Enterprise stents for the treatment of symptomatic non-acute intracranial artery stenosis disease: safety and efficiency evaluation.

BACKGROUND: Enterprise stent was approved for the treatment of wide-necked intracranial aneurysms. However, it has been widely used in the endovascular treatment of intracranial artery stenosis, which is still controversial. The purpose of this study was to evaluate the safety and efficiency of the Enterprise stent in the endovascular treatment of intracranial artery stenosis disease. METHODS: We conducted a retrospective case series of 107 patients with intracranial artery stenosis who received Enterprise stent implantation at Nanjing Drum Tower Hospital from January 2020 to December 2022. The rates of recanalization, perioperative complications, in-stent restenosis at 3-12 months and stroke recurrence were assessed for endovascular treatment. RESULTS: A total of 107 individuals were included in this study, 88 were followed up, and 19 (17.8%) patients were lost to follow-up. The operation success rate was 100%, During the procedure,4（3.7%）patients had vasospasm, and 2(1.9%) patients showed symptomatic bleeding. The overall perioperative complication rate was 5.6%, including 2.8% distal artery embolism, 0.9% in-stent thrombosis, and 1.9% symptomatic bleeding. 88 (82.2%) patients were followed up from 3 to 12 months, of whom 12 (13.6%) had in-stent restenosis, 4 (4.7%) recurrent strokes and 2 died of pulmonary infection caused by COVID-19. Patients were divided into 3 groups according to the cerebral artery, including the middle cerebral artery group, internal carotid artery group, and vertebrobasilar artery group. CONCLUSIONS: In this study, the placement of the Enterprise stent in patients with symptomatic non-acute intracranial stenosis was successful. However, the occurrence of periprocedural and long-term complications after stenting remains of high concern.

Self-expanding versus balloon expandable stent for intracranial arterial stenosis: A systematic review and meta-analysis.

BACKGROUND AND PURPOSE: There are limited data regarding the comparison of balloon expandable stents (BES) and self-expanding stents (SES) for the treatment of intracranial arterial stenosis. METHODS: We conducted a systematic review to identify studies that compared SES and BES in patients with symptomatic intracranial arterial stenosis. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until from January 1, 2010 to September 28, 2023. Statistical pooling with random-effects meta-analysis was undertaken to compare the rates/severity of postprocedure stenosis, technical success, 30-day stroke and/or death, cumulative clinical endpoints, and restenosis rates. RESULTS: A total of 20 studies were included. The standardized mean difference (SMD) for postprocedure stenosis (%) was significantly lower (SMD: -0.52, 95% confidence interval [CI]: -0.79 to -0.24, p < .001, 10 studies involving 1515 patients) with BES. The odds for 30-day stroke and/or death were significantly lower (odds ratio [OR] 0.68, 95% CI: 0.50-0.94, p = .019, 15 studies involving 2431 patients), and cumulative clinical endpoints on follow-up were nonsignificantly lower (OR 0.64, 95% CI: 0.30-1.37, p = .250, 10 studies involving 947 patients) with BES. The odds for restenosis during follow-up were significantly lower (OR 0.50, 95% CI: 0.31-0.80, p = .004, 13 studies involving 1115 patients) with BES. CONCLUSIONS: Compared with SES, BES were associated with lower rates of postprocedure 30-day stroke and/or death with lower rates of restenosis during follow up and the treatment of symptomatic intracranial arterial stenosis.

Blood biomarkers of progressive atherosclerosis and restenosis after stenting of symptomatic intracranial artery stenosis.

