Endarterectomy, Stenting, or Medical Treatment for Symptomatic Carotid Near-Occlusion: Results from CAOS, a Multicenter Registry Study

BACKGROUND AND PURPOSE

The treatment of symptomatic carotid near-occlusion is controversial. Our aim was to analyze the results of carotid endarterectomy and carotid artery stent placement in patients with symptomatic carotid near-occlusion and to identify factors related to technical failure, periprocedural complications, and restenosis.

MATERIALS AND METHODS

We conducted a multicenter, prospective nonrandomized study. Patients with angiography-confirmed carotid near-occlusion were included. We assessed the revascularization rate and periprocedural stroke or death. Twenty-four-month clinical and carotid imaging follow-up was performed, and rates of carotid restenosis or occlusion, ipsilateral stroke, and mortality were analyzed. Carotid artery stent placement, carotid endarterectomy, and medical treatment were compared.

RESULTS

One hundred forty-one patients were included. Forty-four carotid artery stent placement and 23 carotid endarterectomy procedures were performed within 6 months after the event. Complete revascularization was achieved in 83.6%, 81.8% in the carotid artery stent placement group and 87% with carotid endarterectomy (P = .360). Periprocedural stroke or death occurred in 6% (carotid artery stent placement = 2.3%; carotid endarterectomy = 13%; P = .077) and was not related to revascularization failure. The carotid restenosis or occlusion rate was 8.3% (5% restenosis, 3.3% occlusion); with carotid artery stent placement it was 10.5%; and with carotid endarterectomy it was 4.5% (P = .419). The 24-month cumulative rate of ipsilateral stroke was 4.8% in the carotid artery stent placement group, 17.4% for carotid endarterectomy, and 13.1% for medical treatment (P = .223). Mortality was 12%, 4.5%, and 5.6%, respectively (P = .422). Revascularization failure and restenosis occurred more frequently in patients with full collapse compared with patients without full collapse (33.3% versus 5.6%, P = .009; 21.4% versus 2.9%, P = .032, respectively).

CONCLUSIONS

Carotid artery stent placement and carotid endarterectomy are associated with high rates of failure and periprocedural stroke. Carotid near-occlusion with full collapse appears to be associated with an increased risk of technical failure and restenosis. Carotid near-occlusion revascularization does not seem to reduce the risk of stroke at follow-up compared with medical treatment.

The risk of recurrent stroke at 24 months in patients with symptomatic carotid near-occlusion: results from CAOS, a multicentre registry study

BACKGROUND AND PURPOSE

The risk of recurrent stroke amongst patients with symptomatic carotid near-occlusion (SCNO) has not been clearly established, and its management remains controversial. The aim was to define the 24-month risk of recurrent stroke and to analyse the effect of the different treatment modalities (medical treatment and revascularization) in a population of patients with SCNO.

METHODS

A multicentre, nationwide, prospective study from January 2010 to May 2016 was performed. Patients with angiography-confirmed SCNO were included. The primary end-point was ipsilateral ischaemic stroke including periprocedural events within 24 months following the presenting event. Revascularization results and periprocedural complications, ipsilateral transient ischaemic attack, disabling or fatal stroke, and mortality were also noted.

RESULTS

The study population comprised 141 patients from 17 Spanish centres. Seventy patients (49.6%) were treated by revascularization (carotid stenting in 47, endarterectomy in 23). Complete revascularization was achieved in 58 patients (83%). Periprocedural stroke or death occurred in 5.7%. The 24-month cumulative incidence of the primary end-point was 11.1% (95% confidence interval 5.8-16.4; n = 15), 12% in the medical treatment group and 10.2% in the revascularization group, log-rank P = 0.817. The cumulative rates of ipsilateral ischaemic stroke or transient ischaemic attack, disabling or fatal stroke, and mortality, were 17%, 4.5% and 7.5%, respectively.

CONCLUSIONS

The rate of ipsilateral ischaemic stroke in patients with SCNO seems to be lower than the known rate associated with severe carotid stenosis without near-occlusion. The potential benefit of revascularization in the prevention of stroke in patients with SCNO may be influenced by the effectiveness and safety of the procedure.

