Outcomes of Balloon Angioplasty and Stenting for Symptomatic Intracranial Atherosclerotic Stenosis at a High Volume Center.

PURPOSE: This study investigated the periprocedural complication rates, long-term outcome, and restenosis of endovascular treatment for intracranial atherosclerotic stenosis (ICS) at our hospital. METHODS: We retrospectively analyzed the clinical data of 217 patients comprising 256 endovascular treatments for high-grade symptomatic ICS. The lesion was located in the internal carotid artery in 77, the middle cerebral artery in 111, the basilar artery in 29, and the vertebral artery in 39. Patients were divided into two groups, before (early-phase group, 1999-2013) and after approval of Wingspan (late-phase group, 2014-2017). RESULTS: In the early-phase group (n = 163), 157 lesions were treated by balloon angioplasty and 31 (17%) by coronary stenting. In the late-phase group (n = 54), 33 lesions were treated by balloon angioplasty and 35 (52%) by Wingspan stenting. Overall technical success rates were 96% in the balloon angioplasty and 100% in stenting groups. The 30-day rate of stroke, TIA, and death were 4.8% in the early-phase group and 4.4% in the late-phase group. There was one minor stroke and two TIAs during the follow-up period in the late-phase group. CONCLUSIONS: Endovascular treatment for symptomatic ICS in this study appeared to be safe and effective if patients are properly selected. However, future well-designed randomized trials with different techniques and modified patients selection criteria are certainly warranted.

Effects of Aspiration and Re-transfusion Technique with Carotid Artery Stenting.

Objective: Embolic stroke is the most serious complication after carotid artery stenting (CAS). The incidence rate of embolic stroke is reduced by the use of embolic protection devices (EPDs); however, there is no consensus on which EPD is the most effective. The aspiration and re-transfusion technique (ART) with CAS under distal balloon protection was adopted at our center to reduce the incidence of embolic complications. This retrospective study investigated the effects of ART. Methods: From November 2010, 243 consecutive patients treated by CAS under distal balloon protection were included. ART was performed on 202 patients (ART group) and the other 40 patients only received distal balloon protection (non-ART group). In ART, the blood from the aspiration catheter was continuously returned through a filter to the femoral vein. The amount of debris was assessed intermittently using a small blood sample and the rest was returned. We investigated the diffusion-weighted imaging (DWI)-positive rate and symptomatic ischemic stroke one day after CAS. Results: Compared with the non-ART group, the incidence of DWI-positive lesions (22.7% vs 37.5%, P = 0.07) and frequency of symptomatic ischemic stroke (0.9% vs 5.0%, P = 0.12) were reduced in the ART group. The hemoglobin reduction rate was significantly reduced by ART (11.1% vs 14.9%, P <0.01). In the ART group, the frequency of multiple lesions (more than 5) and large lesions (more than 10 mm) was lower than that in the non-ART group (P <0.01, P = 0.14). Conclusion: CAS under distal balloon protection with ART was effective at reducing the incidence of DWI-positive lesions and may be useful to reduce the incidence of symptomatic ischemic stroke.

Contrast-enhanced carotid ultrasonography and MRI plaque imaging to identify patients developing in-stent intimal hyperplasia after carotid artery stenting.

AIM: In-stent intimal hyperplasia (ISH) observed after carotid artery stenting (CAS) may lead to in-stent restenosis. We aimed to investigate whether contrast-enhanced carotid ultrasonography (CEUS) and magnetic resonance imaging (MRI) plaque imaging prior to CAS are predictive for ISH at 6 months after CAS. MATERIAL AND METHOD: A total of 14 patients (13 men, 1 woman; mean age, 74.2 years) were prospectively enrolled. CEUS and MRI plaque imaging were performed before CAS. ISH was diagnosed by carotid angiography at 6 months after CAS. Patients were divided into two groups based on the thicknessof ISH and age, risk factors, enhancement in CEUS, MRI plaque imaging and number of replaced stents were compared between groups. RESULTS: Carotid angiography at 6 months after CAS revealed ISH in 10 patients. Plaque enhancement on CEUS was observed in 6 patients, all of whom showed ISH. A significant association was seen between plaque enhancement on CEUS and development of ISH (χ2 test, CEUS enhancement (+) 100% vs. CEUS enhancement (-) 50% p=0.040). Carotid plaques in 12 patients were diagnosed as unstable by MRI plaque imaging. Presence of ISH was significantly associated with unstable plaque diagnosed by MRI plaque imaging (χ2 test, unstable 83% vs. stable 0%; p=0.016). CONCLUSION: Carotid plaque MRI and CEUS may be useful to predict ISH after CAS.

