Long-Term Follow-up and Mortality Rate of Patients of the Randomized Freeway Stent Study.

PURPOSE: This follow-up study was designed as a reopen of the completed Freeway Stent Study and collected mortality and clinical outcome data for at least 5 years after enrollment to evaluate long-term patient safety and treatment efficacy. The primary study enrolled 204 patients with stenosis or occlusion in the superficial femoral artery and proximal popliteal artery. Patients were randomized to primary nitinol stenting followed by standard PTA or primary nitinol stenting followed by FREEWAY™ paclitaxel-eluting balloon PTA. METHODS: Previous patients were recontacted by phone or during a routine hospital visit, and medical records were reviewed. Vital and clinical status information was collected. RESULTS: No increased late mortality was observed at 5 years, with an all-cause mortality rate of 12.0% in the FREEWAY drug-eluting balloon group versus 15.0% in the non-paclitaxel PTA group. No accumulation of any cause of death was observed in either group, nor was there any correlation with the dose of paclitaxel used. Freedom from clinically driven target lesion revascularization at 5 years was significantly higher in the FREEWAY drug eluting balloon group (85.3%) compared to standard PTA group (72.7%) Log-rank p = 0.032. CONCLUSION: The safety results presented support the recent conclusions that the use of paclitaxel technology does not lead to an increase in mortality. At the same time, the efficacy results clearly demonstrate that the potential benefits of drug-eluting balloon treatment are maintained over a 5-year period.

A Strategy for Minimizing Circulatory Arrest Duration in Complex Aortic Arch Procedures.

Background and Objectives: Aortic arch pathologies represent a surgical challenge. The challenge is partly due to the necessity of complex cerebral, visceral, and myocardial protection measures. Aortic arch surgery generally requires a significant duration of circulatory arrest, which includes deep hypothermia levels with the associated sequelae. This retrospective observational study shows the feasibility of a strategy that reduces circulatory arrest duration and eliminates the need for deep hypothermia during the procedure. Materials and Methods: Between January 2022 and January 2023, 15 patients (n = 15) with type A aortic dissection underwent total arch replacement with a frozen elephant trunk. Cardiopulmonary bypass and organ perfusion were established via arterial lines in the right axillary artery and one of the femoral arteries. In the latter vessels, a y-branched arterial cannula was used (ThruPortTM), allowing for endo-clamping of the stent part of the frozen elephant trunk with a balloon and subsequent perfusion of the lower body. Results: Applying this modified perfusion technique, circulatory arrest time could be reduced to a mean of 8.1 ± 4.2 min, and surgery was performed at a mean lowest body temperature of 28.9 ± 2.3 °C. The mean ICU and hospital stays were 18.3 ± 13.7 days and 23.8 ± 11.7 days, respectively. The rate for 30-day survival was 100%. Conclusions: By applying our modified perfusion technique, the circulatory arrest duration was below ten minutes. As a consequence, deep hypothermia could be avoided, and surgery could be performed at moderate hypothermia. Future studies will have to show whether these changes may be translated into a clinical benefit for our patients.

Characterization of MRI White Matter Signal Abnormalities in the Pediatric Population.

(1) Background and Purpose: The aim of this study was to retrospectively characterize WMSAs in an unselected patient cohort at a large pediatric neuroimaging facility, in order to learn more about the spectrum of the underlying disorders encountered in everyday clinical practice. (2) Materials and Methods: Radiology reports of 5166 consecutive patients with standard brain MRI (2006-2018) were searched for predefined keywords describing WMSAs. A neuroradiology specialist enrolled patients with WMSAs following a structured approach. Imaging characteristics, etiology (autoimmune disorders, non-genetic hypoxic and ischemic insults, traumatic white matter injuries, no final diagnosis due to insufficient clinical information, "non-specific" WMSAs, infectious white matter damage, leukodystrophies, toxic white matter injuries, inborn errors of metabolism, and white matter damage caused by tumor infiltration/cancer-like disease), and age/gender distribution were evaluated. (3) Results: Overall, WMSAs were found in 3.4% of pediatric patients scanned at our and referring hospitals within the ten-year study period. The majority were found in the supratentorial region only (87%) and were non-enhancing (78% of CE-MRI). WMSAs caused by autoimmune disorders formed the largest group (23%), followed by "non-specific" WMSAs (18%), as well as non-genetic hypoxic and ischemic insults (17%). The majority were therefore acquired as opposed to inherited. Etiology-based classification of WMSAs was affected by age but not by gender. In 17% of the study population, a definite diagnosis could not be established due to insufficient clinical information (mostly external radiology consults). (4) Conclusions: An "integrated diagnosis" that combines baseline demographics, including patient age as an important factor, clinical characteristics, and additional diagnostic workup with imaging patterns can be made in the majority of cases.

