Association of Dental Infections with Intracranial Atherosclerotic Stenosis.

INTRODUCTION: Periodontal disease (PD) and dental caries are oral infections leading to tooth loss that are associated with atherosclerosis and cerebrovascular disease. We assessed the hypothesis that PD and caries are associated with asymptomatic intracranial atherosclerosis (ICAS) in the Atherosclerosis Risk in Communities (ARIC) study. METHODS: Full-mouth clinical periodontal measurements (7 indices) collected at 6 sites per tooth from 6,155 subjects from the Dental Atherosclerosis Risk in Communities Study (DARIC) without prior stroke were used to differentiate seven PD stages (Periodontal Profile Class [PPC]-I to -VII) and dental caries on coronal dental surface (DS) and dental root surface (DRS). A stratified subset underwent 3D time-of-flight MR angiogram and 3D high isotropic-resolution black blood MRI. ICAS was graded according to the criteria established by the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial. We evaluated the relationship between PD stage and dental caries with asymptomatic ICAS, graded as no ICAS, <50% ICAS, and ≥50% ICAS. RESULTS: Among dentate subjects who underwent vascular imaging, 801 (70%) had no ICAS, 232 (20%) had <50% ICAS, and 112 (10%) had ≥50% ICAS. Compared to participants without gum disease (PPC-I), participants with mild-moderate tooth loss (PPC-VI), severe tooth loss (PPC-VII), and severe PD (PPC-IV) had higher odds of having <50% ICAS. Participants with extensive gingivitis (PPC-V) had significantly higher odds of having ≥50% ICAS. This association remained significant after adjusting for confounding variables: age, gender, race, hypertension, diabetes, dyslipidemia, 3-level education, and smoking status. There was no association between dental caries (DS and DRS) and ICAS <50% and ≥50%. CONCLUSION: We report significant associations between mild-moderate tooth loss, severe tooth loss, and severe PD with <50% ICAS as well as an association between extensive gingivitis and ≥50% ICAS. We did not find an association between dental caries and ICAS.

Extra- and intra-cranial arterial calcifications in adults depicted as incidental findings on cone beam CT images.

OBJECTIVE: The aim of this study was to evaluate, retrospectively, the gender- and age-related prevalence of incidentally found calcifications, depicted within the course of the extra- and intra-cranial portion of internal carotid artery (ICA), in cone beam computed tomography (CBCT) examinations in adults, and to assess their clinical significance. MATERIALS AND METHODS: Out of a pull of 700 CBCT examinations a total of 484 CBCT scans of adult patients were finally selected according to a set of pre-defined criteria. These were evaluated for arterial calcifications presence within the ICAs course according to gender and age criteria. RESULTS: In total, 492 calcifications were detected: 211 (42.88%) extra-cranial and 281 (57.11%) intra-cranial. Those were recorded in 150 scans (30.99%) and 161 scans (33.26%), respectively. Calcifications, with either extra- or intra-cranial allocation, were found more frequent in males than in females (all p-values < 0.05); also patients who presented with positive findings were older than those without findings (all p-values < 0.05). Furthermore, calcification presence with either extra- or intra-cranial allocation increases with age (all p-values < 0.05). CONCLUSION: Significant calcification frequencies were found within the ICA's course, in CBCT scans. Moreover, an increased incidence of either extra- or intra-cranial presence of these depictions and its relation to age and gender was documented.

Comparison of drug-coated balloon with conventional balloon for angioplasty in symptomatic intracranial atherosclerotic stenosis.

BACKGROUND: Drug-coated balloon (DCB) angioplasty has been studied for reducing the occurrence of restenosis after treatment for intracranial atherosclerotic stenosis (ICAS), but no comparison has been published of the use of drug-coated and non-coated balloons in angioplasty for ICAS. We aim to compare the safety and efficacy of DCB angioplasty with conventional balloon (CB) angioplasty for the treatment of symptomatic ICAS. METHODS: One hundred cases with symptomatic ICAS treated with DCB (n=49) and CB (n=51) angioplasty were retrospectively analyzed. 1:1 propensity score matching (PSM) was completed to eliminate bias in the patients selected for further analysis. The periprocedural events and follow-up outcomes between the two groups were compared. RESULTS: There were 32 cases in each group after PSM. Technical success (<50% residual stenosis) was achieved in 30 cases (93.8%) in the DCB group and in 28 cases (87.5%) in the CB group. The rates of stroke or mortality within 30 days were 3.1% in the DCB group and 6.3% in the CB group (p=1). The incidence of restenosis in the DCB group (6.3%) was significantly lower than that in the CB group (31.3%) (p=0.01). CONCLUSIONS: Compared with CB angioplasty, DCB angioplasty can effectively reduce the incidence of restenosis. Further studies are needed to validate the role of DCB angioplasty in the management of symptomatic ICAS.

Safety and efficacy of drug coated balloon angioplasty for intracranial atherosclerotic disease.

