Abstract 1122‐000095: Revisiting the Role of Angioplasty and Stenting for Symptomatic Intracranial Stenosis ‐ A Case Series

Introduction : Early and long‐term results of the SAMMPRIS trial showed superiority of aggressive medical management over stenting in patients with symptomatic intracranial stenosis, in part due to the high risk of periprocedural complications. However, even with maximal medical management, the risk of recurrent TIA or stroke in patients with high‐grade stenosis often remains elevated. Methods : A review of our stroke database was conducted, identifying three relevant cases. Results : CASE 1: A 69 year‐old man with multiple vascular risk factors and atrial fibrillation on apixaban presented with several months of multiple stereotyped episodes of limb‐shaking TIAs affecting the left leg, often leading to falls. CT angiogram revealed 70–80% stenosis of A2 segment of right ACA. Symptoms completely resolved after stenting with Neuroform Atlas stent. Repeat angiogram at 6 months showed excellent vessel caliber. CASE 2: A 78 year‐old man with hypertension, DM, CAD, and known left ICA occlusion presented with recurrent episodes of aphasia and right arm weakness while on maximal medical therapy. CT angiogram showed severe right supraclinoid ICA stenosis which was corrected with Resolute Onyx DES stent with improvement of symptoms. CASE 3: A 77 year‐old with hypertension, DM, CAD and aortic dissection on dual antiplatelet therapy and high‐intensity statin was admitted with stereotyped, blood pressure‐dependent episodes of aphasia and right face/arm weakness secondary to high‐grade stenosis of both M2 divisions of the left MCA. Successful angioplasty and Y‐stenting with Neuroform EZ and Wingspan stents led to complete resolution of symptoms. Conclusions : At high‐volume centers and with newer interventional devices and techniques, intracranial angioplasty and stenting should be considered as a valuable therapeutic option in patients with symptomatic intracranial stenosis refractory to maximal medical therapy.

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Heterotopic caval valve implantation for the management of severe tricuspid regurgitation: a case series

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa428 ◽

2020 ◽

Author(s):

Aidan Sharkey ◽

Ronny Munoz Acuna ◽

Kiran Belani ◽

Ravi K Sharma ◽

Omar Chaudhary ◽

...

Keyword(s):

Medical Therapy ◽

Tricuspid Regurgitation ◽

Surgical Intervention ◽

Symptom Relief ◽

Vena Cava ◽

Case Series ◽

High Morbidity ◽

Severe Tricuspid Regurgitation ◽

Maximal Medical Therapy ◽

Valve Implantation

Abstract Background Severe tricuspid regurgitation (TR) is a complex condition that can be difficult to treat medically, and often surgical intervention is prohibited due to the high morbidity and mortality associated with this intervention. In patients who have failed maximal medical therapy and have progressive symptoms related to their severe TR, heterotopic caval valve implantation (CAVI) offers potential for symptom relief for these patients. Case summary We present two cases of patients with severe TR with symptoms of heart failure that were refractory to medical therapy. Due to extensive comorbidities in these patient’s surgical intervention was deemed unsuitable and the decision was made to proceed with heterotopic CAVI in order to try and control their symptoms. Both patients successfully underwent the procedure and had an Edwards SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA, USA) implanted in the inferior vena cava/right atrium junction. In both patients, there was improvement in the postoperative haemodynamics as measured by invasive and non-invasive methods. Successful discharge was achieved in both patients with improvement in their symptoms. Discussion Selective use of heterotopic CAVI to treat symptomatic severe TR that is refractory to medical therapy may be a viable option to improve symptoms in those patients that are unsuitable for surgical intervention.

