1,721,006 research outputs found
Size matters! Stent-length is associated with thrombembolic complications after carotid artery stenting
No full textCarotid artery disease: Stenting versus endarterectomy
No full textAtherosclerotic carotid artery stenosis is a major cause of disabling stroke or death. Although carotid endarterectomy (CEA) is currently considered to be the standard of care for patients with a severe symptomatic stenosis and selected patients with an asymptomatic carotid stenosis, carotid angioplasty and stenting (CAS) is increasingly being used as an alternative treatment modality. This article briefly summarizes the current trial data on CEA and CAS. More importantly, potential risk factors for CEA and CAS are reviewed and the complementary role of these techniques in the management of the individual patient is discussed
A risk score to predict ischemic lesions after protected carotid artery stenting
No full textBackground and purpose: While carotid artery stenting can be performed safely in many patients, some have a higher risk for periprocedural complications. The detection of embolic lesions after CAS with DWI could become a useful means to identify these patients. The aim of this study was to determine risk factors for new DWI lesions after CAS. Methods: One hundred seventy-six patients who had undergone protected CAS with pre- and postprocedural DWI between November 2000 and December 2006 were included in this retrospective investigation. The association of potential angiographic and clinical risk factors with the incidence of any new ipsilateral DWI lesion after CAS was analyzed with logistic regression analysis. Subsequently, a simple risk score was developed using area under the curve (ROC) statistics. Results: The proportion of patients with any new ipsilateral DWI lesion was 51%. Advanced age (odds ratio (OR) 1.06; 95% confidence interval (CI) 1.01-1.11, p=0.008), the presence of an ulcerated stenosis (OR 2.28: 95% CI 1.10-4.75; p=0.027) or a lesion length > 1 cm (OR 2.65; 95% CI 1.33-5.28, p=0.006) were independent risk factors for new ipsilateral DWI lesions. A 4 point score ranging from 0 to 4 (age >= 70 years=1 point, age >= 80 years=2 points, lesion length > 1 cm=1 point, and presence of an ulcerated stenosis=1 point)reliably predicted the incidence of this outcome parameter (ROC=0.70, p < 0.001). Conclusions: A simple risk score can be used to identify patients at a high risk for new DWI lesions as a possible surrogate of embolic complications after CAS. (c) 2008 Elsevier B.V. All rights reserved
A Systematic Review on Outcome After Stenting for Intracranial Atherosclerosis
No full textBackground and Purpose-Angioplasty and stenting is increasingly being used for the treatment of intracranial stenoses. Based on a literature search (01/1998 to 04/2008) we sought to determine the immediate and long-term outcomes, as well as the durability of this procedure. Summary of Review-We identified 31 studies dealing with 1177 procedures, which had mainly been performed in patients with a symptomatic (98%) intracranial high-grade stenosis (mean: 78 +/- 7%) at high technical success rates (median: 96%; interquartile range [IQR]: 90% to 100%). The periprocedural minor or major stroke and death rates ranged from 0% to 50% with a median of 7.7% ( IQR: 4.4% to 14.3%). Periprocedural complications were significantly higher in the posterior versus the anterior circulation (12.1%, versus 6.6%, P50% occurred more frequently after the use of a self-expandable stent (16/92; 17.4%, mean follow-up time: 5.4 months) than a balloon-mounted stent (61/443; 13.8%, mean follow-up time: 8.7 months; P<0.001, log-rank test). Conclusions-Although intracranial stenting appears to be feasible, adverse events vary widely. Against the background of the results of this review yielding a high rate of restenoses and no clear impact of new stent devices on outcome, the widespread application of intracranial stenting outside the setting of randomized trials and in inexperienced centers currently does not seem to be justified. (Stroke. 2009; 40: e340-e347.)Boehringer Ingelhei