Results of the pToWin Study: Using the pCONUS Device for the Treatment of Wide-Neck Intracranial Aneurysms.

Coil embolization has become a well-established option for the treatment of intracranial aneurysms. Yet, wide-neck bifurcation aneurysms (WNBAs) remain a challenge. The pCONUS is the first generation of a stent-like implant for the bridging of WNBAs to enable coiling. The pToWin study was a prospective, single-arm, multicenter study conducted to analyze the safety and efficacy of the pCONUS in the treatment of WNBAs. The primary effectiveness endpoint was the rate of adequate occlusion of the aneurysm at 3-6 and 7-12 months. The primary safety endpoint was the occurrence of major ipsilateral stroke or neurological death during the follow-up. A total of 115 patients were included. Aneurysm locations were the middle cerebral artery in 52 (45.2%), the anterior communicating artery in 35 (30.4%), the basilar artery in 23 (20%), the internal carotid artery terminus in three (2.6%), and the pericallosal artery in two (1.7%) patients. Treatment was successfully performed in all but one patient. The morbi-mortality rate was 1.9% and 2.3% at 3-6 and 7-12 months, respectively. Of the aneurysms, 75.0% and 65.6% showed adequate occlusion at 3-6 and 7-12 months, respectively. pCONUS offers a safe and reasonably effective treatment of WNBAs, demonstrated by acceptable adequate aneurysm occlusion and low rates of adverse neurologic events.

Acute Recanalization of Thrombo-Embolic Ischemic Stroke with pREset (ARTESp): the impact of occlusion time on clinical outcome of directly admitted and transferred patients.

OBJECTIVES: Acute Recanalization of Thrombo-Embolic Ischemic Stroke with pREset (ARTESp) is a prospective multicenter study assessing the efficacy and safety of the pREset stent retriever for the treatment of intracranial vessel occlusion. Determination of the effect of transfer status on clinical outcome was a secondary objective. METHODS: Efficacy was measured by recanalization success (Thrombolysis in Cerebral Infarction score ≥2b) and favorable clinical outcome at 90 days (modified Rankin Scale 0-2). Intracranial hemorrhage (ICH) and death at 90 days were safety measures. The outcome of directly admitted (DAP) and transferred (TP) patients was investigated using multivariable regression models. RESULTS: Four study centers included 100 patients (mean age 68.3 years, median National Institutes of Health Stroke Scale score 15). Recanalization success was achieved in 84.4% after a mean of 1.7 passes. ICH was detected in 14.0%, with 2.0% being symptomatic. At 90 days, 62.5% of the patients had a favorable outcome and 7.3% died. TP had longer occlusion times (289 vs 180 minutes, p<0.001) and a lower rate of favorable outcome (58.0% vs 78.4%, p=0.046) than DAP. Multivariable regression revealed occlusion time as the critical determinant (OR=0.963, 95% CI 0.931 to 0.997, p=0.032), whereas transfer status itself showed no significant association (OR=0.565, CI 0.133 to 2.393, p=0.438). CONCLUSIONS: pREset proved to be safe and effective for the treatment of acute intracranial vessel occlusion. Increased occlusion time impaired clinical outcome in TP. TRIAL REGISTRATION NUMBER: NCT02437409; Results.

