Three-Month Outcome of Carotid Artery Stenting in Patients with/without Coexistent Unruptured Intracranial Aneurysms

2020 ◽  
Vol 49 (4) ◽  
pp. 382-387
Author(s):  
Ximeng Yang ◽  
Jun Lu ◽  
Peng Qi ◽  
Junjie Wang ◽  
Shen Hu ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Carotid Artery Stenting ◽  
Intracranial Aneurysms ◽  
Dual Antiplatelet Therapy ◽  
Aneurysm Rupture ◽  
Unruptured Intracranial Aneurysms ◽  
Significant Difference ◽  
Symptomatic Intracranial Hemorrhage ◽  
Baseline Characteristics

Introduction: Safety of carotid artery stenting (CAS) in patients having carotid stenosis with coexistent unruptured intracranial aneurysms (UIAs) is rarely reported. Thus, we studied the 3-month outcome of CAS in the presence of coexistent UIAs in our institution. Methods: A retrospective analysis of patients receiving CAS at our institution from September 2011 to December 2019 was carried out. Patients were stratified into 2 groups: group of CAS with UIAs (CAS-UIA) and group of CAS without UIAs (CAS). The main complications within 3 months after stenting were TIA, ischemic stroke, symptomatic intracranial hemorrhage (sICH), rupture of UIAs, and death. The baseline characteristics and complications of the 2 groups were compared. Results: Five hundred fifty-six patients (CAS, n = 468; CAS-UIA, n = 88) were included and 604 stenting procedures were performed. More patients had hypertension in the CAS-UIA group (87.5 vs. 73.7%, p = 0.006). There was no significant difference in TIAs, ischemic stroke, sICH, and death within 3 months after stenting between the CAS and CAS-UIA groups. None of the 113 coexistent UIAs detected in 88 patients had aneurysm rupture within 3 months after CAS. Conclusions: In our large cohort of CAS patients, coexistent UIAs are not uncommon. Stenting of a carotid artery in the presence of coexistent UIAs could be conducted safely. Together with 3-month dual antiplatelet therapy, CAS did not increase the rupture risk of the coexistent UIAs within 3 months.

Management of carotid artery stenosis in patients with coexistent unruptured intracranial aneurysms

2020 ◽  
Vol 132 (1) ◽  
pp. 94-97 ◽  
Author(s):  
Tiziano Tallarita ◽  
Thomas J. Sorenson ◽  
Lorenzo Rinaldo ◽  
Gustavo S. Oderich ◽  
Thomas C. Bower ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Stenosis ◽  
Intracranial Aneurysms ◽  
Early Period ◽  
Aneurysm Rupture ◽  
Artery Stenosis ◽  
Consecutive Series ◽  
Carotid Revascularization ◽  
Unruptured Intracranial Aneurysms ◽  
Risk Of Rupture

OBJECTIVEConcomitant unruptured intracranial aneurysms (UIAs) are present in patients with carotid artery stenosis not infrequently and result in unique management challenges. Thus, we investigated the risk of rupture of an aneurysm after revascularization of a carotid artery in a contemporary consecutive series of patients seen at our institution.METHODSData from patients who underwent a carotid revascularization in the presence of at least one concomitant UIA at our institution from 1991 to 2018 were retrospectively reviewed. Patients were evaluated for the incidence of aneurysm rupture within 30 days (early period) and after 30 days (late period) of carotid revascularization, as well as for the incidence of periprocedural complications from the treatment of carotid stenosis and/or UIA.RESULTSOur study included 53 patients with 63 concomitant UIAs. There was no rupture within 30 days of carotid revascularization. The overall risk of rupture was 0.87% per patient-year. Treatment (coiling or clipping) of a concomitant UIA, if pursued, could be performed successfully after carotid revascularization.CONCLUSIONSCarotid artery revascularization in the setting of a concomitant UIA can be performed safely without an increased 30-day or late-term risk of rupture. If indicated, treatment of the UIA can take place after the patient recovers from the carotid procedure.

