RESUMEN
Epistaxis is not uncommon, with up to 60% of the population suffering from at least one episode in their lifetime and as many as 6% presenting for medical attention. An analysis of emergency room (ER) visits in the United States between 2009 and 2011 identified 1.2 million encounters for epistaxis, accounting for 0.32% of ER visits. Approximately 6% of patients will require more aggressive, invasive management in the form of transnasal ligation of the sphenopalatine artery or endovascular embolization. This article reviews the epidemiology, rationale for endovascular treatment, strategy for treatment, endovascular technique, postprocedural follow-up, and complications and their management.
Asunto(s)
Isquemia Encefálica/terapia , Educación de Postgrado en Medicina , Radiografía Intervencional/normas , Radiólogos/educación , Radiólogos/normas , Radiología Intervencionista/educación , Radiología Intervencionista/normas , Accidente Cerebrovascular/terapia , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/fisiopatología , Certificación/normas , Competencia Clínica/normas , Consenso , Curriculum , Técnica Delphi , Educación de Postgrado en Medicina/normas , Humanos , Sociedades Médicas , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/fisiopatología , Resultado del TratamientoAsunto(s)
Derivación Arteriovenosa Quirúrgica/normas , Implantación de Prótesis Vascular/normas , Diagnóstico por Imagen/normas , Procedimientos Endovasculares/normas , Oclusión de Injerto Vascular/terapia , Mejoramiento de la Calidad/normas , Indicadores de Calidad de la Atención de Salud/normas , Diálisis Renal/normas , Trombosis/terapia , Derivación Arteriovenosa Quirúrgica/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Consenso , Técnica Delphi , Procedimientos Endovasculares/efectos adversos , Medicina Basada en la Evidencia/normas , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/fisiopatología , Humanos , Valor Predictivo de las Pruebas , Flujo Sanguíneo Regional , Trombosis/diagnóstico por imagen , Trombosis/etiología , Trombosis/fisiopatología , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
A meta-analysis was performed to assess randomized controlled trials comparing local endovascular therapy (with and without intravenous thrombolysis) versus standard care (intravenous thrombolysis alone when appropriate) for acute ischemic stroke. Local endovascular therapy showed a significant improvement in functional independence versus standard care (odds ratio, 1.779; 95% confidence interval, 1.262-2.507; P < .001). This benefit strengthened further on subgroup analyses of trials in which a majority of cases used stent retrievers, trials with intravenous thrombolysis use in both arms when appropriate, and trials that required preprocedural imaging of all patients. There were no significant differences between arms in terms of mortality, hemicraniectomy, intracranial hemorrhage, and cerebral edema rates (P > .05). In conclusion, in the treatment of acute ischemic stroke, local endovascular therapy leads to improved functional independence compared with standard care.
Asunto(s)
Isquemia Encefálica/terapia , Procedimientos Endovasculares , Fibrinolíticos/administración & dosificación , Accidente Cerebrovascular/terapia , Terapia Trombolítica , Administración Intravenosa , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidad , Isquemia Encefálica/fisiopatología , Circulación Cerebrovascular , Evaluación de la Discapacidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Fibrinolíticos/efectos adversos , Humanos , Oportunidad Relativa , Ensayos Clínicos Controlados Aleatorios como Asunto , Recuperación de la Función , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/fisiopatología , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/mortalidad , Resultado del TratamientoAsunto(s)
Angiografía Cerebral/normas , Trastornos Cerebrovasculares/diagnóstico por imagen , Trastornos Cerebrovasculares/terapia , Neuroimagen/normas , Indicadores de Calidad de la Atención de Salud/normas , Radiografía Intervencional/normas , Adulto , Humanos , Guías de Práctica Clínica como Asunto , Estados UnidosRESUMEN
Intracranial atherosclerosis was traditionally believed to carry a risk of stroke of 8% to 22% per annum. The annualized stroke rate in the recent stenting and aggressive medical management for preventing stroke in intracranial stenosis (SAMMPRIS) trial medical management arm was 12.2%. This trial was halted due to excessive periprocedural events in the stent arm. This stroke rate is still unacceptably, high and a treatment strategy is still needed. SAMMPRIS has no bearing on angioplasty alone. Angioplasty alone has always been our primary intervention for intracranial atherosclerosis and remains so to this day due to its relative simplicity, low complication rate, and efficacy. We have, however, made adjustments to our patient management regimen based on the results of SAMMPRIS. This paper outlines our current patient selection, procedural technique, and post-procedure management. The complications we have encountered while developing our technique are described along with how to avoid them and how to manage them. Our most recent results (since previous publications) are also discussed.
