Short-term arteriographic and clinical outcome after cerebral angioplasty and stenting for intracranial vertebrobasilar and carotid atherosclerotic occlusive disease.

BACKGROUND AND PURPOSE: The safe performance of percutaneous transluminal cerebral angioplasty for intracranial atherosclerotic lesions requires that the risk of complications, such as acute occlusion or symptomatic dissection, and restenosis be reduced. Our purpose was to assess the effectiveness, safety, and short-term arteriographic and clinical outcome of cerebral angioplasty and stenting (CAS) for intracranial vertebrobasilar and distal internal carotid atherosclerotic occlusive lesions. METHODS: Between March 1998 and November 1998, 10 patients with 12 intracranial atherosclerotic lesions of the vertebrobasilar artery and the distal internal carotid artery underwent treatment with flexible balloon-expandable coronary stents. RESULTS: Although in two of the 10 patients CAS was not successful because of the inability to access the site of arterial stenosis, 10 lesions in eight patients were successfully dilated with stents. No complications occurred during or after the procedure and no neurologic ischemic events or restenoses occurred during the follow-up period. CONCLUSION: CAS appears to be a safe and effective means for treating intracranial atherosclerotic occlusive disease, yielding a favorable arteriographic and clinical outcome.

Follow-up Study after Intracranial Percutaneous Transluminal Cerebral Balloon Angioplasty.

SUMMARY: To find the angiographic lesions specific characteristics appropriate for intracranial percutaneous transluminal cerebral angioplasty (PTCBA). Forty-two clinically symptomatic patients with 42 haemodynamically significant intracranial lesions (% diameter stenosis > 70) were treated by PTCBA between January 1992 and May 1996. Before the angioplasty treatment, the patients were classified into three groups according to the angiographic lesions' characteristics summarised as follows: type A, a short and concentric stenosis; type B, a tubular lesion, or an extreme eccentric lesion; and type C, a diffuse lesion. They were followed after PTCBA from one month to six years to compare between the three groups. Primary end points were death, stroke, or bypass surgery. The clinical success rates in type A, B and C groups were 92%, 86% and 33% (p=0.0032), respectively. Cumulative risks of fatal or nonfatal ischaemic stroke / ipsilateral bypass surgery in type A, B and C groups were 8%, 26% and 87% (p < 0.0001), respectively. The cumulative risk of 8% in type A group patients appeared to be smaller than in historical studies. PTCBA for intracranial simple (type A) lesions produces a favourable clinical outcome for symptomatic patients.

Balloon angioplasty for embolic total occlusion of the middle cerebral artery and ipsilateral carotid stenting in an acute stroke stage.

A 66-year-old man suffering from neurologic symptoms caused by acute embolic total occlusion of the left middle cerebral artery was treated successfully with balloon angioplasty, and an ipsilateral carotid stenosis subsequently was dilated with stenting. The patient's clinical outcome 30 days later was favorable. This therapeutic option may prove to be a useful means of treating a patient with acute stroke, embolic total occlusion of the middle cerebral artery, and an ipsilateral carotid stenosis.

[Brain oxygen extraction fraction as an indicator for shunting operation in normal pressure hydrocephalus].

It is still difficult for neurosurgeons to determine which patients with suspected idiopathic normal pressure hydrocephalus (NPH) should undergo shunting. We need to find a more accurate indicator to predict the effect of shunting. We introduced a new preoperative examination of brain oxygen extraction fraction (OEF) and examined whether preoperative OEF value is effective for prediction of the surgical results. Global brain OEF was calculated from oxygen contents of arterial blood (AO2) and jugular venous blood (VjO2) selectively sampled from the right jugular bulb using the Seldinger method: OEF = (AO2-VjO2)/AO2. Since June 1996 we have treated 9 patients suspected of idiopathic and 10 patients suspected of secondary NPH. OEF in non-NPH patients with dilated ventricle (n = 10) and in infarct patients (n = 85) were 0.33 +/- 0.02 and 0.38 +/- 0.06, respectively. In contrast, OEF increased both in idiopathic NPH (0.42 +/- 0.04) and secondary NPH (0.45 +/- 0.02), and the NPH patients with the higher preoperative OEF values showed the better symptomatic recovery. The present study suggests that brain function may be reversible when OEF can be increased and that OEF can be a useful indicator for predicting the effect of a shunting operation in NPH.