Dual Antiplatelet Therapy after Intravenous Thrombolysis for Acute Minor Ischemic Stroke

2019 ◽  
Vol 82 (4-6) ◽  
pp. 93-98 ◽  
Author(s):  
Guangjian Zhao ◽  
Fanzhen Lin ◽  
Ziran Wang ◽  
Xiaolin Shao ◽  
Yanxue Gong ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Stroke Recurrence ◽  
Minor Ischemic Stroke ◽  
Significant Difference ◽  
Scale Scores ◽  
Symptomatic Intracranial Hemorrhage

Objective: To verify the efficacy and safety of dual antiplatelet therapy after intravenous thrombolysis for acute minor ischemic stroke (AMIS). Methods: AMIS patients who received recombinant tissue plasminogen activator (rt-PA) intravenous thrombolysis from January to October 2018 were retrospectively analyzed and divided into the aspirin (ASP) and ASP + clopidogrel (ASP-CLO) groups based on the type of antiplatelet therapy to compare the rates of good clinical outcome, symptomatic intracranial hemorrhage (SICH) after thrombolysis, and mortality in 90 days. Results: A total of 207 patients were included (group ASP, 105 patients; group ASP-CLO, 102 patients). There was no significant difference in the baseline clinical data between the 2 groups. The ­90-day modified Rankin scale scores (66.7 vs. 82.4%, p = 0.009) showed a statistically significant difference, but SICH (1.0 vs. 1.0%, p = 0.917) and 90-day mortality (1.9 vs. 1.0%, p = 0.585) showed no significant difference between the 2 groups. Conclusions: Short-term (21 days) dual antiplatelet therapy after rt-PA intravenous thrombolysis for AMIS can improve the prognosis, reduce the risk of stroke recurrence, without increasing the risk of bleeding and mortality.

Clinical characteristics associated with sentinel headache in patients with unruptured intracranial aneurysms

2020 ◽  
pp. 159101992097197
Author(s):  
Zheng Wan ◽  
Hao Meng ◽  
Ning Xu ◽  
Tianyi Liu ◽  
Zhongping Chen ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Clinical Characteristics ◽  
Therapeutic Strategy ◽  
Multivariable Analysis ◽  
Clinical History ◽  
Aneurysm Rupture ◽  
Clinical Feature ◽  
Unruptured Intracranial Aneurysms ◽  
Significant Difference ◽  
Sh Group

Objective Sentinel headache (SH) is considered as a signal of the impending rupture of an aneurysm. However, it is difficult to diagnose whether the headaches of patients are associated with unstable aneurysms. Therefore, there is some doubt about the importance of headaches in patients with unruptured intracranial aneurysms (UIAs). This study was performed to explore the existence and clinical characteristics of SH associated with aneurysms. Methods Thirty-six patients with a single UIA were collected in this study. Patients were symptomatically categorized into two groups: SH and non-SH. The PHASES scores and patient and aneurysm characteristics were analyzed. Two independent MRI experts who were blinded to the patients’ clinical history conducted the analysis of the SWI results. Results There were 15 patients with sentinel headache. No significant difference was found in patient’s basic information and history. The SH group had a higher PHASES score than the non-SH group (P < 0.05). In univariable analysis, abnormal SWI signals were significantly more frequent in the SH group (P < 0.01) and the inflow angle was significantly lower in the non-SH group (P < 0.05). In multivariable analysis, abnormal signals in SWI were an independent factor associated with SH (P < 0.01). Conclusions SH exists in patients with UIAs and may indicate a high risk of aneurysm rupture. Abnormal signals on SWI may serve as a clinical feature to identify aneurysm-related SH and be helpful for the formulation of therapeutic strategy. Aneurysm geometry may also be related to SH but need further studies in the future.

Periprocedural complications of second-generation flow diverter treatment using Pipeline Flex for unruptured intracranial aneurysms: a systematic review and meta-analysis

2019 ◽  
Vol 11 (8) ◽  
pp. 817-824 ◽  
Author(s):  
Kartik Dev Bhatia ◽  
Hans Kortman ◽  
Emanuele Orru ◽  
Jesse M Klostranec ◽  
Vitor M Pereira ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Intracranial Aneurysms ◽  
Second Generation ◽  
Meta Analysis ◽  
Major Complication ◽  
Flow Diverter ◽  
Major Complications ◽  
Unruptured Intracranial Aneurysms ◽  
Symptomatic Intracranial Hemorrhage

