Percutaneous transluminal angioplasty and stenting for symptomatic intracranial arterial stenosis: a systematic review and meta-analysis

OBJECTIVES: The cumulative safety and efficacy measures of percutaneous transluminal angioplasty and stenting (PTAS) for secondary stroke prevention in patients with symptomatic intracranial arterial stenosis (sICAS) have not previously been evaluated using a meta-analytical approach. METHODS: We conducted a systematic review and random effects meta-analysis of all available randomized controlled trials (RCTs) evaluating the safety and efficacy of PTAS (in comparison with medical therapy) for sICAS. RESULTS: Three RCTs (678 total patients) were included in the quantitative analysis. PTAS was associated with a higher risk of recurrent ischemic stroke in the territory of qualifying artery both within 30 days [risk ratio (RR) = 2.21, 95% confidence interval (CI) 1.10-4.43] and 1 year (RR = 1.92, 95% CI 1.10-3.36). PTAS was also related to a higher risk of any ischemic stroke within 30 days from the index event (RR = 2.08, 95% CI 1.17-3.71). The risk for intracranial hemorrhage was found to be higher in PTAS patients both within 30 days (RR = 10.60, 95% CI 1.98-56.62) and 1 year (RR = 8.15, 95% CI 1.50-44.34). The composite outcome of any stroke or death within 1 year (RR = 2.29, 95% CI 1.13-4.66) and 2 years (RR = 1.52, 95% CI 1.04-2.21) was higher in PTAS than in medical therapy. PTAS was associated with a higher risk of any stroke or death within 2 years in the sICAS subgroup located in posterior circulation (RR = 2.37, 95% CI 1.27-4.42). CONCLUSIONS: PTAS is associated with adverse early and long-term outcomes and should not be recommended in patients with sICAS. Further research to identify subgroups of patients who could also serve as candidates for future interventional trials along with efforts to reduce procedure-related complications are needed

Endovascular Treatment for Acute Basilar Artery Occlusion: A Fragility Index Meta-Analysis

Introduction: High-quality evidence regarding the use of endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO) has been provided by recently completed randomized controlled clinical trials (RCTs). Methods: We conducted a systematic review and meta-analysis including all available RCTs that investigated efficacy and safety of EVT in addition to best medical treatment (BMT) versus BMT alone for BAO. The random-effects model was used, while the fragility index (FI) was calculated for dichotomous outcomes of interest. Results: Four RCTs were included comprising a total of 988 patients with acute BAO (mean age: 65.6 years, 70% men, median NIHSS: 24, 39% pretreatment with intravenous thrombolysis). EVT was related to higher likelihood of good functional outcome (RR: 1.54; 95% CI: 1.16–2.05; I2 = 60%), functional independence (RR: 1.83; 95% CI: 1.08–3.08; I2 = 79%) and reduced disability at 3 months (adjusted common OR: 1.96; 95% CI: 1.26–3.05; I2 = 59%) compared to BMT alone. Despite that EVT was associated with a higher risk for symptomatic intracranial hemorrhage (RR: 7.78; 95% CI: 2.36–25.61; I2 = 0%) and any intracranial hemorrhage (RR: 2.85; 95% CI: 1.50–5.44; I2 = 16%), mortality at 3 months was lower among patients that received EVT plus BMT versus BMT alone (RR: 0.76; 95% CI: 0.65–0.89; I2 = 0%). However, sufficient robustness was not evident in any of the reported associations (FI < 10) including the overall effect regarding the primary outcome. The former associations were predominantly driven by RCTs with recruitment limited in China. Conclusions: EVT combined with BMT is associated with a higher likelihood of achieving good functional outcomes and a lower risk of death at 3 months compared to BMT alone, despite the higher risk of sICH. An individual-patient data meta-analysis is warranted to uncover and adjust for potential sources of heterogeneity and to provide further insight