BACKGROUND: Drug coated balloon (DCB) angioplasty can provide sustained anti-restenotic efficacy without the limitations of permanent vascular implantation and is presumably ideal for treating intracranial atherosclerotic disease. However, the safety of paclitaxel in the neurovasculature remains a concern. METHODS: 242 patients with angiographically verified symptomatic stenosis >70% in intracranial arteries treated with DCB angioplasty were reviewed divided into two groups: group A, patients with stenotic intracranial arteries; and group B, patients with acute, subacute, or chronic occluded intracranial arteries. The primary endpoint was any stroke or death within 30 days. The secondary endpoint was arterial restenosis of >50% during follow-up. RESULTS: 16 major and 12 minor complications occurred among 245 procedures (6.5% and 4.9%, respectively). Five patients died within 30 days after the procedure (2.1%, 5/242). 12 major and 12 minor complications occurred among 211 procedures in group A (5.7% and 5.7%). In group B, four major complications occurred among 34 procedures (11.8%). Hyperperfusion and perforator stroke accounted for half of all complications (53.6%, 15/28). Restenosis >50% was present in eight lesions during the follow-up period (4.8%, 8/167). CONCLUSIONS: After treatment with DCB angioplasty, complications were no different from those after standard balloon angioplasty or stenting. This study suggests that DCB angioplasty may be a safe and effective procedure for intracranial arterial stenosis.

Leave Nothing Behind: Treatment of Intracranial Atherosclerotic Disease with Drug-Coated Balloon Angioplasty.

PURPOSE: Intracranial atherosclerosis disease (ICAD) is an essential cause of stroke. The characteristics of effective treatment include low periprocedural risk and a sustained treatment effect. Angioplasty with a conventional balloon for ICAD is safe but has a dauntingly high restenosis rate. Drug-coated balloon (DCB) angioplasty might reduce the risk of restenosis while maintaining the overall safety of the procedure. METHODS: This study included symptomatic ICAD patients with more than 70% stenosis. Intermediate catheters were placed distally, and the lesions were predilated with a conventional balloon, followed by a DCB (SeQuent Please, B Braun, Melsungen, Germany). The primary endpoint was any stroke or death within 30 days or ipsilateral ischemic stroke thereafter. The secondary endpoint was arterial restenosis of more than 50% during follow-up. RESULTS: A total of 39 sessions of DCB angioplasty were performed for 39 lesions in 35 patients between October 2015 and April 2018 in a single center. All of the DCBs could be navigated to the lesions. Major periprocedural complications were noted in two patients (5.7%, 2/35), and minor periprocedural complications were also noted in two patients (5.7%, 2/35). The average percentages of stenosis of the lesions were 76.6% ± 7% before treatment, 32.4% ± 11.2% after DCB angioplasty, and 25% ± 16% at follow-up. Stenosis over 50% was present in 3 lesions during the follow-up period (8.3%, 3/36). CONCLUSION: In this study, the application of DCBs to treat ICAD patients was feasible and safe. A larger scale clinical trial is warranted to further evaluate the safety and efficacy of this treatment.

Dental and periodontal status and risk for progression of carotid atherosclerosis: the inflammation and carotid artery risk for atherosclerosis study dental substudy.

BACKGROUND AND PURPOSE: Dental and periodontal disease are potentially involved in the pathogenesis of atherosclerosis. We investigated whether dental and periodontal status is associated with the presence and future progression of carotid stenosis. METHODS: We randomly selected 411 of 1268 participants from the prospective Inflammation and Carotid Artery Risk for Atherosclerosis Study and evaluated dental and periodontal status and oral hygiene at baseline measuring three World Health Organization-validated indices: DMFT (decayed, missing, filled teeth), SLI (Silness-Löe Index), and CPITN (community periodontal index for treatment needs), respectively. The degree of carotid stenosis was measured by duplex ultrasound at baseline and after median 7.5 months (range=6 to 9 months) to identify patients with progressive carotid stenosis. RESULTS: DMFT (P<0.01), SLI (P=0.048), CPITN (P=0.007), and edentulousness (P=0.007) were associated with the baseline degree of carotid stenosis. Atherosclerosis progression was observed in 48 of 411 patients (11.7%). DMFT (adjusted odds ratio [OR]=1.11, 95% CI=1.01 to 1.22, P=0.032) and SLI (adjusted OR=1.77, 95% CI=1.09 to 2.79, P=0.021), but not CPITN (adjusted OR=1.51, 95% CI=0.89 to 2.45, P=0.16) were significant predictors of disease progression, irrespective of traditional cardiovascular risk factors and the baseline degree of stenosis. Edentulous patients had a significantly increased risk for disease progression as compared with patients with teeth (adjusted OR=2.10, 95% CI=1.06 to 4.16, P=0.33). CONCLUSIONS: Dental status, oral hygiene, and particularly tooth loss are associated with the degree of carotid stenosis and predict future progression of the disease.

Angioplasty and stenting for intracranial atherosclerotic stenosis with nitinol stent: factors affecting technical success and patient safety.