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Homozygous Familial Hypercholesterolemia: Case Series and Review of the Literature

Case Reports in Transplantation ◽

10.1155/2011/154908 ◽

2011 ◽

Vol 2011 ◽

pp. 1-5 ◽

Cited By ~ 4

Author(s):

Carlos H. Palacio ◽

Theresa R. Harring ◽

N. Thao T. Nguyen ◽

John A. Goss ◽

Christine A. O'Mahony

Keyword(s):

Familial Hypercholesterolemia ◽

Medical Therapy ◽

Serum Cholesterol ◽

Clinical Manifestations ◽

Case Series ◽

High Serum ◽

Lipid Lowering ◽

Lifestyle Modifications ◽

Maximal Medical Therapy ◽

Atherosclerotic Changes

Introduction. Familial hypercholesterolemia (FH) is caused by nonfunctioning low-density lipoprotein (LDL) receptors, resulting in high serum cholesterol. Two types of FH are described: the heterozygous form is diagnosed in adults and responds well to medical therapy; the homozygous form is rare, diagnosed in children, and often requires multiple treatments to prevent complications. Cholesterol accumulation in tissues produces common clinical manifestations including cutaneous xanthomas, coronary artery disease, and aortic stenosis. Treatment options consist of lifestyle modifications, lipid-lowering medications, LDL aphaeresis, and orthotopic liver transplantation (OLT).Case Presentation. Two patients with FH presented at young ages due to characteristic cutaneous xanthomas. The patients underwent cardiac testing that revealed atherosclerotic changes. The patients received maximal medical therapy, but only experienced a small decrease in serum cholesterol and LDL levels. After several years of medical treatment without improvement of symptoms, the patients were listed for OLT. The transplantations were successful, and only one patient had a postoperative complication of acute rejection, treated successfully. Currently, both patients are doing well with regression of the cutaneous xanthomas and atherosclerotic changes.Conclusion. OLT is a safe and effective option for patients with homozygous FH refractory to maximal medical therapy and may represent the optimal treatment for these patients.

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Chronic rhinosinusitis: medical versus surgical management

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20212451 ◽

2021 ◽

Vol 7 (7) ◽

pp. 1150

Author(s):

Seema Patel ◽

Tanvi S. Rekhade ◽

Rameshwar T. Pawar ◽

Ashok Z. Nitnaware

Keyword(s):

Chronic Rhinosinusitis ◽

Surgical Management ◽

Medical Therapy ◽

Medical Management ◽

Nasal Polyposis ◽

Individual Case ◽

Treatment Modalities ◽

The Difference ◽

Maximal Medical Therapy ◽

Snot 22

Background: Management protocols of chronic rhinosinusitis (CRS) recommend initial treatment with maximal medical therapy with surgery reserved for refractory cases. Literature comparing the effectiveness of these two treatment modalities is limited. The purpose of this study was to compare the outcome of medical and surgical management for CRS.Methods: This was a prospective cohort study. Patients registered for the study were diagnosed as CRS based on history, clinical examination and investigation findings. All patients were initially subjected to medical management for 3 weeks and refractory cases were then subjected to surgical intervention. Subjective and objective improvements assessed with SNOT-22 score and Lund-Kennedy (LK) score respectively were analysed statistically.Results: Out of the 100 patients registered for the study, 37% had nasal polyposis while 63% were without polyposis. When subjective and objective improvements were compared between groups receiving medical management alone and those receiving combined management, the difference was not found to be statistically significant (p<0.05).Conclusions: Although the decision regarding treatment modality to be used in CRS should depend on individual case, all cases can be subjected to a maximal medical therapy initially while reserving surgery for cases which do not improve.

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Preliminary Experience With Proximal Flow Reversal During Intracranial Balloon Angioplasty and Stenting for Symptomatic, Severe Intracranial Stenosis

Neurosurgery ◽

10.1093/neuros/nyz310_675 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Branden J Cord ◽

Corrado Santarosa ◽

Nanthiya Sujijantarat ◽

Adam Kundishora ◽

Guido Falcone ◽

...

