scholarly journals Update in the treatment of intracranial atherosclerotic disease

2019 ◽  
Vol 5 (1) ◽  
pp. 59-64 ◽  
Author(s):  
Zachary R Barnard ◽  
Michael J Alexander
Keyword(s):  
Patient Outcomes ◽  
Medical Management ◽  
Atherosclerotic Disease ◽  
Intracranial Atherosclerotic Disease ◽  
Technological Developments ◽  
Surgical Bypass ◽  
Surgical Options ◽  
Intracranial Arteries ◽  
Improve Patient ◽  
Treatment Window

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

Medical Management Versus Surgical Bypass for Symptomatic Intracranial Atherosclerotic Disease: A Systematic Review

2019 ◽  
Vol 129 ◽  
pp. 62-71 ◽  
Author(s):  
Adeel Ilyas ◽  
Ching-Jen Chen ◽  
Natasha Ironside ◽  
Thomas J. Buell ◽  
Gustavo Chagoya ◽  
...  
Keyword(s):  
Systematic Review ◽  
Medical Management ◽  
Atherosclerotic Disease ◽  
Intracranial Atherosclerotic Disease ◽  
Surgical Bypass

Abstract P476: Safety and Efficacy of Balloon Mounted Drug-Eluting Stent in the Treatment of Symptomatic Intracranial Atherosclerotic Disease Multicenter International Experience

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Mahmoud Mohammaden ◽  
Raul G Nogueira ◽  
WONDWOSSEN TEKLE ◽  
farhan siddiq ◽  
Diogo C Haussen ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Endovascular Treatment ◽  
Medical Management ◽  
Randomized Clinical Trials ◽  
Atherosclerotic Disease ◽  
Drug Eluting Stent ◽  
Safety And Efficacy ◽  
Intracranial Atherosclerotic Disease ◽  
Drug Eluting

Introduction: Intracranial atherosclerotic disease (ICAD) is a common cause of refractory stroke. Randomized clinical trials failed to prove the safety and efficacy of the endovascular treatment options of symptomatic ICAD (sICAD). However, there are many concerns regarding inclusion criteria in these trials which made them less effective than standard medical management. Herein, we aim to study the safety and efficacy of drug-eluting balloon mounted stents (DES) in the treatment of sICAD. Methods: A retrospective review of endovascular database from 10 comprehensive stroke centers inside and outside the USA from January 2017 to January 2020 was reviewed. Patients were included if they had symptomatic intracranial stenosis ≥70% in the target vessel, failed best medical management, and underwent intracranial stenting with DES. The primary outcome was the occurrence of ischemic stroke, hemorrhage, or mortality within 72 hours of the procedure. Secondary outcomes included rates of symptomatic and angiographic recurrence within 6 months of the procedure. Results: There was a total of 129 patients, the median age was 65 [58-72] years, 40 (31%) were females. The intracranial stenotic lesions were located in anterior circulation in 74 (57.4%) of cases [24 (18.6%) supraclinoid ICA, 5 (3.9%) cavernous ICA, 17 (13.2%) petrous ICA, 5 (19.4%) MCA-M1, and 3 (2.3%) M2] and in posterior circulation in 55 (42.6%) of cases [36 (27.9) vertebral artery V4 segment, 18 (14%) basilar and 1 (0.7%) PCA]. Recurrent stroke was the qualifying event in 101 (78.3%) while transient ischemic attacks (TIA) were identified in 28 (21.7%) of cases. The median time from the qualifying event to stenting was 6 [2-24] days. Strokes were reported within 72 hours of the procedure; 2 (1.6%) ischemic, 2 (1.6%) hemorrhagic strokes and 2 (1.6%) patients suffered inpatient mortality. The median follow-up time was 6 [3-6.75] months. Among 99 patients who had clinical follow up 2 (2%) had TIA and 6 (6.1%) had strokes. Fifty-one patients had follow-up imaging of whom symptomatic ISR was reported in 8 (15.7%). Conclusion: Our study has shown that in appropriately selected patients with sICAD, endovascular treatment using DES is safe and effective. Prospective randomized clinical trials are warranted.

Encephaloduroarteriosynangiosis (EDAS) revascularization for symptomatic intracranial atherosclerotic steno-occlusive (ERSIAS) Phase-II objective performance criterion trial

2020 ◽  
pp. 174749302096725
Author(s):  
Nestor R Gonzalez ◽  
Hao Jiang ◽  
Patrick Lyden ◽  
Shlee Song ◽  
Konrad Schlick ◽  
...  
Keyword(s):  
Phase Ii ◽  
Primary Endpoint ◽  
Medical Management ◽  
Performance Criterion ◽  
Atherosclerotic Disease ◽  
Intracranial Atherosclerotic Disease ◽  
Objective Performance ◽  
Endpoint Event ◽  
One Year ◽  
Event Rates

