scholarly journals Treatment for Intracranial Cerebral Artery Stenosis

2004 ◽  
Vol 10 (2_suppl) ◽  
pp. 13-16
Author(s):  
K. Kawaguchi ◽  
T. Kubo ◽  
H. Takeuchi ◽  
S. Nemoto
Keyword(s):  
Drug Treatment ◽  
Endovascular Treatment ◽  
Cerebral Artery ◽  
Therapeutic Indication ◽  
Bypass Surgery ◽  
Posterior Circulation ◽  
Artery Stenosis ◽  
Anterior Circulation ◽  
History Of ◽  
Low Incidence

Symptomatic intracranial cerebral artery stenosis is largely resistant to drug treatment. Regardless of their locations, lesions may cause cerebral infarction with a frequency of 7–10% in a year, but the natural history of asymptomatic intracranial cerebral artery stenosis remains unclear. Revascularization is indicated for symptomatic lesions which show resistance to drug treatment, while bypass surgery is the accepted therapeutic indication for haemodynamic ischemia. Endovascular treatment is effective in haemodynamic ischemia, and is also expected to be effective against embolic symptoms. Bypass surgery for anterior circulation cases is safe because of its low incidence of complications, whereas bypass surgery for posterior circulation cases is technically difficult and has a high associated complication rate. Hence, endovascular treatment is currently favored for posterior circulation cases, and has also been introduced for anterior circulation cases. Endovascular treatment has become a widespread modality for intracranial cerebral artery stenosis, but there are many unsolved problems associated with complications, technology and devices. Therefore, in practice, endovascular treatment should be used only with a strict indication, and should be performed only after considerable thought and with appropriate informed consent.

Strategy and effect of repeat bypass surgery for anterior/posterior circulation in refractory moyamoya disease

2020 ◽  
Vol 132 (6) ◽  
pp. 1889-1899
Author(s):  
Haruto Uchino ◽  
Daina Kashiwazaki ◽  
Naoki Akioka ◽  
Masaki Koh ◽  
Naoya Kuwayama ◽  
...  
Keyword(s):  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Transient Ischemic Attack ◽  
Bypass Surgery ◽  
Posterior Circulation ◽  
Therapeutic Effects ◽  
Anterior Circulation ◽  
Group A ◽  
Ischemic Attack ◽  
Group B

OBJECTIVEIn this study the authors aimed to describe clinical features, surgical techniques, and long-term outcomes of repeat bypass surgery required for a certain subset of patients with moyamoya disease.METHODSThe authors retrospectively reviewed a total of 22 repeat bypass surgeries for 20 patients (age range 1–69 years) performed during the last 20 years at their institutions. The patients were classified into 2 groups. Group A included 10 patients who underwent repeat bypass surgery for anterior circulation due to insufficient revascularization on the ipsilateral side. Group B included 10 patients who underwent repeat bypass surgery for posterior circulation due to the involvement of the posterior cerebral artery (PCA) after successful initial surgery for anterior circulation.RESULTSPreoperative symptoms included headache in 3 patients, transient ischemic attack in 10, cerebral infarction in 3, and intracranial hemorrhage in 4 patients. Intervals between the initial bypass surgery and repeat bypass surgery were 0.3–30 years (median 3 years). In group A, superficial temporal artery to middle cerebral artery (MCA) anastomosis and indirect bypass were performed on 7 hemispheres. Only indirect bypass was performed on 3 hemispheres because of the lack of suitable donor or recipient arteries. In group B, occipital artery (OA) to PCA anastomosis and indirect bypass were conducted on 4 hemispheres, and OA-MCA anastomosis and indirect bypass on 1 hemisphere. Only indirect bypass was conducted on 7 hemispheres because of the lack of suitable recipient arteries. All 22 repeat bypass surgeries were successfully conducted. During follow-up periods (median 4 years), none of the patients suffered repeat stroke except 1 patient who died of recurrent intracerebral hemorrhage 3 years after repeat bypass surgery for anterior circulation.CONCLUSIONSRepeat bypass surgery was feasible and effective to reduce further incidence of headache attack, transient ischemic attack, and ischemic/hemorrhagic stroke in moyamoya disease patients. Through precise radiological analysis, surgical procedures should be planned to yield maximal therapeutic effects.

