Current Concepts in the Management of Intracranial Atherosclerotic Disease

Neurosurgery ◽  
2006 ◽  
Vol 59 (suppl_5) ◽  
pp. S210-S218 ◽  
Author(s):  
Robert D. Ecker ◽  
Elad I. Levy ◽  
Eric Sauvageau ◽  
Ricardo A. Hanel ◽  
L Nelson Hopkins
Keyword(s):  
Endovascular Treatment ◽  
Poor Prognosis ◽  
Intracranial Stenosis ◽  
Atherosclerotic Disease ◽  
Intracranial Atherosclerosis ◽  
Intracranial Atherosclerotic Disease ◽  
New Models ◽  
Disease Study ◽  
Angioplasty And Stenting ◽  
Neuroimaging Techniques

Abstract MEDICALLY REFRACTORY, SYMPTOMATIC intracranial atherosclerotic disease has a poor prognosis. Based on the results of the Warfarin-Aspirin Symptomatic Intracranial Disease study, the risk of ipsilateral stroke at 1.8 years is between 13 and 14% in patients with symptomatic intracranial atherosclerosis. Synergistic advances in intracranial angioplasty and stenting, modern neuroimaging techniques, and periprocedural and postprocedural antithrombotic regimens are creating new models for the diagnosis and successful endovascular treatment of intracranial stenosis. In this article, the most recent clinical developments and concepts for the diagnosis and endovascular treatment of intracranial atherosclerotic disease are discussed.

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.

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.

Endovascular Treatment of Intracranial Atherosclerotic Disease

2013 ◽  
Vol 23 (4) ◽  
pp. 653-659
Author(s):  
Christopher J. Lenart ◽  
Mandy J. Binning ◽  
Erol Veznedaroglu
Keyword(s):  
Endovascular Treatment ◽  
Atherosclerotic Disease ◽  
Intracranial Atherosclerotic Disease

scholarly journals Current Status and Future Perspective of Stenting for Symptomatic Intracranial Atherosclerotic Disease: A Meta-Analysis

2017 ◽  
Vol 2017 ◽  
pp. 1-11
Author(s):  
Zhong-Hao Li ◽  
Zhen-Hua Zhou ◽  
Xian-Jin Zhu ◽  
Wei Liu ◽  
Ya-Wen Chen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Medical Therapy ◽  
Meta Analysis ◽  
Transluminal Angioplasty ◽  
Atherosclerotic Disease ◽  
Current Status ◽  
Future Perspective ◽  
Cochrane Library ◽  
Intracranial Atherosclerotic Disease ◽  
Angioplasty And Stenting

The aim of this study was to evaluate the safety and effectiveness of percutaneous transluminal angioplasty and stenting (PTAS) for intracranial atherosclerotic disease (ICAD) by conducting a meta-analysis. Two independent observers searched PubMed, EMBASE, and Cochrane Library for relevant studies up to 31 December 2016. A meta-analysis was conducted using Review Manager 5.3. Three studies involving 581 cases were included. The meta-analysis indicated that any stroke (RR = 3.13; 95% CI: 1.80–5.42), ischemic stroke (RR = 2.15; 95% CI: 1.19–3.89), and intracranial hemorrhage (RR = 14.71; 95% CI: 1.96–110.48) within 30 days in medical therapy alone were lower compared with PTAS plus medical therapy, but there were no significant differences in any stroke and ischemic stroke beyond 30 days between the two groups. There were also no significant differences in any death and myocardial infarction between the two groups. This meta-analysis demonstrated that, compared with medical therapy alone, PTAS for ICAD had a high risk of complication, but most complications in PTAS group occurred within 30 days after the operation, and beyond 30 days the PTAS was not inferior compared with medical therapy alone. Further studies are needed to reduce the periprocedural complications and reappraise the PTAS.

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.

Current Advances in Endovascular Treatment of Intracranial Atherosclerotic Disease and Future Prospective

2021 ◽  
Vol 30 (3) ◽  
pp. 105556
Author(s):  
Mostafa Jafari ◽  
Thanh N. Nguyen ◽  
Santiago Ortega-Gutierrez ◽  
Muhammad Shazam Hussain ◽  
Ameer E. Hassan ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Atherosclerotic Disease ◽  
Intracranial Atherosclerotic Disease

Abstract 1122‐000127: An Alternative Reduced Dose Regimen of Ticagrelor for Patients Recieving Neuro‐Endovascular Procedures

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Sonam Thind ◽  
Omar Kass‐Hout ◽  
Ruth Tangonan ◽  
Tareq Kass‐Hout
Keyword(s):  
Retrospective Chart Review ◽  
Optimal Dose ◽  
Hemorrhagic Transformation ◽  
Atherosclerotic Disease ◽  
Single Center Experience ◽  
Intracranial Atherosclerotic Disease ◽  
Increased Risk ◽  
Small Cohort ◽  
Angioplasty And Stenting ◽  
Carotid Angioplasty And Stenting

Introduction : There is a growing use of Ticagrelor in patients undergoing neuroendovascular procedures, especially those who demonstrate Clopidogrel resistance. While multiple dosages are studied in the cardiology literature, the optimal dose for patients with neurological pathology has yet to be established. Here we describe a single center experience involving 39 patients who underwent neuroendovascular procedures that then received an adjusted lower dose of Ticagrelor. Methods : A retrospective chart review was performed between 2013 and 2017 for patients on dual antiplatelet therapy (DAPT) for either cervical or intracranial vascular pathologies, as well as stenting of the neurovasculature, including carotid arteries. Patients were placed on Ticagrelor if their measured PRU responses to Clopidogrel were outside the expected range in our center using the P2Y12 test. All patients were maintained on a dose of 45mg BID except for one patient who received 22.5 mg BID. Responsiveness to Ticagrelor were measured utilizing the P2Y12 test. Results : The mean number of days for follow up post treatment initiation was 532 days. A total of 39 patients were included in the analysis. Of these, 8 patients (21%) received implantation of intracranial stents (5 patients received pipeline embolization devices, 1 patient received stent‐ assisted coiling, and 2 patients received intra‐cranial stents for atherosclerotic disease). Fourteen patients (35%) received carotid angioplasty and stenting. Seventeen patients (44%) did not receive permanent implantation of a stent. All patients on the lower dose Ticagrelor of mg BID achieved responsiveness per the P2Y12 test. Hemorrhagic transformation of ischemic stroke occurred in one patient (2.5%). No other hemorrhagic complications were encountered. No thromboembolic events were recorded aside from one patient (2.5%) with intracranial atherosclerotic disease who had an ischemic event. Conclusions : A lower dose of Ticagrelor (45 mg BID) appears to be a safe and effective in this small cohort of patients who are resistant to Clopidogrel per P2Y12 testing and who have increased risk of ischemic or hemorrhagic strokes due to neurovascular pathologies and implants. Further randomized studies are required to confirm these findings.

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