Endovascular treatment of acute internal carotid artery dissections: technical considerations, clinical and angiographic outcome.

INTRODUCTION: In acute internal carotid artery dissection (a-ICAD) with concomitant intracranial large vessel occlusion or haemodynamic impairment, the effectiveness of medical treatment is limited and endovascular therapy (EVT) can be considered. Feasibility, safety and outcome of EVT in a-ICAD are not well described yet. METHODS: From an institutional database, we retrospectively selected consecutive patients treated for a-ICAD between January 2007 and July 2015. We assessed recanalization results defining <50 % residual stenosis and mTICI ≥2b as successful. Procedural adverse events and symptomatic haemorrhages were reported as well as clinical outcome at 90 days defining a mRS ≤2 as favourable. Follow-up angiographies were reviewed and retreatments reported. RESULTS: In the defined period, 73 patients (mean age 48 years (31-73), mean NIHSS 11 (0-27)) received EVT for a-ICAD. The majority (60 %) had tandem occlusions. Cervical artery reconstruction was successful in 100 % and intracranial thrombectomy in 85 %. Thrombus formation (18 %) and thromboembolism (20 %) were the most frequent adverse events but clinically relevant only in 8 %. Symptomatic haemorrhage occurred in 5 %. Clinical outcome was favourable in 64 %, with a lower chance after tandem occlusion (55 vs. 79 %, p = 0.047). Death rate was 10 %. None of the patients developed recurrent ischaemic symptoms, but control angiography revealed abnormal findings of the reconstructed ICA in 38 % leading to retreatment in 17 %. CONCLUSION: EVT of a-ICAD is feasible with a predominantly favourable clinical outcome. Improvement of devices and techniques is warranted to reduce the risk of thrombus formation and thromboembolism during treatment and insufficient vessel wall healing thereafter.

Solving the Issue of Restenosis After Stenting of Intracranial Stenoses: Experience with Two Thin-Strut Drug-Eluting Stents (DES)-Taxus Element™ and Resolute Integrity™.

PURPOSE: Thin-strut, flexible DES are suitable for intracranial stenting and may improve long-term vessel patency. The purpose of this study was to report our experience with two new-generation DES for the treatment of intracranial atherosclerotic disease. PATIENTS AND METHODS: We retrospectively reviewed all patients treated with Taxus Element™ or Resolute Integrity™ stent for an intracranial atherosclerotic stenosis between March 2011 and August 2013. Technical success was defined as the ability to deploy the device at the desired location and reduce the degree of stenosis below 50 %. All procedure-related strokes were recorded. Control angiography was scheduled after 6 weeks, 3, 6, and 12 months and yearly thereafter. A luminal narrowing ≥50 % was regarded as a restenosis. Stroke recurrence in the territory of the treated artery was reported. RESULTS: In the defined period we treated 101 patients harboring 117 intracranial stenoses. The procedure was successful in 100 (85.5 %) lesions. Procedure-related strokes occurred in 10 (9.9 %) patients with a permanent morbidity in 3 (3.0 %). Follow-up angiography was available for 83 of 100 (83.0 %) successfully treated lesions with an average of 355 days (IQR 153-482 days). Three (3.6 %) asymptomatic restenoses were detected. All occurred after treatment with Resolute Integrity™, none after Taxus Element™ (p = 0.059). New strokes in the territory of the treated artery were encountered in 2 (2.6 %) occasions. CONCLUSION: Thin-strut DES improve long-term patency and reduce the risk of subsequent stroke. Differences between devices may exist. Feasibility is comparable to bare-metal balloon-mounted stents and procedure-related strokes occurred within the expected range.

Pipeline embolization device for the treatment of intra- and extracranial fusiform and dissecting aneurysms: initial experience and long-term follow-up.