In-stent restenosis (ISR) represents a major complication after stenting of intracranial artery stenosis (ICAS). Biomarkers derived from routine blood sampling including C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and mean platelet volume (MPV) have been associated with progressive atherosclerosis. We investigated the role of CRP, NLR, PLR and MPV on the development of intracranial ISR and recurrent stroke risk. We retrospectively included all patients who had undergone stenting of symptomatic ICAS at our university hospital between 2005 and 2016. ISR (≥ 50% stenosis) was diagnosed by regular Duplex sonography follow-up studies and confirmed by digital subtraction angiography or computed tomography angiography (mean follow-up duration: 5 years). Laboratory parameters were documented before stenting, at the time of restenosis and at last clinical follow-up. Of 115 patients (mean age: 73 ± 13 years; female: 34%), 38 (33%) developed ISR. The assessed laboratory parameters did not differ between patients with ISR and those without (p > 0.1). While ISR was associated with the occurrence of recurrent ischemic stroke (p = 0.003), CRP, NLR, PLR and MPV were not predictive of such events (p > 0.1). Investigated blood biomarkers of progressive atherosclerosis were not predictive for the occurrence of ISR or recurrent ischemic stroke after ICAS stenting during a 5-year follow-up.

[Endovascular recanalization of symptomatic non-acute intracranial arterial occlusion: a single center case series].

Objective: To investigate the feasibility and safety of endovascular recanalization for symptomatic non-acute intracranial arterial occlusion (NAICO). Methods: Twenty-five consecutive patients who underwent endovascular recanalization for NAICO between January 2017 and October 2019 at Department of Neurosurgery, Beijing Hospital were retrospectively reviewed.There were 20 males and 5 females, aged (60.5±11.0) years (range: 41 to 73 years).The preoperative modified Rankin score(M(Q(R))) was 2 (2.5)(range: 1 to 5).The occlusion time was 40 (54)days (range: 17 to 570 days).The demographic data were collected. The initial procedural results, including the rate of successful recanalization, periprocedural complications and data pertaining to angiographic and clinical follow-up were recorded. Results: Recanalization was successful in 20 of 27 occlusive lesions of 25 patients. Intraoperative complications occurred in 3 cases, including vascular perforation in 1 case, arterial dissection in 1 case, and perforator occlusion occurred in 1 case. The incidence of permanent complications was 3.7% (1/27). All 25 patients underwent clinical follow-up, with a median period of 8 months (range: 1 to 33 months), and 23 patients with improved or stable modified Rankin scale. One patient developed new ischemic symptoms 2 months after discharge, and 1 patient died of complications of bed rest.The results of the angiography follow-up (median 4 months, range: 2 days to 9 months) showed that reocclusion occurred in 5 of all 20 successfully recanalized patients. Conclusions: Endovascular recanalization for symptomatic NAICO is feasible, relatively safe, and efficacious in highly selected cases. However, further larger scale pilot studies are needed to determine the efficacy and long-term outcome associated with this treatment.

[Exploration on endovascular treatment for symptomatic occlusion of the intracranial vertebral arteries in early non-acute stage].

Objective: To examine the clinical efficacy of endovascular treatment on symptomatic occlusion of intracranial vertebral artery (ICVA) in early non-acute stage. Methods: Nine consecutive patients who presented with aggressive ischemic events in the early non-acute stage of ICVA occlusion from January 2014 to December 2019 and received endovascular treatment at Department of Neurosurgery, Peking University First Hospital were retrospectively reviewed.There were 7 males and 2 females, aged 63.4 years old(range: 52 to 72 years).The average preoperative modified Rankin scale(mRS) was 4.3(range: 4 to 5), the National Institute of Health stroke scale(NIHSS) was 12.3(range: 8 to 18). Among them, 2 patients received a single stage endovascular treatment, and the other 7 patients received staged endovascular treatment.The strategy of staged treatment was as follows: firstly, the occlusion part was passed through by a micro-guidewire and dilated with balloons to maintain the blood flow above Thrombolysis In Cerebral Infarction grade 2b. Then, the intravascular large load thrombus was eliminated by the fibrinolytic system and strengthened antiplatelet drugs. After that, a second stage of angioplasty with stenting was performed on the severe residual stenosis part.The complications and the recanalization rate were collected, and the National NIHSS and mRS after endovascular treatment and in follow-up period were recorded. Results: In the 2 cases received single stage endovascular treatment, although revascularization was achieved lastly, one patient suffered embolus translocation and the other suffered re-occlusion after mechanical thrombectomy during the operation, respectively.Technical success was achieved in 6 of the 7 patients received staged endovascular treatment.On discharge, the average NIHSS scores was 5.7(range: 3 to 4) of the patients. Three months after operation,the average mRS was 1.6(range:0 to 3) and it was 0.9(range: 0 to 2) at the latest follow-up, which were better than preoperative status. Conclusions: Staged endovascular treatment might be a safe, efficient, viable option in carefully selected patients with symptomatic ICVA occlusion in early non-acute stage. It needs to be confirmed by further investigation, preferably in a large controlled setting.