Beware of Nihilism: Favorable Outcome despite Poor Admission Status in Posterior Circulation Aneurysms after Aneurysmal Subarachnoid Hemorrhage

2021 ◽  
Author(s):  
Nina Brawanski ◽  
Sepide Kashefiolasl ◽  
Sae-Yeon Won ◽  
Joachim Berkefeld ◽  
Elke Hattingen ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Mortality Rate ◽  
Cerebral Artery ◽  
Coil Embolization ◽  
Posterior Inferior Cerebellar Artery ◽  
Posterior Circulation ◽  
Anterior Circulation ◽  
Ruptured Aneurysms ◽  
Admission Status ◽  
Posterior Circulation Aneurysms

Abstract Objective As shown in a previous study, aneurysm location seems to influence prognosis in patients with subarachnoid hemorrhage (SAH). We compared patients with ruptured aneurysms of anterior and posterior circulation, undergoing coil embolization, concerning differences in outcome and prognostic factors. Methods Patients with SAH were entered into a prospectively collected database. We retrospectively identified 307 patients with aneurysms of the anterior circulation (anterior cerebral artery, carotid bifurcation, and middle cerebral artery) and 244 patients with aneurysms of the posterior circulation (aneurysms of the basilar artery, posterior inferior cerebellar artery, posterior communicating artery and posterior cerebral artery). All patients underwent coil embolization. The outcome was assessed using the modified Rankin Scale (mRS; favorable [mRS 0–2] vs. unfavorable [mRS 3–6]) 6 months after SAH. Results In interventionally treated aneurysms of the anterior and posterior circulation, statistically significant risk factors for poor outcome were worse admission status and severe cerebral vasospasm. If compared with patients with ruptured aneurysms of the anterior circulation, patients with aneurysms of the posterior circulation had a significantly poorer admission status, and suffered significantly more often from an early hydrocephalus. Nonetheless, there were no differences in outcome or mortality rate between the two patient groups. Conclusion Patients with a ruptured aneurysm of the posterior circulation suffer more often from an early hydrocephalus and have a significantly worse admission status, possibly related to the untreated hydrocephalus. Nonetheless, the outcome and the mortality rate were comparable between ruptured anterior and posterior circulation aneurysms, treated by coil embolisation. Therefore, despite the poorer admission status of patients with ruptured posterior circulation aneurysms, treatment of these patients should be considered.

scholarly journals Posterior cerebral artery stenosis and posterior circulation revascularization surgery in pediatric patients with moyamoya disease

2018 ◽  
Vol 21 (6) ◽  
pp. 632-638 ◽  
Author(s):  
Tomomi Kimiwada ◽  
Toshiaki Hayashi ◽  
Reizo Shirane ◽  
Teiji Tominaga
Keyword(s):  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Pediatric Patients ◽  
Posterior Cerebral Artery ◽  
Posterior Circulation ◽  
Initial Diagnosis ◽  
Occipital Artery ◽  
Anterior Circulation ◽  
Before And After ◽  
Revascularization Surgery

OBJECTIVESome pediatric patients with moyamoya disease (MMD) present with posterior cerebral artery (PCA) stenosis before and after anterior circulation revascularization surgery and require posterior circulation revascularization surgery. This study evaluated the factors associated with PCA stenosis and assessed the efficacy of posterior circulation revascularization surgery, including occipital artery (OA)–PCA bypass, in pediatric patients with MMD.METHODSThe presence of PCA stenosis before and after anterior circulation revascularization surgery and its clinical characteristics were investigated in 62 pediatric patients (< 16 years of age) with MMD.RESULTSTwenty-three pediatric patients (37%) with MMD presented with PCA stenosis at the time of the initial diagnosis. A strong correlation between the presence of infarction and PCA stenosis before anterior revascularization was observed (p < 0.001). In addition, progressive PCA stenosis was observed in 12 patients (19.4%) after anterior revascularization. The presence of infarction and a younger age at the time of initial diagnosis were risk factors for progressive PCA stenosis after anterior revascularization (p < 0.001 and p = 0.002, respectively). Posterior circulation revascularization surgery, including OA-PCA bypass, was performed in 9 of the 12 patients with progressive PCA stenosis, all of whom showed symptomatic and/or radiological improvement.CONCLUSIONSPCA stenosis is an important clinical factor related to poor prognosis in pediatric MMD. One should be aware of the possibility of progressive PCA stenosis during the postoperative follow-up period and consider performing posterior circulation revascularization surgery.