Asunto(s)
Descompresión Quirúrgica/métodos , Descompresión Quirúrgica/normas , Nutrición Enteral/métodos , Nutrición Enteral/normas , Enfermedades Gastrointestinales/terapia , Intubación Gastrointestinal/normas , Cecostomía/normas , Contraindicaciones , Descompresión Quirúrgica/efectos adversos , Nutrición Enteral/efectos adversos , Nutrición Enteral/economía , Gastrostomía/normas , Humanos , Intubación Gastrointestinal/efectos adversos , Yeyunostomía/normasAsunto(s)
Descompresión Quirúrgica/métodos , Descompresión Quirúrgica/normas , Nutrición Enteral/métodos , Nutrición Enteral/normas , Enfermedades Gastrointestinales/terapia , Intubación Gastrointestinal/normas , Cecostomía/normas , Contraindicaciones , Descompresión Quirúrgica/efectos adversos , Nutrición Enteral/efectos adversos , Nutrición Enteral/economía , Gastrostomía/normas , Humanos , Intubación Gastrointestinal/efectos adversos , Yeyunostomía/normas , Complicaciones PosoperatoriasAsunto(s)
Antibacterianos/administración & dosificación , Profilaxis Antibiótica/normas , Procedimientos Quirúrgicos del Sistema Digestivo/normas , Procedimientos Endovasculares/normas , Radiografía Intervencional/normas , Procedimientos Quirúrgicos Vasculares/normas , Adulto , Esquema de Medicación , Farmacorresistencia Bacteriana , Medicina Basada en la Evidencia , Humanos , Sociedades Médicas/normas , Terminología como AsuntoRESUMEN
PURPOSE: To compare the clinical and angiographic outcomes of endovascular treatment of symptomatic intracranial stenosis between octogenarian and younger patients. METHODS: Data for 244 consecutive patients (173 men; mean age 61.6 years) who underwent angioplasty and/or stenting for intracranial atherosclerotic disease at 5 specialized centers were pooled. Baseline, 30-day, and follow-up clinical and angiographic information were collected. Rates of clinical and angiographic endpoints were compared between patients >or=80 years old versus those <80 years. RESULTS: Patients >or=80 years (n = 15) were more likely to be hypertensive (87% versus 69%) and have underlying coronary artery disease (73% versus 36%, p<0.05) compared to younger patients (n = 229). The rate of periprocedural stroke and/or death was 3-fold higher among patients aged >or=80 years compared with those <80 years (20% versus 7%, p = 0.11). No recurrent stroke or death (excluding periprocedural events) was observed during follow-up in the octogenarian group. In patients who had follow-up angiography, a similar rate of >or=50% restenosis was observed among patients aged >or=80 years and those aged <80 years (25% versus 29%, p>0.1). CONCLUSION: The 3-fold higher periprocedural death and/or stroke rate suggests cautious use of intracranial angioplasty and/or stent placement in octogenarians.
Asunto(s)
Angioplastia/efectos adversos , Angioplastia/instrumentación , Arteriosclerosis Intracraneal/terapia , Stents , Accidente Cerebrovascular/etiología , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Angiografía Cerebral , Distribución de Chi-Cuadrado , Constricción Patológica , Femenino , Humanos , Arteriosclerosis Intracraneal/diagnóstico por imagen , Arteriosclerosis Intracraneal/mortalidad , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Selección de Paciente , Recurrencia , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Adulto JovenAsunto(s)
Angiografía/normas , Angioplastia/normas , Prótesis Vascular/normas , Garantía de la Calidad de Atención de Salud/normas , Obstrucción de la Arteria Renal/diagnóstico por imagen , Obstrucción de la Arteria Renal/cirugía , Stents/normas , Adulto , Humanos , Implantación de Prótesis/normas , Cintigrafía , Estados UnidosAsunto(s)
Isquemia Encefálica/tratamiento farmacológico , Angiografía Cerebral/normas , Educación de Postgrado en Medicina/normas , Fibrinolíticos/administración & dosificación , Radiografía Intervencional/normas , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/normas , Isquemia Encefálica/complicaciones , Isquemia Encefálica/diagnóstico por imagen , Competencia Clínica/normas , Habilitación Profesional/normas , Curriculum , Fibrinolíticos/efectos adversos , Humanos , Grupo de Atención al Paciente/normas , Garantía de la Calidad de Atención de Salud/normas , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/etiología , Terapia Trombolítica/efectos adversos , Resultado del TratamientoRESUMEN
OBJECTIVE: Stent-assisted coiling of intracranial aneurysms is performed by placing a microcatheter through a stent's interstices or jailing the microcatheter between the stent and the artery. Both approaches impede manipulation of the microcatheter during coiling. We describe a modified jailing technique that improves catheter maneuverability and report the safety and efficacy of the method for the treatment of complex, wide-necked aneurysms. METHODS: The semi-jailing technique involves the partial deployment of a retrievable stent, bridging part of the aneurysm neck while leaving space to maneuver the microcatheter. Twenty-two complex, wide-necked aneurysms, including 3 ruptured and 5 dissecting, were treated using the semi-jailing technique (15 women; mean age, 55.2 years). RESULTS: The semi-jailing technique was successfully applied in all cases. Immediate posttreatment angiograms showed total occlusion of the aneurysm in 17 cases (77%), neck remnant in 3 cases (14%), and aneurysm dome filling in 2 cases (9%). Follow-up angiography available in 10 patients at an average of 8.5 months showed progressive occlusion in 1 aneurysm and 7 remained occluded. In 2 cases of dissecting aneurysms, retreatment was required. No permanent periprocedural morbidity was encountered. One patient died of complications secondary to intracranial hemorrhage 6 days after treatment. In 2 cases (9%), thromboembolic events after final stent placement were successfully treated with intraarterial thrombolysis. No delayed stent migration was seen. CONCLUSION: Semi-jailing is a safe and effective stent-assisted coiling technique that facilitates treatment of complex, wide-necked aneurysms.