Cerebral angioplasty and stenting for intracranial vertebral atherosclerotic stenosis.

A 72-year-old man underwent cerebral angioplasty and stenting for a high-grade eccentric atherosclerotic stenosis (93%) of the right intracranial vertebral artery. The lesion was sufficiently and smoothly dilated very easily with the use of a highly flexible, balloon-expandable coronary stent. No complications occurred during or after the procedure. This therapeutic option may prove to be a safe and useful means to resolve an intracranial atherosclerotic stenosis.

Successful cerebral artery stent placement for total occlusion of the vertebrobasilar artery in a patient suffering from acute stroke. Case report.

A 64-year-old man suffering from crescendo brainstem symptoms due to acute total occlusion of the vertebrobasilar artery was successfully treated by cerebral artery stent placement. The total occlusion of a long segment of the vertebrobasilar artery was completely recanalized by implanting two flexible, balloon-expandable coronary stents. The patient's clinical outcome 30 days later was favorable. No complications occurred during or after the procedure. This therapeutic option may prove to be a useful means to revascularize an acute total occlusion of the vertebrobasilar artery.

Intraventricular hemorrhage after carotid stenting.

PURPOSE: To report an important complication related to carotid stenting. METHODS AND RESULTS: A 71-year-old man with symptomatic subtotal occlusion of the left internal carotid artery had a 30-mm lesion treated percutaneously with implantation of 2 stents. Although the procedure was completed satisfactorily, left intraventricular hemorrhage occurred 4 hours later, possibly related to hyperperfusion injury. The patient expired 30 days after the stent procedure. Preoperative single-photon emission computed tomography revealed severely reduced vasoreactivity in the affected territory after acetazolamide challenge. CONCLUSIONS: The risk of hyperperfusion injury must be considered and minimized in patients with significant restriction of regional vasoreactivity. We recommend that cerebral hemodynamic status be determined prior to carotid stenting.

Stenting treatment for intra- and extra-cranial atherosclerotic diseases.

The purpose of this study was to investigate the effect, safety and short-term outcome of stenting treatment for extra- and intra-cranial atherosclerotic diseases. Forty-one patients underwent stenting treatment using coronary and biliary stents. Eleven patients had tubular or diffuse high-grade stenoses not amenable to standard balloon angioplasty involving intra-cranial arteries, while in thirty, extra-cranial arteries were involved. Stents were successfully implanted in 36 out of 41 lesions (88%) with 2% (1/41) of overall procedural morbidity rate. Procedural and clinical success rate of intra-cranial stent placement was 64% (7/11) and no complications occurred during or after intra-cranial stent placement: the morbidity rate was 0%. Hyperperfusion injury occurred in two patients after successful implantation of stents in subtotal occlusion of the internal carotid artery, and consequently the overall clinical success rate was 80% (33/41). Restenosis occurred in four (12%) out of 33 patients who underwent six month follow-up arteriography. No ischemic attacks or stent-deformation occurred during follow-up after stenting treatment. For lesions not amenable to standard balloon angioplasty, endovascular stent placement seems to be a safe and effective treatment of modality.

Follow-up study after intracranial percutaneous transluminal cerebral balloon angioplasty.

BACKGROUND AND PURPOSE: Our objective was to find the specific angiographic characteristics of atherosclerotic lesions that indicate suitability for intracranial percutaneous transluminal cerebral balloon angioplasty (PTCBA). METHODS: Forty-two clinically symptomatic patients with 42 hemodynamically significant intracranial lesions (>70% stenosis) were treated by PTCBA between January 1992 and May 1996. Before treatment, the patients were assigned to three groups according to the angiographic characteristics of the lesions, as follows: type A, short (5 mm or less in length) concentric or moderately eccentric lesions less than totally occlusive; type B, tubular (5 to 10 mm in length), extremely eccentric or totally occluded lesions, less than 3 months old; and type C, diffuse (more than 10 mm in length), extremely angulated (>90 degrees) lesions with excessive tortuosity of the proximal segment, or totally occluded lesions, and 3 months old or older. The patients were followed up for a period of 1 month to 6 years to compare the results of PTCBA treatment among the three groups. Primary end points were death, stroke, or bypass surgery. RESULTS: The clinical success rates for the type A, B, and C groups were 92%, 86%, and 33%, respectively. Cumulative risks of fatal or nonfatal ischemic stroke or ipsilateral bypass surgery in type A, B, and C groups were 8%, 26%, and 87%, respectively. The cumulative risk of 8% among patients in the type A group appeared to be smaller than in studies reported in the literature. CONCLUSION: PTCBA for intracranial simple (type A) lesions yields a favorable clinical outcome for symptomatic patients.