BACKGROUND: Flow-diverting stents offer a promising treatment option for complex aneurysms. OBJECTIVE: To evaluate the safety and efficacy of the Pipeline embolization device (PED) in the treatment of fusiform and dissecting aneurysms. METHODS: Sixty-five consecutive patients with 69 fusiform and dissecting aneurysms underwent endovascular treatment with the use of the PED. Target vessels included the internal carotid artery (n = 28), middle cerebral artery (n = 2), anterior cerebral artery (n = 1), vertebral artery (n = 20), basilar artery (n = 17), and posterior cerebral artery (n = 1). An average of 3.0 PEDs per target vessel were deployed. RESULTS: Exclusion of the aneurysm(s) immediately after PED deployment was not observed. Angiographic follow-up examinations were performed in 63/65 patients (67/69 lesions). They showed complete cure of the target lesion in the first follow-up angiography (3.4 months mean interval) in 24 (36%) cases, partial elimination in 30 (45%), and no improvement in 13 (19%). After the latest follow-up (>1 digital subtraction angiography, n = 49, 27.4 months mean interval) complete cure of the target lesion was observed in 33 (67%), partial elimination in 14 (29%), and no change in 2 (4%). Taking all follow-up examinations together, 39/67 (58%) aneurysms were cured. The morbidity and mortality in the entire series were 5% and 8%, respectively. CONCLUSION: Flow diverters offer a promising treatment option in fusiform and dissecting aneurysms. The introduction of flow diverters with different densities might help to identify the optimal amount of coverage needed given different anatomic presentations of fusiform and dissecting aneurysms.

Clinical experience with the pREset stent retriever for the treatment of acute ischemic stroke--a review of 271 consecutive cases.

INTRODUCTION: The purpose of this study was to evaluate the safety and efficacy of the pREset stent retriever in a real-world clinical setting. METHODS: Patients treated with pREset were selected from a prospectively maintained single-center database. A TICI score ≥2b after ≤3 passes was regarded as successful recanalization. All device-related complications and their clinical significance were reported. Parenchymal hematomas (PH) were classified according to ECASS, adding focal and diffuse subarachnoid hemorrhage (SAH) as categories. A 90-day mRS of 0-2 was defined as favorable outcome. In addition, we separately analyzed patients treated with >3 pREset passes and patients receiving other rescue maneuvers. RESULTS: We included 271 patients. Successful recanalization was achieved in 76.4 %. Device-related complications occurred in 9.2 % of which 2.2 % were clinically significant. PH I, PH II, focal SAH, and diffuse SAH was observed in 5.2, 4.8, 12.2, and 2.2 %, respectively. A total of 39.5 % of patients had favorable clinical outcome. Considering treatments with >3 pREset passes or other rescue procedures, an additional 8.5 and 9.3 % of target vessels were recanalized. The chance of favorable clinical outcome decreased significantly with any kind of rescue therapy. In addition, the rate of PH I was significantly higher in patients treated with >3 pREset passes, whereas all other types of hemorrhage showed no difference. CONCLUSION: In terms of safety and effectiveness, pREset performed comparably to other stent retriever devices. To avoid futile recanalization and potential additional harm, escalation of therapy beyond three thrombectomy passes should only be performed after careful individual consideration of each case.

Predictors of outcome after mechanical thrombectomy for anterior circulation large vessel occlusion in patients aged ≥80 years.