BackgroundFlow diverters are a breakthrough treatment for large and giant intracranial aneurysms but carry a risk of periprocedural death or major stroke. Pipeline Flex is a second-generation device that is thought to have lower complication rates because of improvements in the delivery system as well as increased operator experience. Our objective was to analyze the risk of periprocedural death or major complications using Pipeline Flex for unruptured intracranial aneurysms.MethodsA systematic search of three databases was performed for studies of ≥10 treatments using Pipeline Flex for unruptured intracranial aneurysms (2014–2019) using PRISMA guidelines. Random effects meta-analysis was used to pool the rates of periprocedural (<30 days) death, major ischemic stroke, symptomatic intracranial hemorrhage, and minor stroke/transient ischemic attack.ResultsWe included eight studies reporting 901 treatments in 879 patients. Periprocedural mortality (<30 days) was 0.8% (5/901; 95% CI 0.4% to 1.5%; I2=0%). Rate of major complications (death, major ischemic stroke, or symptomatic intracranial hemorrhage) was 1.8% (14/901; 95% CI 1.0% to 2.7%; I2=0%). Aneurysm size ≥10 mm was a statistically significant predictor of a major complication (OR 6.4; 95% CI 2.0 to 20.7; p=0.002). Risk of a major complication in aneurysms <10 mm was 0.9% (95% CI 0.3% to 1.7%; I2=0%). The meta-analysis was limited by the predominance of anterior circulation aneurysms.ConclusionTreatment of unruptured intracranial aneurysms using the Pipeline Flex flow diverter has a low periprocedural risk of death (0.8%) or major complication (1.8%). The risk of a major complication is significantly higher for large/giant aneurysms (4.4%) and is very low for aneurysms <10 mm (0.9%).

Dual antiplatelet therapy after carotid artery stenting: trends and outcomes in a large national database

2020 ◽  
Vol 13 (1) ◽  
pp. 8-13
Author(s):  
Eric S Sussman ◽  
Michael Jin ◽  
Arjun V Pendharkar ◽  
Benjamin Pulli ◽  
Austin Feng ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Antiplatelet Therapy ◽  
Carotid Artery Stenting ◽  
Dual Antiplatelet Therapy ◽  
National Database ◽  
Increased Risk ◽  
Hemorrhagic Complications ◽  
The Impact ◽  
Large National Database

BackgroundWhile dual antiplatelet therapy (dAPT) is standard of care following carotid artery stenting (CAS), the optimal dAPT regimen and duration has not been established.MethodsWe canvassed a large national database (IBM MarketScan) to identify patients receiving carotid endarterectomy (CEA) or CAS for treatment of ischemic stroke or carotid artery stenosis from 2007 to 2016. We performed univariable and multivariable regression methods to evaluate the impact of covariates on post-CAS stroke-free survival, including post-discharge antiplatelet therapy.ResultsA total of 79 084 patients diagnosed with ischemic stroke or carotid stenosis received CEA (71 178; 90.0%) or CAS (7906; 10.0%). After adjusting for covariates, <180 days prescribed post-CAS P2Y12-inhibition was associated with increased risk for stroke (<90 prescribed days HR=1.421, 95% CI 1.038 to 1.946; 90–179 prescribed days HR=1.484, 95% CI 1.045 to 2.106). The incidence of hemorrhagic complications was higher during the period of prescribed P2Y12-inhibition (1.16% per person-month vs 0.49% per person-month after discontinuation, P<0.001). The rate of extracranial hemorrhage was nearly six-fold higher while on dAPT (6.50% per patient-month vs 1.16% per patient-month, P<0.001), and there was a trend towards higher rate of intracranial hemorrhage that did not reach statistical significance (5.09% per patient-month vs 3.69% per patient-month, P=0.0556). Later hemorrhagic events beyond 30 days post-CAS were significantly more likely to be extracranial (P=0.028).ConclusionsIncreased duration of post-CAS dAPT is associated with lower rates of readmissions for stroke, and with increased risk of hemorrhagic complications, particularly extracranial hemorrhage. The potential benefit of prolonging dAPT with regard to ischemic complications must be balanced with the corresponding increased risk of predominantly extracranial hemorrhagic complications.

Risk of Aneurysm Rupture After Thrombolysis in Patients With Acute Ischemic Stroke and Unruptured Intracranial Aneurysms