Follow-up study after percutaneous transluminal cerebral angioplasty.

The purpose of this study was to assess the safety and efficacy of percutaneous transluminal cerebral balloon angioplasty (PTCBA) of extra- and intra-cranial arteries by investigating procedural outcome. Eighty haemodynamically significant extra- and intra-cranial lesions (% diameter stenosis > 70) in 74 clinically symptomatic patients were treated by elective and initial PTCBA between March 1991 and February 1996 and thereafter followed. Death, stroke, surgery, or repeated angioplasty of restenosis or new lesions were regarded as cerebral events after the initial PTCBA. The procedural and clinical success rates were 81 % (65 of 80) and 81 % (60 of 74), respectively. Progressively ischaemic symptoms disappeared completely after clinically successful dilatation. Angiographic restenosis rate at 3 months was 22 %(14 of 65). By life-table method, the death/stroke risk was 16 %, and any cerebral event risk was 49 % at 2 years following PTCBA, respectively. The most common of first cerebral events presented was repeated angioplasty of restenosis. In conclusion, PTCBA has great efficacy in decreasing recurrent neurological symptoms and produces a favourable short-term outcome, whereas restenosis limits long-term benefit.

Percutaneous transluminal angioplasty using kissing balloon technique for carotid bifurcation stenoses coupled with the proatlantal intersegmental artery: a case report.

A 65-year-old man, who suffered from recurrent syncopal attacks after a minor stroke, was treated by percutaneous transluminal angioplasty using the kissing balloon technique (KBT) in which two angioplasty balloons were inflated simultaneously for the right carotid bifurcation stenoses. Because they involved the right internal carotid artery and the right external carotid artery coupled with the right proatlantal intersegmental artery, neither of them should close after the angioplasty. Bifurcation stenoses were sufficiently dilated with KBT and no syncopal attacks have recurred since the treatment.

Follow-up Study after Percutaneous Transluminal Cerebral Angioplasty.

SUMMARY: The purpose of this study was to assess the safety and efficacy of percutaneous transluminal cerebral balloon angioplasty (PTCBA) of extra- and intra-cranial arteries by investigating procedural outcome. Eighty haemodynamically significant extra- and intra-cranial lesions (% diameter stenosis > 70) in 74 clinically symptomatic patients were treated by elective and initial PTCBA between March 1991 and February 1996 and followed thereafter. Death, stroke including transient ischemia, surgery, or repeated angioplasty of restenosis or new lesions were regarded as cerebral events after the initial PTCBA. Crescendo ischaemic symptoms disappeared completely after clinically successful dilatation. The clinical success rate was 81% (65/80). Angiographic restenosis rate at 3 months was 22% (14/65). By life-table method, the death/stroke risk was 16% and death/stroke/surgery/repeated PTCBA risk was 49% at 2 years following PTCBA, respectively. In conclusion, PTCBA successfully, decreased recurrent neurological symptoms and produced a favourable short-term outcome, whereas restenosis limited long-term benefit.

Carotid and vertebral stenting: preliminary report.

SUMMARY: We report our initial experience of carotid and vertebral stenting. Three haemodynamically significant extra-cranial lesions (% diameter stenosis > 70) in 3 clinically symptomatic patients were treated by stenting between March 1996 and September 1996. Two lesions of the internal carotid arteries were ostial and in one case a subtotal stenosis and ostial lesion of the vertebral artery were observed. All lesions looked more widely and smoothly dilated by stenting than by ordinary standard balloon angioplasty.