Background Intracranial atherosclerotic disease (ICAD) is one of the most challenging stroke etiologies, with frequent recurrences despite optimized medical management. Encephaloduroarteriosynangiosis (EDAS) is an indirect revascularization method that produces extra-cranial collaterals to intracranial vessels. We present the results of a phase-II trial of EDAS in intracranial atherosclerotic disease patients. Aims To evaluate the feasibility, safety, and preliminary efficacy of EDAS in intracranial atherosclerotic disease patients. Methods ERSIAS was a prospective objective-performance-criterion trial of EDAS plus intensive medical management (IMM) in intracranial atherosclerotic disease (ICAD) patients failing medical treatment. Primary endpoint was any stroke/death within 30-days post-surgery or stroke in the territory of the qualifying artery beyond 30 days. The primary analysis compared event rates through one year with an objective-performance-criterion based on a 10% reduction from the 20% rate in the intensive medical management arm of the stenting versus aggressive medical management for preventing recurrent stroke in intracranial stenosis trial (SAMMPRIS) in patients with poor collaterals. Event rates through two years were compared with propensity-score-matched (PSM) medically treated patients from SAMMPRIS and the carotid occlusion surgery study (COSS). Results During a median follow-up of 24.5 months, 5 (9.6%) of 52 patients had a primary endpoint event. The primary endpoint rate at one year met the threshold for nonfutility and advancement to phase III (<10%). In the sensitivity analysis, primary endpoint event rate at two years was lower than in PSM controls, 9.6% versus 21.2% (p < 0.07). Overall, 86% of EDAS-plus-intensive medical management patients were functionally independent at last follow-up and 89% demonstrated neovascularization. There were two (3.8%) surgical complications and no intracranial hemorrhages. Conclusion ERSIAS phase II provides evidence of safety and strong signals of efficacy of EDAS-plus-intensive medical management, supporting advancement to a seamless phase-IIb/III trial. Clinical Trial Registration URL: https://www.clinicaltrials.gov.NCT01819597 .

Endovascular Advances for Intracranial Occlusive Disease

Neurosurgery ◽  
2014 ◽  
Vol 74 (suppl_1) ◽  
pp. S126-S132 ◽  
Author(s):  
Mandy J. Binning ◽  
Erol Veznedaroglu
Keyword(s):  
United States ◽  
Ischemic Stroke ◽  
Stent Placement ◽  
The United States ◽  
Atherosclerotic Disease ◽  
High Grade ◽  
Intracranial Atherosclerosis ◽  
Intracranial Atherosclerotic Disease ◽  
Surgical Bypass ◽  
Angioplasty And Stenting

Abstract Stroke is the fourth leading cause of death in the United States. Intracranial atherosclerotic disease accounts for 8%-10% of ischemic stroke in the United States. So far, surgical bypass has not proved to be superior to medical therapy. As both medical and endovascular therapies for intracranial atherosclerosis evolve, so too do the guidelines for treatment. Initial reports on the results of stent placement for symptomatic high-grade intracranial atherosclerotic disease were encouraging; however, recent trials suggest that initial medical management may be preferable. Currently, intracranial angioplasty and stenting for symptomatic intracranial atherosclerosis is now more controversial. Further trials are necessary to help determine which patients are ideal for endovascular therapies.

scholarly journals An On-Top-Plasty Reconstruction for Complicated Radial Polydactyly

Hand ◽  
2018 ◽  
Vol 13 (3) ◽  
pp. NP10-NP13 ◽  
Author(s):  
Brian P. Kelley ◽  
Carrie Kubiak ◽  
Kevin C. Chung
Keyword(s):  
Patient Outcomes ◽  
Clinical Presentation ◽  
Spare Part ◽  
Distal Phalanx ◽  
Careful Planning ◽  
Surgical Options ◽  
Web Space ◽  
Improve Patient

Background: The clinical presentation of radial polydactyly can vary greatly. Careful planning and appreciation of the anatomic subtleties provides alternative surgical options to improve patient outcomes. Methods: We present a case of a well-formed accessory web space thumb and a hypoplastic primary thumb. Results: Rather than excising the accessory digit, we performed a spare-part, on-top-plasty reconstruction to replace the diminutive distal phalanx of the primary thumb. Conclusions: This novel case applied the principle of spare-part surgery to reconstruct a more aesthetic and functional reconstructed digit.

scholarly journals Managing Bony Defects of the Shoulder Joint that Occur in Association with Dislocation

2017 ◽  
Vol 11 (1) ◽  
pp. 1245-1257 ◽  
Author(s):  
Jonathan Brian Yates ◽  
Muhammad Naghman Choudhry ◽  
Mohammad Waseem
Keyword(s):  
Patient Outcomes ◽  
Humeral Head ◽  
Shoulder Joint ◽  
Articular Surface ◽  
Compression Fracture ◽  
Optimal Method ◽  
Treatment Techniques ◽  
Surgical Options ◽  
Defect Filling ◽  
Improve Patient