Neurology ◽  
2021 ◽  
Vol 97 (18) ◽  
pp. e1790-e1798
Author(s):  
Jyri Juhani Virta ◽  
Daniel Strbian ◽  
Jukka Putaala ◽  
Miikka Korja
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Aneurysms ◽  
Aneurysm Rupture ◽  
Radiology Reports ◽  
Stroke Study ◽  
Unruptured Intracranial Aneurysms ◽  
The Mean ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background and ObjectivesUnruptured intracranial aneurysms (UIAs) are considered to be a relative contraindication for IV thrombolysis (IVT) in acute ischemic stroke (AIS). Currently, however, data are limited on the risk of UIA rupture after IVT. Our objective was to assess whether IVT for AIS can lead to a UIA rupture and intracranial hemorrhages (ICHs) in patients with unruptured UIAs.MethodsThis was a prospective cohort study of consecutive patients treated in a comprehensive stroke center between 2005 and 2019. We assessed radiology reports and records at the Finnish Care Register for Health Care to identify patients with UIAs among all patients with AIS treated with IVT at the center. We analyzed patient angiograms for aneurysm characteristics and other brain imaging studies for ICHs after IVT. The main outcome was in-hospital ICHs attributable to a UIA rupture after IVT. Secondary outcomes were in-hospital symptomatic ICHs (European-Australian Cooperative Acute Stroke Study [ECASS-2] criteria, i.e., NIH Stroke Scale score increase ≥4 points) and any in-hospital ICHs.ResultsA total of 3,953 patients were treated with IVT during the 15-year study period. One hundred thirty-two (3.3%) of the 3,953 patients with AIS had a total of 155 UIAs (141 saccular and 14 fusiform). The mean diameter of UIAs was 4.7 ± 3.8 mm, with 18.7% being ≥7 mm and 9.7% ≥10 mm in diameter. None of the 141 saccular UIAs ruptured after IVT. Three patients (2.3%, 95% confidence interval [CI] 0.6%–5.8%) with large fusiform basilar artery UIAs had a fatal rupture at 27 hours, 43 hours, and 19 days after IVT. All 3 were administered anticoagulation treatments after IVT, and anticoagulation took effect during the UIA rupture. Any ICHs and symptomatic ICHs were detected in 18.9% (95% CI 12.9%–26.2%) and 8.3% (95% CI 4.4%–13.8%) of all patients with AIS, respectively.DiscussionIVT appears to be safe in patients with AIS with saccular UIAs, including larges UIAs (≥10 mm). Anticoagulation after AIS in patients with large fusiform posterior circulation UIAs may increase the risk of aneurysm rupture.

Carotid Artery Stenting and Intracranial Thrombectomy for Tandem Cervical and Intracranial Artery Occlusions

Neurosurgery ◽  
2019 ◽  
Vol 86 (2) ◽  
pp. 213-220 ◽  
Author(s):  
Byungjun Kim ◽  
Byung Moon Kim ◽  
Oh Young Bang ◽  
Jang-Hyun Baek ◽  
Ji Hoe Heo ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Stenting ◽  
Internal Carotid ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Efficacy And Safety ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Significant Difference ◽  
Symptomatic Intracranial Hemorrhage

Abstract BACKGROUND It remains controversial whether carotid artery stenting (CAS) is needed in cases of tandem cervical internal carotid artery occlusion (cICAO) and intracranial large vessel occlusion (LVO). OBJECTIVE To investigate the efficacy and safety of CAS in combination with endovascular thrombectomy (CAS-EVT) in cICAO-LVO patients and to compare its outcomes with those of EVT without CAS (EVT-alone). METHODS We identified all patients who underwent EVT for tandem cICAO-LVO from the prospectively maintained registries of 17 stroke centers. Patients were classified into 2 groups: CAS-EVT and EVT-alone. Clinical characteristics and procedural and clinical outcomes were compared between 2 groups. We tested whether CAS-EVT strategy was independently associated with recanalization success. RESULTS Of the 955 patients who underwent EVT, 75 patients (7.9%) had cICAO-LVO. Fifty-six patients underwent CAS-EVT (74.6%), and the remaining 19 patients underwent EVT-alone (25.4%). The recanalization (94.6% vs 63.2%, P = .002) and good outcome rates (64.3% vs 26.3%, P = .007) were significantly higher in the CAS-EVT than in the EVT-alone. Mortality was significantly lower in the CAS-EVT (7.1% vs 21.6%, P = .014). There was no significant difference in the rate of symptomatic intracranial hemorrhage between 2 groups (10.7 vs 15.8%; P = .684) and according to the use of glycoprotein IIb/IIIa inhibitor (10.0% vs 12.3%; P = .999) or antiplatelet medications (10.2% vs 18.8%; P = .392). CAS-EVT strategy remained independently associated with recanalization success (odds ratio: 24.844; 95% confidence interval: 1.445-427.187). CONCLUSION CAS-EVT strategy seemed to be effective and safe in cases of tandem cICAO-LVO. CAS-EVT strategy was associated with recanalization success, resulting in better clinical outcome.

