Browse

INTRODUCTION: Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are means of carotid revascularisation in patients with carotid artery stenosis. Recent large randomised control trials (RCTs) have compared these two methods of carotid revascularisation, with conflicting results. We review the outcomes of all patients who have undergone CAS at a single centre. We also contrast the clinical features and outcomes of patients with symptomatic versus asymptomatic carotid artery disease. METHODS: We maintained a database of all patients undergoing CAS over a 10-year period. Patient demographic information was collected, as well as intra-procedural details, complications occurring within 30 days of the procedure and clinical follow-up. RESULTS: 203 patients underwent CAS over 10 years. After exclusions, 199 patients (M:F, 134:65) were included. Our patient population consisted largely of those unsuitable for surgery and therefore comprised a higher-risk group when compared to the patient population in the RCTs. There were more symptomatic patients (n=123, 61.8%) than asymptomatic patients (n=76, 38.2%). The 30-day major adverse event (MAE) rate was 8.5 % (n=17), including stroke (n=6, 3.2 %), myocardial infarction (MI) (n=2, 1.0 %) and death (n=9, 4.5 %). There was no statistical difference between MAEs in the symptomatic (n=11, 8.9 %) compared to the asymptomatic group (n=6, 7.9 %). CONCLUSIONS: The outcomes of CAS performed at our centre in an unrestricted high-risk group of patients compare favourably with those of recent RCTs. Despite a higher incidence of ischaemic heart disease (IHD) in patients with asymptomatic disease, outcomes were similar to those of symptomatic patients. Our data suggests that CAS is a safe and dependable method of carotid revascularisation when offered as an alternative to CEA or if patients are unsuitable for CEA.

INTRODUCTION: This study aims to determine whether contrast enhanced magnetic resonance angiography (CEMRA) is preferable to computed tomographic angiography (CTA) as primary diagnostic tool in patients presenting with subarachnoid haemmorhage (SAH). When an intracranial aneurysm is the source of SAH it is of primordial importance to exclude it from circulation as soon as possible, preferably using endovascular coiling. The preferred diagnostic tool, therefore, must be able to quickly and accurately predict coilability of the aneurysm. In this study we evaluated both CEMRA and CTA in this aspect. METHODS: Two experienced neuroradiologists evaluated CEMRA and CTA images of 75 consecutive patients with SAH. Accuracy in predicting coilability of aneurysms of both modalities was evaluated using digital subtraction angiography (DSA) as standard of reference. RESULTS: 65 aneurysms were detected in 57 patients. No significant difference was found between the 2 modalities with respect to accuracy in assessing the feasibility of endovascular treatment: sensitivity and specificity for both were rather low (52.8-72.2 and 80.9-89.4 respectively), and Kappa was only 0.49 for both. CONCLUSION: The diagnostic performance of CEMRA does not significantly differ to that of CTA in the work-up of patients presenting with SAH; additionally, both modalities are found to have a rather low accuracy in predicting coilability of intracranial aneurysms.

PURPOSE: In this international multispecialty document, quality benchmarks for processes of care and clinical outcomes are defined. It is intended that these benchmarks be used in a quality assurance program to assess and improve processes and outcomes in acute stroke revascularization. MATERIALS AND METHODS: Members of the writing group were appointed by the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society of Cardiac Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Swiss Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology. The writing group reviewed the relevant literature from 1986 through February 2012 to create an evidence table summarizing processes and outcomes of care. Performance metrics and thresholds were then created by consensus. The guideline was approved by the sponsoring societies. It is intended that this guideline be fully updated in 3 years. RESULTS: In this international multispecialty document, quality benchmarks for processes of care and clinical outcomes are defined. These include process measures of time to imaging, arterial puncture, and revascularization and measures of clinical outcome up to 90 days. CONCLUSIONS: Quality improvement guidelines are provided for endovascular acute ischemic stroke revascularization procedures.