Endovascular therapy versus thrombolysis in patients with anterior circulation stroke in everyday clinical practice
No full textBackground: In patients with large vessel occlusions, endovascular treatment has been shown to be superior to intravenous thrombolysis in recent trials. Aims: The aim of this study was to analyze the impact of endovascular treatment on clinical and radiological outcome in everyday clinical practice. Methods: We compared the rates of good outcome (modified Rankin scale = 75 years (31% endovascular treatment vs. 19% intravenous thrombolysis, p= 14 (24% endovascular treatment vs. 11% intravenous thrombolysis, p<0.05). Conclusion: In everyday clinical practice and compared with intravenous thrombolysis, endovascular treatment significantly improved clinical outcome and was associated with smaller infarctions. This beneficial effect appeared to be highest in older patients, more severely affected patients, and in those with M1 occlusions
4D CT Angiography More Closely Defines Intracranial Thrombus Burden Than Single-Phase CT Angiography
No full textBACKGROUND AND PURPOSE: In patients with acute stroke, the location and extent of intravascular thrombi correlate with clinical and imaging outcomes and have been used to predict the success of intravenous thrombolysis. We hypothesized that 4D-CTA reconstructed from whole-brain CTP more closely outlines intracranial thrombi than conventional single-phase CTA. MATERIALS AND METHODS: Sixty-seven patients with anterior circulation occlusion were retrospectively analyzed. For 4D-CTA, temporal maximum intensity projections were calculated that combine all 30 spiral scans of the CTP examination through temporal fusion. Thrombus extent was assessed by a semi-quantitative clot burden score (0-10; in which 0 = complete unilateral anterior circulation occlusion and 10 = patent vasculature). In patients with sufficient collateral flow, the length of the filling defect and corresponding hyperdense middle cerebral artery sign on NCCT were measured. RESULTS: Clot burden on temporal maximum intensity projection (median clot burden score, 7.0; interquartile range, 5.1-8.0) was significantly lower than on single-phase CT angiography (median, 6.0; interquartile range, 4.5-7.0; P < .0001). The length of the hyperdense middle cerebral artery sign (14.30 +/- 5.93 mm) showed excellent correlation with the filling defect in the middle cerebral artery on temporal maximum intensity projection (13.40 +/- 6.40 mm); this filling defect was larger on single-phase CT angiography (18.08 +/- 6.54 mm; P = .043). CONCLUSIONS: As the result of an increased sensitivity for collateral flow, 4D-CTA temporal maximum intensity projection more closely outlines intracranial thrombi than conventional single-phase CT angiography. Our findings can be helpful when planning acute neurointervention. Further research is necessary to validate our data and assess the use of 4D-CTA in predicting response to different recanalization strategies.Siemens Healthcar
Inflammation and in-stent restenosis: the role of serum markers and stent characteristics in carotid artery stenting.