BACKGROUND: There is uncertainty about the role of endovascular recanalization procedures for the treatment of acute ischemic stroke in patients aged ≥80 years. Therefore, careful patient selection is mandatory. Our aim was to find valid predictors of clinical outcome after mechanical thrombectomy (mTE) based on the sparse information available in the emergency setting. METHODS: We included consecutive patients aged ≥80 years treated by mTE for anterior circulation thromboembolic vessel occlusion in our department between January 2008 and January 2013. Successful recanalization was defined as a thrombolysis in cerebral infarction (TICI) score of 2b or 3. The rates of parenchymal hemorrhage types I (PHI) and II (PHII) according to the ECASS definition and the rate of focal and diffuse subarachnoid hemorrhage (SAH) were reported. A modified Ranking scale (mRS) score of 0-2 at 90 days was defined as a favorable outcome. We evaluated the influence of gender, smoking habits, atrial fibrillation, diabetes, hypertension, hyperlipidemia, coronary artery and peripheral artery disease, National Institutes of Health Stroke Scale (NIHSS) score, Totaled Health Risks in Vascular Events (THRIVE) score, Alberta Stroke Program Early CT Score (ASPECTS), and duration of symptoms on favorable outcome. Significant predictors were then included in a stepwise logistic regression analysis. Odds ratios (OR), 95% confidence intervals (CI), and receiver operating characteristics (ROC) curves were calculated. p < 0.05 was considered statistically significant. RESULTS: In the defined period, we treated 109 patients aged ≥80 years with 116 occluded anterior circulation target vessels. Successful recanalization was achieved in 87.9% of the targets. The rates of PHI, PHII, and focal and diffuse SAH were 6.4, 5.5, 12.8, and 7.3%, with an overlap between PH and SAH. The combined rate of PHII and/or diffuse SAH was 9.2%. Despite good recanalization rates and reasonable rates of hemorrhage, only 19 patients (17.4%) were functionally independent at 90 days. An additional 12 patients (11.0%) suffered from moderate disability (mRS score 3), 26 (23.9%) were severely disabled (mRS score 4-5) and 52 (47.7%) were deceased. NIHSS, ASPECTS, and THRIVE scores significantly predicted a favorable outcome. Stepwise logistic regression identified NIHSS (OR 0.89; 95% CI 0.82-0.96; p = 0.009) and ASPECTS (OR 2.27; 95% CI 1.28-4.02; p = 0.005) as independent predictors. The ROC area was 0.81. CONCLUSION: ASPECTS and NIHSS were independent predictors of a favorable outcome in patients aged ≥80 years after mTE for anterior circulation large vessel occlusion and may support decision making with regard to the treatment modality. Since the chances of gaining functional independence are limited, careful consideration of each individual case is mandatory. Further studies comparing endovascular and standard treatment in octogenarians are warranted.

Prevention and treatment of neurovascular in-stent stenoses: review of the concepts.

Advances in medical devices technology now allow the endovascular treatment of stenotic lesions of the intracranial arteries with the help of the implantation of microstents. The technical development in stent, catheter and guidewire technology now allows the application of these devices in the intracranial arteries, where access issues due to difficult anatomy and length of the access pathway pose far more hurdles to accurately, efficiently and safely navigate these devices as compared with the treatment of lesions of the peripheral arteries or the coronary system. Although the efficacy and safety of these procedures show a continuous improvement with decreased periprocedural complication rates, the development of a significant intraluminal stenotic lesion as a result of neointimal hyperplasia induced within the implants remains a serious delayed complication. In this review, the authors give an overview of the factors affecting the development of neointimal hyperplasia and review the currently available possibilities of the prevention as well as the treatment of the already existing intraimplant stenotic lesions.

Prevention of intracranial in-stent restenoses: predilatation with a drug eluting balloon, followed by the deployment of a self-expanding stent.