One-year prognosis of non-traumatic cortical subarachnoid haemorrhage: A prospective series of 34 patients

INTRODUCTION

Cortical subarachnoid haemorrhage (cSAH) has multiple aetiologies. No prospective study has reported the long-term progression of the condition. The objective of this study is to describe the clinical and aetiological characteristics of patients with cSAH and to gain insight into prognosis.

METHODS

We performed a prospective, observational, multi-centre study. Data on clinical and radiological variables were collected; during a one-year follow-up period, we recorded data on mortality, dependence, rebleeding, and the appearance of dementia.

RESULTS

The study included 34 patients (mean age, 68.3 years; range, 27-89). The most frequent symptoms were headache and focal neurological deficits, which were frequently transient and recurrent. CT scans returned pathological findings in 28 patients (85%). Brain MRI scans were performed in 30 patients (88%), revealing acute ischaemia in 10 (29%), old haemorrhage in 7 (21%), and superficial siderosis in 2 (6%). Aetiology was identified in 26 patients (76.5%): causes were cerebral amyloid angiopathy in 8, ischaemic stroke in 5, vasculitis in 4, reversible posterior encephalopathy in 2, venous thrombosis in 2, reversible cerebral vasoconstriction syndrome in 2, carotid occlusion in 1, Marfan syndrome in 1, and meningeal carcinomatosis in 1. Three patients died during follow-up (2 due to causes related to the cause of cSAH). Three patients developed dementia, 3 had lobar haemorrhages, and one had a second cSAH.

CONCLUSIONS

The most frequent causes of cSAH in our series were cerebral amyloid angiopathy, ischaemic stroke, and vasculitis. This type of haemorrhage has a worse prognosis than other non-aneurysmal cSAH. There are numerous possible causes, and prognosis depends on the aetiology. In elderly patients, intracranial haemorrhage is frequently associated with cognitive impairment.

Tendencies in cerebral aneurism treatment: Analysis of a hospital series

INTRODUCTION AND OBJECTIVE

To discover if there have been changes in the treatment time for SAH in our hospital environment.

MATERIAL AND METHODS

Comparative analysis of 571 patients treated at Hospital Universitari la Fe during 2 different time periods. The SAH-OLD group consisted of 462 patients attended consecutively between April 1997 and March 2005, while SAH-NEW comprised 109 patients attended consecutively between March 2007 and April 2010. We analysed demographic factors, risk factors, severity at time of admission, time to arteriography, diagnosis of aneurysm, use of surgical or endovascular treatment and time to treatment, frequency of neurological complications, in-hospital deaths, and modified Rankin Scale (mRS) at discharge.

RESULTS

Mean time to arteriography was 2.18 ± 2.5 days for the SAH-OLD group and 2.37 ± 2.23 days, for the SAH-NEW group (P=.49). Mortality rates for SAH-OLD patients were calculated at 30%, compared to 18.3% in SAH-NEW patients (P=.01). Among patients surviving the hospital stay in the SAH-OLD group, 13.3% had an mRS > 3, compared to 21.3% of survivors in the SAH-NEW group (P=.06). Two hundred forty-five patients in the SAH-OLD group had cerebral aneurysms and 208 were treated (45% of the patient total). Sixty-five of the SAH-NEW patients received treatment (60% of the patient total, P=.007). In the SAH-OLD group, 62.9% of the patients underwent embolisation vs 74.6% in the SAH-NEW group (P=.08). Time to embolisation was 4.7 ± 8.2 days for SAH-OLD patients and 2.12 ± 2.2 days for SAH-NEW patients (P=.01). Twenty-two percent of SAH-OLD patients underwent surgery, compared to 25.4% in the SAH-NEW group (P=.62).

CONCLUSIONS

Care for SAH patients has improved in this hospital: results include fewer mortalities, a higher number of treatments with a smaller proportion of endovascular treatments, and shorter times to treatment. Elapsed time to arteriography remains stable.