Association between inflammatory biomarkers and progression of intracranial large artery stenosis after ischemic stroke.

BACKGROUND: Proinflammatory state has been implicated as a pathogenetic mechanism in the progression of intracranial large artery atherosclerosis (ILA). High levels of inflammatory biomarkers in healthy populations and in patients with acute stroke or acute coronary syndrome are known to be associated with subsequent stroke events. This study investigated the relationship between circulating biomarkers measured early after stroke onset and future ILA progression. METHODS: In 48 patients with acute ischemic stroke, high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), IL-18, tumor necrosis factor-α, matrix metalloproteinase (MMP)-2 and MMP-9 were measured within 48 hours after onset. Baseline severity and ILA progression were assessed by serial magnetic resonance angiography (MRA). The median follow-up period for MRA was 3.1 years. Hazard ratio (HR) was calculated using the Cox proportional hazard model adjusted for traditional risk factors, and accuracy of predicted ILA progression was analyzed by receiver operating characteristic (ROC) curve analysis. RESULTS: ILA progression was observed in 6 of 48 patients (12.5%). After adjusting for age, sex, and presence of hypertension, baseline ILA severity score (HR 2.814; 95% confidence interval [CI] 1.172-6.754) and IL-6 (HR 1.215; 95% CI 1.002-1.473) were significantly associated with ILA progression. Area under the ROC curve (AUC) for prediction of ILA progression by traditional risks, baseline ILA severity score and IL-6, was 0.647. When IL-6 was removed from this model, AUC remained at 0.631. CONCLUSIONS: In addition to traditional risk factors and baseline radiologic findings, circulating levels of IL-6 measured soon after stroke onset are associated with future ILA progression.

[Effects of early statin treatment on inflammatory biomarkers and clinical deterioration in patients with acute ischemic stroke].

We prospectively studied the effects of early statin treatment on stroke-induced changes in the levels of inflammatory biomarkers. Patients admitted within 48 hours after the onset of ischemic stroke were enrolled. They were divided into 2 groups according to their lipid profiles and history of statin treatment. In patients who had received statin treatment prior to admission and those who had abnormal lipid profiles on admission, daily treatment with 10 mg atorvastatin was initiated within 48 hours after the onset of stroke (Statin group; n = 45). In patients who had normal lipid profiles on admission, statin was not administered for at least 2 weeks after admission (Non-Statin group; n = 101). The serum concentrations of interleukin (IL)-6, IL-10, IL-18, matrix metalloproteinase (MMP)-2, MMP-9, and high sensitive C-reactive protein were measured on days 1, 3, 7, and 14. In percentage changes in serially measured circulating IL-6 levels, a significant interaction between group and repeated measures (group X time factor) was demonstrated (p = 0.047). Frequency of neurological deterioration episodes (NIHSS score > or = 2) during 14 days after admission was lower in the Statin group than in the Non-Statin group, however the difference did not reach statistically significant level (7.9% vs 20.2%, p = 0.118). The initiation of usual dose of atorvastatin early after the onset of ischemic stroke significantly decreased the elevation of IL-6 and may protect against the early neurological deterioration. Circulating levels of IL-6 may be one of the candidates for monitoring the acute effects of statin. Further studies wherein IL-6 levels are monitored in larger samples would be feasible for investigating the effect of early treatment with usual dose of atorvastatin on the functional outcome.