Unruptured intracranial aneurysms in children: 18 years’ experience in a tertiary care pediatric institution

2019 ◽  
Vol 24 (2) ◽  
pp. 184-189 ◽  
Author(s):  
Daniel-Alexandre Bisson ◽  
Peter Dirks ◽  
Afsaneh Amirabadi ◽  
Manohar M. Shroff ◽  
Timo Krings ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Natural History ◽  
Internal Carotid Artery ◽  
Intracranial Aneurysms ◽  
Internal Carotid ◽  
Tertiary Care ◽  
Unruptured Intracranial Aneurysms ◽  
History Of ◽  
Mean Size

OBJECTIVEThere are little data in the literature on the characteristics and natural history of unruptured intracranial aneurysms in children. The authors analyzed their experience with unruptured intracranial aneurysms in the pediatric population at their tertiary care pediatric institution over the last 18 years. The first objective was to assess the imaging characteristics and natural history of these aneurysms in order to help guide management strategies in the future. A second objective was to evaluate the frequency of an underlying condition when an incidental intracranial aneurysm was detected in a child.METHODSThe authors conducted a Research Ethics Board–approved retrospective review of incidental intracranial aneurysms in patients younger than 18 years of age who had been treated at their institution in the period from 1998 to 2016. Clinical (age, sex, syndrome) and radiological (aneurysm location, type, size, thrombus, mass effect) data were recorded. Follow-up imaging was assessed for temporal changes.RESULTSSixty intracranial aneurysms occurred in 51 patients (36 males, 15 females) with a mean age of 10.5 ± 0.5 years (range 9 months–17 years). Forty-five patients (88.2%) had a single aneurysm, while 2 and 3 aneurysms were found in 3 patients each (5.8%). Syndromic association was found in 22 patients (43.1%), most frequently sickle cell disease (10/22 [45.5%]). Aneurysms were saccular in 43 cases (71.7%; mean size 5.0 ± 5.7 mm) and fusiform in the remaining 17 (28.3%; mean size 6.5 ± 2.7 mm). Thirty-one aneurysms (51.7%) arose from the internal carotid artery (right/left 1.4), most commonly in the cavernous segment (10/31 [32.3%]). Mean size change over the entire follow-up of 109 patient-years was a decrease of 0.6 ± 4.2 mm (range −30.0 to +4.0 mm, rate −0.12 ± 9.9 mm/yr). Interval growth (2.0 ± 1.0 mm) was seen in 8 aneurysms (13.3%; 4 saccular, 4 fusiform). An interval decrease in size (8.3 ± 10.7 mm) was seen in 6 aneurysms (10%). There was an inverse relationship between aneurysm size and growth rate (r = −0.82, p < 0.00001). One aneurysm was treated endovascularly with internal carotid artery sacrifice.CONCLUSIONSUnruptured pediatric intracranial aneurysms are most frequently single but can occur in multiples in a syndromic setting. None of the cases from the study period showed clinical or imaging signs of rupture. Growth over time, although unusual and slow, can occur in a proportion of these patients, who should be identified for short-term imaging surveillance.

Successful carotid artery stenting in patients with aortic dissection

2020 ◽  
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Aortic Dissection ◽  
Cerebral Infarction ◽  
Acute Ischemic Stroke ◽  
Aortic Arch ◽  
Common Carotid Artery ◽  
Carotid Artery Stenting ◽  
Acute Aortic Dissection ◽  
Optimal Timing

Background: There are no guidelines for the optimal timing of surgery (emergency vs. delayed) for ascending aortic dissection with acute ischemic stroke. We retrospectively compared the prognoses and radiological and clinical findings for concomitant aortic dissection and ischemic stroke in a series of case reports. Case presentation: Three patients presented with left hemiparesis. Patient 1 underwent surgery for acute aortic dissection without treatment for acute ischemic stroke. In Patient 2, emergency stenting could not be performed due to cardiac tamponade and hypotension. Therefore, emergency acute aortic dissection surgery was performed. Patient 3 underwent emergency right common carotid artery stenting followed by surgery for acute aortic dissection. Brain perfusion computed tomography angiography (CTA) was performed to diagnose severe stenosis of the right common carotid artery or occlusion concomitant with acute aortic dissection involving the aortic arch with a cerebral perfusion mismatch in all the patients. Patient 3 had postoperative local cerebral infarction, whereas patients 1 and 2 (without stent insertion) had extensive postoperative cerebral infarction. Conclusion: Patient 3 showed a better prognosis than patients without stent treatment. We suggest that perfusion CTA of the aortic arch in suspected acute ischemic stroke can facilitate early diagnosis and prompt treatment in similar patients.

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