hyperperfusion syndrome is a serious complication of endovascular angioplasty and stent placement for long-standing intracranial stenosis, resulting in neurologic dysfunction, seizure, or reperfusion hemorrhage. Rigorous control of blood pressure is commonly used in the perioperative period to prevent cerebral hyperperfusion syndrome, but the optimal blood pressure is often arbitrary. We describe the angiographic features that reflect impaired cerebral autoregulation and microvascular transit abnormality, which may be used to gauge the optimal blood pressure parameters in the immediate postintervention period for prevention of cerebral hyperperfusion syndrome.
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Affiliation(s)
- M Ghuman
- From the Department of Medical Imaging (M.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - A C O Tsang
- Division of Neurosurgery (A.C.O.T.), Department of Surgery, The University of Hong Kong, Hong Kong
- Department of Medical Imaging (A.C.O.T., J.M.K., T.K.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - J M Klostranec
- Department of Medical Imaging (A.C.O.T., J.M.K., T.K.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - T Krings
- Department of Medical Imaging (A.C.O.T., J.M.K., T.K.), Toronto Western Hospital, Toronto, Ontario, Canada
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28
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Wang T, Yang K, Wang X, Luo J, Gao P, Ma Y, Jadhav V, Zhao N, Jiao L. Endovascular therapy versus medical treatment for symptomatic intracranial artery stenosis. Hippokratia 2019. [DOI: 10.1002/14651858.cd013267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Tao Wang
- Xuanwu Hospital, Capital Medical University; Department of Neurosurgery; No. 45 Changchun Street Beijing China 100053
| | - Kun Yang
- Xuanwu Hospital, Capital Medical University; Department of Evidence-based Medicine; No. 45 Changchun Street Beijing China 100053
| | - Xue Wang
- Xuanwu Hospital, Capital Medical University; Medical Library of Xuanwu Hospital; No. 45 Changchun Street Beijing China 100053
| | - Jichang Luo
- Xuanwu Hospital, Capital Medical University; Department of Neurosurgery; No. 45 Changchun Street Beijing China 100053
| | - Peng Gao
- Xuanwu Hospital, Capital Medical University; Department of Neurosurgery; No. 45 Changchun Street Beijing China 100053
| | - Yan Ma
- Xuanwu Hospital, Capital Medical University; Department of Neurosurgery; No. 45 Changchun Street Beijing China 100053
| | - Vikram Jadhav
- CentraCare Health System; Neurosciences - Stroke and Cerebrovascular; 1406 Sixth Ave North St Cloud Minnesota USA
| | - Na Zhao
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University; Department of Anesthesiology; Beijing China
| | - Liqun Jiao
- Xuanwu Hospital, Capital Medical University; Department of Neurosurgery; No. 45 Changchun Street Beijing China 100053
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29
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Wang T, Yang K, Luo J, Gao P, Ma Y, Wang Y, Li L, Liu Y, Feng Y, Wang X, Jiao L. Outcomes after stenting for symptomatic intracranial arterial stenosis: a systematic review and meta-analysis. J Neurol 2019; 267:581-590. [PMID: 30612142 DOI: 10.1007/s00415-018-09176-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/26/2018] [Accepted: 12/27/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Stenting is a common endovascular therapy for symptomatic intracranial arterial stenosis (ICAS). We sought to update the evaluation of global short-term safety and long-term efficacy outcomes after stenting for symptomatic ICAS and explore their distributional characteristics. METHODS Major databases including Cochrane Library, MEDLINE, EMBASE were systematically searched from January 1st, 2005, for RCTs and observational studies which reported short- and long-term outcomes after stenting for symptomatic ICAS. Each outcome was pooled with meta-analysis and the impacts of study location, publication time, and other population characteristics were further assessed by the univariate and multivariate Poisson regression analyses. RESULTS A total of 8408 patients were identified in 92 studies from 16 countries across five WHO regions. The estimated rate of short-term stroke or death was 6.68% (95% CI 5.60-8.36%), and the rate of long-term stroke or death was 4.43% (95% CI 2.61-6.60%). After adjustment of age, sex, study location, preprocedual stenosis, publication period and study design, multivariate regression analysis showed that the rate of short-term stroke or death was different between Western and Eastern countries (10.27% versus 5.52%, p = 0.018). The rates of short-term, stroke, ischemic stroke and long-term death were also significantly higher in Western compared to Eastern countries. CONCLUSION This systematic review provided the worldwide profile of short- and long-term outcomes of stenting for symptomatic ICAS. The generally acceptable outcomes indicate that stenting may still be feasible in selected patients. Regional disparity calls for more cautious decisions and future studies.
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Affiliation(s)
- Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China
| | - Jichang Luo
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Peng Gao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Yabing Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Long Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Yiran Liu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China.
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