Changes in intracranial stenotic lesions after extracranial-intracranial bypass surgery

1984 ◽  
Vol 60 (4) ◽  
pp. 771-776 ◽  
Author(s):  
Issam Awad ◽  
Anthony J. Furlan ◽  
John R. Little
Keyword(s):  
Bypass Surgery ◽  
Internal Carotid Artery Stenosis ◽  
Artery Stenosis ◽  
Arterial Stenosis ◽  
Intracranial Arterial Stenosis ◽  
Content Type ◽  
Stenotic Lesion ◽  
Bypass Patency ◽  
History Of ◽  
Stenotic Lesions

✓ The natural history of intracranial arterial stenosis is not well understood. The lesions are pathologically quite diverse, and are subject to resolution, progression, or occlusion. The authors undertook an investigation to examine what effects, if any, extracranial-intracranial (EC-IC) bypass surgery had on the evolution of intracranial arterial stenosis in 18 patients undergoing EC-IC bypass procedures for ipsilateral hemispheric ischemia. There was inaccessible internal carotid artery stenosis in 14 patients, and middle cerebral artery stenosis in four patients. Early (within 2 weeks) and late (at 6 months) postoperative angiography was performed in all patients. During the period of the study, there was a significant change in the arterial stenosis in 50% of the patients (nine of 18). The stenotic artery became occluded in four patients while the grafts were widely patent. The occlusion occurred within a few days after the operation in three of the four cases, and was accompanied by an ischemic stroke in these patients. There was improvement or resolution of the stenotic lesion in five patients; the graft became occluded in two of these cases and was patent but showed poor cortical artery filling in the other three. All these patients remained asymptomatic and the change was detected on routine late postoperative angiograms. It is concluded that arterial stenoses should not be viewed as static or inflexible lesions, and that EC-IC bypass procedures can modify the hemodynamic parameters across stenotic lesions, predisposing them to improvement or worsening. This, in turn, may affect bypass patency. Such hemodynamic interactions are accompanied by ischemic symptoms in some patients, and contribute to the relatively higher morbidity associated with EC-IC bypass surgery in the setting of arterial stenosis.

scholarly journals Microstent-Assisted Coiling for Wide-Necked Intracranial Aneurysms

2005 ◽  
Vol 32 (1) ◽  
pp. 71-81 ◽  
Author(s):  
Marlise Peruzzo dos Santos Souza ◽  
Ronit Agid ◽  
Robert A. Willinsky ◽  
Michael Cusimano ◽  
Walter Montanera ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Neurological Complication ◽  
Posterior Circulation ◽  
Technical Failure ◽  
Anterior Circulation ◽  
Neck Size ◽  
Clinical Complications ◽  
Class 1

Objective:To describe the results, technical feasibility, efficacy and challenges encountered in our preliminary experience using a self-expandable microstent, optimized for intracranial use, as an adjunct in the endovascular treatment of wide-necked aneurysms.Methods:Only broad-necked aneurysms (dome-to-neck ratio £2, or an isolated neck size > 4.5 mm) were treated with Neuroform microstent from July 2003 to May 2004. The techniques used for stent deployment were either parallel or sequential. Angiographic results were recorded immediately for all patients and classified as Class 1 (complete occlusion), Class 2 (neck remnant) or Class 3 (sac remnant) by three interventional neuroradiologists not involved in the procedure. Follow-up angiography at six months was obtained for one case. Modified Rankin Score scale was assessed for all patients.Results:Seventeen intracranial aneurysms in a total of 18 patients were treated (mean age, 52.2 yr). Eight patients (44.4%) presented with acute subarachnoid hemorrhage. Eleven aneurysms (61.1%) were in the posterior circulation. Average dome size was 10.2 mm (range, 3.7-19.8 mm) and average neck size was 5.36 mm (range, 3.0-10.0 mm). Six out of seven aneurysms of the anterior circulation were approached with parallel technique. Eight aneurysms of the posterior circulation were approached with sequential technique. Average number of coils deployed was 9.64 (range, 4-23 coils). Eleven aneurysms (64.8%) resulted in Class 1 and/or Class 2. One technical failure was observed. Technical complications were recognized in four patients (23.5%), all of them with unruptured aneurysms in the anterior circulation. Two patients (11.7%) presented transient immediate clinical complications. One patient (5.8%) had minor permanent neurological complication. Neither major clinical complications nor death were encountered. Favorable clinical outcome (Modified Rankin Scale score 0-2) was observed in 88.2% of the patients (average follow-up time, 4.72 months).Conclusion:Absence of major permanent complications and satisfactory immediate obliteration degree in our preliminary experience indicates that microstent-assisted coiling technique is useful for the minimally invasive treatment of broad-necked complex aneurysms that are not ideal for conventional endovascular treatment and are at a high risk for conventional surgical treatment.