Keyword(s):

Balloon Angioplasty ◽

Recurrent Stroke ◽

Carotid Bifurcation ◽

Flow Reversal ◽

Intracranial Stenosis ◽

Artery Embolism ◽

Proximal Protection ◽

Maximal Medical Therapy ◽

A Minor ◽

Angioplasty And Stenting

Abstract INTRODUCTION The frequency of balloon-angioplasty and stenting for symptomatic intracranial stenosis was drastically reduced after publication of the negative SAMMPRIS trial. In part, this was due to a higher than expected periprocedural complication rate (14.7% 30-d stroke or death) compared to maximal medical therapy (5.8%). Although the cause of periprocedural stroke was not defined, intraprocedural artery-to-artery embolism is a likely contributor. The Silk Road ENROUTE Transcarotid Neuroprotection System (TCNS) was designed as an alternative revascularization strategy for carotid bifurcation disease. It provides direct transcarotid access and proximal protection through flow reversal. We adapted this system as a proximal protection strategy for balloon angioplasty and stenting of severe, symptomatic intracranial stenosis. METHODS From May-2017 to May-2019, 7 patients underwent intracranial balloon angioplasty and stenting for symptomatic intracranial stenosis using the TCNS. Baseline demographics, comorbidities, procedure-related parameters, and outcomes were assessed. RESULTS A total of 7 patients (mean age 63, SEM 4.7 yr, 57% female) with severe (84% +/− 5%) supraclinoid internal carotid artery (ICA) and/or M1 stenosis presented with recurrent strokes (86% left sided) despite dual antiplatelet therapy (DAPT). Angiographically, cessation or reversal of flow was seen in the supraclinoid ICA in all patients, with confirmation by transcranial doppler in selected cases, after the institution of flow reversal by the TCNS. A noncompliant balloon was used to perform submaximal angioplasty, followed by stenting with intracranial stents. All procedures were technically successful with no evidence of periprocedural thromboembolic complications. Follow-up ranged from 6 to 12 mo. One patient suffered a fatal reperfusion hemorrhage on POD 3. One patient suffered from a minor recurrent stroke at 7 mo (after the cessation of DAPT) and was restarted on DAPT. CONCLUSION Traditional methods of intracranial balloon angioplasty and stenting suffer from high periprocedural ischemic stroke rates. TCNS can be adapted to provide a means of proximal protection during the treatment of these high-risk lesions. This procedural innovation warrants further investigation.

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Anterior Segment Findings in Ocular Myocysticercosis in Children: Is it non- specific?

Nepalese Journal of Ophthalmology ◽

10.3126/nepjoph.v13i1.28452 ◽

2021 ◽

Vol 13 (1) ◽

pp. 141-145

Author(s):

Prabhakar Singh ◽

Abhishek Gupta ◽

Richa Gupta

Keyword(s):

Anterior Chamber ◽

Surgical Management ◽

Medical Therapy ◽

Medical Management ◽

Extraocular Muscle ◽

Pediatric Patients ◽

Early Stage ◽

Anterior Segment ◽

Case Series ◽

Ocular Cysticercosis

Ocular cysticercosis is a preventable cause of blindness. Medical therapy has been recommended for the retro-orbital and extraocular muscle form. Surgical management is largely done in cases with conjunctival or lid affliction. Though, the medical management is simple; however, the diagnosis is challenging. The anterior segment findings often mimic the more common pathologies and hence often missed at the early stage. This case series of 3 pediatric patients, tries to highlight certain clinical clues which are suggestive of ocular myocysticercosis in children. Literature often recalls anterior segment findings in ocular myocysticercosis as “non- specific and nondiagnostic”. Canthal congestion and contiguous conjunctival congestion extending upto corresponding limbal border in absence of anterior chamber inflammation with other clinical clues are very suggestive of corresponding recti myocysticercosis.