Endovascular treatment of broad-necked intracranial aneurysms

Background: Endovascular treatment of intracranial aneurysms with electrolytically detachable coils, although clinically safe, is associated with low rates of immediate post-treatment occlussion and increased rate of recanalization in follow up, particularly concerning the large, giant and anatomically complex aneurysms, which were the initial indications of the method. The remodelling technique with the use of balloon protection, the combination of stenting and coiling and finally the use of liquid embolic agents (Onyx) have been used to overcome this problem. The purpose of this study is to evaluate the results of these methods for the treatment of this special category of intracranial aneurysms which have the propensity to recanalize on follow up. Method-Results: From June 2004 we have treat 117 patients with 120 broad-necked aneurysms. In 52 aneurysms coilling under balloon protection was used with 79% complete occlusion, 10% residual neck and 12% residual aneurysm. In follow up, 82% were complete occluded, and 18% had residual aneurysm. 55 aneurysms were treated by stent placement and coilling with 82% complete occlusion, 5% residual neck and 13% residual aneurysm. In follow up, 91% were complete occluded, and 9% had residual aneurysm. 13 aneurysms that were treated with vessel reconstruction with Onyx were totally occluded immediately post embo. In the follow up, 15% were recanalized, necessitating retreatment with Onyx and stent placement. One patient suffered extensive occlusion of the ICA immediately after stent placement due to Plavix resistance. There was no morbidity or mortality attributed to the method of treament. None of the ruptrures aneurysms rebled during the follow up. Conclusion: Our experience from embolization of broad necked aneurysms was extremely interesting. Coilling with balloon protection is proposed for aneurysms with broad neck, where a small portion of the vessel perimetre is participating in the neck. In aneurysms where vessel wall reconstruction is needed, stent and coilling has better and more stable results. Finally, in aneurysms that originate from dysplastic parent vessels Onyx with stent placement can achieve better vessel wall reconstruction at the level of the necl, offering a permanent solution for dysplastic large, giant and dysplastic intracranial aneurysms.Εισαγωγή: Η ενδαγγειακή θεραπεία με ηλεκτρολυτικά αποσπώμενα σπειράματα ως εναλλακτική μέθοδος αντιμετώπισης των ενδοκρανίων ανευρυσμάτων παρ' ότι κλινικά ασφαλής, συνδέεται με χαμηλά ποσοστά άμεσης απόφραξης και με αυξημένο ποσοστό υποτροπής στο follow-up που αφορά ιδιαίτερα τα μεγάλα και ανατομικά περίπλοκα ανευρύσματα που αποτέλεσαν την αρχική ένδειξη της μεθόδου. Στόχος αυτής της μελέτης ήταν να διερευνήσει τα αποτελέσματα των μεθόδων που χρησιμοποιούνται στην αντιμετώπιση εκείνης της κατηγορίας ανευρυσμάτων που έχουν την τάση να παρουσιάζουν υψηλά ποσοστά επανασηραγγοποίησης. Η μέθοδος της ανακατασκευής του τοιχώματος του αγγείου με την χρησιμοποίηση μπαλονιού προστασίας, η τοποθέτησις μεταλλικών ενδοπροθέσεων με πλήρωση του ανευρύσματος με σπειράματα και τέλος η χρησιμοποίησις υγρού εμβολικού υλικού (Onyx) με ή χωρίς τοποθέτηση ενδοπροθέσεως. Μέθοδος-Αποτελέσματα: Από τον Ιούλιο 2004 μέχρι σήμερα, αντιμετωπίσθηκαν με εμβολισμό 117 ασθενείς, με 120 ανευρύσματα ευρέος αυχένος. Σε 52 ανευρύσματα χρησιμοποιήθηκε μπαλόνι προστασίας και έγινε πλήρωση με σπειράματα. Πλήρης απόφραξη επιτεύχθηκε σε ποσοστό 79%, σε 10% παρέμεινε υπολειμματικός αυχένας και σε 12% υπολλειμματικό ανεύρυσμα. Εκ των 46 ασθενών με follow-up, 82% είχαν πλήρη απόφραξη, 18% υπολειμματικό ανεύρυσμα. Σε 55 ανευρύσματα που αντιμετωπίσθηκαν με τοποθέτηση ενδοπρόθεσης και σπειραμάτων επιτεύχθηκε πλήρης απόφραξη σε 82%, παρουσία υπολειμματικού αυχένα σε 5% και υπολειμματικού ανευρύσματος σε 13%. Στο follow-up, 91% είχαν πλήρη απόφραξη και 9% υπολειμματικό ανεύρυσμα. Σε 13 ανευρύσματα που αντιμετωπίσθηκαν με Onyx επιτεύχθηκε πλήρης απόφραξη στο 100%. Εξ’ αυτών, 15% παρουσίασαν επανασηραγγοποίηση στο follow-up και χρειάσθηκε να αντιμετωπισθούν εκ νέου με Onyx και stent με πλήρη επιτυχία. Κανένας από τους ασθενείς που αντιμετωπίσθηκαν δεν υπέστη επαναιμορραγία στο χρόνο του follow up. Μία ασθενής παρουσίασε εκτεταμένη θρόμβωση της έσω καρωτίδος αμέσως μετά την τοποθέτηση μεταλλικής ενδοπροθέσεως, που οφείλετο σε αντίσταση στην κλοπιδογρέλη. Δεν παρατηρήθηκε θνητότητα ή νοσηρότητα που να αποδίδεται στην μέθοδο της θεραπείας. Συμπέρασμα: Η εμπειρία μας από τον εμβολισμό ανευρυσμάτων ευρέος αυχένα, είναι εξαιρετικά ενδιαφέρουσα. Ο εμβολισμός με μπαλόνι προστασίας προσφέρεται για ανευρύσματα ευρέως αυχένα όπου δεν συμμετέχει μεγάλο τμήμα της περιμέτρου του αγγείου. Σε ανευρύσματα όμως όπου χρειάζεται ανακατασκευή του τοιχώματος στο επίπεδο του αυχένα, η μέθοδος ενδοπρόθεσης σε συνδυασμό με σπειράματα έχει καλύτερα και σταθερότερα αποτελέσματα. Τέλος σε ιδιαίτερα δυσπλαστικά ανευρύσματα η μέθοδος με Onyx σε συνδυασμό με ενδοπρόθεση εξασφαλίζει την προσφορότερη λύση, αν και είναι ιδιαίτερα περίπλοκη για ευρεία χρήση. Μελλοντικές εξελίξεις στην τεχνολογία των ενδοπροθέσεων με μικροπορώδη υφή ενδέχεται στο μέλλον να προσφέρουν την δυνατότητα αντιμετωπίσεως μόνο με ενδοπροθέσεις για ειδικές κατηγορίες ανευρυσμάτων, επιτρέποντας την πλήρη ανακατασκευή του τοιχώματος του θυγατρικού αγγείου στο επίπεδο του αυχένος του ανευρύσματος, προσφέροντας οριστική θεραπεία των ιδιαίτερα δυσπλαστικών, μεγάλων και γιγαντιαίων ανευρυσμάτων εγκεφάλου