ENDOVASCULAR TREATMENT OF MIDDLE CEREBRAL ARTERY ANEURYSMS WITH DETACHABLE COILS

Neurosurgery ◽  
2009 ◽  
Vol 64 (5) ◽  
pp. 876-889 ◽  
Author(s):  
Shuichi Suzuki ◽  
Satoshi Tateshima ◽  
Reza Jahan ◽  
Gary R. Duckwiler ◽  
Yuichi Murayama ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Coil Embolization ◽  
Bypass Surgery ◽  
Combined Treatment ◽  
Mortality Rates ◽  
Morbidity And Mortality ◽  
Surgical Clipping ◽  
Endovascular Coil Embolization

Abstract OBJECTIVE Because of their anatomic configuration, middle cerebral artery (MCA) aneurysms are most often treated with surgical clipping. However, endovascular coil embolization of these aneurysms is an increasingly used alternative. We retrospectively reviewed the anatomic and clinical outcomes of patients with MCA aneurysms who underwent endovascular treatment at our institution. METHODS One hundred fifteen MCA aneurysms in 115 patients (mean age, 55.1 years) were treated by an endovascular technique from April 1990 to March 2007. Forty-eight patients (42%) presented with acute subarachnoid hemorrhage, and 67 patients (58%) had unruptured aneurysms. Fifty-three aneurysms (46%) were small with a small neck, 28 (24%) were small with a wide neck, 22 (19%) were large, and 12 (11%) were giant. RESULTS Angiographic results immediately after embolization showed complete occlusion in 53 aneurysms (46%), a neck remnant in 51 (44%), and incomplete occlusion in 3 (3%). Because of anatomic difficulties, we could not embolize 8 aneurysms (7%). Thirteen patients underwent combined treatment that included endovascular and extracranial-intracranial bypass surgery. Morbidity and mortality rates were 6.9% (8 patients) and 3% (3 patients), respectively. Procedure-related complications were encountered in 10 patients (9%). Seventy patients had long-term follow-up angiograms. Seven aneurysms (10%) were recanalized; all were large or giant. One partially embolized large aneurysm ruptured 13 months after embolization. CONCLUSION In this series, endovascular coil embolization of MCA aneurysms has morbidity and mortality rates comparable to those of conventional surgical clipping. Combined treatment of endovascular and bypass surgery can successfully treat large or giant complex fusiform MCA aneurysms.

scholarly journals Posterior Circulation Ischemia in the Endovascular Era

Neurology ◽  
2021 ◽  
Vol 97 (20 Supplement 2) ◽  
pp. S158-S169
Author(s):  
Roberta Novakovic-White ◽  
Juan Mario Corona ◽  
Jonathan A. White
Keyword(s):  
Risk Factors ◽  
Systematic Review ◽  
Endovascular Treatment ◽  
Ct Perfusion ◽  
Posterior Circulation ◽  
Basilar Artery Occlusion ◽  
Current Evidence ◽  
Anterior Circulation ◽  
Limb Weakness ◽  
Presenting Symptoms

Background and ObjectivesTo perform literature review of clinical, radiographic, and anatomical features of posterior circulation ischemia (PCI) and systematic review of the literature on the management of basilar artery occlusion (BAO) and associated outcomes.MethodsReview of literature was conducted to identify publications describing the risk factors, etiology, clinical presentation, and imaging for PCI. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. PubMed and Ovid MEDLINE were searched from 2009 to 2020 for articles relating to management of BAO. A synthesis was compiled summarizing current evidence on management of BAO.ResultsPCI accounts for 15%–20% of strokes. Risk factors are similar to anterior circulation strokes. Dizziness (47%), unilateral limb weakness (41%), and dysarthria (31%) are the most common presenting symptoms. A noncontrast head CT will identify PCI in 21% of cases; diffusion-weighted MRI or CT perfusion increase sensitivity to 85%. Recent trials have shown endovascular therapy can achieve >80% recanalization of BAO. In select patients, 30%–60% who receive endovascular treatment can achieve favorable outcome vs without. A total of 13% achieve good outcome and there is an 86% mortality rate.DiscussionPCI can present with waxing and waning symptoms or clinical findings that overlap with stroke mimics and anterior circulation ischemia, making diagnosis more heavily dependent on imaging. Recanalization is an important predictor of improved functional outcome and survival. In this endovascular era, trials of BAO are fraught with deterrents to enrollment. Despite limitations, endovascular treatment has shown improved outcome in select patients.