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Stenting for intracranial stenosis: potential future for the prevention of disabling or fatal stroke

Stroke and Vascular Neurology ◽

10.1136/svn-2018-000158 ◽

2018 ◽

Vol 3 (3) ◽

pp. 140-146 ◽

Cited By ~ 13

Author(s):

Wengui Yu ◽

Wei-Jian Jiang

Keyword(s):

Medical Management ◽

Recurrent Stroke ◽

Group Versus ◽

Intracranial Stenosis ◽

Medical Group ◽

Intracranial Stenting ◽

Fatal Stroke ◽

Stent System ◽

Post Market ◽

Angioplasty And Stenting

Intracranial stenosis is a common cause of ischaemic strokes, in particular, in the Asian, African and Hispanic populations. The randomised multicentre study Stenting and Aggressive Medical Management for the Prevention of Recurrent stroke in Intracranial Stenosis (SAMMPRIS) showed 14.7% risk of stroke or death in the stenting group versus 5.8% in the medical group at 30 days, and 23% in the stenting group versus 15% in the medical group at a median follow-up of 32.4 months. The results demonstrated superiority of medical management over stenting and have almost put the intracranial stenting to rest in recent years. Of note, 16 patients (7.1%) in the stenting group had disabling or fatal stroke within 30 days mostly due to periprocedural complications as compared with 4 patients (1.8%) in the medical group. In contrast, 5 patients (2.2%) in the stenting group and 14 patients (6.2%) in the medical group had a disabling or fatal stroke beyond 30 days, indicating significant benefit of stenting if periprocedural complications can be reduced. Recently, the results of the Chinese Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis trial and the Wingspan Stent System Post Market Surveillance Study (WEAVE trial) showed 2%–2.7% periprocedural complications. It is time to evaluate the role of intracranial stenting for the prevention of disabling or fatal stroke.

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Revisiting Angioplasty Without Stenting for Symptomatic Intracranial Atherosclerotic Stenosis After the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) Study

Neurosurgery ◽

10.1227/neu.0b013e318271bcb8 ◽

2012 ◽

Vol 71 (6) ◽

pp. 1103-1110 ◽

Cited By ~ 29

Author(s):

Travis M. Dumont ◽

Peter Kan ◽

Kenneth V. Snyder ◽

L. Nelson Hopkins ◽

Adnan H. Siddiqui ◽

...

Keyword(s):

Medical Management ◽

Recurrent Stroke ◽

Case Series ◽

Intracranial Stenosis ◽

Event Free Survival ◽

Ischemic Event ◽

Free Survival ◽

One Year ◽

Aggressive Medical Management

ABSTRACT BACKGROUND: The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study stopped recruiting patients because of higher-than-expected perioperative morbidity of primary stenting in patients with symptomatic intracranial stenosis. An alternative treatment, submaximal angioplasty without stenting, performed concurrently with SAMMPRIS, may offer revascularization benefits with a lower incidence of stenting-related risks. OBJECTIVE: To present the results of a consecutive case series of primary submaximal angioplasty procedures performed for symptomatic severe atherosclerotic intracranial stenosis refractory to medical treatment. METHODS: A database review identified primary submaximal angioplasty procedures performed in 41 patients for the treatment of >70% intracranial stenosis associated with an acute, symptomatic ischemic event in the distribution of the diseased vessel. For results analysis, 30-day events were reported as a percentage of patients treated. One-year periprocedural and ischemic event--free survival was reported as a percentage of all patients treated and displayed graphically with a Kaplan-Meier survival curve. RESULTS: Three events in 41 patients included 1 intraprocedural vessel perforation, 1 reperfusion hemorrhage < 24 hours postoperatively, and 1 transient ischemic attack 3 months postprocedurally (30-day event rate, 2 of 41, 4.9%). Median clinical follow-up duration after submaximal angioplasty was 19 months, with ≥ 1 year of follow-up available for 32 patients. One-year perioperative and ischemic event-free survival was high (29 of 32 patients, 91%). CONCLUSION: In this series, periprocedural safety of submaximal angioplasty in the setting of acute, symptomatic atherosclerotic intracranial stenosis was demonstrated. Although direct comparison is impossible because many patients were ineligible for stenting procedures, the complication profile compares favorably with rates of identically defined event-free survival for patients randomized to the medical (88%) and surgical (77%) arms of SAMMPRIS despite the absence of aggressive medical management.