Treatment of complex intracranial pathologies with transcirculation endovascular approaches / Tratamiento de enfermedades intracraneales complejas con enfoques endovasculares de transcirculación

OBJECT: The breadth and complexity of neurovascular pathologies treated with endovascular neurosurgery has expanded dramatically in recent years. Many aneurysms remain difficult to treat safely. Transcirculation (contralateral and/or retrograde) approaches through the circle of Willis are useful alternatives for treating challenging lesions endovascularly. Here, we present a series of patients treated with unconventional transcirculation techniques. METHODS: A total of six patients were treated: four patients with five aneurysms, one patient with an MCA stroke, and one patient with a meningioma requiring preoperative embolization were initially thought not to be amenable to endovascular treatment. The decision was made to treat these patients with transcirculation approaches. All patients were treated by one interventionist. One aneurysm was located in the cavernous internal carotid artery (ICA), one in the vertebral artery, two in the paraclinoid ICA, and one in a cerebellar AVM feeder vessel were treated. RESULTS: Five of six patients (83%) made a full neurologic recovery. Three aneurysms were treated to complete occlusion, one aneurysm was left with small residual neck filling, and one aneurysm was not able to be treated. One patient underwent mechanical thrombectomy of a middle cerebral artery (MCA) embolus and MCA filling was restored after treatment. One patient underwent complete embolization of the deep vascular supply of a meningioma. CONCLUSIONS: Although many neurovascular pathologies remain unsuitable for endovascular treatment, transcirculation approaches can allow for safe, successful treatment of challenging lesions in select patients

OBJETIVO: La variedad y la complejidad de las enfermedades neurovasculares tratadas con neurocirugía endovascular ha aumentado drásticamente en los últimos años. Muchos aneurismas continúan siendo difíciles de tratar de forma segura. Los enfoques de transcirculación (contralateral y/o retrógrada) a través del círculo de Willis son alternativas útiles para el tratamiento endovascular de lesiones difíciles. Presentamos una serie de casos de pacientes tratados con técnicas de transcirculación no convencionales. MÉTODOS: Se trató a un total de 6 pacientes que inicialmente se creía que no eran aptos para el tratamiento endovascular: 4 pacientes con 5 aneurismas, un paciente con un ictus de la arteria cerebral media (ACM) y un paciente con un meningioma que requería embolización preoperatoria. Se tomó la decisión de tratar a estos pacientes con métodos de transcirculación. Todos los pacientes fueron tratados por un solo especialista. Se localizaron y trataron un aneurisma en el segmento cavernoso de la arteria carótida interna (ACI), otro en la arteria vertebral, 2 en el segmento paraclinoideo de la ACI y otro en una malformación arteriovenosa cerebelosa de un vaso nutriente. RESULTADOS: Cinco de los 6 pacientes (83%) alcanzaron una recuperación neurológica completa. Se trataron 3 aneurismas hasta una oclusión completa, un aneurisma se dejó con un pequeño relleno de cuello residual y otro aneurisma no pudo ser tratado. Un paciente fue sometido a una trombectomía mecánica de un émbolo en la ACM y el relleno de la ACM se restauró después del tratamiento. Un paciente se sometió a embolización completa del riego vascular profundo de un meningioma. CONCLUSIONES: Aunque muchas enfermedades neurovasculares siguen sin ser adecuadas para el tratamiento endovascular, los enfoques de transcirculación pueden permitir el tratamiento seguro y exitoso de lesiones difíciles en pacientes seleccionados

Early Multicenter Experience With the Neuroform Atlas Stent: Feasibility, Safety, and Efficacy.