Basilar Apex Aneurysms in the Setting of Carotid Artery Stenosis: Case Series and Angiographic Anatomic Study

2019 ◽  
Vol 16 (1) ◽  
pp. 12-18 ◽  
Author(s):  
Mihael D. Rosenbaum ◽  
Daniel M. Heiferman ◽  
Osama A. Raslan ◽  
Brendan Martin ◽  
Jose F. Dominguez ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Stenosis ◽  
Case Series ◽  
Posterior Circulation ◽  
Artery Stenosis ◽  
Anatomic Study ◽  
Anterior Circulation ◽  
Aneurysm Neck ◽  
Symptomatic Carotid ◽  
Life Threatening

Background: Intracranial aneurysms (IAs) are life-threatening lesions known within the literature to be found incidentally during routine angiographic workup for carotid artery stenosis (CAS). As IAs are associated with vascular shear stress, it is reasonable to expect that altered flow demands within the anterior circulation, such as with CAS, increase compensatory flow demands via the Circle of Willis (COW) and may induce similar stress at the basilar apex. Objective: We present a series of nine unruptured basilar apex aneurysms (BAA) with CAS and a comparative radiographic analysis to BAA without CAS. Methods: Twenty-three patients with BAA were retrospectively identified using records from 2011 to 2016. CAS by North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria, morphology of BAA, competency of COW, and anatomic relationships within the posterior circulation were examined independently by a neuroradiologist using angiographic imaging. Results: Nine (39%) of the twenty-three BAA patients had CAS, with six having stenosis ≥50%. Four (67%) of the patients with ≥50% CAS demonstrated aneurysm flow angles contralateral to the side with highest CAS. Additionally, the angle between the basilar artery (BA) trajectory and aneurysm neck was observed to be smaller in patients with ≥50% CAS (61 vs 74 degrees). No significant differences in COW patency, posterior circulation morphology, and degree of stenosis were observed. Conclusion: Changes in the cervical carotid arteries may lead to blood flow alterations in the posterior circulation that increase the propensity for BAA formation. Posterior circulation imaging can be considered in CAS patients to screen for BAA.

Abstract TP15: A Case for the Chase? A Case Series of Mechanical Thrombectomy of M2 Occlusions

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Hisham Salahuddin ◽  
Julie Shawver ◽  
Gretchen Tietjen ◽  
Syed Zaidi ◽  
Mouhammad Jumaa
Keyword(s):  
Endovascular Treatment ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Randomized Clinical Trials ◽  
Mechanical Thrombectomy ◽  
Tertiary Care ◽  
Case Series ◽  
Anterior Circulation ◽  
Institutional Review ◽  
Tertiary Care Centers

Introduction: Randomized clinical trials have demonstrated an improvement in outcomes with endovascular treatment of large vessel occlusions, however studies evaluating the effectiveness of endovascular treatment of smaller vessels of the anterior circulation are lacking. We present initial data from two tertiary care centers with a focus on outcomes of patients with isolated middle cerebral artery (MCA) M2 occlusions. Methods: With institutional review board approval, we retrospectively reviewed medical records of patients who underwent mechanical thrombectomy (MT) between September 2013 and June 2016. The following data was collected: demographics, stroke risk factors, intravenous tPA use, MT treatment times, grade of recanalization, complications, and 3 month modified Rankin Scores. A favorable clinical outcome was defined as a modified Rankin Scale (mRS) 0-2 at 90 days. Results: A total of 50 patients were included in this analysis with 19 (38%) women and 31 (62%) men, with a mean age of 70 (63-80) years. One patient had an occlusion of both superior and inferior divisions of the middle cerebral artery (MCA) artery, 20 had occlusion of the inferior M2 artery, and the remaining 29 had occlusion of the superior division of the MCA. Baseline characteristics are summarized below. Average door to groin time was 75 (46-112) minutes, mean procedure time was 30 (25-47) minutes, and mean onset of symptoms to recanalization time was 220 (156-305) minutes. Of the cohort, 22 patients had a change of mRS of 3 or more at the time of discharge, 25 (50%) patients had a favorable outcome at 3 months, and 4 (8%) patients were lost to follow up. Ten (20%) patients developed hemorrhagic infarction and five (10%) developed parenchymal hematoma. Conclusions: Our data on MT targeting M2 occlusions demonstrates reasonable safety, recanalization rates, complications, and functional outcomes. Randomized studies are needed to confirm the benefit of pursuing MCA M2 occlusions with MT.

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