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Surgery and Neurointervention for Intracranial Atherosclerotic Steno-occlusive Disease

European Neurological Review ◽

10.17925/enr.2013.08.02.170 ◽

2013 ◽

Vol 8 (2) ◽

pp. 170

Author(s):

Sepideh Amin-Hanjani ◽

Simon Chun Ho Yu ◽

Fady Charbel ◽

Joji Inamasu ◽

Yoko Kato ◽

...

Keyword(s):

Medical Therapy ◽

Recurrent Stroke ◽

High Volume ◽

Occlusive Disease ◽

Carotid Occlusion ◽

Intracranial Stenosis ◽

Ischaemic Event ◽

Operative Morbidity ◽

Maximal Medical Therapy

Neurosurgeons and neurointerventionists interested in cerebral revascularisation to prevent stroke from intracranial atherosclerotic steno-occlusive disease were disappointed in 2011 with the closure of two important negative studies: the Carotid Occlusion Surgery Study (COSS) and Stenting and Aggressive Medical Therapy for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study. Debates are centred on what causes these failures. While extracranial-intracranial (EC-IC) bypass and neurointervention (angioplasty and/ or stenting) cannot be considered a routine intervention for patients presenting with initial ischaemic event in the setting of atherosclerotic steno-occlusive disease, selected patients with severe haemodynamic impairment and/or recurrent symptoms despite maximal medical therapy may still benefit from surgery and neurointervention at high-volume centres, which can offer the procedure with low peri-operative morbidity.

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Intermediate-term outcome of placement of Baerveldt glaucoma implant for refractory glaucoma in a Malaysian population

Asian Journal of Ophthalmology ◽

10.35119/asjoo.v17i1.500 ◽

2020 ◽

Vol 17 (1) ◽

pp. 108-119

Author(s):

Clarissa Ern Hui Fang ◽

Seng Kheong Fang

Keyword(s):

Medical Therapy ◽

Medical Records ◽

Case Series ◽

Glaucoma Drainage Device ◽

Retrospective Case ◽

Term Outcome ◽

Baerveldt Glaucoma Implant ◽

Baseline Characteristics ◽

Maximal Medical Therapy

Objective: To report baseline characteristics and surgical outcomes of placement of Baerveldt glaucoma implant (BGI) in Asian eyes with considerably elevated intraocular pressure (IOP) despite maximal medical therapy. Design: Retrospective case series of surgical cases from a single surgeon. Retrospective review of medical records of last clinic visits. Participants: One hundred and ninety-seven eyes of patients underwent placement of 350-mm2 Baerveldt implant. Methods: The medical records of consecutive patients who underwent placement of a Baerveldt 350-mm2 glaucoma drainage device (GDD) at the International Specialist Eye Centre from 2007 to 2014 were reviewed. Patients with a minimum 1-year follow-up were included. Baseline characteristics, pre-operative and post-operative IOP, number of glaucoma medications, visual acuity (VA) and complications were recorded. The pre-operative IOP is compared with the IOP at 1, 2, 3 and 5 years. Measures: The IOP, VA, supplemental medical therapy, complications and success and failures were recorded. Results: One hundred and ninety-seven patients were followed up at 1-year post-operation, 157 patients at 2 years, 120 at 3 years and 37 at 5 years. The mean baseline IOP of 29.2 ± 10.6 mmHg was significantly reduced at all time points post-operatively. Mean number of glaucoma medications was significantly lower at last follow-up than pre-operatively (1.8 vs. 2.7). Conclusions: Placement of GDDs effectively reduces IOP without much long-term complication and may be useful in glaucomatous eyes with considerably elevated pre-operative IOP not well controlled with maximal medical therapy in the Asian population.

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