BACKGROUND: The Neuroform Atlas stent™ (by Stryker, Fremont, California) represents the most recent widely available upgrade to intracranial stenting, providing a laser cut open cell stent with a diameter of 3.0 to 4.5 mm that is delivered through an 0.017-inch microcatheter. OBJECTIVE: To report our initial multicenter experience of the safety, efficacy, and feasibility of the Atlas stent used for treating aneurysms, as well as one case of intracranial stenosis and one carotid artery dissection as well as other pathologies. METHODS: A retrospective multicenter study of subjects treated with Atlas stent during the period 2018 to 2019. RESULTS: The total number of patients included in our analysis was 71 patients. The stent was utilized to treat 69 aneurysm cases. Of the aneurysms, 36% presented with acute rupture and 56% of the ruptured aneurysms were high grade. Mean aneurysm dimension was 7 mm with an average neck width of 4.1 mm. Around 30% had received prior treatment. Telescoping or Y-stent was used in 16% of cases. We did not observe any symptomatic major complications in our series. Asymptomatic major complications were seen in 7 patients (10.1%); technical complications occurred in 4.3%. Immediate modified Raymond-Roy-occlusion-outcome class I/II was observed in 87%, and this increased to 97.7% at latest follow-up, which was at 4 mo; 91.8% of patients achieved favorable clinical outcome, and mortality rate was 1.4%. CONCLUSION: Our series demonstrates the safety, feasibility, and efficacy of the Atlas stent. The low complication rate and the high obliteration rate managing complex aneurysms, even in an acute ruptured setting, are notable.

Surgical Approaches to Stroke Risk Reduction.

PURPOSE OF REVIEW: Surgical vascular intervention is an important tool in reducing the risk of stroke. This article examines the evidence for using the available options. RECENT FINDINGS: Carotid endarterectomy is an effective treatment option for reducing the risk of stroke in appropriately selected patients. Patients should be stratified for future stroke risk based on both the degree of stenosis and the presence of symptoms referable to the culprit lesion. Carotid stenting is also useful in reducing stroke risk, again in carefully selected patients. Because of the publication of significant data regarding both carotid endarterectomy and carotid artery stenting in the last several years, selection can be far more personalized and refined for individual patients based on demographics, sex, patient preference, and medical comorbidities. Routine extracranial-intracranial bypass surgery remains unproven as a therapeutic option for large vessel occlusion in reducing the incidence of ischemic stroke although some carefully screened patient populations remaining at high risk may benefit; procedural risks and pathology related to alterations in blood flow dynamics are challenges to overcome. Indirect revascularization remains an appropriate solution for carefully selected patients with cerebral large vessel steno-occlusive disease, and multiple variations of surgical technique are patient specific. Indirect revascularization may benefit from clinical trials with larger patient populations for validation in specific pathologies and offers the advantages of lower surgical complication rates and reduced risk of pathologic responses to altered cerebral flow dynamics. SUMMARY: Surgical solutions to reduce stroke risk provide important alternatives in appropriately selected patients and should be considered in addition to medical management and lifestyle modification for optimizing patient outcomes.

Optical coherence tomography evaluation of vertebrobasilar artery stenosis: case series and literature review.

BACKGROUND: Intracranial vertebrobasilar artery stenosis is an important cause of ischemic stroke. With its high resolution, intravascular optical coherence tomography (OCT) provides detailed assessment of vessel wall features. It is widely applied to identify high-risk plaque in the cardiovascular system, but its use in the intracranial artery has been limited. OBJECTIVE: To explore, in this pilot study, the usefulness of OCT in imaging of the intracranial artery wall. METHODS: Between November 2017 and July 2018, four patients with severe intracranial vertebrobasilar artery stenosis were enrolled for preintervention OCT evaluation of the lesion artery. Stenosis was present in the basilar artery in one case and in the intracranial vertebral artery in three cases. RESULTS: OCT images of the lesions showed various features of plaque vulnerability, such as intraluminal thrombus, lipid-rich plaque with plaque rupture, thin fibrous cap, macrophage accumulations, and a mixed lesion with dissecting aneurysm. In view of the OCT findings, all patients received balloon angioplasty and stent implantation. CONCLUSIONS: These cases describe the successful implementation of OCT in intracranial vertebrobasilar artery stenosis. No side effects were seen during the OCT imaging. This technology may help in the diagnosis and treatment of cerebrovascular disease.