PURPOSE: Stenting in intracranial atherosclerotic disease (ICAD) is increasingly debated, due to issues of procedural safety, technical efficacy, and in-stent recurrent stenoses (ISR). In the present study, feasibility, safety, and efficacy of angioplasty using a drug-eluting balloon (DEB) followed by the implantation of a self-expanding stent (Enterprise) were evaluated for the treatment of ICAD lesions. METHODS: Fifty-two patients (median age: 71 years; range: 54-86 years; male/female ratio 37:15) underwent stenting of high-grade ICAD lesions between February 2010 and November 2011 in a single center. Angioplasty using a paclitaxel coated SeQuent Please (B. Braun, Germany) or DIOR (Eurocor, Germany) coronary PTCA balloon, followed by the implantation of a self-expanding stent (Enterprise, Codman, USA) was performed in 54 lesions. Angiographic and clinical follow-up was performed at 6 and 12 weeks, 6 and 12 months, and yearly thereafter. Technical success rate, periprocedural complications, occurrence of recurrent ischemic symptoms, and the development of an ISR were analyzed. RESULTS: Angioplasty using a DEB followed by stent implantation was successfully performed in 44 (81 %) cases. DEB insertion failed in 19 % of the cases and angioplasty was finally performed using a conventional PTCA balloon. The combined procedure related permanent neurologic morbidity and mortality rate (stroke, ICH, and subarachnoid hemorrhage) at 30 days and beyond was 5 %. Angiographic and clinical follow-up were obtained in 33 (61 %) lesions in 32 patients. Recurrent stenosis was seen in one (3 %) lesion. CONCLUSION: Angioplasty and stenting using a DEB is safe and yields encouragingly low ISR rates. Further technical developments to improve lesion accessibility are, nevertheless, mandatory.

Does mechanical thrombectomy in acute embolic stroke have long-term side effects on intracranial vessels? An angiographic follow-up study.

PURPOSE: Mechanical thrombectomy (mTE) proved to be effective treating acute vessel occlusions with an acceptable rate of procedural complications. Potential long-term side effects of the vessel wall trauma caused by mechanical irritation of the endothelium are unknown up to now. METHODS: From a retrospectively established database of 640 acute stroke treatments, we selected 261 patients with 265 embolic vessel occlusions treated successfully by mTE without permanent implantation of a stent. Analysis comprised the type of devices used and the number of passes performed. Digital subtraction angiography immediately after treatment was evaluated for vasospasm, dissection, and extravasation. Control angiographic images were evaluated for any morphological change compared to the immediate posttreatment angiographic run. RESULTS: Recanalization was achieved with a median of one (range 1-10) mTE maneuvers. Vasospasm occurred in 69 territories (26.0 %) and was treated with glyceroltrinitrate in three. Dissection was observed in one vessel (0.4 %). Intraprocedural hemorrhage in two patients (0.8 %) was either wire or device induced. Follow-up digital subtraction angiography was available for 117 territories after a median of 107 days, revealing target vessel occlusion in one segment (0.9 %) and a de novo stenosis of four segments (3.4 %). All findings were clinically asymptomatic. Posttreatment vasospasm was more frequent in patients with de novo stenosis and occlusion (p = 0.038). CONCLUSION: De novo stenoses and occlusions occur in a small proportion of patients after mTE. Because all lesions were clinically asymptomatic, this finding does not affect the overall benefit of the treatment. Vasospasm may predict late vessel wall changes.

Complication rates using balloon-expandable and self-expanding stents for the treatment of intracranial atherosclerotic stenoses : analysis of the INTRASTENT multicentric registry.

INTRODUCTION: Using balloon-expandable stents (BES) for treatment of intracranial stenoses, high inflation pressures and rigidity of the device are regarded as major drawbacks limiting feasibility and safety of the procedure. Self-expanding stents (SES) were developed to facilitate lesion access and to allow for less aggressive dilatation. We analyzed data of the INTRASTENT multicentric registry to assess whether self-expanding stents significantly reduced peri-interventional complication rates. METHODS: Records of intracranial stent procedures were entered consecutively into the registry. Datasets were divided into two groups according to the type of stent used. For outcome measurement, we chose three categories: TIA/minor stroke [modified Rankin score (mRS) <2], disabling stroke, and patient death. Clinical outcome was compared between BES and SES. We analyzed types of adverse events occurring in each group in addition. RESULTS: Of 409 atherosclerotic lesions, 254 were treated with BES and 155 with SES. Technical success rates were 97.6% and 98.7%, respectively. Adverse event rates were 4.9%, 3.7%, and 0.8% for TIA/nondisabling stroke, disabling stroke, and death in the BES group compared with 5.3%, 6.0%, and 4.0% in the SES group. The differences were not statistically significant. We observed more perforator strokes after use of BES, but thromboembolic events occurred more often in the SES treatment group. CONCLUSION: Data of the INTRASTENT registry do not support the hypothesis that introduction of SES lowered the overall complication rate of intracranial stent procedures. There might be an advantage using self-expanding stents in vessel segments with important perforating arteries.