Background: Defects to the articular surface of the humeral head have been known to be associated with shoulder dislocation since the 19th century. It wasn't until 1934 that the first description of the ubiquitous compression fracture of the posterolateral humeral head that occurs with traumatic anterior instability appeared. From 1940, this defect became referred to as a Hill-Sachs lesion after the investigators who reported the condition. The significance of, and therefore treatment of, these and other such bony defects around the shoulder joint has been hotly debated. Methods: We reviewed the available current literature to determine and report on the most up to date concepts and treatment techniques being used to manage bony defects of the shoulder. Results: Numerous surgical options have been proposed to manage bony defects of the shoulder, including a variety of defect-filling procedures, with good outcomes. However, the small numbers and diversity of case mix makes for difficult comparisons. Conclusion: We are currently developing a greater appreciation of how both the humeral and glenoid defects interact and therefore should be assessed and addressed simultaneously in order to improve patient outcomes. More research and collaboration is needed to determine the optimal method of assessing and managing these patients.

scholarly journals Clopidogrel plus Aspirin for Symptomatic Intracranial Atherosclerotic Stenosis: A Pilot Study

2016 ◽  
Vol 5 (3-4) ◽  
pp. 157-164 ◽  
Author(s):  
Tareq Kass-Hout ◽  
Melanie Winningham ◽  
Omar Kass-Hout ◽  
Laura Henriquez ◽  
Frank Tong ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Medical Management ◽  
Dual Antiplatelet Therapy ◽  
Recurrent Stroke ◽  
Intracranial Stenosis ◽  
Atherosclerotic Disease ◽  
Vascular Events ◽  
Intracranial Atherosclerotic Disease ◽  
Atherosclerotic Stenosis ◽  
Aggressive Medical Management

Background and Purpose: There are limited data on the optimal duration of dual antiplatelet therapy for secondary stroke prevention in patients with symptomatic intracranial atherosclerotic disease. Methods: Consecutive patients presenting with high-grade (70-99%) symptomatic intracranial stenosis from January 1, 2011, to December 31, 2013, and evaluated within 30 days of the index event were eligible for this analysis. All patients underwent treatment with aspirin plus clopidogrel for a target duration of 12 months along with aggressive medical management based on the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) protocol; all patients were given gastrointestinal prophylaxis for the duration of their aspirin and clopidogrel treatment. Clinical and safety outcomes of our cohort were compared with the medical arm of the SAMMPRIS trial cohort (n = 227). Results: Our cohort included 25 patients that met the inclusion criteria. Achievement of blood pressure and LDL cholesterol targets were similar between our cohort and the SAMMPRIS cohort. At 1 year, the rates of stroke, myocardial infarction or vascular death were 0% in our cohort and 16% in the SAMMPRIS cohort (p = 0.03). At 1 year, major bleeding rates were similar between our cohort and the SAMMPRIS cohort (4 vs. 2.2%, p = 1.0). Conclusion: A prolonged course of dual antiplatelet therapy for symptomatic intracranial atherosclerotic disease may be associated with less vascular events with no increase in hemorrhagic complications.

Safety and efficacy of balloon-mounted stent in the treatment of symptomatic intracranial atherosclerotic disease: a multicenter experience

2021 ◽  
pp. neurintsurg-2021-017818
Author(s):  
Mahmoud H Mohammaden ◽  
Raul G Nogueira ◽  
Wondwossen Tekle ◽  
Santiago Ortega-Gutierrez ◽  
Mudassir Farooqui ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Medical Management ◽  
Randomized Clinical Trials ◽  
Recurrent Stroke ◽  
Atherosclerotic Disease ◽  
Anterior Circulation ◽  
Safety And Efficacy ◽  
Intracranial Atherosclerotic Disease ◽  
Long Term Follow Up

BackgroundRandomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications.ObjectiveTo study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD.MethodsProspectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up.ResultsA total of 232 patients were eligible for the analysis (mean age 62.8 years, 34.1% female). The intracranial stenotic lesions were located in the anterior circulation in 135 (58.2%) cases. Recurrent stroke was the qualifying event in 165 (71.1%) while recurrent TIA was identified in 67 (28.9%) cases. The median (IQR) time from the qualifying event to stenting was 5 (2–20.75) days. Strokes were reported in 13 (5.6%) patients within 72 hours of the procedure; 9 (3.9%) ischemic and 4 (1.7%) hemorrhagic, and mortality in 2 (0.9%) cases. Among 189 patients with median follow-up time 6 (3–14.5) months, 12 (6.3%) had TIA and 7 (3.7%) had strokes. Three patients (1.6%) died from causes not related to stroke.ConclusionOur study has shown that BMS may be a safe and effective treatment for medically refractory symptomatic ICAD. Additional prospective randomized clinical trials are warranted.

Combined Approaches to the Skull Base for Intracranial Extension of Tumors via Perineural Spread can Improve Patient Outcomes

2016 ◽  
Vol 77 (S 01) ◽  
Author(s):  
Sheri Palejwala ◽  
Jonnae Barry ◽  
Crystal Rodriguez ◽  
Chandni Parikh ◽  
Stephen Goldstein ◽  
...  
Keyword(s):  
Skull Base ◽  
Patient Outcomes ◽  
Intracranial Extension ◽  
Perineural Spread ◽  
Improve Patient
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