Endovascular "Boost": External Carotid Angioplasty to Augment Flow Before Superficial Temporal-Middle Cerebral Artery Bypass.

BACKGROUND: Superficial temporal artery-middle cerebral artery (STA-MCA) bypass may be used to augment cerebral blood flow in patients with select cerebrovascular pathologies or after failed attempts at revascularization. In this article we describe the use of balloon angioplasty to boost the flow of the external carotid artery (ECA) including the STA to be later used as a donor artery for a STA-MCA bypass procedure. CASE DESCRIPTION: A 67-year-old male with bilateral carotid artery stenosis presented 2 days after a right middle cerebral artery (MCA) stroke and was admitted for medical management. Over the next 4 days his examination worsened; magnetic resonance imaging and computed tomography perfusion confirmed a right MCA stroke with penumbra and angiography revealed complete occlusion of the right internal carotid artery within a prior carotid stent. There was also a right ECA stenosis at its origin, thus limiting options for traditional extracranial-intracranial bypass. Therefore the patient underwent balloon angioplasty of the right ECA by traversing the carotid stent followed by right STA-MCA bypass, resulting in increased flow, clinical stability, and improved cerebral perfusion. CONCLUSIONS: This case highlights a unique strategy for the management of internal carotid artery occlusion in combination with an ipsilateral ECA stenosis. We also demonstrate the utility of endovascular adjuncts to open vascular surgery when complex patterns of stenosis or occlusion exist.

Endovascular recanalization of symptomatic non-acute intracranial artery occlusion: Procedural and mid-term clinical outcomes in the anterior circulation.

OBJECTIVE: Symptomatic non-acute intracranial arterial occlusion (NAICO) is not uncommon. We report a single-center experience of the feasibility and safety of endovascular treatment of anterior circulation NAICO and summarize the outcomes of patient groups with successful or failed recanalization. METHODS: Patients who underwent endovascular therapy for intracranial arterial stenosis between January 2010 and May 2017 were retrospectively reviewed. Thirty-eight patients with symptomatic NAICO (symptom onset > 24 hours) in the anterior circulation were identified. RESULTS: Successful recanalization was achieved in 76.3% of patients (29/38). Intraprocedural events occurred in 10.5% (4/38), including intima dissection (n = 1), parent artery rupture (n = 1) and acute in-stent thrombosis (n = 2). Mean follow-up duration after successful recanalization was 36.5 months. One patient died 68 days after the procedure because of a newly developed posterior circulation stroke. Acute reocclusion was observed in two patients (6.7%); subacute or delayed reocclusion was observed in three patients (10%). Good final outcome (modified Rankin Scale score ≤ 2) was achieved in 25 of 28 patients (89.3%) at three months. Mean follow-up duration of the nine patients with failed recanalization was 41.4 months. Three patients underwent extra-intracranial bypass for worsening symptoms. The other six patients showed stable or improved neurological status with antiplatelet medications. Good final outcome was achieved in eight of nine patients (88.9%) at three months. CONCLUSIONS: Endovascular revascularization can be a viable option with an acceptable safety profile in selected patients with symptomatic NAICO in the anterior circulation. Further characterization of aborted cases would facilitate proper patient selection for endovascular treatment.

Orbitozygomatic craniotomy in three pieces: tips and tricks.

OBJECTIVE: Didactically describe the orbitozygomatic craniotomy made in three pieces. METHOD: This approach was performed, from 2002 to 2011, in 49 patients admitted at Beneficência Portuguesa of São Paulo Hospital. RESULTS: Twenty-seven patients had vascular lesions and twenty-two suffered for intracranial skull base tumors. The vascular lesions varied from cavernous angiomas inside the mesencephalum, high bifurcation basilar tip aneurysms, superior cerebellar arteries aneurysms and arteriovenous malformations in the interpeduncular cistern. Skull base tumors as meningiomas, interpeduncular hamartomas and third ventricle floor gliomas were among the neoplastic lesions approached. We had no permanent injuries and minimal transient complications had occurred. CONCLUSION: It is a descriptive text, organized in the sequence of the main stages in which such a craniotomy is performed, describing in details the technique in which this group of evolutionarily authors came to accomplish the task.