Intracranial stenting in atherosclerotic disease-recent results and challenges to face.

Intracranial stenting is increasingly used as an add-on to medical therapy despite the fact that the overall clinical benefit remains a matter of debate, since we lack results of randomized trials. Decision making on interventional treatment is made on the grounds of the anticipated risk of stroke with antiplatelet medication on one hand and on the experience with stent treatment based on data from case series and registries on the other hand. This review will summarize the current knowledge on both topics serving as the fundament of patient selection for intracranial stenting. A second objective is to highlight some specific problems that are encountered when treating patients interventionally. Procedure-related complication rates and rates of in stent stenoses are still too high to be confident that endovascular treatment is superior to medical therapy of symptomatic stenoses. Optimization of patient selection criteria, stent technology, and periprocedural management are necessary to become undoubtedly competitive with antiplatelet therapy. With the current stage of development, interventional treatment of intracranial stenoses should be confined to specialized centers with a high expertise in neurovascular procedures.

In-hospital complication rates after stent treatment of 388 symptomatic intracranial stenoses: results from the INTRASTENT multicentric registry.

BACKGROUND AND PURPOSE: Stenting is increasingly used as an adjunct to medical therapy in symptomatic intracranial stenoses. High periprocedural adverse event rates are one of the limitations of endovascular treatment. Data from the INTRASTENT multicentric registry should demonstrate in-hospital complications at the current stage of clinical development of the stent procedure. METHODS: Participating centers entered the records of all their consecutive intracranial stent procedures into the database. To determine the clinical outcome in the acute phase, we distinguished transient ischemic attack/nondisabling stroke (modified Rankin Scale <2), disabling stroke, death, and intracranial hemorrhage as clinical complications and analyzed whether they were associated with patient- or stenosis-related risk factors. RESULTS: Data from 372 patients with 388 stenoses proved 4.8% disabling strokes and 2.2% deaths. Transient or minor events were detected in 5.4% of the cases. Hemorrhagic events (3.5%) occurred more frequently after treatment of middle cerebral artery stenoses (P=0.004) and were associated with significantly higher morbidity and mortality rates. Ischemic strokes by compromise of perforating branches were detected mainly in the posterior circulation. However, the overall rate of severe adverse events was not dependent from location, degree, and morphology of the stenosis or from patient's age, gender, vascular risk factors, or type of qualifying event. CONCLUSIONS: The complication rates within the registry are within the limits of previously published data. Severe adverse events were equally distributed between potential risk groups with similar rates but different types of main complications in the anterior and posterior circulation.

Recanalization results after intracranial stenting of atherosclerotic stenoses.

The purpose of this investigation was to provide a detailed description of the angiographic results after stenting of high-grade intracranial stenosis using balloon-expandable stents. Forty consecutive patients with symptomatic atherosclerotic intracranial stenosis >50% received endovascular treatment by placement of balloon-expandable stents using the concept of slight underdilation and strict avoidance of overdilation. Intra-arterial digital subtraction angiography images before and after stenting in the same projection were reviewed for pre- and post-therapeutic measurement of the degree of stenosis and evaluation of morphologic criteria like plaque coverage, stent apposition, patency of side branches, and signs of dissection or vasospasm. Stenting decreased the mean percentage stenosis from 76.2 (WASID criteria) to 20.8%. Residual stenosis ranged from 0 to 55% with residual stenosis >50% in two of 40 cases. Technical success rate was 95%. There were no major vessel complications, but minor abnormalities like incomplete stent apposition (8/40) or plaque coverage (7/40), incomplete filling of side branches (13/40), and minor dissections after stenting (2/40) were seen. One case with incomplete stent apposition and two cases with side branch compromise were associated with clinical symptoms. In conclusion, intracranial stenting with slight underdilation avoided major vessel complication and created reliable luminal gain. Suboptimal recanalization results were frequently detected and may be the source of neurological complications in individual cases.