INTRODUCTION: Stenting with a Y-configuration is an endovascular option for repairing wide-neck aneurysms spanning vascular bifurcations. Most reports focus on basilar tip aneurysms. We report mid-term results for the largest series of Y-stenting in the anterior circulation. METHODS: Retrospective review of anterior circulation aneurysms treated with Y-stenting at Rush University Medical Center between 2004 and 2011. RESULTS: Fourteen patients met inclusion criteria. Ten middle cerebral artery (MCA) aneurysms were treated: 4/10 Raymond 1 post-treatment; 6/6 Raymond 1 at follow-up. Two internal carotid artery (ICA) aneurysms were Raymond 3 initially; 1/1 Raymond 1 at follow-up. One ICA aneurysm had a peri-procedural mortality. Two anterior communicating artery (Acomm) aneurysms were treated: 1/2 Raymond 1, 1/2 Raymond 3; neither changed at follow-up. In total, 93 % of anterior circulation aneurysms had Raymond 1 occlusion at follow-up. The single aneurysm that did not achieve Raymond 1 occlusion failed clipping prior to Y-stenting and did not undergo coiling. CONCLUSION: Y-stenting is an effective option for treatment of wide-neck bifurcation aneurysms in the anterior circulation. A number of aneurysms initially had evidence of residual neck or aneurysmal sac but in nearly all cases follow-up angiography revealed Raymond 1 occlusion. The overall risk of Y-stenting remains a concern. We did not encounter any serious complications in treating MCA and Acomm aneurysms; however, 1 death in this series occurred in an ICA aneurysm. In summary, the Y-stenting technique is very effective for aneurysm treatment, but the safety remains uncertain.

INTRODUCTION: Most centres use computed tomographic angiography (CTA) as the primary diagnostic tool in patients presenting with a subarachnoid haemorrhage (SAH). Contrast enhanced magnetic resonance angiography (CEMRA) might be an alternative. In this study the ability to detect cerebral aneurysms with CEMRA in patients presenting with a SAH is investigated and compared with CTA. METHODS: In 75 consecutive patients, two experienced neuroradiologists evaluated CEMRA and CTA images. Digital subtraction angiography (DSA) served as standard of reference. The diagnostic performance in detection of aneurysms was calculated for both modalities and a comparison was made between the two. RESULTS: No significant difference was found between the two modalities for the detection of aneurysms: sensitivities for the two observers were 96.6 and 93.8 respectively for CEMRA and 90.8 and 92.3 respectively for CTA; specificities were 77.8 and 88.9 for CEMRA and 94.4 for both observers for CTA. Kappa values for interobserver variability were 0.82 for CEMRA and 0.85 for CTA. CONCLUSION: The diagnostic accuracy of CEMRA and CTA in the work-up of patients presenting with a SAH does not differ significantly. The choice to use either CEMRA or CTA depends on preference or availability.

A new era of stroke treatment may have begun with mechanical thrombectomy (MT) by fully deployed closed-cell self-expanding stents (stent-triever). Multiple case series and the first randomised controlled trials (RCTs) have now been published. More studies are under way involving large numbers of patients, which in turn has resulted in less strict “pragmatic” study protocols. Problems with current trials include a lack of standardisation in the conduct of the recanalisation procedure, the definition of primary endpoints such as the grade of arterial recanalisation and tissue reperfusion, and the post-surgical care provided. In Part 1 of this two part series, we outline the current situation and the major research questions.

This review summarises the reported clinical experience with flow diverters for the reconstruction of the parent artery of intracranial aneurysms, since their introduction 5 years ago. Over this period, the literature has documented treatment concepts and initial results. Safety concerns, some of which have proved unwarranted, have limited the use of these devices to the treatment of aneurysms which were likely to fail or had failed to be effectively treated by endosaccular coil embolisation. The emerging data now allows the risks of complications specific to this technology to be quantified and the emerging consensus on its efficacy has extended its use to include aneurysms suitable for conventional coil embolisation, in some centres. The need for antiplatelet prophylaxis will probably limit its use to anatomically complex and dissecting aneurysms in patients after spontaneous intracranial haemorrhage. This extending role highlights the need for systematic retrospective analysis of existing large case series and randomised comparative studies.