[Carotid angioplasty in stenosis following radiotherapy: a review of 12 cases]

INTRODUCTION

Carotid stenosis is a complication of cervical radiotherapy. In these cases carotid angioplasty has been considered as the elective revascularisation treatment. Yet, the indication to treat is under discussion due to the high rate of restenosis and the scarcity of studies conducted on the long-term development.

AIMS

To report on a series of patients with carotid stenosis following radiotherapy who were treated by means of angioplasty, the aim being to analyse their long- and short-term development.

PATIENTS AND METHODS

Of a series of 426 patients with carotid stenosis treated by endovascular means, 12 of them (2.8%) had previously received radiotherapy in the neck. All of them were submitted to a clinical and imaging follow-up. Data were collected concerning the rate of complications during the first four weeks and in the long term, as well as the rate of restenosis in the follow-up.

RESULTS

The mean interval between radiotherapy and the detection of stenosis was 14.7 years. Ten patients (83.3%) were symptomatic. No complications occurred during the first four weeks following the angioplasty. The mean follow-up time was 45.09 months: 16.7% of patients presented a stroke, 8.3% suffered acute myocardial infarction and 33.3% died (16.6% due to cancer). At least six patients (50%) were diagnosed with restenosis, all equal to or greater than 50% and none of them were symptomatic.

CONCLUSIONS

Carotid angioplasty is a safe, effective technique in stenosis following radiotherapy, with few short-term complications. The rate of carotid restenosis is high. The main cause of death is cancer.

[Endovascular treatment of symptomatic intracranial stenoses: short- and long-term results in a single center]

OBJECTIVES

We present the short- and long-term results of a series of patients with symptomatic intracranial arterial stenoses treated with angioplasty and stenting.

MATERIAL AND METHODS

We reviewed patients with symptomatic intracranial stenoses greater than 50% who were treated with angioplasty, stenting, or both. We recorded demographic data and risk factors (hypertension, diabetes, dyslipemia, ischemic heart disease). We classified all lesions treated according to their location, degree of stenosis, and length. The degree of stenosis was classified as moderate (50%-70%) or severe (>70%). In the follow-up, we assessed cerebrovascular accidents, episodes of ischemic heart disease, and deaths in the first 30 days and in later follow-up.

RESULTS

Between 2006 and 2010, we treated 26 patients (21 men and 5 women; age range, 44-79 years; mean age, 63 years) with 29 intracranial lesions. The endovascular procedure (angioplasty+stenting) was successfully performed in 23 cases (92.0%). In the first 30 days after the procedure, 3 (11.5%) patients had adverse effects of vascular origin: 1 stroke, 1 hemorrhage, and 1 death due to thrombosis of the stent. Long-term follow-up (5-46 months) in the 25 patients who survived more than 30 days detected no recurrence of symptoms.

CONCLUSION

Endovascular treatment of intracranial stenosis is technically feasible. Short-term complications are highly prevalent. No recurrence of symptoms was detected during long-term follow-up.

Angioplasty and stenting of symptomatic and asymptomatic vertebral artery stenosis: to treat or not to treat

BACKGROUND AND PURPOSE

Comprehensive indications for treatment of symptomatic vertebral stenosis remain unavailable. Even less is known about endovascular treatment of asymptomatic cases. We treated symptomatic and asymptomatic vertebral ostium stenosis with angioplasty and stenting and investigated the long term outcome.

METHODS

Consecutive patients with two different indications were included. Group 1 (G1) had symptomatic >50% stenosis. Group 2 (G2) had asymptomatic >50% stenosis and severe lesions of anterior circulation and were expected to benefit from additional cerebral blood supply.

RESULTS

Twenty nine vertebral origin stenoses in 28 patients (75% men, mean age 64 +/- 9 years) were treated. There were 16 G1 and 13 G2 cases. Technical success rate was 100%. Immediate neurological complications rate was 3.4% (one G1 patient with vertebral TIA due to release of emboli). Two further strokes were seen during follow up (32 +/- 24 months): vertebrobasilar stroke in a G2 patient with permeable stent in V1 segment, new ipsilateral V3 occlusion and high-risk cardioembolic source, and carotid stroke in a G1 patient who had had ipsilateral carotid stenting. There were no deaths of any cause. Asymptomatic restenosis was observed in one out of 19 patients from both groups who underwent a follow up angiography.

