Safety and efficacy of percutaneous transluminal angioplasty for intracranial atherosclerotic stenosis

BACKGROUND AND PURPOSE

Percutaneous transluminal angioplasty (PCTA) is increasingly used to treat extracerebral arterial stenosis. The present study evaluates the safety and efficacy of PCTA treatment of symptomatic intracranial atherosclerotic stenosis.

METHODS

A series of 22 vessels in 17 patients were treated with PCTA. All patients had recurrent neurological symptoms referable to the stenotic vessel despite optimal medical therapy. Critical (> 70%) arterial stenosis was confirmed by angiogram, and angioplasty was performed with a 3.0- to 3.5-mm Stealth balloon.

RESULTS

The average preangioplasty stenosis (North American Symptomatic Carotid Endarterectomy Trial criteria) was 72 +/- 8% (mean +/- SD), with a significant improvement seen after angioplasty; the best angiographic stenosis (after healing of intimal injury, if any) was 43 +/- 24% (P < .001). Overall PCTA was successful in 82% of the vessels. There were two strokes during angioplasty for a 30-day morbidity rate of 9.1% per treated vessel and 11.7% per case. The other 15 patients were clinically evaluated at 3 and 6 months; all cases were without further events. Restenosis was evaluated in 8 patients (12 vessels) with an angiogram at 6 months showing further improvement compared with the initial post-PCTA stenosis (51 +/- 10% versus 37 +/- 21% [P = .05]).

CONCLUSIONS

PCTA may be a beneficial therapy in selected cases of symptomatic intracranial atherosclerotic stenosis. Further study using a randomized trial is needed.

Safety and efficacy of delayed intraarterial urokinase therapy with mechanical clot disruption for thromboembolic stroke

PURPOSE

To evaluate safety and efficacy of delayed intraarterial urokinase therapy with mechanical disruption of clot to treat thromboembolic stroke.

METHODS

Thirteen patients with cerebral thrombolic disease (10 carotid territory, 3 basilar territory) were treated with catheter-directed intraarterial urokinase therapy with mechanical disruption of the clots. All patients were excluded from a 6-hour multicenter thrombolytic trial by either time, recent surgery, age, seizure, or myocardial infarction. Time elapsed before treatment ranged from 3.5 to 48 hours (12 +/- 13 hours), with 200,000 to 900,000 U of urokinase used.

RESULTS

Ten patients had successful vessel recanalization, confirmed by repeat angiography. Cases with distal branch vessel occlusions were less likely to recanalize. Asymptomatic hemorrhagic conversion occurred in 2 patients on repeat scans. Both acute neurologic and functional outcomes were assessed with significant improvement occurring in 9 (69%) of 13 patients at 48 hours (greater than four-point change on the National Institutes of Health scale) and in 100% of 3-month survivors. All patients who improved had normal initial CT scans.

CONCLUSIONS

Intraarterial cerebral thrombolysis with mechanical disruption of clot seems to be a useful therapy in selected stroke cases even after 6 hours.

Pseudoaneurysm of the thoracic aorta: a late complication of umbilical artery catheterization

Pseudoaneurysm of the thoracic aorta developed in an infant eight months following neonatal catheterization of the umbilical artery. Infection and placement of a stiff polyvinyl chloride catheter in the thoracic aorta appear to be the etiological factors. Preoperative diagnosis was posterior mediastinal tumor, and pseudoaneurysm was not included in the differential. Dacron graft patch angioplasty repair using partial cardiopulmonary bypass was successful. Postoperatively the patient has done well with no pressure gradient. Pseudoaneurysm should be suspected whenever a mediastinal mass appears in children who have had thoracic placement of umbilical artery catheters.