No full textBACKGROUND: Carotid angioplasty and stenting (CAS) may currently be recommended especially in younger patients with a high-grade carotid artery stenosis. However, evidence is accumulating that in-stent restenosis (ISR) could be an important factor endangering the long-term efficacy of CAS. The aim of this study was to investigate the influence of inflammatory serum markers and procedure-related factors on ISR as diagnosed with duplex sonography. METHODS: We analyzed 210 CAS procedures in 194 patients which were done at a single university hospital between May 2003 and June 2010. Periprocedural C-reactive protein (CRP) and leukocyte count as well as stent design and geometry, and other periprocedural factors were analyzed with respect to the occurrence of an ISR as diagnosed with serial carotid duplex ultrasound investigations during clinical long-term follow-up. RESULTS: Over a median of 33.4 months follow-up (IQR: 14.9-53.7) of 210 procedures (mean age of 67.9±9.7 years, 71.9% male, 71.0% symptomatic) an ISR of ≥70% was detected in 5.7% after a median of 8.6 months (IQR: 3.4-17.3). After multiple regression analysis, leukocyte count after CAS-intervention (odds ratio (OR): 1.31, 95% confidence interval (CI): 1.02-1.69; p = 0.036), as well as stent length and width were associated with the development of an ISR during follow-up (OR: 1.25, 95% CI: 1.05-1.65, p = 0.022 and OR: 0.28, 95% CI: 0.09-0.84, p = 0.010). CONCLUSIONS: The majority of ISR during long-term follow-up after CAS occur within the first year. ISR is associated with periinterventional inflammation markers and influenced by certain stent characteristics such as stent length and width. Our findings support the assumption that stent geometry leading to vessel injury as well as periprocedural inflammation during CAS plays a pivotal role in the development of carotid artery ISR
on computed tomography angiography source images on outcome after thrombolysis or endovascular therapy in large vessel occlusions
No full textBackground and purpose: Endovascular therapy (ET) is superior to intravenous thrombolysis (IVT) in selected patients with anterior circulation large vessel occlusions. However, it is unclear if this positive effect also applies to patients with extensive early ischaemic changes. The aim of this study was to analyze the impact of the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) on the CT angiography source images (SI) on outcome after ET or IVT. Methods: Using our prospectively obtained stroke database and the admission SI-ASPECTS divided into three groups (0-5, 6-7 and 8-10), primarily the rates of good outcome = [modified Rankin Scale (mRS) <= 2 at discharge] after either ET (n = 255) or IVT (n = 479) were compared. Results: A favorable SI-ASPECTS (8-10) was present in 501 patients, 132 patients had a moderately favorable SI-ASPECTS (6-7) and 101 patients had an unfavorable SI-ASPECTS (0-5). Irrespective of the treatment modality, no patient with an unfavorable SI-ASPECTS had a good outcome and 38% died during hospital stay. Whilst significantly more patients with a favorable SI-ASPECTS had a good outcome after ET than after IVT (51% vs. 35%, P < 0.01), there was only a non-significant trend towards a good outcome after ET than after IVT in patients with a moderately favorable ASPECTS (25% vs. 14%, P = 0.1). Conclusion: Patients with extensive early ischaemic changes on CT scans (SI-ASPECTS <= 5) might not profit from ET. The impact of ET on outcome in patients with moderately favorable SI-ASPECTS should be addressed in further trials
Clinical predictors to identify paroxysmal atrial fibrillation after ischaemic stroke
No full textBackground and purposeDetection of paroxysmal atrial fibrillation (pAF) after an ischaemic cerebrovascular event is of imminent interest, because oral anticoagulation as a highly effective secondary preventive treatment is available. Whereas permanent atrial fibrillation (AF) can be detected during routine electrocardiogram (ECG), longer detection duration will detect more pAF but might be resource consuming. The current study tried to identify clinical predictors for pAF detected during long-term Holter ECG and clinical follow-up. MethodsPatients with acute ischaemic stroke were prospectively investigated with an intensified algorithm to detect pAF (7-day Holter ECG, follow-up investigations after 90days and 1year). ResultsTwo hundred and eighty-one patients were included, 44 of whom had to be excluded since they presented with permanent AF and another 13 patients had to be excluded due to other causes leaving 224 patients (mean age 68.5years, 58.5% male). Twenty-nine (12.9%) patients could be identified to have pAF during prolonged Holter monitoring, an additional 13 (5.8%) after follow-up investigations. Multivariate analysis identified advanced age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01-1.08] as well as clinical symptoms >24h (OR 5.17, 95% CI 1.73-15.48) and a history of coronary artery disease (OR 3.14, 95% CI 1.35-7.28) to be predictive for the detection of pAF. ConclusionsIn acute stroke patients with advanced age, history of coronary artery disease and clinical symptoms >24h, a prolonged Holter ECG monitoring and follow-up is warranted to identify pAF. This could increase the detection rate of patients requiring anticoagulation and may be able to reduce the risk of recurrent stroke in the case of successful anticoagulation of these patients
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