BACKGROUND: Angioplasty and stenting using nitinol stents is a recognized treatment option for intracranial atherosclerosis. OBJECTIVE: To identify procedure-related factors that may affect patient safety and technical outcome. METHODS: In this prospective study of 57 consecutive patients, the primary end points were intraprocedural technical problems, periprocedure morbidity, and complications. Major periprocedure complication was defined as all stroke or death at 30 days. Technical failure was defined as the inability to complete the procedure because of technical or safety problems. Procedure failure was defined as a procedure outcome of technical failure or major periprocedure complication. Secondary end points were procedure-related factors that may affect patient safety and technical outcome. RESULTS: Procedure failure rate was 12.3% (7/57) (major periprocedure complication rate, 5.3% [3/57]; technical failure rate, 7% [4/57]). Initial failure in tracking of balloon or stent occurred in 20 patients, other technical problems occurred in 11 patients, including kinking or trapping of balloon catheter (2 cases), difficulty in unsheathing of stent (3 cases), forward migration of stent during deployment (4 cases), trapping of nose cone after stent deployment (1 case), fracture of delivery system (2 cases), and guidewire fracture (1 case). Unfavorable vascular morphology signified by the presence of 2 or more reverse curves along the access path was found to associate with initial failure in the tracking of instruments (OR = ∞), and occurrence of other technical problems (OR = 25). CONCLUSION: Procedure-related factors could be identified and lead to improvements in patient safety and technical outcome. Tortuous vascular morphology is a key factor to be overcome.

Radiological assessment of stenosis of the internal carotid artery at the junction with the common.

Stenoses at the origin of 100 internal carotid arteries from patients with ischemic cerebrovascular disease were studied by intra-arterial angiography. Three principles were employed to evaluate the degree of stenosis: 1) verbal description, grading stenoses as mild, moderate of severe, 2) estimation of the true residual diameter, and 3) calculation of percent stenosis, defined here as the diameter of the artery at the origin relative to that at the level of the angle of the mandible. The true diameter, estimated to the nearest whole mm, corresponded well with the verbal description, and correlated significantly with percent stenosis. Since the true diameter is precisely defined, easy to estimate, and directly related to its hemodynamic effect, we suggest that this simple parameter, rather than the more commonly used, but more vaguely defined term "percent lumen reduction", is used to grade stenoses of the internal carotid artery.

Accuracy of duplex ultrasound in evaluating carotid artery anatomy before endarterectomy.

PURPOSE: Anatomic features, such as a high carotid bifurcation (< 1.5 cm from the angle of the mandible), excessive distal extent of plaque (> 2.0 cm above the carotid bifurcation), or a small diameter (< or = 0.5 cm) redundant or kinked internal carotid artery can complicate carotid endarterectomy. In the past, arteriography was the only preoperative study capable of imaging these features. This study assessed the ability of duplex ultrasound to evaluate their presence before surgery. METHODS: A consecutive series of 20 patients who underwent 21 carotid endarterectomies had preoperative duplex ultrasound evaluations of these anatomic features. These evaluations were correlated with operative measurements from an observer blinded to the duplex findings. RESULTS: The mean difference between duplex and operative measurements for the distance between the carotid bifurcation and the angle of the mandible, the distal extent of plaque, and the internal carotid artery diameter was 0.9 cm, 0.3 cm, and 0.8 mm, respectively. The correlation coefficient between the two methods was 0.86, 0.75, and 0.59, respectively. Duplex ultrasound predicted a high carotid bifurcation, excessive distal extent of plaque, or a redundant or kinked internal carotid artery with 100% sensitivity (p < 0.05, p < 0.01, and p < 0.001, respectively). The sensitivity of duplex ultrasound in predicting a small internal carotid artery diameter was 80%. The specificity of duplex ultrasound for predicting excessive distal extent of plaque, small internal carotid artery diameter, high carotid bifurcation, and a coiled or kinked carotid artery was 92%, 56%, 100%, and 100%, respectively. CONCLUSION: Duplex ultrasound can predict the presence of anatomic features that may complicate carotid endarterectomy. Preoperative duplex imaging of these features may be helpful in patients who undergo carotid endarterectomy without preoperative arteriography.

Combined endarterectomy of the internal carotid artery and persistent hypoglossal artery: an unusual case of carotid revascularization.

Persistence of the hypoglossal artery is an unusual congenital abnormality of the carotid arterial system, and the simultaneous occurrence of atheromatous disease in the internal carotid artery and persistent hypoglossal artery is even more uncommon. Carotid surgery in this situation is challenging, and the surgeon must be aware of potential inherent pitfalls. A 74-year-old woman with asymptomatic stenosis of both internal carotid and hypoglossal arteries associated with occlusion of the contralateral internal carotid artery underwent successful revascularization. The anatomy of this unusual lesion and the surgical strategies, which included cranial nerve dissection and mandibular subluxation, are reviewed.