CONCLUSIONS

Angioplasty and stenting appears to be technically feasible and safe in asymptomatic and symptomatic vertebral stenosis. More studies are needed in order to clarify its role in primary and secondary prevention of vertebrobasilar stroke. High risk anterior circulation lesions should be taken into account as a possible indication in patients with asymptomatic vertebral stenosis.

[Spontaneous subarachnoid haemorrhage: a study of 462 patients]

AIMS

To describe the demographic characteristics of patients with spontaneous subarachnoid haemorrhage (SAH) in our population and to compare the endovascular and surgical treatment of intracranial aneurysms.

PATIENTS AND METHODS

We conducted a retrospective study of 462 patients who were admitted to the Hospital Universitario La Fe in Valencia between April 1997 and March 2005.

RESULTS

The mean age was 56.8 +/- 14.8 years and 55.8% of the patients were females. The risk factors were: arterial hypertension, 40.3%; smoking, 32.7%; dyslipidemia, 16.0%; diabetes mellitus, 10.6%; alcoholism, 6.7%. A cerebral arteriography was performed in 369 patients and intracranial aneurysms were detected in 246 of them. Aneurysms were treated by embolisation in 62.6% of cases and by surgery in 22%. On comparing the embolisation and surgery groups, there were non-significant differences in the rates of complications. Infections were present in 21.9% of patients in the embolisation group versus 10.2% in the surgery group; epileptic seizures 6.1% versus 8%; hydrocephalus 2.7% versus 4%; rebleeding 4.1% versus 10.2%; clinical vasospasm 8.9% versus 6.1%. The rate of sequelae on discharge (a score on the modified Rankin Scale > 3) was 13.7% among surviving patients in the embolisation group and 15.5% in the group that had undergone surgery. The mortality rates in the two groups were 10.3 and 10%, respectively. Overall mortality rate was 30.1%.

CONCLUSIONS

The presentation and course of SAH in our population follow a pattern that is similar to those reported in other countries. No differences in morbidity and mortality were detected between the endovascular and surgical treatment of ruptured intracranial aneurysms.

[Hemifacial spasm: over 10 years of treatment with botulinum toxin]

INTRODUCTION

The short-term beneficial and adverse effects of treatment with botulinum toxin (BT) in hemifacial spasm (HS) are well documented, but this is not the case with its long-term derivatives. AIMS. To describe the characteristics, the dose development, the side effects and the reason for giving up therapy in patients who have been on BT treatment for more than 10 years. We also sought to evaluate the effectiveness and safety of prolonged treatment in patients with HS.

PATIENTS AND METHODS

We reviewed the demographic and clinical characteristics of patients who had had HS for more than 10 years since follow-up began. We analysed the mean dose development of BT per visit and year, the number of sessions per year, side effects and reasons for dropping out. We focused our attention on cases with more than 10 years' continuous treatment.

RESULTS

The percentage of patients who had been on treatment for over ten years was 53.7%. The mean dose of BT per year rose progressively, and was significant (p < 0.05) during the first four years of treatment. There was no significant increase in the number of sessions. Altogether 46 side effects were observed, ptosis being the most frequent. These occurred during the first years of the early stages of the technique. The most common cause of dropout was loss to follow-up in 22 patients, followed by death in 11 cases.

CONCLUSIONS

BT is a feasible, safe treatment option (with very few benign side effects) in the prolonged treatment of patients with HS.

Optical properties of porphyrin molecules immobilized in nano-porous silicon

The paper aims at studying optical properties of porous silicon powders and thin films which were impregnated with different porphyrin molecules. It has been shown that introducing porphyrins into porous silicon matrix results in quenching of luminescence from porous silicon, while luminescence of porphyrins survives, though its structure changes. At the same time, porphyrins in porous silicon matrix which was preliminarily oxidized does not alter luminescence from porphyrins. Generation of singlet oxygen by illuminated porphyrin/porous silicon composite is confirmed by additional oxidation of porous silicon and by the observation of characteristic 1270 nm luminescence band.