Orbitozygomatic craniotomy in three pieces: tips and tricks / Craniotomia orbitozigomática em três peças: dicas e truques

ABSTRACT Objective Didactically describe the orbitozygomatic craniotomy made in three pieces. Method This approach was performed, from 2002 to 2011, in 49 patients admitted at Beneficência Portuguesa of São Paulo Hospital. Results Twenty-seven patients had vascular lesions and twenty-two suffered for intracranial skull base tumors. The vascular lesions varied from cavernous angiomas inside the mesencephalum, high bifurcation basilar tip aneurysms, superior cerebellar arteries aneurysms and arteriovenous malformations in the interpeduncular cistern. Skull base tumors as meningiomas, interpeduncular hamartomas and third ventricle floor gliomas were among the neoplastic lesions approached. We had no permanent injuries and minimal transient complications had occurred. Conclusion It is a descriptive text, organized in the sequence of the main stages in which such a craniotomy is performed, describing in details the technique in which this group of evolutionarily authors came to accomplish the task.

RESUMO Objetivo Descrever didaticamente a craniotomia orbitozigomática realizada em três peças. Método Esse acesso foi realizado em 49 pacientes, de 2002 a 2011 em pacientes admitidos no Hospital Beneficência Portuguesa de São Paulo. Resultados Vinte e sete pacientes apresentavam lesões vasculares e vinte e dois sofriam de tumores da base do crânio. As lesões vasculares variaram entre angiomas cavernosos do mesencéfalo, aneurismas topo da artéria basilar com bifurcações altas, aneurismas da artéria cerebelas superior a malformações arteriovenosas na cisterna interpeduncular. Tumores da base do crânio como meningeomas, hamartomas interpedunculares e gliomas no assoalho do terceiro ventrículo estão entre as lesões neoplásicas abordadas. Nós não tivemos sequelas definitivas e tivemos mínimas complicações temporárias. Conclusão Trata-se de um texto descritivo, dividido conforme as principais etapas da realização desta craniotomia, o qual descreve com detalhes a técnica com que o presente grupo de autores evolutivamente veio a realizá-la.

Bilateral pial synangiosis in a child with PHACE syndrome.

The acronym PHACE has been used to denote a constellation of abnormalities: posterior fossa anomalies, facial hemangiomas, arterial anomalies, cardiac anomalies, and eye abnormalities. Approximately 30% of patients with large facial hemangiomas have PHACE syndrome, with the vast majority having intracranial arteriopathy. Few reports characterize neurological deterioration from this intracranial arteriopathy, and even fewer report successful treatment thereof. The authors report on a case of a child with PHACE syndrome who presented with an ischemic stroke from a progressive intracranial arteriopathy and describe her successful treatment with bilateral pial synangiosis. An 8-month old girl diagnosed with PHACE syndrome was found to have bilateral internal carotid artery stenosis. Although initially asymptomatic, a few months after diagnosis she suffered a right frontal and parietal stroke. MRI and cerebral angiography investigations demonstrated progressive intracranial arterial stenosis and occlusion. The patient then underwent indirect cerebral revascularization surgery. At 2-year follow-up, she exhibited clinical improvement with persistent speech and motor developmental delay. Follow-up MRI and cerebral angiography showed no new ischemic events and robust extensive vascular collateralization from surgery. PHACE syndrome is an uncommon disease, and affected patients often have cerebral arteriopathy. Although the underlying natural history of cerebral arteriopathy in PHACE remains unclear, cerebral revascularization may represent a potential therapy for symptomatic patients.

Encephaloduroarteriosynangiosis for adult intracranial arterial steno-occlusive disease: long-term single-center experience with 107 operations.