Transcranial Color-Coded Duplex in Acute Encephalitis: Current Status and Future Prospects

BACKGROUP AND PURPOSE: There are limited data regarding the diagnostic yield of transcranial color-coded Doppler (TCCD) in acute encephalitis. We present our preliminary observations of consecutive ultrasound evaluations in 2 patients with acute encephalitis and we review the possible diagnostic role of TCCD in such cases. METHODS: We describe two cases of acute encephalitis that presented with aphasia and confusion and underwent repeat TCCD evaluation at baseline and after 48 hours in both patients. We also critically review the current literature regarding potential TCCD applications in acute central nervous system infections. RESULTS: Serial TCCD evaluations revealed the following triad of abnormal findings in both patients: (i) elevated pulsatility index (PI) in the left middle cerebral artery (M1 MCA) at baseline (>1.2), (ii) increased PI in left M1 MCA by >25% in comparison to right M1 MCA, and (iii) decrease in PI in left M1 MCA by >25% at the follow-up evaluation at 48 hours. The decrease in PI in left M1 MCA coincided with symptom improvement in both patients. DISCUSSION: The focal transient increase in left M1 MCA PI may be attributed to focally increased intracranial pressure or peripheral vasospasm of distal left MCA branches. Since there are limited reports in the literature concerning TCCD evaluation of patients with central nervous system infections, our preliminary findings require independent confirmation in a larger series of patients.SCOPUS: ar.jFLWINinfo:eu-repo/semantics/publishe

High-resolution vessel wall magnetic resonance imaging in varicella-zoster virus vasculitis

Varicella-zoster virus vasculopathy is a rare but potentially treatable condition. Diagnosis has been based on angiography, brain magnetic resonance imaging (MRI), and cerebrospinal fluid analysis. High-resolution vessel wall MRI may aid to the diagnosis by differentiating inflammation from other vessel wall pathologies. We present the characteristic MRI findings of this condition in a young patient presenting with ischemic stroke.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Yin-Yang vascular imaging sign in basilar artery dissection

SCOPUS: le.jinfo:eu-repo/semantics/publishe

Subclavian Steal Syndrome with or without Arterial Stenosis: A Review

The subclavian-vertebral artery steal syndrome (SSS) is the hemodynamic phenomenon of blood flow reversal in the vertebral artery due to significant stenosis or occlusion of the proximal subclavian artery or the innominate artery. Occasionally, SSS is diagnosed in patients not harboring arterial stenosis. With the exception of arterial congenital malformations, the limited case reports of SSS with intact subclavian artery are attributed to dialysis arteriovenous fistulas (AVFs). Interestingly, these cases are more frequently symptomatic than those with the classical atherosclerotic SSS forms. On the other hand, the disclosure of SSS due to subclavian/innominate artery atherosclerotic stenosis, even in the absence of accompanying symptoms, should prompt a thorough cardiovascular work-up for the early detection of coexisting coronary, carotid, or peripheral artery disease. Herein, we review the incidence, clinical presentation, sonographic findings, and therapeutic interventions related to SSS with and without subclavian/innominate artery stenosis. We also review the currently available data in the literature regarding the association of SSS and dialysis AVF. In addition, we present a patient with bilateral symptomatic SSS as the result of an arteriovenous graft (AVG) that was introduced after the preexisting AVF in the contralateral arm became nonfunctional. SSS due to subclavian or innominate artery stenosis/occlusion is rarely symptomatic warranting interventional treatment. In contrast, when it is attributed to AVF, surgical correction is frequently necessary.SCOPUS: re.jFLWINinfo:eu-repo/semantics/publishe

Mechanical thrombectomy for acute middle cerebral artery occlusion caused by a giant, thrombosed, extracranial internal carotid artery aneurysm

SCOPUS: le.jinfo:eu-repo/semantics/publishe