Risk assessment of symptomatic intracerebral hemorrhage after thrombolysis using DWI-ASPECTS.

BACKGROUND AND PURPOSE: Pretreatment lesion size on diffusion-weighted imaging (DWI) is a risk factor for symptomatic intracerebral hemorrhage (sICH) associated with thrombolytic treatment. Here, we investigated whether the Alberta Stroke Programme Early CT Score (ASPECTS) applied to DWI images (DWI-ASPECTS) predicts sICH risk accurately. METHODS: In this retrospective multicenter study, prospectively collected data of 217 patients with anterior circulation stroke treated with intravenous or intraarterial thrombolysis within 6 hours after symptom onset were analyzed. Pretreatment DWI-ASPECTS scores were assessed by 2 independent investigators. For bleeding risk analysis, DWI-ASPECTS scores were either categorized into 0 to 7 (n=105) or 8 to 10 (n=112) or in 3 groups of similar sample size (DWI-ASPECTS 0 to 5 [n=69], 6 to 7 [n=70], and 8 to 10 [n=78]). RESULTS: DWI-ASPECTS scores correlated well with the DWI lesion volume (r=0.77, P<0.001, Spearman Rank test). Interobserver reliability for the assessment of DWI-ASPECTS was moderate (weighted kappa 0.441 [95% CI 0.373 to 0.509]). Twenty-three (10.6%) patients developed sICH. The sICH rate was significantly higher in patients with DWI-ASPECTS scores 0 to 7 (n=21, 15.1%) as compared to patients with DWI-ASPECTS scores 8 to 10 (n=2, 2.6%, P=0.004). sICH risk was 20.3%, 10%, and 2.6% in the 0 to 5, 6 to 7, and 8 to 10 DWI-ASPECTS groups, respectively. DWI-ASPECTS remained an independent prognostic factor for sICH after adjustment for clinical baseline variables (age, NIHSS, time to thrombolysis). CONCLUSIONS: DWI-ASPECTS predicts sICH risk after thrombolysis and may be helpful to contributing to quick sICH risk assessment before thrombolytic therapy.

Evaluation of angiographic and technical aspects of carotid stenting with diffusion-weighted magnetic resonance imaging.

The detection of clinically silent ischemic lesions on postprocedural diffusion-weighted magnetic resonance images has become a preferred method for the description of embolic risks. The purpose of this single-center study was to evaluate whether diffusion-weighted imaging (DWI) could determine material related or technical risk factors of filter-protected carotid stenting. Eighty-four patients with symptomatic severe (> or = 60%) carotid artery stenoses received filter-protected carotid stenting. Standard DWI (b = 1000) was performed within 48 h before and after carotid stenting. The occurrence and load of new postinterventional DWI lesions were assessed. Multivariate analysis was performed to determine risk factors associated with DWI lesions, with emphasis on technical factors such as use of different access devices (guiding catheter method vs. long carotid sheath method), type of stent (open-cell nitinol stent vs. closed-cell Wallstent), and protective device (filters with 80-microm vs. 110-120-microm pore size). Markers for generalized atherosclerosis and for degree and site of stenosis were assessed to allow comparison of adequate risk profiles. Access, protective device, and stent type were not significantly associated with new embolic DWI lesions when we compared patients with equivalent risk profiles (long carotid sheath method 48% [11 of 23] vs. guiding catheter method 44% [27 of 61], Wallstent 47% [15 of 32] vs. nitinol stent 44% [23 of 52], and small pore size filter 61% [11 of 18] vs. large pore size filter 41% [27 of 66]). Single-center DWI studies with a moderate number of cases are inadequate for proper assessment of the embolic risk of technical- or material-related risk factors in carotid stenting. Larger multicenter studies with more cases are needed.