OBJECT: Encephaloduroarteriosynangiosis (EDAS) is a form of revascularization that has shown promising early results in the treatment of adult patients with moyamoya disease (MMD) and more recently in patients with intracranial atherosclerotic steno-occlusive disease (ICASD). Herein the authors present the long-term results of a single-center experience with EDAS for adult MMD and ICASD. METHODS: Patients with ischemic symptoms despite intensive medical therapy were considered for EDAS. All patients undergoing EDAS were included. Clinical data, including recurrence of transient ischemic attack (TIA) and/or stroke, functional status, and death, were collected from a retrospective data set and a prospective cohort. Perren revascularization and American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) collateral grades were recorded from angiograms. RESULTS: A total of 107 EDAS procedures were performed in 82 adults (36 with ICASD and 46 with MMD). During a median follow-up of 22 months, 2 (2.4%) patients had strokes; both patients were in the ICASD group. TIA-free survival and stroke-free survival analyses were performed using the product limit estimator (Kaplan-Meier) method. The probability of stroke-free survival at 2 years in the ICASD group was 94.3% (95% CI 80%-98.6%). No patient in the MMD group suffered a stroke. The probability of TIA-free survival at 2 years was 89.4% (95% CI 74.7%-96%) in ICASD and 99.7% (95% CI 87.5%-99.9%) in MMD. There were no hemorrhages or stroke-related deaths. Angiograms in 85.7% of ICASD and 92% of MMD patients demonstrated Perren Grade 3 and improvement in ASITN/SIR grade in all cases. CONCLUSIONS: EDAS is well tolerated in adults with MMD and ICASD and improves collateral circulation to territories at risk. The rates of stroke after EDAS are lower than those reported with other treatments, including intensive medical therapy in patients with ICASD.

Improvement in cerebral hemodynamic parameters and outcomes after superficial temporal artery-middle cerebral artery bypass in patients with severe stenoocclusive disease of the intracranial internal carotid or middle cerebral arteries.

OBJECT: Both the older and the recent extracranial-intracranial (EC-IC) bypass trials for symptomatic carotid occlusion failed to demonstrate a reduction in stroke recurrence. However, the role of superficial temporal artery (STA)-middle cerebral artery (MCA) bypass in patients with symptomatic intracranial stenoocclusive disease has been rarely evaluated. The authors evaluated serial changes in various cerebral hemodynamic parameters in patients with severe stenoocclusive disease of the intracranial internal carotid artery (ICA) or middle cerebral artery (MCA) and impaired cerebral vasodilatory reserve (CVR), treated by STA-MCA bypass surgery or medical treatment. METHODS: Patients with severe stenoocclusive disease of the intracranial ICA or MCA underwent transcranial Doppler (TCD) ultrasonography and CVR assessment using the breath-holding index (BHI). Patients with impaired BHI (< 0.69) were further evaluated with acetazolamide-challenge technitium-99m hexamethylpropyleneamine oxime ((99m)Tc HMPAO) SPECT. STA-MCA bypass surgery was offered to patients with impaired CVR on SPECT. All patients underwent TCD and SPECT at 4 ± 1 months and were followed up for cerebral ischemic events. RESULTS: A total of 112 patients were included. This total included 73 men, and the mean age of the entire study population was 56 years (range 23-78 years). (99m)Tc HMPAO SPECT demonstrated impaired CVR in 77 patients (69%). Of these 77 patients, 46 underwent STA-MCA bypass while 31 received best medical treatment. TCD and acetazolamide-challenge (99m)Tc HMPAO SPECT repeated at 4 ± 1 months showed significant improvement in the STA-MCA bypass group. During a mean follow-up of 34 months (range 18-39 months), only 6 (13%) of 46 patients in the bypass group developed cerebral ischemic events, as compared with 14 (45%) of 31 patients receiving medical therapy (absolute risk reduction 32%, p = 0.008). CONCLUSIONS: STA-MCA bypass surgery in carefully selected patients with symptomatic severe intracranial stenoocclusive disease of the intracranial ICA or MCA results in significant improvement in hemodynamic parameters and reduction in stroke recurrence.